Open Rotator Cuff Repair



Figure 5.1
AP Shoulder



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Figure 5.2
Axillary Lateral


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Figure 5.3
Lateral Scapular View




Diagnosis/Assessment


The patient was diagnosed with a symptomatic, recurrent moderate-sized full-thickness rotator cuff tear. We had a lengthy chat discussing the risks and results of a revision rotator cuff repair including the possibility of partial cuff repair or the cuff being nonrepairable. The patient was very keen to proceed with surgery and he consented to an open cuff repair. We prefer the use of an open approach in the case of a revision cuff repair. This approach in our hands gives us the flexibility of grafting defects or performing transfers if needed.


Management


The anesthetist administered an ultrasound-guided intrascalene nerve block in the preanesthetic area. The block has several advantages. It minimizes the need for intraoperative and postoperative opioid analgesia. As the patient is relatively pain free during the procedure, the anesthetist can often control the blood pressure more accurately, as pain causes sympathetic stimulation that in turn leads to an increase in the blood pressure, and this minimizes intraoperative bleeding and improves the surgeon’s view of the field.

The patient was administered a general anesthetic and a second-generation cephalosporin. The patient was positioned in the beach-chair position , at 45° of inclination with a shoulder positioner (T-max®, Smith and Nephew, USA) (Fig. 5.4). All the bony prominences are padded. The upper extremity was prepped and draped in a sterile fashion and the patient’s arm was held by a pneumatic articulating arm (Spider®, Smith and Nephew, USA).

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Figure 5.4
Beach-chair position

The surface anatomy was marked on the skin including the clavicle, acromion, acromioclavicular joint, and coracoid and the skin incision was marked with a line from the posterior margin of the AC joint to the anterolateral edge of the acromion and extending another 3 cm distally. This results in a total incision length of about 5 cm (Fig. 5.5).

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Figure 5.5
The skin incision is marked

Five milliliters of Marcaine with adrenaline was injected in the subcutaneous tissue and the skin incision was made. The skin and subcutaneous tissue were retracted so we could see the deltoid muscle. The junction of the anterior and middle portions of the deltoid is the raphe identified by a fat streak (Fig. 5.6) and split so as to minimize trauma to the deltoid muscle. The deltoid origin was dissected off the superior surface of the acromion with anterior and posterior flaps. Care must be taken during this step to elevate about 2 cm of the anterior deltoid along with the periosteum as a single layer. The coracoacromial ligament was incised off the acromion and the underlying artery that bleeds copiously was coagulated. The posterior deltoid flap was 1 cm in length and also included its periosteum. While we do not routinely perform a subacromial decompression, our indication being impingement signs on physical examination and radiographs with a type II or type III acromion, in this case the subacromial decompression began with a Cobb’s elevator being inserted into the subacromial space and the humeral head being depressed. The anterior 1/3 of the undersurface of the acromion was excised with the aid of a 1 cm wide osteotome. An oscillating saw can alternatively be used. The undersurface was flattened with a rasp. At the end of the subacromial decompression the surgeon can easily insert the tip of the index finger under the acromion with the arm in minimal traction. Next the thick subacromial bursa was excised along with the bursa from under the anterior, lateral, and posterior deltoid. This is easier with external and internal rotation of the flexed shoulder.

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Figure 5.6
The deltoid raphe

The rotator cuff tear size, pattern, and retraction were next determined. This was made easier by placing multiple traction stitches with 1.0 Vicryl suture into the edge of the tendon (Figs. 5.7 and 5.8) so that the best repair could be planned. We identified each rotator cuff tendon. First the subscapularis was inspected. The biceps tendon was retracted posteriorly and the arm was internally rotated and flexed to 90° to take the tension off the subscapularis. The subscapularis tendon is better seen after the rotator interval is opened and the rotator interval tissue is excised. An anteriorly subluxed biceps tendon or a biceps tendon which subluxes with internal rotation of the humeral head (Sentinel sign) is highly suggestive of a subscapularis tendon tear. Next was the supraspinatus. The size, pattern, and retraction of the tear were noted. Retraction was classified according to the Patte classification. Stage 1 is the torn tendon edge being close to its bony insertion. Stage 2 is the torn tendon edge at the level of humeral head. Stage 3 is the torn tendon edge at the glenoid. Delamination of the tendon was also noted. In cases of chronic rupture where the tendon is retracted to the glenoid rim it may be difficult to delineate the tendon from the superior labrum as the tendon is stuck down to it. Lastly the infraspinatus and teres minor were inspected. The arm was placed besides the thorax and maximally internally rotated. Traction was applied to the posterior cuff so that the extent of the tear could be seen. To do so, the posterior subdeltoid bursa needs to be totally excised, and as it is usually very vascular, the use of electrocautery is preferred.

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Figure 5.7
Supraspinatus traction suture


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Figure 5.8
Infraspinatus traction suture

Most important in large-to-massive chronic cuff tears, we also performed a systematic cuff mobilization for our moderate-sized tear. This was performed in an anterior-to-posterior direction and for large-to-massive retracted tears we prefer a general anesthetic with muscle relaxation. First the coracohumeral ligament was incised medially close to its origin from the coracoid while traction was applied to the torn edge of the supraspinatus tendon. This usually results in a sudden increase in the excursion of the tendon. Then the subacromial adhesions to the supraspinatus were excised with the use of Mayo scissors to the spine of the scapula, which is palpable posteriorly. The undersurface of the supraspinatus was released off its adhesions to the glenoid labrum. A No. 15 blade can be used to incise the interval between the labrum and the supraspinatus. This window was then utilized and a Mayo scissors or a Cobb elevator was used to release the medial undersurface of the supraspinatus. Care must be taken to avoid injury to the infraspinatus branch of the suprascapular nerve which lies 1 cm medial to the glenoid surface. If the tendon is delaminated, traction is applied to the inferior leaflet while the release is done.

Now the quality of tendon, and its excursion, was evaluated with the patient under a general anesthetic under complete paralysis. It must be noted that a premature evaluation of the cuff mobility may misguide the surgeon and lead to a cuff repair under excessive tension. Three situations may now arise. First, the rotator cuff can be mobilized to the lateral edge of the cuff footprint. This is the ideal scenario where the cuff mobilization is complete and a double-row repair can be performed. This is our preferred technique. Second, there can be incomplete mobilization of the cuff to the osteochondral junction or the medial edge of the footprint. In this scenario, the rotator cuff is repaired medial to the footprint with a single-row technique. This repair may be augmented with a synthetic or an allogenic graft or patch. Lastly, there can be mobilization medial to the humeral head. For these irreparable rotator cuff tears the options include a subacromial decompression and lysis of adhesions or a muscle transfer procedure such as a latissimus dorsi transfer. The decision is based upon the patient’s age, function, as well as extent of glenohumeral arthrosis. An older patient with retracted irreparable cuff tear would be a candidate for a reverse total shoulder arthroplasty.

There is a fine balance between cuff mobilization and cuff damage. We caution against performing large interval slides and excessive cuff debridement as this may result in denervation of the muscle or compromise the blood supply.

For our transosseous repair ( Figs. 5.9 , 5.10 , and 5.11 ) four strands of #5 Ethibond were passed through the greater tuberosity from lateral to medial with 2 cm bone bridges, exiting near the articular margin. Drill holes were avoided as we think this weakens the bone and we want to minimize suture cut out as often the bone is osteopenic. The next step is to bring the torn edge of the anterior supraspinatus to its location on the greater tuberosity just posterolateral to the biceps groove. The sutures were passed through the rotator cuff about 1.5 cm medial to the rotator cable with the Mason-Allen technique. The result was a horizontal suture configuration medially that provided traction to the cuff and a vertical transosseous suture configuration laterally that compressed the cuff onto the footprint of the greater tuberosity for minimal gap forming between the tendon and the bone. This technique maximizes contact across the footprint and reproduces in essence a double-row repair. Prior to tying down the transosseous sutures consider closing any defects in the intervals with side-to-side sutures; these sutures can take considerable tension off the primary repair.
Jan 31, 2018 | Posted by in ORTHOPEDIC | Comments Off on Open Rotator Cuff Repair
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