Rotator Cuff Repair Using Coracoacromial Ligament Autograft for Supraspinatus Footprint Augmentation

Abstract

Failure of rotator cuff repair can be a disastrous clinical outcome. Although failure is a multifactorial issue, recent interest has piqued in understanding the biology of the insertional components of the supraspinatus and infraspinatus at the footprint. When the torn tendon is of poor quality, especially if it is diminutive or thin, rotator cuff repair augmentation should be considered to aid in long-term healing. Various allograft options have been described in the past, and more recently, xenografts and synthetics have become more commonly used. The use of autografts in the treatment of insertional footprint deficiency has great potential; however, few grafts have been described. This study describes the surgical technique for footprint augmentation in arthroscopic supraspinatus repair using harvested autologous coracoacromial ligament tissue.

Fig 1

Lateral shoulder positioning and setup for arthroscopy, shown from behind the posterior side of the patient (right shoulder).

Fig 2

Anterior, lateral, and posterior arthroscopic portals used in shoulder arthroscopy from the lateral decubitus position (right shoulder) for the described procedure, as seen from the head of the operating room table.

Fig 3

Viewing from the posterior portal in the subacromial space, meticulous exposure is performed to visualize the coracoacromial ligament (right shoulder). Superiorly, the acromion is visualized, with the shaver immediately inferior actively removing bursal tissue. The supraspinatus rotator cuff tissue and footprint can be visualized inferiorly.

Fig 4

Viewing from the posterior portal in the subacromial space, partial acromial undersurface contouring is performed with a burr (right shoulder). Superiorly, the acromion is visualized, with the motorized burr removing bone from lateral (right) to medial (left). The adjacent bursal tissue and rotator cuff is visualized inferior to the acromion.

Fig 5

Viewing from the posterior portal in the subacromial space, a massive tear is noted in the supraspinatus and infraspinatus (labeled “rotator cuff”) with retraction to the level of the humeral head. Lateral (right) to the exposed humeral head is the bony footprint of the supraspinatus.

Fig 6

Photograph from operating room Mayo stand showing the coracoacromial ligament graft measuring approximately 15 mm wide by 8 mm long by 3 mm thick. The sutures from 2 medial-row footprint anchors are placed 8 mm apart in the graft (marked with purple dots).

Fig 7

Viewing from the posterior portal in the subacromial space, the coracoacromial ligament is observed to be approximated to the footprint with the sutures from the medial-row anchors traveling through the coracoacromial ligament graft (deep) and then the native rotator cuff tissue (superficial).

Fig 8

Viewing from the posterior portal in the subacromial space, the medial row and luggage-tag sutures are tensioned over the native cuff (superficial) and coracoacromial ligament autograft (deep) as the sutures are pulled from medial (left) to lateral (right) while being loaded into a lateral-row anchor.

Fig 9

Viewing from the posterior portal in the subacromial space, the final double-row construct shows appropriate tension and compression of the cuff and graft at the supraspinatus insertion.