JOINT MOVEMENT Advances in arthroscopy let surgeons perform major tendon repairs through small ports.

I haven't performed an open or mini-open rotator cuff repair in about 15 years, thanks in large part to several advances in arthroscopy that make arthroscopic repairs of most tendon tears possible. Arming your orthopedic surgeons with the latest technology lets you fill ORs with the increasing number of older patients (see "Baby Boomers Aren't Slowing Down" on page 66) who seek minimally invasive surgery so they can quickly return to active lifestyles.

• Anchor systems. Improvements in bony fixation let surgeons repair tendons back to the bone using anchors that are easier to place and provide good pull-out strength.

The newer anchor systems are comprised of bioabsorbable material attached to metal tips, which surgeons can tap into tough bone. The streamlined process means surgeons are able to place anchors in essentially any location, meaning they can place access portals in locations to attack joints at optimal angles. Some controversy surrounds the use of bioabsorbable anchor material based on beliefs that it may cause bony absorption or splits in bone, but I haven't experienced those adverse events. The other benefit of bioabsorbable anchors is that if they were to dislodge, they'd absorb into tissue on their own.

• Specialized suture. Suture that's a little wider than traditional options and reinforced with a Gore-Tex-like material makes tendon fixation extremely strong. It also spreads the tension across a larger surface area on the tendon to enhance overall healing of the rotator cuff footprint.

Newer sutures also allow for knotless repair, which involves placing a suture around the labrum or the rotator cuff, then fixing it with an anchor that essentially sucks the suture into the bone. That creates secure, knotless fixation and avoids knot "towers" from forming in the joint. The towers can cause irritation and pain at the joint, and can irritate cartilage. Knotless suturing also removes a technically demanding component of arthroscopic procedures that adds several minutes to cases. My rotator cuff repairs are 30 minutes shorter because I don't have to tie sutures.

POTENTIAL PATIENTS
Baby Boomers Aren't Slowing Down

BABY BOOM Christopher R. Sforzo, MD, meets a heavy demand for minimally invasive shoulder surgery.

People who come to my practice in Sarasota, Fla., with bum shoulders seek a return to active lifestyles — tennis, golf and fishing are favorites. Although many individuals with rotator cuff tears don't require surgery, patients with symptomatic tears face a decision when physical therapy and rest haven't allowed them a return to full physical activity. The latest arthroscopic techniques make that choice a little easier for those who are chronologically older, but physiologically still very young and feel like they have a lot of time left to lead productive lives.

Bone and tissue quality tends to deteriorate with advanced age, but patients in their 60s and 70s can have joints fixed arthroscopically and do very well. A key component of what I do is educating patients about the benefits and risks of surgery, and helping them make an educated decision about their options.

I tell them it's easier and better to heal from surgery at age 65 than it is at age 75. I think it's important to let patients know that they'll be healthier and bounce back quicker with better tissue and bone quality if they undergo arthroscopic joint repair at the start of their golden years.

We've done a great job of advancing minimally invasive techniques and reducing post-op pain, but we haven't sped up the healing time, which takes a good 4 to 6 months after arthroscopic rotator cuff repair. That's probably the most frustrating aspect for patients. Still, newer arthroscopic technologies allow patients to heal faster than ever and get back to normal routines and active lifestyles with longer-lasting benefits.

— Christopher R. Sforzo, MD

• Improved imaging. High-definition cameras and monitors have greatly enhanced the potential of arthroscopic surgery, because now surgeons can see details they never saw before, which helps to pinpoint pathology and confirm that the repair is optimal without guessing about the quality of the fixation.
• Cannula systems. Surgeons want cannula systems that are easy to use and that allow for smooth instrument passing and mobility once the tools enter the joint. This is surgeon-dependent, based on their experience and preferred technique, but in general, surgeons need to place portals in locations that allow them to approach pathology correctly and make repairs efficiently and effectively.

Patient positioning also plays a key role in those abilities, especially during shoulder repairs. During rotator cuff repairs, I prefer to have patients placed in the beach chair position so that the spine is in line and bony prominences are well-padded.

• Pump pressure. It's important to have good visualization, which is achieved with minimal pressure from the arthroscopy pump in order to keep the joint open and maintain a safe, but low blood pressure. During shoulder arthroscopy, I run the irrigation pump's pressure very low — around 30 or 35 mmHg for the whole case — to help lessen post-op pain and swelling. Automatic irrigation pumps that sense when distention pressure is dropping — including recognizing when burrs and shavers are in use — and adjust pressure accordingly are helpful.

Surgeons must avoid flooding the soft tissue around joints when pumping in fluid, which tends to run down fascial planes. The higher the pump pressure during shoulder surgery, for example, the greater the chance fluid will flow into the chest wall or neck. Although those risks are small, surgeons still want to keep the pressure as low as possible in order to avoid potential adverse events.

There's a fine line between managing the pump pressure and maintaining the patient's blood pressure. It's dangerous if the patient's blood pressure drops too low — that's something I'm constantly monitoring and gauging during arthroscopy procedures — especially in the beach chair position. Surgeons must have a great rapport with anesthesia providers, who want to keep the patient's blood pressure as low as possible, because the pump can only do so much in maintaining a safe pressure inside the joint. If the blood pressure is higher than the pressure inside the joint that's maintained by the pump, there's essentially no way to stop bleeding in the surgical field. Even a trace amount of blood can hinder the surgeon's efforts during arthroscopy — the effect is similar to a drop of vegetable dye dispersing through water in a glass.

• Instruments. The system I use features shavers, cutters and burrs designed for high-speed power and pinpoint precision and control, the essential elements of successful arthroscopic outcomes. The real game-changer, though, is the radiofrequency probe I use to simultaneously cut and coagulate tissue, which minimizes the bleeding that, as mentioned, can severely hamper the surgeon's view.