Arthroscopic Treatment of Combined Shoulder Instability and Rotator Cuff Tear



Figure 7.1
(a, b) Post-reduction AP and Y-lateral x-rays after initial dislocation demonstrating reduction of the joint. Note glenohumeral degenerative changes



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Figure 7.2
T2-weighted MRI images . (a) Coronal section showing intact subscapularis with tendinosis. (b, c) Coronal sections demonstrating large, retracted rotator cuff tear with Hill-Sachs impaction fracture. (d) Sagittal section demonstrating massive rotator cuff tear




Diagnosis/Assessment


Treatment of combined instability and rotator cuff tear is usually operative, and accomplished arthroscopically. The aims of surgical treatment are the restoration of the dynamic coronal and axial force couples of the shoulder, as well as the static stabilizers of the shoulder joint [1]. Repair of the rotator cuff is usually sufficient to restore glenohumeral stability and shoulder function [2]. Arthroscopic techniques for labral repair and rotator cuff repair have been well described.


Management


The patient was placed in the right lateral decubitus position with a beanbag. The operative arm was held with a suspension apparatus. The scope was entered traumatically and immediately seen were significant glenohumeral degenerative changes without full-thickness chondral defect. There was a small tear of the subscapularis tendon that was not retracted, so the coracoid was exposed and its connections with the subscapularis tendon were released. No repair was attempted as repair of the subscapularis was felt to lead to loss of external rotation, tightening of the glenohumeral joint, and worsening of degenerative changes. No Bankart lesion was noted. Following this, the posterior capsule was released followed by the anterior inferior capsule in order to reduce proximal humeral migration and lessen tension on the rotator cuff repair. Attention was taken to the rotator cuff which had a large, retracted tear of the supraspinatus and infraspinatus tendons. The infraspinatus had more mobility so this was repaired as a “reverse L”-type tear. Despite appreciable supraspinatus atrophy 2 margin convergence sutures approximated the posterior cuff to the coracohumeral ligament. Following this, an anchor with fiber tape in the remaining anterior and posterior limbs affected a near-complete repair. An arthroscopic photograph of the repair is shown in Fig. 7.3. The patient was placed in a sling with range of motion initiated 6 weeks postoperative.

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Figure 7.3
Arthroscopic photo demonstrating repair of the rotator cuff to the greater tuberosity


Outcome


At 6-month follow-up, the patient had no complaints of left shoulder pain. Shoulder external rotation was 4+/5 in adduction and abduction range of motion was full. However, 1 year post op, the patient fell and sustained a recurrent dislocation. Figure 7.4 shows pre- and post-reduction X-rays of the glenohumeral joint. He again demonstrated weakness in shoulder abduction. He also had internal rotation weakness and tenderness over the coracoid. He consented for revision rotator cuff repair and shoulder stabilization.

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Figure 7.4
(a, b) AP and lateral x-ray views of the left shoulder show anterior glenohumeral dislocation. (c) Post-reduction AP shows reduction of the glenohumeral joint with degenerative changes again noted

Upon arthroscopic evaluation, again noted were degenerative changes in the glenohumeral joint. No Bankart lesion was seen. The subscapularis tendon was torn from the lesser tuberosity with “comma tissue” (combined retracted SGHL and CHL tissue evident). As we were concerned that the prior surgery had failed to prevent recurrent instability because of worsening of the subscapularis tear over time we repaired the subscapularis. Of note, there was no capsulolabral injury present. The subscapularis tendon was then freed through exposure of the coracoid. The subscapularis footprint on the lesser tuberosity was identified. A suture was passed through the subscapularis tendon using a suture-passing device at the junction of the tendon and comma tissue. A 4.75 mm anchor was then placed in the footprint of the lesser tuberosity with the instruments being as close as possible to the patient’s face to allow the appropriate angle for drilling and fixation.

Attention was then directed toward repair of the retracted supra- and infraspinatus tendon tears. Revision repair was carried out after mobilization of the soft tissues and placement of margin convergence sutures. Sutures were placed in the infraspinatus/supraspinatus and secured to the coracohumeral ligament. The converged margin of tissue was fixed to the greater tuberosity with suture anchors. Figure 7.5 shows the subscapularis tear and repair, as well as the repair of the infraspinatus.

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Figure 7.5
Arthroscopic photos from revision rotator cuff repair with mobilization and repair of the subscapularis. (a) Repair of subscapularis to lesser tuberosity. (b) Retracted rotator cuff tear. (c) Margin convergence sutures placed. (d) Approximation of rotator cuff with fiber tape through the anchor


Case Presentation


A 38-year-old, right-hand-dominant male presented with right shoulder pain after a fall 1 month earlier. Since the fall, he has had pain at night and with overhead activity. Pain was localized to the subdeltoid region. His past medical history revealed type 2 diabetes mellitus. On physical examination of the left shoulder he had forward elevation to 170°, external rotation with the arm at the side of 60°, and external rotation at 90° of shoulder abduction was 90° internal rotation and was 30°. There was no muscle wasting. No tenderness was elicited about the acromioclavicular joint, biceps tendon, coracoid process, or greater tuberosity. Strength was normal at 5/5 strength in abduction, external rotation, and internal rotation. The right shoulder had forward elevation to 170°. External rotation with the arm at the side and at 90° of shoulder external rotation was 90° and internal rotation was 30°. There was some muscle wasting noted of the supraspinatus and infraspinatus. Tenderness was elicited about the coracoid process and greater tuberosity. Weakness in abduction and external and internal rotations was noted.

X-rays were taken and are shown in Fig. 7.6. They revealed calcification within the rotator cuff as well as sclerosis and cystic changes about the greater tuberosity. No significant glenohumeral degenerative changes were noted. A large rotator cuff tear was suspected, and an MRI was ordered. Representative images are shown in Fig. 7.7. MRI showed a high-grade undersurface tear of the posterior supraspinatus tendon involving greater than 50% tendon thickness and measuring 10 mm anteroposterior with underlying moderate tendinopathy, and no fatty muscle atrophy. There was a low-grade partial-thickness undersurface tearing of the anterior infraspinatus tendon with moderate underlying tendinosis without atrophy. The teres minor muscle was normal without atrophy. Moderate subscapularis tendinosis with interstitial tearing distally was also noted, without muscle atrophy. Also noted was tendinosis and medial subluxation of the proximal long head of the biceps tendon into the substance of the subscapularis tendon. There was also extensive tearing of the superior and posterior glenoid labrum. Finally, full-thickness cartilage loss along the posterior superior glenoid with associated subchondral bone marrow edema was seen.

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Figure 7.6
(a–c) AP in internal and external rotation and scapular Y x-ray views of the shoulder demonstrating calcification in the rotator cuff as well as productive changes in the greater tuberosity


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Figure 7.7
T2-weighted MRI images . (a) Coronal section showing medial displacement of the biceps tendon. (b) Coronal section showing articular sided supraspinatus tear with tendinosis. (c) Sagittal section demonstrating increased signal at the subscapularis insertion. Note the medial displacement of the biceps tendon

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Jan 31, 2018 | Posted by in ORTHOPEDIC | Comments Off on Arthroscopic Treatment of Combined Shoulder Instability and Rotator Cuff Tear
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