Abstract
Often a surgeon feels that a repair is possible preoperatively, based on imaging, but realizes at the time of surgery that it is not. If the tear is truly irreparable, arthroscopic treatment has significant advantages over open treatment. It allows a thorough débridement, glenohumeral joint inspection, preservation of the deltoid insertion, and a complete inspection and manipulation of the rotator cuff without the need for acromioplasty, coracoacromial ligament resection, or subscapularis detachment. Arthroscopic débridement with biceps tenotomy can improve pain, but will not impact strength. If strength and function are an issue, other options exist, such as reverse shoulder arthroplasty.
Keywords
irreparable rotator cuff tear, débridement, biceps tenotomy, rotator cuff tear arthropathy
The biggest problem with the arthroscopic treatment of massive rotator cuff tears is the possibility of misdiagnosis. Often, a massive tear is retracted and appears irreparable, but after soft tissue release, the defect is partially or completely reparable. On the other hand, often the surgeon feels that a repair is possible preoperatively based on imaging, but realizes at the time of surgery that it is not ( Fig. 14.1 ). If the lesion is truly irreparable, arthroscopic treatment has significant advantages over open treatment. It allows a thorough débridement, glenohumeral joint inspection, preservation of the deltoid insertion, and a complete inspection and manipulation of the rotator cuff without the need for acromioplasty, coracoacromial ligament resection, or subscapularis detachment. Perhaps the most difficult patients to treat are those whose irreparable tears were diagnosed after open acromioplasty and coracoacromial ligament resection were performed. Loss of the static restraint of the coracoacromial arch allows anterior superior escape of the humeral head. Relatively painful shoulder elevation is converted to very painful shoulder shrugging—the classic pseudoparalytic shoulder.
Literature Review
When a massive, irreparable defect in the rotator cuff tendons is identified at surgery, the surgeon has various treatment options to choose from. Local tissue transfer from the remaining intact rotator cuff, use of the upper portion of the subscapularis, incorporation of the intra-articular portion of the biceps tendon, supraspinatus advancement, deltoid muscle flap, synthetic materials, and tendon allograft have been proposed. Latissimus dorsi transfer has been described by Gerber and others, but there are questions about the morbidity of this procedure as well as the dynamic function of the graft. For patients in whom overhead work and stronger external rotation are vital, the relatively modest gains afforded by latissimus dorsi transfer can be of major importance. Subscapularis transfer and biceps incorporation are rarely performed. Synthetic grafts are currently a source of great interest, but little science is available to guide the orthopedic surgeon. Superior capsular reconstruction is gaining popularity, but more data are needed. Because irreparable tendon tears are almost always accompanied by profound muscle atrophy and fatty infiltration, it seems unlikely that synthetic tendon connected to non-viable muscle will function.
One of the most widely used open procedures was described by Rockwood, who débrided the edges of the necrotic tendon, thoroughly decompressed the subacromial space by performing an anterior and inferior acromioplasty, resected the coracoacromial ligament, and removed the subacromial bursa. The deltoid was meticulously repaired. Postoperatively, the patient was started on an immediate rehabilitation program. Rockwood obtained good results using this technique, with patients achieving pain relief and marked improvement in function. Our own experience was not as positive. The success rate was lower, and we found that after this procedure some patients experienced an improvement in pain, but a loss of strength.
Since these reports appeared, Nirschl has taught us to avoid acromioplasty in these patients. Preserving the coracoacromial arch helps keep the humeral head centered in the glenohumeral joint and prevents the disastrous complication of anterior superior humeral head subluxation.
Less has been written about the arthroscopic treatment of patients with irreparable tears. We have achieved good pain relief with arthroscopic treatment in a limited number of patients; reasonable pain relief has been documented in most patients at up to 5 years’ follow-up. We emphasize thorough débridement and synovectomy, accompanied by the removal of any downward-protruding acromial or acromioclavicular joint spurs. Burkhart reported that among 25 patients with massive irreparable tears, 88% had good or excellent results after arthroscopic treatment; those results have not deteriorated with the passage of time. Many older individuals have relatively good active and passive motion; however, pain is their primary complaint. Arthroscopic débridement and biceps tenotomy can provide good pain relief with little morbidity. For individuals who need more motion or strength, reverse shoulder arthroplasty is a viable option.
Diagnosis
Physical examination usually demonstrates a normal or near-normal passive range of motion; however, there may be limits because of capsular contractures. The active range of motion is decreased. Supraspinatus and infraspinatus atrophy may be observed. Manual muscle testing demonstrates grade 3 or lower strength with external rotation and elevation. The patient’s subscapularis function should be evaluated using either the belly-press test or the lift-off test with the arm internally rotated to the back.
Plain radiographs may show the humeral head centered in the glenoid, but superior migration may be present. Magnetic resonance imaging (MRI), which some surgeons do not use routinely in older patients, is often of great value in this clinical setting. The amount of tendon retraction is more clearly defined on MRI than on arthrography and, perhaps more importantly, the degree of atrophy and fatty degeneration or substitution in the rotator cuff muscles can be appreciated ( Fig. 14.2 ). If the patient’s rotator cuff strength is grade 3 or less, and MRI demonstrates humeral head superior migration, retraction of the tendon to the glenoid rim, and severe muscular atrophy, the cuff defect is almost certainly irreparable.
The status of the subscapularis requires close attention. Patients with irreparable, retracted subscapularis tears can be treated with arthroscopic débridement. However, Burkhart has shown that patients with reparable subscapularis tears benefit from subscapularis repair even in the presence of superior humeral head migration ( Fig. 14.3 ).
Nonoperative Treatment
Nonoperative treatment consists of activity modification, nonsteroidal antiinflammatory medications, cortisone injections, and a physical therapy program designed to maintain or improve shoulder range of motion and to strengthen the deltoid, scapular rotators, biceps, and intact rotator cuff muscles.
We continue nonoperative treatment for at least 6 months. A surprising number of patients have reduced pain as the inflammation decreases, and they regain adequate function with muscle strengthening exercises. Stretching can often improve capsular contracture and further diminish pain.
Indications for Surgery
Indications for operation include pain interfering with work or activities of daily living, or nighttime pain unresponsive to the nonoperative treatment outlined earlier. Patients should have a well-preserved glenohumeral joint space on plain radiographs and relatively pain-free passive external rotation with the arm at the side. The presence of an intact biceps that could serve as a pain generator and that might respond to tenotomy is helpful. The presence of a dislocated biceps, usually medial, is often very painful and responds well to biceps tenotomy.
Another less common indication for surgery is recurrent hemarthrosis in patients with rotator cuff tear arthropathy.
Contraindications to Surgery
Because the goal of this procedure is pain relief, patients who require strength for overhead work usually will not be satisfied with the results of débridement. Débridement is most effective in older and less active patients who want to avoid arthroplasty. Patients with painful passive external and internal rotation and advanced glenohumeral joint arthritis are not candidates for arthroscopic débridement. These patients, with true rotator cuff tear arthropathy, are best managed with reverse shoulder arthroplasty.
Operative Technique
Examine the shoulder for range of motion and compare it with the contralateral shoulder. Perform a gentle manipulation to correct any losses of motion in abduction, elevation, and external and internal rotation. There is generally no loss of passive motion.
Glenohumeral Joint
A standard posterior portal is used to enter and inspect the glenohumeral joint. Because there is no infraspinatus tendon, the joint is entered easily. Patients with irreparable rotator cuff tears are often older, and multiple glenohumeral abnormalities are identified. We pay less attention to areas of labral fraying as they are likely not the cause of the pain. On the other hand, labral flap tears that could cause mechanical abnormalities (a glenoid surface abnormality, e.g., a step-off, or a capsular contracture) should be addressed. A standard anterior portal is created to place instruments. Labral tears are débrided and hypertrophic synovium excised with a shaver or cautery. The biceps tendon is assessed; if it is still intact, a tenotomy is done. Rarely will the long head of the biceps appear normal. It will often have moderate synovitis, partial tearing, or will be subluxated.
Subacromial Space
It may seem unnecessary to remove the cannula and reinsert it because, with an irreparable tear, the surgeon can view both the glenohumeral joint and the subacromial space. However, it is surprising how the perspective changes with simple redirection of the arthroscope. Often, a better perspective of the infraspinatus is achieved. The same posterior skin incision is used to enter the subacromial space. The trocar is directed parallel to the acromion and is then slid along the inferior surface until the trocar tip is 1 cm posterior to the anterior edge of the acromion. This has three beneficial effects: (1) the trocar tip can be used to dissect any rotator cuff tendon that is adhering to the acromion ( Fig. 14.4 ); (2) the cannula is positioned parallel to the inferior surface of the acromion, not directed superiorly; and (3) the arthroscope is positioned at the maximal distance from the humeral head, which improves the perspective of the size and shape of the rotator cuff lesion.
As discussed in prior chapters, a bursectomy is initiated with the camera in the posterior portal prior to moving the arthroscope to the lateral portal. This view generally allows for a better assessment of the tear ( Figs. 14.5 and 14.6 ). The same process of assessment is done (as described in Chapter 13 ) by pulling on the rotator cuff edges to assess excursion ( Figs. 14.7–14.10 ). If the rotator cuff tendons are absent, or if excessive tension is necessary to complete a repair, a débridement is done. A shaver and cautery are used to remove rotator cuff remnants from the greater tuberosity. If the greater tuberosity is prominent or hypertrophic, a burr is used to flatten it ( Figs. 14.11 and 14.12 ). Bursa and adhesions to the deltoid in the anterior, lateral, and posterior gutters are excised.
