Shoulder Instability with a Rotator Cuff Tear: Management of the Cuff and Labrum


Chapter 27

Shoulder Instability with a Rotator Cuff Tear


Management of the Cuff and Labrum



Philippe Hardy, André Thès, and Peter Upex

Introduction


The shoulder is the least constrained and most mobile joint, making instability a frequent condition in a young and active population. The rotator cuff creates a concavity compression mechanism that dynamically stabilizes the shoulder. Rotator cuff tear favors instability, and therefore the association of both pathologies should be researched even after a single dislocation. Treatment options include nonoperative and operative management. Careful evaluation should precede the surgeon’s decision.

Procedure


Anterior stabilization and rotator cuff repair is proposed to patients with associated capsulolabral lesions (Bankart, anterior labral periosteal sleeve avulsion) and rotator cuff tear. Arthroscopic Bankart repair and double-row rotator cuff repair (suture bridge technique) are described below.

Patient History



Patient Examination



Imaging



Treatment Options: Nonoperative and Operative





  1. • Nonoperative treatment with physiotherapy in low-demand patients gives worse results for pain and mobility than surgical treatment.
  2. • Rotator cuff repair alone is preferred when no instability lesion is identified on the preoperative imaging studies. Careful arthroscopic examination should eliminate any lesion of the capsulolabral complex.
  3. • Repair of the subscapularis muscle when torn with associated instability offers good results for stability and pain but inconstant results for mobility. The modality of the repair depends on the quality of the remaining muscle in the particular case of revision surgery. Transosseous sutures or suture anchor reinsertion is possible when the muscle is of good quality (little retraction, low fatty infiltration). Nevertheless, one should never exclude the possibility of performing a split pectoralis major transfer.
  4. • Stabilization alone is advocated in case of massive or irreparable tears with an intact subscapularis muscle. The Trillat intervention (Fig. 27.1) lowers and medializes the coracoid process. The coracoid fragment is fixed to the glenoid neck. It improves glenohumeral stability and lessens external rotation by lowering the subscapularis muscle. This procedure can be performed arthroscopically but is contraindicated in case of major Hill-Sachs lesions or glenoid erosion. The Latarjet procedure (Fig. 27.2) or Hill-Sachs remplissage should be preferred in these cases.
  5. • In case of a reparable cuff tear associated with a labral lesion, a combined procedure should be performed. It associates labral and rotator cuff repair.
  6. • A reverse shoulder arthroplasty should be preferred in case of associated osteoarthritis.

Surgical Anatomy



Surgical Indications


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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Shoulder Instability with a Rotator Cuff Tear: Management of the Cuff and Labrum

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