Rotator Cuff Cases


Rotator Cuff Cases


WESTERN WISDOM


Followin’ the crowd is the quickest way to get nowhere.


CASE 1: MASSIVE TRAUMATIC ROTATOR CUFF TEAR WITH INTRATENDINOUS DISRUPTION NEAR THE MUSCULOTENDINOUS JUNCTION


History:



  • 43-year-old contractor who fell through a hole in the attic of a home he was building
  • Tried to break his fall by grabbing a support beam
  • Hyperabduction injury to left shoulder

Exam:



  • Pain with elevation above 90°
  • Very weak resisted external rotation

Imaging:



  • X-rays are normal.
  • MRI shows complete retracted tears of supraspinatus and infraspinatus, with tendon disruption near the musculotendinous junction, and a large tendon stump attached to the greater tuberosity.

Arthroscopic Findings:



  • Large retracted traumatic disruption of supraspinatus (SS) and infraspinatus (IS) tendons
  • Short tendon leader still attached to SS and IS muscles
  • Large viable tendon stump still attached to greater tuberosity (Fig. 26.1A)

Procedures Performed:



  • Arthroscopic repair with suture anchors reinforced by a FiberTape rip-stop load-sharing tendon-to-bone construct (Fig. 26.1B)

Key Points:



  • With a large distal tendon stump, simple sutures between tendon ends will not provide good fixation and will not hold.
  • If the distal stump were removed and the proximal musculotendinous segment were advanced to the bone bed, the muscle-tendon unit would likely be overtensioned.
  • In order to accomplish the two goals of strong fixation and normal length–tension relationship of the muscle-tendon unit, we perform an augmented suture anchor repair using a FiberTape rip-stop load-sharing tendon-to-bone construct. Multiple knotted sutures around the FiberTape rip-stop enhance the tendon fixation.

CASE 2: “RESCUE ANCHOR” TECHNIQUE FOR AUGMENTING SUTURE ANCHOR REPAIR IN SOFT BONE


History:



  • 67-year-old female
  • Chronic pain and weakness in dominant shoulder for 4 years
  • Temporary relief from injections

Exam:



  • Very weak resisted external rotation
  • Normal bear-hug and belly-press tests
  • Active elevation 30° and passive elevation 180° (pseudoparalysis)

image

Figure 26.1 A: Left shoulder, posterior subacromial viewing portal, demonstrates a medial rotator cuff tear with a lateral tendon stump. B: Same shoulder. Two rip-stop sutures have been placed; the anterior FiberTape (Arthrex, Inc., Naples, FL) rip-stop (blackarrows) encircles simple stitches (bluearrows) based from the anteromedial anchor, and the posterior rip-stop (redarrows) encircles simples stitches (greenarrows) based from the posteromedial anchor. H, humeral head; SS, supraspinatus tendon.


Imaging:



  • X-rays show marked osteopenia of proximal humerus.
  • MRI shows retracted tear of supraspinatus and infraspinatus, with good quality muscle on T-1 parasagittal ­sections.

Arthroscopic Findings:



  • Large crescent-shaped tear of SS and IS, easily reducible to bone bed with relatively small amount of tension (Fig. 26.2A)

Procedures Performed:



  • Arthroscopic suture anchor repair of the rotator cuff, augmented by “rescue anchor” technique (Figs. 26.2B and 26.3)

Key Points:



  • In osteopenic bone, a suture anchor may begin to tip medially, even under low loads, resulting in a loose anchor with a “reverse deadman angle.”
  • A laterally placed “rescue anchor” (SwiveLock) can restore an anatomic footprint reduction by anchoring FiberWire suture into the relatively stronger ­metaphyseal cortex (lateral to the corner of the greater ­tuberosity).

image

Figure 26.2 A: Left shoulder, posterior subacromial viewing portal. After knot tying, an anchor placed for a rotator cuff repair has tilted medially (blackarrow). B: Same shoulder demonstrates a rescue anchor (blue arrow) that has been used to reinforce the medial anchor. RC, rotator cuff.


image

Figure 26.3 Schematic of the “rescue anchor” technique for a loose anchor. A: An anchor has been placed in the greater tuberosity for rotator cuff repair. However, while securing the rotator cuff the anchor has tilted medially under tension in poor quality bone. B: Although the tear is not amenable to double-row fixation because of limited mobility, a lateral anchor can be used to salvage the construct. The suture tails passed through the rotator cuff are left long and secured in the lateral greater tuberosity with a knotless SwiveLock anchor (Arthrex, Inc., Naples, FL). C: The lateral anchor effectively shares the load of the medial anchor.

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Dec 26, 2016 | Posted by in SPORT MEDICINE | Comments Off on Rotator Cuff Cases

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