8 Massive Rotator Cuff Repair (Mobilization Techniques, Slides)
Abstract
When repairing massive rotator cuff tears, it is essential to avoid overtensioning the repaired tissue. Extensive releases of scarred and adherent tissue and interval slide techniques are essential tools to optimize the repair viability. The fixation method chosen is important, but is often secondary to proper tissue management.
8.1 Goals of Procedure
To adequately mobilize adherent and scarred rotator cuff tendons in massive tears.
To optimize fixation of the repaired tissue.
To improve the milieu of healing in the most difficult cases by increasing tendon-to-bone fixation and making it possible to perform double-row constructs to improve healing.
8.2 Advantages
Allows for a tension-free repair in order to maximize repair success.
Increases tendon-to-bone interface in the repair construct.
Allows for double-row fixation when possible.
8.3 Indications
Massive reparable rotator cuff tears, chronic retracted tears with no evidence of muscle atrophy.
8.4 Contraindications
Irreparable tears, fatty atrophy of the rotator cuff muscles (Goutallier 3 or above). 1
Severe comorbidities that can adversely affect outcomes such as diabetics and smokers.
8.5 Preoperative Preparation/Positioning
A detailed history and physical examination are essential for proper patient evaluation. Specifically, a history of prior trauma or previous surgeries should be elucidated.
Standard X-rays including anteroposterior (AP), true shoulder AP, scapula Y lateral, and axillary views should be routinely obtained to evaluate for any glenohumeral arthritis, superior migration of the humeral head, and classification of the type of acromion.
MRI is the preferred imaging modality in order to visualize any soft-tissue pathology. Standard T1 and T2 sequences as well as short tau inversion recovery (STIR) sequences can help identify fatty atrophy of muscle versus edema. Sagittal STIR sequences are especially useful in evaluating the extent of muscle atrophy of the rotator cuff musculature.
MR arthrography is helpful for visualizing labral pathology, but is less useful for rotator cuff pathology and as such is not routinely obtained.
CT scans are helpful in evaluating glenoid or humeral bone loss but are not routinely obtained for suspected rotator cuff pathology.
8.6 Expert Suggestions/Comments
Depending on the surgeon’s preference, the patient should be positioned in the beach-chair or lateral decubitus position. Prior to starting the procedure, it is essential to ensure that all equipment and implants are available, including both tied and knotless technology, to ensure the best fixation options for single- or double-row lateral fixation.
The mobilization and fixation techniques are dependent on proper visualization, evaluation, and classification of the rotator cuff tear.
8.7 Operative Technique
8.7.1 Anesthesia/Positioning
We prefer regional interscalene block with relaxation or general anesthesia. We routinely use the beach-chair position for rotator cuff pathology.
8.7.2 Portals
Standard posterolateral viewing portal is made, followed by the anterior rotator interval working portal. Once in the subacromial space, the standard direct lateral portal is made. After evaluating the rotator cuff tear type and mobility, additional portals are made as needed to serve as working portals or percutaneous anchor insertion portals. Multiple working portals are routinely used for large, retracted tears.
8.7.3 Debridement and Bursectomy
A significant bursectomy and debridement should be performed for the dual purpose of visualization and cuff mobilization as the bursal adhesions between the rotator cuff and the local tissue can be a significant inhibitor of rotator cuff mobility (specifically, adhesions to the acromion and subdeltoid fascia/lateral shelf). In massive tears, retention of the coracoacromial ligament should be considered in order to prevent postoperative superior migration of the humeral head. However, in cases where there is significant acromial pathology, we perform an acromioplasty in routine fashion. The biceps tendon functions as both a dynamic and static humeral head depressor. However, its role in the case of massive rotator cuff tears is unclear. If there is any evidence of biceps pathology, it should be tenotomized and tenodesed.
Debridement should not be limited to the subacromial space, as an intra-articular release between the cuff tissue and superior labrum/capsule can greatly improve cuff mobility.
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