- See:
-
Acromioplasty
-
Arthrography:
-
Impingement Syndrome:
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Rotator Cuff Tear:
- Discussion:
- by definition, invovles RTC tears of more than 5 cm and involves more than than one tendon;
- further, massive tears cannot be repaired w/o excessive tension after lysis cuff adhesions and release of the
coracohumeral ligament; (see
cuff mobilization)
- Management:
-
rotator cuff repair:
- assessment of size of rotator cuff tear:
- infraspinatus insertion zone was identified by laying the two branches of the forceps over the scapular spine so that the forceps
were in line with the fibers of the cuff;
- fibers coming from a level inferior to the scapular spine are infraspinatus fibers;
- teres minor insertion was identified by locating its insertion on the respective tubercle, which lies inferior and slightly
medial to the infraspinatus insertion;
- medialization of the supraspinatus tendon:
- indicated for situations in which the rotator cuff cannot be adequately mobilized;
- instead of reattachement of the cuff to the greater tuberosity, the cuff is re-attached to the a groove created on the anatomic
neck or on the humeral head;
- as noted by Liu MD et al 1998, about 1 cm of medialization may be acceptable but 17 mm of supraspinatus medialization will
result in a significant reduction in the moment arm;
- ref: Biomechanical Effect of Medial Advancement of the Supraspinatus Tendon.
A study in cadavera. J. Liu MD et al.
JBJS. Vol 80-A. No 6. Jun 1998. p 853.
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acromioplasty and cuff debridement:
- in well selected patients, cuff debridement and acromioplasty can lead to a significant decrease in pain and increase in ROM;
- good prognostic indicators are an intact anterior deltoid and an intact long head of the biceps;
- poor prognostic factors include non-functioning anterior deltoid and previous acromioplasty and attempted RTC repair;
- if an acromioplasty is indicated, then attempt to leave the CA ligament intact and the acriomplasty should be conservative;
- some feel that excision of the CA ligament and an agressive acriomplasty may lead to postop weakness and/or glenohumeral subluxation;
- w/ a potential irrepairable cuff tear, consider leaving the CA ligament intact;
- intact ligament helps prevent superior migration of humeral head;
- relative contra-indications:
-
superior migration of humeral head;
- as noted by G.M. Gartsman (1997), all patients w/ radiographic superior migration of the humeral head had a poor result;
- deficient deltoid, subscapularis, and/or teres minor (either by clinical exam or by MRI) are more likely to lead to poor results;
- technical considerations:
- after performing an appropriate
acromioplasty, debride all avascular tissue;
- when cuff is not repairable, ensure that there is no soft tissue remanants of the cuff which could be impinged between the humeral head and acromion;
- when an exostosis on the greater tuberosity is present, it should be removed;
- apply bone wax to prevent recurrance;
- ensure that the deltoid is firmly anchored to the remaining acromion;
- some recommend preservation of the biceps tendon whenever possible, others will consider excision of the tendon if it is loose or frayed;
-
latissimus dorsi transfer:
- references:
-
Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
-
Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff.
- Transfer of the Latissimus Dorsi Muscle After Failed Repair of a Massive Tear of the Rotator Cuff. A two to five-year Review*
A. Miniaci and M. Macledo.
JBJS Vol 81-A. No 8. Aug 1999.
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shoulder hemiarthroplasty in the rotator cuff deficient patient:
Debridement of degenerative, irreparable lesions of the rotator cuff.
Massive, Irreparable Tears of the Rotator Cuff.
Results of Operative Debridement and Subacromial Decompression.
G.M. Gartsman MD.
JBJS Vol. 79-A. No 5. May 1997.
Progress in 1991--General Orthopaedics: Shoulder: Arthroscopic Treatment of Massive Rotator Cuff Tears: Clinical Results and Biomechanical Rationale.
Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale.
Superior humeral dislocation. A complication following decompression and debridement for rotator cuff tears.
The use of freeze-dried allografts in the management of global rotator cuff tears.
The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff.
Cuff-tear arthropathy.
Debridement of degenerative, irreparable lesions of the rotator cuff.
