- See:
- Acromioplasty
- Complications of Rotator Cuff Surgery:
- Massive Rotator Cuff Tear
- Mobilization of the Supraspinatus and Methods of Repair:
- Rotator Cuff Tear - Discussion:
- indications for RTC tear:
- shoulder pain (especially night pain);
- symptoms which cause loss of function or quality of life;
- failure of NSAIDS and formal physical therapy;
- failure of series of marcaine / steroid injections;
- full passive ROM pre-op is necessary for a successful operation (rule out frozen shoulder);
- relative contra-indications:
- superior migration of humeral head (which indicates massive rotator cuff tear);
- 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;
- Surgical Exposure:
- Acromioplasty and Subacromial Dissection: 
- w/ a potential irrepairable cuff tear, consider leaving the CA ligament intact;
- incision is then deepened to expose subacromial bursa, which is opened, allowing limited view of underlying rotator cuff;
- exposure may be improved by elevating acromion w/ small right angled retractor distracting humeral head downward, & resecting
CA ligament (which is accompanied by acromial branch of thoracoacromial artery);
- in the report by BA Goldberg et al, the authors evaluated on shoulder function at a minimum of 2 years after 27 full thickness
RC repairs were done w/o deltoid detachment, acromioplasty, or section of CA ligament;
- 8 of 12 individual Simple Shoulder Test functions were significantly improved after the procedure;
- there also was a significant improvement in the Short Form-36 comfort, physical role function and mental health scores;
- the authors conclude that when done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered
deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion;
- references:
- Improvement in Comfort and Function After Cuff Repair Without Acromioplasty
- Open rotator cuff repair without acromioplasty.
- Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes.
- Assessment of Cuff Tear: (see management of massive rotator cuff tear);
- after exposure, tear in rotator cuff must be identified, although this may be difficult if reactive bursal changes are present;
- freeing bursa from scar allows one to recognize normal tendon and to continue tissue dissection in the same plane over torn area;
- rotator cuff size is best described by surface area and by muscle compliance rather than a simple linear measurement;
- posterior cuff will be brought into operative field by extending and internally rotating the shoulder - which is acomplished by pinning patient's arm between
OR table and surgeons hip while it is positioned in full exernal rotation;
- additional exposure is obtained by depressing the humeral head (accomplished by traction on the arm and by applying either a Homan retractor or a lamina
spreader between the acomion and humeral head);
- 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;
- Additional Considerations:
- distal clavicle excision: (w/ concomitant arthrosis);
- greater tuberosity debridement:
- prominent tuberosity can be excised if there is further impingment;
- biceps tendon:
- w/ obvious pathology of the long head of the biceps, consider proximal release of the tendon w/ or w/o tenodesis;
- references:
- To detach the long head of the biceps tendon after tenodesis or not: outcome analysis at the 4-year follow-up of two different techniques.
- Mobilization of Rotator Cuff:
- when mobilizing the rotator cuff, it is first useful to pass a "traction" suture thru the muscle (using a Kessler type stitch);
- this allows the cuff to be pulled forward under tension without damaging the muscle;
- place a blunt right angle retractor underneath the acromion and to apply traction to the forearm inorder to widen the exposure;
- the surgeon can then pass his finger above and below the muscle, freeing up adhesions;
- 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 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. JBJS. Vol 80-A. No 6. Jun 1998. p 853.
- superior capsular release:
- superior capsular release and rotator interval-coracohumeral ligament release is performed when needed to allow a low-tension reduction of the
supraspinatus tendon to its anatomical position;
- Rotator Cuff Repair Techniques::
- Deltoid Repair:
- both the superficial and deep fascial layers of the deltoid must be included in the suture repair of the deltoid to the acromion (thru acromial drill holes);
- consider using a Mason-Allen stitch thru the deltoid muscle;
- Post Op Care:
- with rotator cuff tears, passive range of motion may begin on day 1, and active assist exercises at week four;
- consider early active assited elevation and external rotation in the supine position;
- Outcomes:
- in the report by RH Cofield et al. 2001, 105 shoulders with a chronic rotator cuff tear underwent open surgical
repair and acromioplasty between 1975 and 1983;
- patients were followed for an average of 13.4 years (range, two to twenty-two years);
- there were 16 small tears, 40 medium tears, 38 large tears, and 11 massive tears;
- tears were repaired directly (72 tears), by V-Y plasty (12), by tendon transposition (twenty), or by reinforcement with a fascia lata graft (one);
- long head of the biceps had been previously torn in eleven shoulders and was tenodesed in three other shoulders. In fifty-six shoulders, the distal
part of the clavicle was excised for treatment of degenerative arthritic changes, often associated with osteophyte formation;
- satisfactory pain relief was obtained in 96 shoulders (p < 0.0001);
- there was significant improvement in active abduction (p < 0.001) and external rotation (p < 0.007) as well as
in strength in these directions of movement (p < 0.03 and p < 0.002, respectively);
- at the latest follow-up evaluation, the result was rated as excellent for 68 shoulders, satisfactory for 16,
and unsatisfactory for 21;
- tear size was the most important determinant of outcome with regard to active motion, strength, rating of the
result, patient satisfaction, and need for a reoperation;
- older age, less preoperative active motion, preoperative weakness, distal clavicular excision, and
a transposition repair technique were all associated with larger tear size.
- ref: Surgical Repair of Chronic Rotator Cuff Tears. A Prospective Long-Term Study. Robert H. Cofield, MD. J Bone Joint Surg [Am] 83-A: 71-7, 2001
- References
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.
Prevention of shoulder stiffness after rotator cuff repair.
Clinical and Structural Results of Open Repair of an Isolated One-Tendon Tear of the Rotator Cuff.
