Case 22

Differential Diagnosis

An anteroposterior (AP) and scapular Y view of the shoulder are obtained (Fig. 22–1).

Diagnosis

Full-Thickness Rotator Cuff Tear. This patient’s history of persistent symptoms despite a rather extensive nonoperative treatment program including organized physical therapy and subacromial injections suggest chronic impingement or full-thickness rotator cuff tearing. His significant weakness to forward flexion makes the possibility of a full-thickness rotator cuff tear more likely. His normal passive motion and the absence of significant degenerative changes radiographically make significant arthritis a much less likely etiology. Although this patient may not actually have a full-thickness rotator cuff tear, his moderately persistent symptoms despite these nonoperative interventions make surgical treatment a valuable alternative.

Magnetic resonance imaging (MRI) would probably assess the status of the rotator cuff accurately. However, the authors would generally not obtain an MRI in this situation because, regardless of whether a tear exists, this patient would certainly benefit from an acromioplasty. Because the authors perform this decompression arthroscopically, an excellent opportunity for accurate assessment of the rotator cuff tendon both on the articular and bursal sides would be possible. The authors have found MRI to be more valuable for patients with significant functional deficits who have failed to respond to an organized program for several weeks. This is particularly true in younger or athletically inclined individuals who sustain an acute, traumatic injury. Although rotator cuff contusions can lead to significant losses of active motion for a few weeks, persistent loss of active function is usually due to a complete tear, and MRI is valuable in assessing the status of the tendon.

Surgical Management

Patients failing to respond to an adequate nonoperative treatment program including organized exercises and nonsteroidal antiinflammatory medications are candidates for surgical intervention. Repair of full-thickness rotator cuff tears by open subacromial decompression and rotator cuff tendon reapproximation has proven successful in restoring function and decreasing pain in patients who have failed nonoperative treatment. However, open rotator cuff repair does have certain inherent limitations and drawbacks. Failure of the deltoid repair following open rotator cuff surgery has been reported and may lead to significant functional deficits in postoperative strength and in active motion. Also, active strengthening exercises must always be delayed following deltoid muscle release in an effort to protect the deltoid repair. Detachment of the deltoid can be avoided through the use of an arthroscopically assisted deltoid splitting mini-arthrotomy technique or a purely arthroscopic technique. However, these mini-open or purely arthroscopic approaches to rotator cuff repair can be used only after an arthroscopic subacromial decompression has been performed. Acromioplasty cannot be effectively accomplished through a mini-open incision.

When a full-thickness rotator cuff tear is identified, debridement of the rotator cuff edges is accomplished arthroscopically (Fig. 22–2). The underlying greater tuberosity bone is then abraded using the arthroscopic instruments. Care is taken not to disrupt the cortical surface of the greater tuberosity as this may significantly reduce the pull-out strength of the suture anchors to be employed. Attention is then turned to the acromion, where an arthroscopic acromioplasty is carried out using standard technique.

Following the completion of an arthroscopic decompression, the rotator cuff tendon is evaluated for its ability to be lateralized into the bleeding bony bed. If mobilization of the tendon is required, this can often be accomplished arthroscopically. Small freers can allow for significant lateralization of small, medium, and even some large tears. When adequate mobilization has been accomplished, suture anchors can be placed into the bleeding bony bed in the area of the anatomic insertion of the tendon. The authors prefer no. 2 nonabsorbable sutures for rotator cuff repair, and such sutures are threaded through the eyelet of the anchor prior to placement. The number of suture anchors varies depending on the size and character of the rotator cuff tendon tear. As a general rule, the authors use one anchor for every centimeter of detached rotator cuff tendinous tissue. As each suture anchor is placed into the bleeding bony bed under arthroscopic visualization, a suture retriever is then passed through the substance of the tendon using an accessory portal and the ends retrieved through the tendon and out the accessory portal. The authors have found it easiest to complete the passage and tying of an individual suture anchor before proceeding to the placement and passing of the sutures for a second anchor. Such a technique allows for a minimum number of intraarticular sutures, making orientation easier and suture overlapping less likely. However, all sutures may be passed before any are tied depending on the size and orientation of the rotator cuff tear. Following the completion of suture anchor placement, suture passage through the tendon, and arthroscopic knot tying, a probe is used to confirm the adequacy and stability of the repair.

Figure 22–2. Arthroscopic identification and treatment of a full-thickness rotator cuff tear. (A) The full-thickness rotator cuff tear is identified by visualizing the rotator cuff from the posterior portal while in the subacromial space. (B) Debridement of the rotator cuff edges and abrasion on the underlying greater tuberosity bone are then carried out. (C) An arthroscopic acromioplasty as viewed from the lateral portal is carried out using standard technique. (D) While viewing from the posterior portal, suture anchors are placed into the bleeding bony bed of the greater tuberosity arthroscopically. (See Color Plates 22–2A–D.) Figure 22–2 (continued). (E) The nonabsorbable sutures are passed through the rotator cuff tendon using a suture retriever. (F) Arthroscopic knot tying then allows for reapproximation of the tendinous tissue into the previously abraded greater tuberosity bony bed (See Color Plates 22–2E,F.)

When a purely arthroscopic technique for rotator cuff repair is not possible or technical factors preclude its implementation, a mini-open rotator cuff repair technique is used. The authors have found that the great majority of rotator cuff tears can be repaired through this mini-open approach, making deltoid detachment rarely necessary. The mini-open repair technique is exactly the same as the purely arthroscopic technique until the placement of suture anchors is to be carried out. That is, arthroscopic glenohumeral joint evaluation, arthroscopic rotator cuff debridement, and greater tuberosity abrasion along with arthroscopic acromioplasty are accomplished prior to carrying out the limited arthrotomy. Following the completion of the arthroscopic component of the procedure, a limited transverse incision is made over the shoulder in the area where the rotator cuff tendon tear is present. This transverse incision has been found by the authors to be much more cosmetically pleasing than a longitudinal incision of the same length (Fig. 22–3). After incision of the skin has been completed, the deltoid is bluntly split in line with its fibers and the subacromial space entered. A self-retaining retractor is placed in the deltoid split. No deltoid is released from the acromion, but care is taken to avoid avulsion of the deltoid from the acromion. This is particularly true after arthroscopic resection of a large amount of subacro mial bone. Extensive removal of bone can weaken the insertion of the deltoid, making intraoperative avulsion a possibility. The rotator cuff tendon tear can then be identified within the depths of the incision. The size of the rotator cuff tear and quality of the tissue can be assessed. Traction sutures or small graspers can be used to assess the mobility of the rotator cuff tissue. Suture anchors are then placed into the previously abraded greater tuberosity bed if the bone is of adequate quality. If significant osteopenia is present and precludes the use of suture anchors, a no. 2 or no. 5 nonabsorbable suture can be passed through transosseous drill holes and tied over the greater tuberosity. Also, a Marlex patch is sometimes used by the authors over the greater tuberosity to further reinforce the bony post where the sutures are tied. This is accomplished by simply passing the sutures through the Marlex patch prior to tying, so that these sutures are tied not only over the greater tuberosity bone but over this patch as well. When suture anchors are used, they are placed into the bleeding bony bed using standard technique, with the drill holes directed toward the glenohumeral joint. The sutures are then passed in a horizontal mattress fashion and sequentially tied. The rotator cuff repair is then assessed for stability by probing and under direct visualization through a range of motion. Following the confirmation of the adequacy of repair, the deltoid fascia is reapproximated with interrupted absorbable sutures. The sub-cutaneous tissues are reapproximated with absorbable sutures and a running subcuticular 4-0 PDS is used to approximate the skin.

Related posts:

11. Anterior Instability: Open Repair Technique 9. Lateral Third Clavicle Fractures 53. Posterior Interosseous Nerve Entrapment 45. Distal Biceps Rupture—Acute 8. Extraarticular Fractures of the Scapula—Scapular Neck and Body 17. Multidirectional Instability

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