17
Massive Rotator Cuff Repair
Open or Arthroscopic
The spectrum of rotator cuff tears ranges from partial-thickness tears to massive tears. A massive tear has been defined as one that includes more than one tendon or is greater than 5 cm. These tears always include the supraspinatus insertion and generally extend posteriorly through the infraspinatus and/or anteriorly through the subscapularis (Fig. 17–1A). A combination of inferior migration of the cuff tendon edges and superior migration of the humeral head dilates the size of the hole and reduces the normal function of the rotator cuff (Fig. 17–1B). Many of these tears, as seen by the arthroscope, extend medially into the infraspinatus tendon or along the rotator cuff interval. Repair of a massive tear often requires sutures securing tendon to tendon along these medial extensions, combined with tuberosity reattachment laterally (Fig. 17–1C).
Indications
1. Pain
2. Loss of active motion with preserved passive motion
3. Loss of function
4. Need to limit further tear enlargement and advanced muscular atrophy
Contraindications
1. Significant superior migration of the humeral head with erosive changes to the acromion.
2. It is not known whether advanced fatty infiltration of the cuff muscles on magnetic resonance imaging (MRI) and marked atrophy will improve if surgical repair is undertaken.
3. Significant glenohumeral arthritis.
Mechanism of Injury
Many of these tears represent an acute extension of a smaller chronic tear. The precipitating injury may be minor, as in starting a lawn mower, or more severe, as in preventing a fall. The less painful tears may have a more subtle presentation of pain associated with athletics, such as after tennis serving.
Physical Examination
1. Examination of the exposed posterior shoulder may demonstrate some degree of atrophy when compared to the asymptomatic side.
2. Active flexion and external rotation deficits exist and the patient substitutes scapular muscles to elevate the arm.
3. External rotation weakness against resistance is demonstrated.
4. The subscapularis liftoff test to evaluate internal rotation strength demonstrates weakness.
5. Impingement findings are positive with passive flexion (Neer) or cross-chest internal rotation (Hawkins).
Diagnostic Tests
1. Standard radiographic series including anteroposterior view of the acromioclavicular joint, transcapular lateral view, and axillary view.
2. MRI or computed tomography scan to evaluate tear location and the degree of fatty infiltration on medial views.
3. EMGs should be performed on selected shoulders with weakness that is poorly explained by size of tear.
Special Considerations
The intact portions of the rotator cuff will function below the axis of the humeral head. The uncoupled larger muscles will produce superior migration of the humerus as they contract. Loss of rotational control can permit superior migration anterosuperiorly or posterosuperiorly depending on the tear pattern. The medial tendon-to-tendon (“side-to-side”) repair is essential to realign the axis of action of the rotator cuff (Fig. 17–1C).
Preoperative Planning and Timing of Surgery
1. Early nonoperative treatment is recommended to avoid stiffness and identify shoulders that may improve with a conservative approach.
2. Surgery is reserved for symptomatic shoulders that plateau in improvement. Intervention should follow general medical clearance.
3. Patient education includes postoperative exercises, possible intraoperative decisions (including dealing with an injured biceps), the anticipated period of convalescence, and protected use within a sling. Due to the medial extension of the tear, it can be difficult to use the “mini-open” or deltoid split approach if open surgery is elected. Either a combination of arthroscopic medial repair to these techniques or a traditional anterolateral approach to the deltoid allows for tendon mobilization near the glenoid.
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