Arthroscopic Management of Massive Rotator Cuff Tears


Chapter 25

Arthroscopic Management of Massive Rotator Cuff Tears



Giuseppe Milano, Maristella Francesca Saccomanno, and Giuseppe Sircana

Introduction


Massive rotator cuff tears have historically been defined as tears that are greater than 5 cm in size in either the anterior-posterior or medial-lateral length, or tears involving at least two tendons. They account for 20% of all cuff tears and 80% of recurrent tears. Reparability is dependent mainly on tendon quality and retraction, muscle atrophy, and fatty infiltration as well as chronicity. Numerous arthroscopic techniques have been described, ranging from partial or complete repair to biologic augmentation, such as use of growth factors, patch graft or marrow-stimulating procedures, or a combination of them. Selection of the most effective treatment for a single patient can be challenging and is based mainly on tear characteristics as well as on the surgeon’s experience and skill set.

Procedure


Complete repair without excessive tension is the goal of arthroscopic treatment of massive rotator cuff tears. Adequate mobilization and identification of the shape of the tear are the principal surgical steps needed to achieve a successful repair. In case of retracted massive cuff tears, suture anchors are usually placed in a single-row configuration at the articular margin of the humeral head to minimize tension in the repaired tendons. Margin convergence repair is commonly combined with suture anchor repair, based on the tear shape, to further reduce tension in the repair.

Patient History



Patient Examination





  1. • Inspection of both shoulders in order to detect side-to-side differences: in massive rotator cuff tears, marked muscle atrophy can create deformity of both the supraspinatus and infraspinatus fossae.
  2. • Evaluation of passive range of motion: loss of shoulder motion due to posttraumatic joint stiffness or to primary adhesive capsulitis must be ruled out.
  3. • Evaluation of active range of motion: pseudoparalysis, defined as the inability to actively elevate the arm beyond 90 degrees with full passive forward flexion and no neurological impairment, is a common finding in traumatic massive cuff tears.
  4. • Assessment of scapular kinematics and kinetics: scapula protraction and elevation can be a compensatory mechanism for the loss of active forward flexion.
  5. • Subacromial crepitus can be a sign of upper migration of the humeral head and progression to osteoarthritis.
  6. • Assessment of muscle strength through specific tests: positive external rotation lag sign as well as drop arm sign and a positive hornblower’s sign are usually indicative of a massive cuff tear.
  7. • Involvement of the subscapularis tendon must be assessed with the following specific tests: belly press, lift-off, bear hug, internal rotation resistance at 90 degrees of abduction and external rotation.

  9. • Involvement of the long head of the biceps must be assessed with the following specific tests: palm-up and Yergason tests. A typical Popeye deformity can be found in case of biceps rupture.
  10. • Neurological examination in order to differentiate weakness due to cuff deficiency from neurological disorders. Presence of paresthesia is usually not related to cuff deficiency.

Imaging



Treatment Options: Nonoperative and Operative


Nonoperative


These strategies are usually indicated in patients who cannot undergo surgery because of age and/or multiple comorbidities. Conservative options are daily activity modification, use of nonsteroidal antiinflammatory drugs, subacromial corticosteroids or hyaluronic acid injections, physical modalities, and therapeutic exercises. They are palliative strategies whose aim is to reduce pain with slight functional improvement.

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FIG. 25.1 Right shoulder, lateral portal view of a complete single-row rotator cuff repair.

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FIG. 25.2 Right shoulder, lateral portal view of a functional rotator cuff repair. A U-shaped lesion has been repaired by performing one side-to-side repair at the apex of the lesion in order to reduce the tension of the repair and by placing one anterior and one posterior anchor in order to reestablish the force couple balance. An additional side-to-side repair has been performed with one suture of the anterior anchor.

Operative





  1. • Complete repair: when possible, a watertight complete arthroscopic cuff repair without excessive tension is attempted (Fig. 25.1). Pain reduction, functional recovery, and structural healing of the repaired tendons are the main goals of this operative treatment.
  2. • Functional (partial) repair: this is performed when a complete repair is not possible; its aim is to restore function, not anatomy (force couple balancing) (Fig. 25.2).
  3. • Biologic augmentation: marrow-stimulating techniques, the use of patch grafts, growth factors, or a combination of these procedures (Fig. 25.3) have recently been suggested as options to enhance tendon-to-bone healing.


  5. image
    FIG. 25.3 Biologic enhancement of rotator cuff repair. (A) Right shoulder, lateral portal view. Augmentation of the repair with a patch graft. (B) Right shoulder, posterior portal view. The combined effect of the patch graft (red asterisk) and microfracture of the greater tuberosity is supposed to enhance tendon-to-bone healing.

  6. • Tendon transfers: these are usually indicated in active patients with massive irreparable tears (primary or recurrent). Integrity of subscapularis and teres minor tendons is required to achieve acceptable functional results in posterosuperior tendon transfers, such as latissimus dorsi transfer. Combined anterior and posterosuperior transfer has been described as a salvage procedure, although results are not promising.
  7. • Superior capsule reconstruction: this has recently been proposed for cases of irreparable posterosuperior tear; its aim is to recenter the humeral head.
  8. • Biceps tenotomy as palliative surgery: the aim of this procedure is pain reduction.

Surgical Anatomy



Surgical Indications





  1. • Watertight complete cuff repair: this is the most effective procedure to reduce pain and improve function. Best functional results can be achieved in recent traumatic tears (less than 4 months) in young or middle-aged patients, with fatty infiltration not higher than stage 2 and good-quality tendons, still reducible without excessive tension. Massive cuff tear after shoulder dislocation should also be repaired to improve function and to treat instability symptoms as well. A complete repair can also be attempted in chronic massive degenerative tear with high stage of fatty infiltration if cuff tendons are not retracted beyond the glenoid, albeit that expected functional improvement is less predictable and the risk of retear is the same.
  2. • Patch graft augmentation: this is indicated in revision cases or primary massive cuff tear if tendon quality is poor.
  3. • Functional (partial) repair: this provides early postoperative patient satisfaction in terms of pain relief and functional recovery, and it is performed when a complete repair is not possible. Reestablishing force couple balance is reasonable to prevent tear progression and subsequent degenerative changes, even if anatomy is not completely restored.
  4. • Tendon transfers: these are indicated in massive irreparable tears in young and active patients with no radiological and arthroscopic signs of glenohumeral osteoarthritis.
  5. • Superior capsule reconstruction: this is a good alternative to partial repair because it seems to be effective in limiting upper migration of the humeral head.
  6. • Biceps tenotomy: palliative surgery for massive irreparable tears in old patients no longer responsive to nonoperative options.


Surgical Technique Setup


Positioning: How to Set Up Room and Patient



Possible Pearls



Possible Pitfalls



Equipment



Surgical Exposure/Portals


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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Arthroscopic Management of Massive Rotator Cuff Tears

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