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Arthroscopic Repair of Massive Rotator Cuff Tears
PROCEDURE 5
Arthroscopic Repair of Massive Rotator Cuff Tears Marc S. Kowalsky and Leesa M. Galatz
INDICATIONS PITFALLS
• Candidates for arthroscopic massive rotator cuff repair must have the ability to comply with a prolonged course of rehabilitation. • Concomitant arthritis may indicate need for arthroplasty. • Advanced atrophy and fatty change of rotator cuff musculature suggest irreparable tear and may be indication for arthroplasty. • Rule out adhesive capsulitis.
INDICATIONS • Symptomatic, painful rotator cuff tear that does not respond to conservative modalities (nonsteroidal antiinflammatory medication, physical therapy, and possible injections) • Repairable rotator cuff tear as determined by careful evaluation of the characteristics of the tear on advanced imaging and intraoperative examination, including chronicity, size, retraction, muscle atrophy, and fatty degeneration • An acute tear that results in severe weakness or loss of overhead elevation • Massive tear in a younger (<60-year-old), high-demand individual
EXAMINATION/IMAGING INDICATIONS CONTROVERSIES
• One should approach certain patients with caution, as advanced age, tobacco use, or certain systemic diseases may decrease the likelihood of successful repair with healing and symptomatic relief (Galatz et al., 2004; Keener et al., 2010). • Some surgeons have achieved effective pain relief and improved clinical outcomes with arthroscopic debridement, subacromial decompression, and biceps tenotomy, and they offer this approach as an alternative, particularly when the reparability of a massive tear is in question (Boileau et al., 2007). • A massive tear in a patient older than 70 years of age may benefit from arthroplasty, even in the absence of arthritis, given the higher recurrence rate after repair (Boileau et al., 2005; Galatz et al., 2004; Le et al., 2014).
Physical Examination • Visual inspection may reveal atrophy of the infraspinatus or supraspinatus, scapular winging with range of motion (ROM) indicating nerve injury, and shoulder asymmetry. • Both active and passive ROM are evaluated, including forward elevation, external rotation (ER) at the side, ER in abduction, and internal rotation/extension as measured by the most cephalad spinous process reached with the affected extremity. • Manual strength testing is conducted. • ER with shoulder in slight internal rotation • “Thumbs-down” abduction with arms in scapular plane • Certain findings indicate larger tears. • Lag sign with arm in maximal ER at the side—supraspinatus, infraspinatus • Hornblower’s (strength in abduction and ER)—teres minor • Abdominal compression test—subscapularis • Lift-off test—subscapularis • Provocative maneuvers are helpful to diagnose cuff-generated pain. • Neer and Hawkins signs, as well as the Jobe and drop arm signs • Provocative tests for pain from the long head of the biceps brachii, including Speed and Yergason tests • The acromioclavicular joint must be assessed. • Tenderness to palpation • Pain with cross-body adduction
Imaging Studies • Radiographs • Anteroposterior (AP), true AP, scapular lateral, and axillary views are reviewed for acromioclavicular joint osteoarthritis, glenohumeral joint osteoarthritis, and acromial morphology. • Decreased acromiohumeral interval and/or proximal humeral migration of the humeral head in relation to the glenoid indicates large or chronic tear that may be irreparable (Keener et al., 2009). • Magnetic resonance imaging (MRI) is used to assess tear size and tendon involvement, tendon retraction, muscle quality and degree of degeneration, and glenohumeral joint pathology. • Degenerative labral and biceps lesions are common and not usually the primary source of pain. • Sagittal and coronal oblique T2-weighted images are used to quantify the tear size and the degree of retraction, respectively (Fig. 5.1). A massive tear typically involves greater than 5 cm of the rotator cuff footprint, or at least two tendons. 64
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
Greater tuberosity Torn rotator cuff Humeral head
FIG. 5.1
FIG. 5.2 The arrow points to the lateral edge of the torn rotator cuff tendon.
• Axial images are used to evaluate the subscapularis and long head of the biceps brachii. • Medial images of the sagittal T1-weighted sequence are used to assess atrophy and fatty infiltration of the rotator cuff muscle bellies (Fuchs et al., 1999; Liem et al., 2007). • Ultrasound has been proven to be a reliable modality for assessment of the rotator cuff (Fig. 5.2; Teefey et al., 2004). • Ultrasonographer dependent • Very accurate for rotator cuff pathology • Not as useful for intraarticular biceps pathology
SURGICAL ANATOMY • The rotator cuff consists of the tendons of four muscles: the subscapularis anteriorly, the supraspinatus superiorly, and the infraspinatus and teres minor posteriorly. The rotator cuff muscles function in force couples, in which the deltoid counters the inferior rotator cuff (infraspinatus, teres minor, and subscapularis below the center of rotation), and the anterior rotator cuff (subscapularis) counters the posterior cuff (infraspinatus, teres minor) to maintain a centered humeral head relative to the glenoid. • The rotator cable represents a crescenteric thickening of the tendon that inserts onto the greater tuberosity anteriorly and posteriorly. The function of this structure has been theorized to protect the relatively avascular zone of the rotator cuff tendon from stress during force transmission. Furthermore, this structure preserves the coronal force couple even in the presence of an isolated supraspinatus tear by transmitting force along the cable to the greater tuberosity. • The rotator cuff insertion, or enthesis, consists of four zones: tendon, fibrocartilage, mineralized fibrocartilage, and bone. This continuous microstructure serves to distribute stress along the entire enthesis. • Understanding of the anatomy of the rotator cuff footprint, and the contribution of each muscle, has evolved over time (Fig. 5.3; Mochizuki et al., 2008). • According to the most current analysis thereof, the supraspinatus footprint is smaller than previously thought, representing a triangle with a medial-lateral length of 6.9 mm and an anterior-posterior length of 12.6 mm at its largest point adjacent to the humeral head articular surface.
TREATMENT OPTIONS
• Nonoperative management • Nonsteroidal antiinflammatory medications • Physical therapy • Possible corticosteroid injections • Open rotator cuff repair • Arthroscopically assisted mini-open rotator cuff repair • Biceps tenotomy or tenodesis • Subacromial decompression and debridement • Reverse shoulder arthroplasty
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
Lc
Wms
Wmi
Ls
Li LT GT
FIG. 5.3
• The infraspinatus footprint has a trapezoidal shape and measures 10.2 mm in medial-lateral length and 20.2–32.7 mm in anterior-posterior length. • The glenohumeral joint capsule inserts on the superior aspect of the greater tuberosity immediately adjacent to the humeral head articular surface and has a medial-lateral footprint of 4.5 mm. As one moves posteriorly along the greater tuberosity, a bare area arises between the capsule and humeral head articular surface with no soft tissue attachments. • The scapular spine serves as a landmark between the muscle bellies of the infraspinatus and supraspinatus, which can be used to determine the appropriate location for a posterior interval slide. Likewise, the coracoid serves as the landmark to determine the interval between the supraspinatus and subscapularis and can be helpful when an anterior interval slide is performed. Even when interval releases are not required, releasing the coracohumeral ligament, which originates on the coracoid and becomes confluent with the rotator interval tissue, is often necessary to adequately mobilize the rotator cuff for repair without tension. • The rotator interval consists of the space and tissue between the upper border of the subscapularis and the anterior border of the supraspinatus. Soft tissues comprise the coracohumeral ligament and the superior glenohumeral ligament. • The long head of the biceps tendon arises from the superior labrum at the supraglenoid tubercle and is intraarticular for approximately 2.8 cm before it exits the joint at the intertubercular groove. Normal anatomy of the superior and anterosuperior labrum is variable. • The suprascapular nerve arises from the upper trunk of the brachial plexus and enters the supraspinatus fossa through the suprascapular notch, just medial to the coracoclavicular ligaments. It courses posteriorly approximately 1.5 cm medial to the superior glenoid rim and enters the spinoglenoid notch to innervate the infraspinatus. • The nerve can be released arthroscopically, and its role in shoulder pain associated with rotator cuff tears is controversial. • This nerve should be protected inferior to the cuff during mobilization of retracted cuff tissue. • The axillary nerve arises from the posterior cord of the brachial plexus. It courses inferior to the subscapularis and glenohumeral joint capsule as it travels posteriorly to innervate the deltoid and teres major and to provide sensation to the lateral arm.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.4
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FIG. 5.5
POSITIONING PEARLS
POSITIONING • Arthroscopic rotator cuff repair is performed in the beach chair or lateral decubitus position, of which the authors prefer beach chair. • The patient is placed in a sitting position 60 degrees relative to the horizontal. The posterior shoulder must be adequately exposed to ensure proper access to the operative field (Fig. 5.4). • The head is secured using a secure head positioner, maintaining the cervical spine in a neutral position. • Using either a commercially available wedge or the operating table, the hips and knees are flexed appropriately to avoid undue tension on the neurovascular structures of the lower extremities. • The contralateral extremity is secured to an armboard in a comfortable position. The ulnar nerve is padded. • The table is angled approximately 45 degrees away from the operative extremity to allow access to the posterior aspect of the shoulder.
• Adequate exposure to both anterior and posterior shoulder is needed; the patient must be positioned as far as possible toward the operative side. • A mechanical arm holder assists in holding the operative arm during the procedure and allows placement of traction on the arm to enlarge the subacromial space during repair (Fig. 5.5).
POSITIONING PITFALLS
• Inadequate exposure. • Unstable cervical spine and head position. • Inadequate padding of the contralateral arm and lower extremities. • Some elderly patients may be at risk for a sudden drop in blood pressure while being positioned upright, so the back should be raised slowly with blood pressure monitoring.
PORTALS/EXPOSURES • A posterior viewing portal is created 1–2 cm distal and 0.5–1 cm medial to the posterolateral corner of the acromion (Fig. 5.6). • If this portal is used exclusively for viewing, no cannula is necessary; however, if it will also be used as a working portal, then a 7-mm cannula can be inserted to ease movement of the arthroscope among portals. • An anterolateral working portal is created 3 fingerbreadths distal to the lateral edge of the acromion, slightly anterior to the posterior edge of the acromioclavicular joint (Fig. 5.7). • A 7-mm cannula is inserted in this portal to allow insertion of instruments, including suture-passing devices. • A rotator interval portal is created immediately lateral to the coracoid process (Fig. 5.8). • This portal is used during the intraarticular examination. The cannula is redirected into the subacromial space to be used as a working portal during the rotator cuff repair. • If this portal is used exclusively for suture shuttling, a 5.5-mm cannula can be inserted; however, if it will also be used for suture passage, a 7-mm cannula can be inserted to allow insertion of suture-passing instruments.
POSITIONING EQUIPMENT
• A commercially available extremity positioner • Either a commercially available beach chair adapter or an operating table that can accommodate the beach chair position PORTALS/EXPOSURES CONTROVERSIES
• Some surgeons prefer to perform arthroscopic rotator cuff repair in the lateral decubitus position. This decision should be based primarily on surgeon experience and comfort. • Increasing attention has been given to the relationship between the beach chair position and cerebral perfusion. The surgeon and anesthesiologist must assure that the patient’s blood pressure resulting from elevation of the torso as well as hypotensive anesthesia remains within a safe range relative to the patient’s baseline status.
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.6
FIG. 5.7
PORTALS/EXPOSURES PEARLS
• An accessory posterolateral portal on the lateral shoulder closer to the posterolateral corner of the acromion can be created to allow better visualization of the tear for tear pattern recognition. A 7-mm cannula can be inserted to ease movement of the arthroscope among portals. • Percutaneous portals created along the anterolateral, lateral, and posterolateral borders of the acromion are created for insertion of anchors at the ideal angle. • Percutaneous portals can also be used for antegrade suture-passing devices. These devices are helpful in retracted tears with tenuous tissue to allow suture placement as medial as possible. FIG. 5.8
PORTALS/EXPOSURES PITFALLS
• The anterior and posterior portals should be placed sufficiently distal relative to the acromion to avoid caudal angulation of the cannulas as shoulder swelling increases. • Particularly when using a posterior viewing portal exclusively, this portal should be placed sufficiently lateral to allow optimal visualization of the rotator cuff tear. Therefore, these authors advise creating this portal only slightly medial to the posterolateral acromial edge rather than the traditional description of 1 cm medial to this landmark. PORTALS/EXPOSURES EQUIPMENT
• 7-mm threaded cannulas for all working portals • 5.5-mm cannula for the anterior shuttling portal STEP 1 PEARLS
• Tears of the subscapularis are often missed and/or underappreciated.
PROCEDURE Step 1 • Standard intraarticular diagnostic arthroscopy is first performed, with the arthroscope inserted through the posterior portal, and instruments are inserted through the anterior rotator interval portal. • The long head of the biceps brachii tendon should be carefully examined for evidence of an unstable biceps origin, intrasubstance tearing, or instability in the bicipital groove. A biceps tenotomy or tenodesis may be indicated (Fig. 5.9). • The subscapularis integrity is assessed to determine if repair is indicated (Fig. 5.10A and B). • Other structures examined during intraarticular assessment include the undersurface of the cuff, the cartilaginous surfaces, labral tissue, and the inferior pouch. Their condition should be noted. • The posterosuperior rotator cuff can be evaluated from the intraarticular perspective before proceeding to the subacromial space (Fig. 5.11). This can provide valuable information regarding the degree of retraction, presence of delamination, and the status of the most posterior aspect of the rotator cuff.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.9
A
B FIG. 5.10 A–B
FIG. 5.11
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
Step 2
STEP 1 PITFALLS
• Failure to identify and address concomitant long head of the biceps brachii tendon disease may lead to failed repair of a rotator cuff tear due to persistent postoperative pain. STEP 2 CONTROVERSIES
• The decision to do a tenotomy or tenodesis of the biceps is based on factors such as patient age, activity level, and body habitus. Older patients and those who will tolerate the cosmetic deformity well are treated with tenotomy. Young patients, or those who may be troubled by a cosmetic deformity, are instead treated with open tenodesis using screw fixation.
STEP 2 PEARLS
• Inserting the arthroscope into the anterolateral or accessory posterolateral viewing portal may aid in tear pattern recognition. • Acromioplasty, if required, is reserved until after rotator cuff repair, as performing this step of the procedure, including takedown of the coracoacromial ligament, often allows escape of fluid into the deltoid and subcutaneous tissues and may lead to excessive swelling.
• The arthroscope is removed from the glenohumeral joint space and inserted into the subacromial space. Using slow deliberate movements, the bursa is swept in a medial-to-lateral direction from the underlying rotator cuff and overlying acromion. • The anterolateral portal is created under direct visualization after spinal needle localization. The portal location should allow insertion of instruments parallel to the undersurface of the acromion for later acromioplasty and allow access to the rotator cuff for suture passage. The cannula inserted through the anterior rotator interval portal is redirected into the subacromial space for later suture shuttling. • A comprehensive bursectomy is performed using a combination of the arthroscopic shaver and the thermoablation device. This is an exceedingly important step to assure visualization throughout the entire case, both medially for suture retrieval and laterally over the greater tuberosity for placement of lateral row anchors. • Debridement of the rotator cuff tear is performed to define the tear edge, taking care to preserve as much tissue substance as possible (Fig. 5.12). The arthroscopic shaver and burr are also used to debride the rotator cuff footprint on the greater tuberosity to create a healing bed (Fig. 5.13). • The rotator cuff tear is then carefully inspected to allow for recognition of the tear pattern. A tissue grasper can be inserted through the anterolateral portal to determine the optimal method of reducing the tear to its footprint and to assess the degree of retraction and mobility of the tissue (Fig. 5.14). One must recognize if the tear is midsubstance in location. Identification of the myotendinous junction can also indicate the amount of residual tendon available for repair.
STEP 2 PITFALLS
• Failure to recognize the tear pattern and optimal method of reduction and repair of the torn tendon may result in nonanatomic repair, which in turn will increase the likelihood of failure of the repair construct.
STEP 2 EQUIPMENT
• 5.0-mm full-radius arthroscopic shaver • Arthroscopic thermoablation device
FIG. 5.12
FIG. 5.13
FIG. 5.14
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
• If the tear cannot be reduced to its footprint without excessive tension, releases will be necessary. • Using the thermoablation device, the torn tendon can be released from the surrounding tissue on the glenoid and subacromial aspects. Care should be taken to maintain the device parallel to the tendon to avoid injury to the tissue. The tendon is released from adhesions in the subacromial space, especially at the base of the scapular spine. Adhesions can also occur between the cuff and the superior labrum. • Release of the coracohumeral ligament is often very helpful in increasing mobility of the torn rotator cuff. The authors do not typically use posterior interval releases in the repair of massive rotator cuff tears. • As the tear pattern dictates, margin convergence side-to-side suture repair may be necessary to translate the tendon edge laterally, closer to its footprint. This may further decrease the tension necessary to reduce the tendon to the greater tuberosity.
Step 3 • The rotator cuff tear and tuberosity should be inspected to determine the optimal number of medial-row anchors. Typically, two to three anchors are used along the medial row. These anchors are placed before insertion of the cannula into the anterolateral portal to avoid interference. • A spinal needle is used to localize the percutaneous portal used for anchor insertion (Fig. 5.15). The starting point is typically along the lateral border of the acromion, and this should allow anchor insertion at an angle of approximately 45 degrees relative to the plane of the tuberosity. • The knife is used to create a skin incision large enough to accommodate the suture anchor. A hemostat clamp is used to enlarge the path through the deltoid into the subacromial space. • The first suture anchor is inserted, using a mallet to engage the threads of the anchor (Fig. 5.16). The anchor is then inserted to a depth immediately beneath the cortical bone. Furthermore, the orientation of the eyelet, as determined by a laser line on the inserter, should be perpendicular to the long axis of the tendon. This will allow the suture to slide more easily after passage in a horizontal mattress fashion. • The inserter is removed, and traction on the sutures assures that the anchor is secure. The sutures are left in the percutaneous portal for later passage, and the other anchors are then inserted in a similar manner through separate percutaneous portals (Fig. 5.17).
FIG. 5.15
STEP 2 CONTROVERSIES
• Some extoll the virtues of posterior and anterior interval slides to enhance the mobility of a retracted massive rotator cuff tear. These authors feel that these techniques alter the biomechanical relationships of the individual rotator cuff tendons and render the tissue difficult to manage during repair.
STEP 3 PEARLS
• The arm should be maximally adducted during anchor insertion to assure the ideal angle of insertion in the coronal plane. • The arm can be internally and externally rotated to ease insertion of each anchor along the medial aspect of the tuberosity. For example, external rotation improves access to the anterior aspect of the tuberosity and internal rotation improves access to the posterior aspect of the tuberosity.
STEP 3 PITFALLS
• One must assure optimal depth of insertion of the suture anchors. Anchors that are inserted too deep may result in suture failure against cortical bone or repair construct elongation if the suture cuts through the cortical bone.
STEP 3 EQUIPMENT
• An anchor specifically designed for rotator cuff repair is necessary to accommodate the soft and often osteopenic bone of the greater tuberosity. These anchors are larger and have broader threads compared to anchors designed for use in the glenoid.
FIG. 5.16
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STEP 3 CONTROVERSIES
• Anchors are available in many different materials. No one anchor or material has an established superiority over another. Metallic anchors have optimal resistance to pullout in poor-quality bone over time. They are visible on radiographs, should there be a need to localize them in the future. Bioabsorbable anchors often create a localized acidic environment resulting in lucency around the anchor and possible loosening, and it is important to use an anchor designed for use in the greater tuberosity, with greater core and thread diameter to avoid failure of fixation in the bone.
STEP 4 PEARLS
• Careful examination of the tear pattern, as discussed previously, is exceedingly important in determining the optimal location for suture passage. The goal should always be reduction of the rotator cuff tendon to the greater tuberosity in as anatomic a position as possible. • These authors typically park the passed suture limbs in the anterior cannula. Alternatively, these sutures can be retrieved through the percutaneous portal through which the anchor was inserted.
Step 4 • After all medial-row suture anchors have been placed, the 7.0-mm threaded cannula is inserted through the anterolateral portal. Sutures will be passed in a horizontal mattress fashion, working from anterior to posterior. • The anterior-most suture limb of the first suture loaded through the anterior suture anchor is retrieved through the anterolateral portal using a suture grasper. Care is taken to avoid unloading the anchor while pulling this suture limb. • A retrograde suture passing device (Scorpion) is used to pass each suture limb through the torn rotator cuff tendon (Fig. 5.18A and B). The suture limb is then retrieved through the anterior portal. This is repeated for each limb of each suture loaded through the anterior anchor. • Care is taken to assure that enough substantial tendon tissue is captured with suture passage. If this cannot be achieved with the retrograde device, an antegrade device can be used from the Neviaser portal (Banana Lasso; Fig. 5.19A and B). One must also assure that a sufficient bridge exists between the limbs of each suture to allow knot tying without cutout of the suture through the tendon. Once each of the sutures from a given anchor is passed through the tendon and retrieved through the anterior portal, they are clamped together to avoid confusion and entanglement. • This procedure is repeated for each of the sutures loaded through the remaining anchors of the medial row. All are retrieved through the anterior portal and clamped to separate the sutures of each anchors.
STEP 4 PITFALLS
• It is important to determine the orientation of the limbs of each suture through the anchor eyelet. The anterior limb should be retrieved and passed anteriorly to avoid crossing the limbs. Crossing suture limbs may inhibit sliding or result in suture abrasion against the eyelet. • Strangulating the tissue with too many sutures can result in a medial rupture of the tendon.
FIG. 5.17
A
B FIG. 5.18 A–B
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
A
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B FIG. 5.19 A–B STEP 5 EQUIPMENT
• 7-mm threaded cannula • Scorpion retrograde suture-passing device (Arthrex; Naples, Florida) • Banana Lasso antegrade suture-passing device (Arthrex; Naples, Florida) • Arthroscopic tissue grasper • Arthroscopic suture grasper STEP 5 PEARLS
FIG. 5.20
Step 5 • Once all suture limbs have been passed, sutures are tied beginning posteriorly. • The first pair of suture limbs is retrieved from the anterior portal through the anterolateral portal. • Sutures are tied using two half-hitch knots in the same direction to assure loop security, followed by three alternating half-hitch knots, alternating the post on the final throw, to achieve knot security (Fig. 5.20). • After tying knots, the suture is retrieved through the percutaneous portal through which the anchor was previously placed for later placement of the lateral row anchors. • The remainder of the sutures are retrieved and tied through the anterolateral portal in sequence (Fig. 5.21A and B).
Step 6 • The authors use a transosseous-equivalent technique of repair (Park et al., 2007a, 2007b). Once all sutures of the medial row have been tied, the lateral-row knotless suture anchors are placed. One suture limb from each of the medial-row anchors is retrieved through the anterolateral portal, and the limbs are threaded through the eyelet of the knotless suture anchor (4.75-mm PEEK SwiveLock SP). • The arm is brought into abduction to allow perpendicular placement of the anchor into the greater tuberosity. Just as the medial-row anchors are spaced equally along the medial aspect of the rotator cuff tear footprint, the lateral-row anchors should
• Traction sutures can be placed in the torn rotator cuff and can be used to apply traction to the rotator cuff tendon, thus reducing the tendon prior to knot tying. • The most posterior limb of the posterior sutures and the anterior limb of the anterior sutures should be chosen as the post to assure that the knots are placed posteriorly and anteriorly on the rotator cuff tendon. • This divergence will assure, when placing the lateral row, that the suture configuration results in maximal surface area of compression of the tendon upon the footprint. STEP 5 PITFALLS
• While secure knot tying is integral to assuring the strength of the repair construct, one must avoid abrading the suture, which may jeopardize the strength of the repair construct. STEP 6 EQUIPMENT
• Arthroscopic suture grasper • Arthroscopic knot pusher STEP 6 CONTROVERSIES
• The choice of knot is a matter of surgeon preference. These surgeons use two half-hitch knots in the same direction, followed by alternating half-hitches, alternating the post on the final throw. • Alternatively, for the first knot, one can use a sliding knot such as the Tennessee Slider, or a sliding locking knot such as the Weston.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
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B
A
FIG. 5.21
FIG. 5.22
STEP 6 PEARLS
• The eyelet retention suture can be preserved and used to eliminate any residual “dog-ear” deformity by passing one limb through the tendon in either an antegrade or retrograde fashion. Otherwise, it can simply be removed and discarded.
STEP 6 PITFALLS
• The knotless suture anchor must be inserted to the appropriate depth. • Inserting the anchor below cortical bone may jeopardize fixation, while inserting the anchor above the level of the cortex may result in impingement within the subacromial space.
FIG. 5.23
be spaced equally along the lateral aspect of the greater tuberosity relative to the rotator cuff tear footprint. The arm can be rotated internally or externally to reveal the optimal location for anchor insertion. • The thermoablation device is used to clear soft tissue from the lateral cortex to expose the bone for anchor insertion. • The anchor is impacted using a mallet until the eyelet lies beneath the cortex. Preliminary tension is applied to the sutures to compress the torn rotator cuff tendon upon the footprint. The anchor is then impacted further until the tip of the anchor contacts the cortical bone. Final tension is applied to the sutures, and this tension is maintained. The anchor is then inserted by holding the thumb pad and rotating the handle until it is at the level of the cortical bone to ensure optimal fixation (Fig. 5.22). The eyelet retention suture is released, and the driver is removed. The suture limbs are then cut using an arthroscopic suture cutter. • The rotator cuff repair should be examined from the posterior and anterolateral portals while internally and externally rotating the extremity (Fig. 5.23). The arthroscope may also be inserted into the glenohumeral joint space to examine the repair from the articular perspective.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.24
Step 7 • Once the repair is completed, attention is then turned to the acromioplasty. An acromioplasty is performed only in the presence of an acromial spur; it is not necessarily a routine part of the procedure. • The borders of the acromion are defined using the thermoablation device. The acromial spur is exposed while taking care to preserve the deep deltoid fascia (Fig. 5.24). • An acromioplasty is then performed using a 4.85-mm oval burr, removing only enough bone to reveal the native acromion and to assure a flat undersurface (Fig. 5.25). • The shaver is then used to complete the bursectomy and to remove any loose osseous fragments from the acromioplasty.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients who undergo massive rotator cuff repair are managed with a standard postoperative rehabilitation regimen: • Weeks 1–6: sling immobilization, waist-level activities of daily living, elbow/wrist/ hand motion, no reaching/lifting/pulling/pushing. • Weeks 6–8: discontinue sling, begin passive ROM • Weeks 8–10: begin active-assisted ROM and active ROM • Weeks 10–12: begin progressive strengthening • While healing rates of massive rotator cuff tears have been historically low, particularly in older patients with more aggressive rehabilitation, these patients are often still able to achieve favorable clinical outcomes (Galatz et al., 2004; Gerber et al., 2000; Harryman et al., 1991; Sugaya et al., 2007). • Complications are rare with arthroscopic repair of massive rotator cuff tears. As discussed above, perhaps failure to heal is the most common complication. In addition, these patients may encounter stiffness, particularly when managed with a conservative rehabilitation regimen consisting of prolonged immobilization. Late stiffness can be treated with judicious use of corticosteroid injections and, in refractory cases, with arthroscopic lysis of adhesions.
EVIDENCE Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojanl C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg [Am]. 2007;89:747–57. In this study, 68 patients who underwent arthroscopic biceps tenotomy or tenodesis for the treatment of massive irreparable rotator cuff tears were retrospectively reviewed at a minimum of 2 years after surgery; 78% of patients were satisfied. The mean Constant score improved from 46.3
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FIG. 5.25
STEP 7 CONTROVERSIES
• Controversy exists regarding single-row versus double-row repair. Double-row repairs have demonstrated enhanced biomechanical properties and restoration of the native footprint with compression of tendon to bone over a larger surface contact area. • Effects of single-row versus double-row repair on healing and clinical outcome are varied and inconclusive, though improved postoperative structural integrity has been demonstrated with double-row techniques (Charousset et al., 2007; Park et al., 2008; Sugaya et al., 2005). • Increased cost of double-row repair is a disadvantage. • The authors prefer a double-row repair in younger patients in whom anatomic healing will likely have a greater effect on outcome and satisfaction.
STEP 7 EQUIPMENT
• 4.75-mm SwiveLock SP suture anchor (Arthrex; Naples, Florida) • Arthroscopic suture cutter • 4.85-mm arthroscopic bur • 5.0-mm arthroscopic shaver
STEP 7 PEARLS
• Avoid excessive bone removal. • Protect the deltoid from injury.
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
STEP 7 PITFALLS
• Excessive bone removal, injury to the deltoid, and resection of the coracoacromial ligament could lead to iatrogenic anterior-superior instability. • In the presence of an os acromiale, an acromioplasty is deferred to avoid destabilizing the fragment. • If one is concerned about the security of the repair or likelihood of successful healing, one should consider deferring the acromioplasty to preserve the coracoacromial arch, which serves as a restraint to anterosuperior escape.
POSTOPERATIVE PEARLS
• Adequate pain control is necessary to allow patients to progress with prescribed therapy. • Cold therapy is useful in pain control and postoperative comfort.
POSTOPERATIVE PITFALLS
• Overly aggressive initial therapy may risk early repair failure.
POSTOPERATIVE CONTROVERSIES
• Conclusive evidence does not yet exist to support any specific rehabilitation protocol. Earlier protocols relied on early motion to avoid stiffness associated with open procedures. • These authors have moved to a more conservative rehabilitation program because of the low rate of healing after repair of massive rotator cuff tears. Furthermore, stiffness may be less of a concern in the context of arthroscopic repair.
to 66.5. There was no difference in outcome between the tenodesis and tenotomy groups. Cosmetic deformity occurred in 62% of patients, but none was symptomatic after tenotomy. Atrophic teres minor, pseudoparalysis, and severe cuff tear arthropathy were associated with worse clinical outcomes. (Level III evidence). Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Sur Am. 2005;87(6):1229–40. This study was one of the first to show decreased healing after rotator cuff repair in patients over the age of 65 years. Sixty-five shoulders with chronic rotator cuff tears were evaluated for outcomes and tendon integrity after repair. Absence of healing was associated with decreased strength. Patients over the age of 65 had a 43% chance of healing. Charousset C, Grimberg J, Duranthon LD, Beilaiche L, Petrover D. Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair? A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment. Am J Sports Med. 2007;35:1247–53. This prospective investigation compared patients who underwent arthroscopic single-row or doublerow rotator cuff repair with minimum postoperative follow-up of 2 years using Constant scores, patient satisfaction, return to work, and postoperative computed tomography (CT) arthrogram to assess repair integrity at 6 months. There was no significant different in Constant scores between groups, with improvement in pain, activity, and strength in both groups. In addition, there was no difference in subjective satisfaction or return to work. While no statistically significant difference was detected in the incidence of “watertight” repairs on CT arthrogram (77.4% for double row, 60% for single row), there was a significantly higher incidence of “anatomic” footprint restoration in the double-row group. (Level II evidence). Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8:599–605. This study examined 41 patients undergoing shoulder surgery with CT and MRI to establish whether these methods were comparable in assessing rotator cuff fatty infiltration and to establish a relationship between fatty infiltration and rotator cuff muscle atrophy. The study concluded that CT and MRI had excellent interobserver reliability, although the latter demonstrated superior reliability. The correlation between CT and MRI was fair to moderate, and a relationship between fatty infiltration and atrophy was established. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg [Am]. 2004;86:219–24. In this study, 18 patients who had complete arthroscopic repair of a tear measuring greater than 2 cm in the transverse dimension were evaluated at a minimum of 12 months and at 2 years after surgery. Seventeen of 18 patients demonstrated recurrent tears. Despite this lack of healing, clinical improvement was noted in certain patients at 12 months, including American Shoulder and Elbow Surgeons (ASES) scores greater than 90 points in 13 patients, improved functional outcome scores in 16, resolution of pain in 12, and improved motion with elevation above shoulder level in all 18. Clinical outcomes declined somewhat at 2 years, including ASES scores and forward elevation. (Level IV evidence). Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg [Am]. 2000;82:505–15. This study prospectively evaluated 27 patients who underwent open repair of massive rotator cuff tears at a minimum of 2 years postoperatively with imaging and clinical evaluation. Overall, patients demonstrated improvement in the Constant score, ROM, and pain; and 63% of tendons demonstrated healing on final evaluation. Patients with recurrent tears demonstrated clinical improvement, albeit less than in those patients with intact repairs. Fatty infiltration was found to be irreversible, and muscle atrophy was only somewhat reversible in intact supraspinatus repairs. (Level IV evidence). Harryman 2nd DT, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen 3rd FA. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg [Am]. 1991;73:982–9. In this study, 105 patients who underwent open rotator cuff repair were retrospectively reviewed at a minimum of 2 years postoperatively with imaging and clinical evaluation. Eighty percent of isolated supraspinatus tears successfully healed on ultrasound, whereas 50% of larger tears healed. Increased prevalence of recurrent tears was found in older patients and those who had undergone previous attempted repair. Most patients reported pain relief and satisfaction postoperatively, regardless of the status of the repair. However, patients with an intact repair demonstrated better function, ROM, and strength. Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg [Am]. 2009;91:1405–13. In this study, 117 patients with rotator cuff tears, both symptomatic and asymptomatic, were prospectively evaluated with plain radiographs and ultrasound. Proximal humeral migration was greater
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears in symptomatic tears, as well as those tears that involved the infraspinatus. For symptomatic tears greater than 175 mm, pain and tear size have a significant effect on proximal migration. However, tear area was determined to be the most important predictor of proximal humeral migration. (Level II evidence). Keener JD, Wei AS, Klm HM, et al. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome. J Bone Joint Surg [Am]. 2010;92:590–8. This study retrospectively reviewed 21 patients who underwent revision arthroscopic rotator cuff repair at a minimum of 2 years after surgery. These patients demonstrated improvement in pain, Simple Shoulder Test scores, ASES scores, forward elevation, and ER. Forty-eight percent of patients demonstrated healing on postoperative ultrasound examination, including 70% of those with single-tendon tears and 27% of those with supraspinatus/infraspinatus tears. Patient age and number of torn tendons had a negative correlation with postoperative repair integrity. Those patients with intact repairs demonstrated higher Constant scores and improved scapular-plane elevation. (Level IV evidence). Le BTN, Wu XL, Lam PH, Murrell GAC. Factors predicting rotator cuff retears: an analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med. 2014;42(5):1134–1142. In a retrospective study of 1000 patients, the retear rate was 17% 6 months after surgery. Retears occurred in 27% of full thickness tears and 5% of partial thickness tears. Factors associated with retears are age at the time of surgery and tear size, both the AP and medial-lateral dimensions. Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair. J Bone Joint Surg [Am]. 2007;89:1770–6. This study retrospectively reviewed 53 patients with isolated supraspinatus tears at a minimum of 24 months postoperatively. Overall, patients demonstrated improvement in the Constant score regardless of repair integrity. Seventy-five percent of patients demonstrated healing on final evaluation. Patients with recurrent tears demonstrated diminished abduction strength and decreased Constant scores. Preoperative fatty infiltration of grade 2 or more, supraspinatus atrophy, and age all were found to be associated with recurrent tears. Neither progression nor reversal of fatty infiltration or atrophy was observed in healed tears. However, recurrent tears demonstrated progression of both of these characteristics. (Level IV evidence). Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus: new anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg [Am]. 2008;90:962–9. This cadaveric study of 113 shoulders sought to define the insertional footprint of the posterosuperior rotator cuff tendons, and discovered the footprint of the supraspinatus to be smaller, and that of the infraspinatus to be larger, than previously thought. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of singleand double-row repairs in rotator cuff tears. Am J Sports Med. 2008;36:1310–6. This investigation compared patients who underwent single-row and double-row arthroscopic rotator cuff repair. These patients were evaluated at a minimum of 22 months with ASES and Constant scores, as well as a Shoulder Strength index. Overall, all outcomes improved in both groups with no statistically significant difference between groups. However, when large and massive tears (>3 cm) were examined separately, the double-row group demonstrated superior results compared to the single-row group. (Level II evidence). Park MC, Elattrache NS, Tibone JE, Ahmad CS, Jun B-J, Lee TQ. Part I: footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007a;16(4):461–8. Park MC, Tibone JE, Elattrache NS, Ahmad CS, Jun B-J, Lee TQ. Part II: biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a doublerow repair technique. J Shoulder Elbow Surg. 2007b;16(4):469–76. These studies established the biomechanical and physical characteristics for the transosseous equivalent repair commonly used in practice. The first evaluated the contact area of the tendon to the native footprint of the rotator cuff tendon insertion on the greater tuberosity, and the transosseous repair better approximated the anatomic footprint. The second study compared the transosseous equivalent repair to a double row technique, and the transosseous repair improved ultimate failure strength but did not differ in stiffness or gap formation. Sugaya H, Maeda K, Matsuki K, Morüshi J. Functional and structural outcome after arthroscopic fullthickness rotator cuff repair: single-row versus dual-row fixation. Arthroscopy. 2005;21:1307–16. This investigation compared patients who underwent single-row and double-row arthroscopic rotator cuff repair. These patients were evaluated at a minimum of 2 years postoperatively with UCLA and ASES scores, as well as with MRI to assess structural integrity. Although all patients demonstrated improvement in outcome scores, with no statistically significant difference among groups, structural integrity did differ. Significantly more subjects in the single-row group demonstrated insufficient thickness and recurrent defects in the rotator cuff repair. Subjects with large to massive tears demonstrated a higher incidence of recurrent defects in the single-row group compared to the double-row group (44% versus 29%, respectively). (Level III evidence).
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears Sugaya H, Maeda K, Matsuki K, Morüshi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg [Am]. 2007;89:953–60. In this study, 86 patients who underwent arthroscopic double-row rotator cuff repair were evaluated prospectively at a minimum of 2 years postoperatively. Overall, all clinical outcome scores, including Japanese Orthopedic Association (JOA), UCLA, and ASES scores, improved on final evaluation. Eighty-three patients demonstrated healing on MRI, including 95% of small and medium tears and 60% of large and massive tears. Patients with a recurrent major defect demonstrated diminished outcome scores and strength, while those with a recurrent minor defect demonstrated no functional compromise. (Level IV evidence). Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg [Am]. 2004;86:708–16. In this study, 71 patients who underwent shoulder arthroscopy were prospectively studied to examine the relative accuracy of ultrasound in evaluating the rotator cuff relative to MRI and arthroscopy. Ultrasound demonstrated accuracy comparable to MRI with regard to identifying a rotator cuff tear and distinguishing partial-thickness and full-thickness tears, as well as determining the dimensions of the tear. (Level 1-1 evidence).
Arthroscopic Repair of Massive Rotator Cuff Tears Marc S. Kowalsky and Leesa M. Galatz
INDICATIONS PITFALLS
• Candidates for arthroscopic massive rotator cuff repair must have the ability to comply with a prolonged course of rehabilitation. • Concomitant arthritis may indicate need for arthroplasty. • Advanced atrophy and fatty change of rotator cuff musculature suggest irreparable tear and may be indication for arthroplasty. • Rule out adhesive capsulitis.
INDICATIONS • Symptomatic, painful rotator cuff tear that does not respond to conservative modalities (nonsteroidal antiinflammatory medication, physical therapy, and possible injections) • Repairable rotator cuff tear as determined by careful evaluation of the characteristics of the tear on advanced imaging and intraoperative examination, including chronicity, size, retraction, muscle atrophy, and fatty degeneration • An acute tear that results in severe weakness or loss of overhead elevation • Massive tear in a younger (<60-year-old), high-demand individual
EXAMINATION/IMAGING INDICATIONS CONTROVERSIES
• One should approach certain patients with caution, as advanced age, tobacco use, or certain systemic diseases may decrease the likelihood of successful repair with healing and symptomatic relief (Galatz et al., 2004; Keener et al., 2010). • Some surgeons have achieved effective pain relief and improved clinical outcomes with arthroscopic debridement, subacromial decompression, and biceps tenotomy, and they offer this approach as an alternative, particularly when the reparability of a massive tear is in question (Boileau et al., 2007). • A massive tear in a patient older than 70 years of age may benefit from arthroplasty, even in the absence of arthritis, given the higher recurrence rate after repair (Boileau et al., 2005; Galatz et al., 2004; Le et al., 2014).
Physical Examination • Visual inspection may reveal atrophy of the infraspinatus or supraspinatus, scapular winging with range of motion (ROM) indicating nerve injury, and shoulder asymmetry. • Both active and passive ROM are evaluated, including forward elevation, external rotation (ER) at the side, ER in abduction, and internal rotation/extension as measured by the most cephalad spinous process reached with the affected extremity. • Manual strength testing is conducted. • ER with shoulder in slight internal rotation • “Thumbs-down” abduction with arms in scapular plane • Certain findings indicate larger tears. • Lag sign with arm in maximal ER at the side—supraspinatus, infraspinatus • Hornblower’s (strength in abduction and ER)—teres minor • Abdominal compression test—subscapularis • Lift-off test—subscapularis • Provocative maneuvers are helpful to diagnose cuff-generated pain. • Neer and Hawkins signs, as well as the Jobe and drop arm signs • Provocative tests for pain from the long head of the biceps brachii, including Speed and Yergason tests • The acromioclavicular joint must be assessed. • Tenderness to palpation • Pain with cross-body adduction
Imaging Studies • Radiographs • Anteroposterior (AP), true AP, scapular lateral, and axillary views are reviewed for acromioclavicular joint osteoarthritis, glenohumeral joint osteoarthritis, and acromial morphology. • Decreased acromiohumeral interval and/or proximal humeral migration of the humeral head in relation to the glenoid indicates large or chronic tear that may be irreparable (Keener et al., 2009). • Magnetic resonance imaging (MRI) is used to assess tear size and tendon involvement, tendon retraction, muscle quality and degree of degeneration, and glenohumeral joint pathology. • Degenerative labral and biceps lesions are common and not usually the primary source of pain. • Sagittal and coronal oblique T2-weighted images are used to quantify the tear size and the degree of retraction, respectively (Fig. 5.1). A massive tear typically involves greater than 5 cm of the rotator cuff footprint, or at least two tendons. 64
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
Greater tuberosity Torn rotator cuff Humeral head
FIG. 5.1
FIG. 5.2 The arrow points to the lateral edge of the torn rotator cuff tendon.
• Axial images are used to evaluate the subscapularis and long head of the biceps brachii. • Medial images of the sagittal T1-weighted sequence are used to assess atrophy and fatty infiltration of the rotator cuff muscle bellies (Fuchs et al., 1999; Liem et al., 2007). • Ultrasound has been proven to be a reliable modality for assessment of the rotator cuff (Fig. 5.2; Teefey et al., 2004). • Ultrasonographer dependent • Very accurate for rotator cuff pathology • Not as useful for intraarticular biceps pathology
SURGICAL ANATOMY • The rotator cuff consists of the tendons of four muscles: the subscapularis anteriorly, the supraspinatus superiorly, and the infraspinatus and teres minor posteriorly. The rotator cuff muscles function in force couples, in which the deltoid counters the inferior rotator cuff (infraspinatus, teres minor, and subscapularis below the center of rotation), and the anterior rotator cuff (subscapularis) counters the posterior cuff (infraspinatus, teres minor) to maintain a centered humeral head relative to the glenoid. • The rotator cable represents a crescenteric thickening of the tendon that inserts onto the greater tuberosity anteriorly and posteriorly. The function of this structure has been theorized to protect the relatively avascular zone of the rotator cuff tendon from stress during force transmission. Furthermore, this structure preserves the coronal force couple even in the presence of an isolated supraspinatus tear by transmitting force along the cable to the greater tuberosity. • The rotator cuff insertion, or enthesis, consists of four zones: tendon, fibrocartilage, mineralized fibrocartilage, and bone. This continuous microstructure serves to distribute stress along the entire enthesis. • Understanding of the anatomy of the rotator cuff footprint, and the contribution of each muscle, has evolved over time (Fig. 5.3; Mochizuki et al., 2008). • According to the most current analysis thereof, the supraspinatus footprint is smaller than previously thought, representing a triangle with a medial-lateral length of 6.9 mm and an anterior-posterior length of 12.6 mm at its largest point adjacent to the humeral head articular surface.
TREATMENT OPTIONS
• Nonoperative management • Nonsteroidal antiinflammatory medications • Physical therapy • Possible corticosteroid injections • Open rotator cuff repair • Arthroscopically assisted mini-open rotator cuff repair • Biceps tenotomy or tenodesis • Subacromial decompression and debridement • Reverse shoulder arthroplasty
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Lc
Wms
Wmi
Ls
Li LT GT
FIG. 5.3
• The infraspinatus footprint has a trapezoidal shape and measures 10.2 mm in medial-lateral length and 20.2–32.7 mm in anterior-posterior length. • The glenohumeral joint capsule inserts on the superior aspect of the greater tuberosity immediately adjacent to the humeral head articular surface and has a medial-lateral footprint of 4.5 mm. As one moves posteriorly along the greater tuberosity, a bare area arises between the capsule and humeral head articular surface with no soft tissue attachments. • The scapular spine serves as a landmark between the muscle bellies of the infraspinatus and supraspinatus, which can be used to determine the appropriate location for a posterior interval slide. Likewise, the coracoid serves as the landmark to determine the interval between the supraspinatus and subscapularis and can be helpful when an anterior interval slide is performed. Even when interval releases are not required, releasing the coracohumeral ligament, which originates on the coracoid and becomes confluent with the rotator interval tissue, is often necessary to adequately mobilize the rotator cuff for repair without tension. • The rotator interval consists of the space and tissue between the upper border of the subscapularis and the anterior border of the supraspinatus. Soft tissues comprise the coracohumeral ligament and the superior glenohumeral ligament. • The long head of the biceps tendon arises from the superior labrum at the supraglenoid tubercle and is intraarticular for approximately 2.8 cm before it exits the joint at the intertubercular groove. Normal anatomy of the superior and anterosuperior labrum is variable. • The suprascapular nerve arises from the upper trunk of the brachial plexus and enters the supraspinatus fossa through the suprascapular notch, just medial to the coracoclavicular ligaments. It courses posteriorly approximately 1.5 cm medial to the superior glenoid rim and enters the spinoglenoid notch to innervate the infraspinatus. • The nerve can be released arthroscopically, and its role in shoulder pain associated with rotator cuff tears is controversial. • This nerve should be protected inferior to the cuff during mobilization of retracted cuff tissue. • The axillary nerve arises from the posterior cord of the brachial plexus. It courses inferior to the subscapularis and glenohumeral joint capsule as it travels posteriorly to innervate the deltoid and teres major and to provide sensation to the lateral arm.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.4
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FIG. 5.5
POSITIONING PEARLS
POSITIONING • Arthroscopic rotator cuff repair is performed in the beach chair or lateral decubitus position, of which the authors prefer beach chair. • The patient is placed in a sitting position 60 degrees relative to the horizontal. The posterior shoulder must be adequately exposed to ensure proper access to the operative field (Fig. 5.4). • The head is secured using a secure head positioner, maintaining the cervical spine in a neutral position. • Using either a commercially available wedge or the operating table, the hips and knees are flexed appropriately to avoid undue tension on the neurovascular structures of the lower extremities. • The contralateral extremity is secured to an armboard in a comfortable position. The ulnar nerve is padded. • The table is angled approximately 45 degrees away from the operative extremity to allow access to the posterior aspect of the shoulder.
• Adequate exposure to both anterior and posterior shoulder is needed; the patient must be positioned as far as possible toward the operative side. • A mechanical arm holder assists in holding the operative arm during the procedure and allows placement of traction on the arm to enlarge the subacromial space during repair (Fig. 5.5).
POSITIONING PITFALLS
• Inadequate exposure. • Unstable cervical spine and head position. • Inadequate padding of the contralateral arm and lower extremities. • Some elderly patients may be at risk for a sudden drop in blood pressure while being positioned upright, so the back should be raised slowly with blood pressure monitoring.
PORTALS/EXPOSURES • A posterior viewing portal is created 1–2 cm distal and 0.5–1 cm medial to the posterolateral corner of the acromion (Fig. 5.6). • If this portal is used exclusively for viewing, no cannula is necessary; however, if it will also be used as a working portal, then a 7-mm cannula can be inserted to ease movement of the arthroscope among portals. • An anterolateral working portal is created 3 fingerbreadths distal to the lateral edge of the acromion, slightly anterior to the posterior edge of the acromioclavicular joint (Fig. 5.7). • A 7-mm cannula is inserted in this portal to allow insertion of instruments, including suture-passing devices. • A rotator interval portal is created immediately lateral to the coracoid process (Fig. 5.8). • This portal is used during the intraarticular examination. The cannula is redirected into the subacromial space to be used as a working portal during the rotator cuff repair. • If this portal is used exclusively for suture shuttling, a 5.5-mm cannula can be inserted; however, if it will also be used for suture passage, a 7-mm cannula can be inserted to allow insertion of suture-passing instruments.
POSITIONING EQUIPMENT
• A commercially available extremity positioner • Either a commercially available beach chair adapter or an operating table that can accommodate the beach chair position PORTALS/EXPOSURES CONTROVERSIES
• Some surgeons prefer to perform arthroscopic rotator cuff repair in the lateral decubitus position. This decision should be based primarily on surgeon experience and comfort. • Increasing attention has been given to the relationship between the beach chair position and cerebral perfusion. The surgeon and anesthesiologist must assure that the patient’s blood pressure resulting from elevation of the torso as well as hypotensive anesthesia remains within a safe range relative to the patient’s baseline status.
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FIG. 5.6
FIG. 5.7
PORTALS/EXPOSURES PEARLS
• An accessory posterolateral portal on the lateral shoulder closer to the posterolateral corner of the acromion can be created to allow better visualization of the tear for tear pattern recognition. A 7-mm cannula can be inserted to ease movement of the arthroscope among portals. • Percutaneous portals created along the anterolateral, lateral, and posterolateral borders of the acromion are created for insertion of anchors at the ideal angle. • Percutaneous portals can also be used for antegrade suture-passing devices. These devices are helpful in retracted tears with tenuous tissue to allow suture placement as medial as possible. FIG. 5.8
PORTALS/EXPOSURES PITFALLS
• The anterior and posterior portals should be placed sufficiently distal relative to the acromion to avoid caudal angulation of the cannulas as shoulder swelling increases. • Particularly when using a posterior viewing portal exclusively, this portal should be placed sufficiently lateral to allow optimal visualization of the rotator cuff tear. Therefore, these authors advise creating this portal only slightly medial to the posterolateral acromial edge rather than the traditional description of 1 cm medial to this landmark. PORTALS/EXPOSURES EQUIPMENT
• 7-mm threaded cannulas for all working portals • 5.5-mm cannula for the anterior shuttling portal STEP 1 PEARLS
• Tears of the subscapularis are often missed and/or underappreciated.
PROCEDURE Step 1 • Standard intraarticular diagnostic arthroscopy is first performed, with the arthroscope inserted through the posterior portal, and instruments are inserted through the anterior rotator interval portal. • The long head of the biceps brachii tendon should be carefully examined for evidence of an unstable biceps origin, intrasubstance tearing, or instability in the bicipital groove. A biceps tenotomy or tenodesis may be indicated (Fig. 5.9). • The subscapularis integrity is assessed to determine if repair is indicated (Fig. 5.10A and B). • Other structures examined during intraarticular assessment include the undersurface of the cuff, the cartilaginous surfaces, labral tissue, and the inferior pouch. Their condition should be noted. • The posterosuperior rotator cuff can be evaluated from the intraarticular perspective before proceeding to the subacromial space (Fig. 5.11). This can provide valuable information regarding the degree of retraction, presence of delamination, and the status of the most posterior aspect of the rotator cuff.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.9
A
B FIG. 5.10 A–B
FIG. 5.11
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
Step 2
STEP 1 PITFALLS
• Failure to identify and address concomitant long head of the biceps brachii tendon disease may lead to failed repair of a rotator cuff tear due to persistent postoperative pain. STEP 2 CONTROVERSIES
• The decision to do a tenotomy or tenodesis of the biceps is based on factors such as patient age, activity level, and body habitus. Older patients and those who will tolerate the cosmetic deformity well are treated with tenotomy. Young patients, or those who may be troubled by a cosmetic deformity, are instead treated with open tenodesis using screw fixation.
STEP 2 PEARLS
• Inserting the arthroscope into the anterolateral or accessory posterolateral viewing portal may aid in tear pattern recognition. • Acromioplasty, if required, is reserved until after rotator cuff repair, as performing this step of the procedure, including takedown of the coracoacromial ligament, often allows escape of fluid into the deltoid and subcutaneous tissues and may lead to excessive swelling.
• The arthroscope is removed from the glenohumeral joint space and inserted into the subacromial space. Using slow deliberate movements, the bursa is swept in a medial-to-lateral direction from the underlying rotator cuff and overlying acromion. • The anterolateral portal is created under direct visualization after spinal needle localization. The portal location should allow insertion of instruments parallel to the undersurface of the acromion for later acromioplasty and allow access to the rotator cuff for suture passage. The cannula inserted through the anterior rotator interval portal is redirected into the subacromial space for later suture shuttling. • A comprehensive bursectomy is performed using a combination of the arthroscopic shaver and the thermoablation device. This is an exceedingly important step to assure visualization throughout the entire case, both medially for suture retrieval and laterally over the greater tuberosity for placement of lateral row anchors. • Debridement of the rotator cuff tear is performed to define the tear edge, taking care to preserve as much tissue substance as possible (Fig. 5.12). The arthroscopic shaver and burr are also used to debride the rotator cuff footprint on the greater tuberosity to create a healing bed (Fig. 5.13). • The rotator cuff tear is then carefully inspected to allow for recognition of the tear pattern. A tissue grasper can be inserted through the anterolateral portal to determine the optimal method of reducing the tear to its footprint and to assess the degree of retraction and mobility of the tissue (Fig. 5.14). One must recognize if the tear is midsubstance in location. Identification of the myotendinous junction can also indicate the amount of residual tendon available for repair.
STEP 2 PITFALLS
• Failure to recognize the tear pattern and optimal method of reduction and repair of the torn tendon may result in nonanatomic repair, which in turn will increase the likelihood of failure of the repair construct.
STEP 2 EQUIPMENT
• 5.0-mm full-radius arthroscopic shaver • Arthroscopic thermoablation device
FIG. 5.12
FIG. 5.13
FIG. 5.14
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
• If the tear cannot be reduced to its footprint without excessive tension, releases will be necessary. • Using the thermoablation device, the torn tendon can be released from the surrounding tissue on the glenoid and subacromial aspects. Care should be taken to maintain the device parallel to the tendon to avoid injury to the tissue. The tendon is released from adhesions in the subacromial space, especially at the base of the scapular spine. Adhesions can also occur between the cuff and the superior labrum. • Release of the coracohumeral ligament is often very helpful in increasing mobility of the torn rotator cuff. The authors do not typically use posterior interval releases in the repair of massive rotator cuff tears. • As the tear pattern dictates, margin convergence side-to-side suture repair may be necessary to translate the tendon edge laterally, closer to its footprint. This may further decrease the tension necessary to reduce the tendon to the greater tuberosity.
Step 3 • The rotator cuff tear and tuberosity should be inspected to determine the optimal number of medial-row anchors. Typically, two to three anchors are used along the medial row. These anchors are placed before insertion of the cannula into the anterolateral portal to avoid interference. • A spinal needle is used to localize the percutaneous portal used for anchor insertion (Fig. 5.15). The starting point is typically along the lateral border of the acromion, and this should allow anchor insertion at an angle of approximately 45 degrees relative to the plane of the tuberosity. • The knife is used to create a skin incision large enough to accommodate the suture anchor. A hemostat clamp is used to enlarge the path through the deltoid into the subacromial space. • The first suture anchor is inserted, using a mallet to engage the threads of the anchor (Fig. 5.16). The anchor is then inserted to a depth immediately beneath the cortical bone. Furthermore, the orientation of the eyelet, as determined by a laser line on the inserter, should be perpendicular to the long axis of the tendon. This will allow the suture to slide more easily after passage in a horizontal mattress fashion. • The inserter is removed, and traction on the sutures assures that the anchor is secure. The sutures are left in the percutaneous portal for later passage, and the other anchors are then inserted in a similar manner through separate percutaneous portals (Fig. 5.17).
FIG. 5.15
STEP 2 CONTROVERSIES
• Some extoll the virtues of posterior and anterior interval slides to enhance the mobility of a retracted massive rotator cuff tear. These authors feel that these techniques alter the biomechanical relationships of the individual rotator cuff tendons and render the tissue difficult to manage during repair.
STEP 3 PEARLS
• The arm should be maximally adducted during anchor insertion to assure the ideal angle of insertion in the coronal plane. • The arm can be internally and externally rotated to ease insertion of each anchor along the medial aspect of the tuberosity. For example, external rotation improves access to the anterior aspect of the tuberosity and internal rotation improves access to the posterior aspect of the tuberosity.
STEP 3 PITFALLS
• One must assure optimal depth of insertion of the suture anchors. Anchors that are inserted too deep may result in suture failure against cortical bone or repair construct elongation if the suture cuts through the cortical bone.
STEP 3 EQUIPMENT
• An anchor specifically designed for rotator cuff repair is necessary to accommodate the soft and often osteopenic bone of the greater tuberosity. These anchors are larger and have broader threads compared to anchors designed for use in the glenoid.
FIG. 5.16
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STEP 3 CONTROVERSIES
• Anchors are available in many different materials. No one anchor or material has an established superiority over another. Metallic anchors have optimal resistance to pullout in poor-quality bone over time. They are visible on radiographs, should there be a need to localize them in the future. Bioabsorbable anchors often create a localized acidic environment resulting in lucency around the anchor and possible loosening, and it is important to use an anchor designed for use in the greater tuberosity, with greater core and thread diameter to avoid failure of fixation in the bone.
STEP 4 PEARLS
• Careful examination of the tear pattern, as discussed previously, is exceedingly important in determining the optimal location for suture passage. The goal should always be reduction of the rotator cuff tendon to the greater tuberosity in as anatomic a position as possible. • These authors typically park the passed suture limbs in the anterior cannula. Alternatively, these sutures can be retrieved through the percutaneous portal through which the anchor was inserted.
Step 4 • After all medial-row suture anchors have been placed, the 7.0-mm threaded cannula is inserted through the anterolateral portal. Sutures will be passed in a horizontal mattress fashion, working from anterior to posterior. • The anterior-most suture limb of the first suture loaded through the anterior suture anchor is retrieved through the anterolateral portal using a suture grasper. Care is taken to avoid unloading the anchor while pulling this suture limb. • A retrograde suture passing device (Scorpion) is used to pass each suture limb through the torn rotator cuff tendon (Fig. 5.18A and B). The suture limb is then retrieved through the anterior portal. This is repeated for each limb of each suture loaded through the anterior anchor. • Care is taken to assure that enough substantial tendon tissue is captured with suture passage. If this cannot be achieved with the retrograde device, an antegrade device can be used from the Neviaser portal (Banana Lasso; Fig. 5.19A and B). One must also assure that a sufficient bridge exists between the limbs of each suture to allow knot tying without cutout of the suture through the tendon. Once each of the sutures from a given anchor is passed through the tendon and retrieved through the anterior portal, they are clamped together to avoid confusion and entanglement. • This procedure is repeated for each of the sutures loaded through the remaining anchors of the medial row. All are retrieved through the anterior portal and clamped to separate the sutures of each anchors.
STEP 4 PITFALLS
• It is important to determine the orientation of the limbs of each suture through the anchor eyelet. The anterior limb should be retrieved and passed anteriorly to avoid crossing the limbs. Crossing suture limbs may inhibit sliding or result in suture abrasion against the eyelet. • Strangulating the tissue with too many sutures can result in a medial rupture of the tendon.
FIG. 5.17
A
B FIG. 5.18 A–B
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
A
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B FIG. 5.19 A–B STEP 5 EQUIPMENT
• 7-mm threaded cannula • Scorpion retrograde suture-passing device (Arthrex; Naples, Florida) • Banana Lasso antegrade suture-passing device (Arthrex; Naples, Florida) • Arthroscopic tissue grasper • Arthroscopic suture grasper STEP 5 PEARLS
FIG. 5.20
Step 5 • Once all suture limbs have been passed, sutures are tied beginning posteriorly. • The first pair of suture limbs is retrieved from the anterior portal through the anterolateral portal. • Sutures are tied using two half-hitch knots in the same direction to assure loop security, followed by three alternating half-hitch knots, alternating the post on the final throw, to achieve knot security (Fig. 5.20). • After tying knots, the suture is retrieved through the percutaneous portal through which the anchor was previously placed for later placement of the lateral row anchors. • The remainder of the sutures are retrieved and tied through the anterolateral portal in sequence (Fig. 5.21A and B).
Step 6 • The authors use a transosseous-equivalent technique of repair (Park et al., 2007a, 2007b). Once all sutures of the medial row have been tied, the lateral-row knotless suture anchors are placed. One suture limb from each of the medial-row anchors is retrieved through the anterolateral portal, and the limbs are threaded through the eyelet of the knotless suture anchor (4.75-mm PEEK SwiveLock SP). • The arm is brought into abduction to allow perpendicular placement of the anchor into the greater tuberosity. Just as the medial-row anchors are spaced equally along the medial aspect of the rotator cuff tear footprint, the lateral-row anchors should
• Traction sutures can be placed in the torn rotator cuff and can be used to apply traction to the rotator cuff tendon, thus reducing the tendon prior to knot tying. • The most posterior limb of the posterior sutures and the anterior limb of the anterior sutures should be chosen as the post to assure that the knots are placed posteriorly and anteriorly on the rotator cuff tendon. • This divergence will assure, when placing the lateral row, that the suture configuration results in maximal surface area of compression of the tendon upon the footprint. STEP 5 PITFALLS
• While secure knot tying is integral to assuring the strength of the repair construct, one must avoid abrading the suture, which may jeopardize the strength of the repair construct. STEP 6 EQUIPMENT
• Arthroscopic suture grasper • Arthroscopic knot pusher STEP 6 CONTROVERSIES
• The choice of knot is a matter of surgeon preference. These surgeons use two half-hitch knots in the same direction, followed by alternating half-hitches, alternating the post on the final throw. • Alternatively, for the first knot, one can use a sliding knot such as the Tennessee Slider, or a sliding locking knot such as the Weston.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
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B
A
FIG. 5.21
FIG. 5.22
STEP 6 PEARLS
• The eyelet retention suture can be preserved and used to eliminate any residual “dog-ear” deformity by passing one limb through the tendon in either an antegrade or retrograde fashion. Otherwise, it can simply be removed and discarded.
STEP 6 PITFALLS
• The knotless suture anchor must be inserted to the appropriate depth. • Inserting the anchor below cortical bone may jeopardize fixation, while inserting the anchor above the level of the cortex may result in impingement within the subacromial space.
FIG. 5.23
be spaced equally along the lateral aspect of the greater tuberosity relative to the rotator cuff tear footprint. The arm can be rotated internally or externally to reveal the optimal location for anchor insertion. • The thermoablation device is used to clear soft tissue from the lateral cortex to expose the bone for anchor insertion. • The anchor is impacted using a mallet until the eyelet lies beneath the cortex. Preliminary tension is applied to the sutures to compress the torn rotator cuff tendon upon the footprint. The anchor is then impacted further until the tip of the anchor contacts the cortical bone. Final tension is applied to the sutures, and this tension is maintained. The anchor is then inserted by holding the thumb pad and rotating the handle until it is at the level of the cortical bone to ensure optimal fixation (Fig. 5.22). The eyelet retention suture is released, and the driver is removed. The suture limbs are then cut using an arthroscopic suture cutter. • The rotator cuff repair should be examined from the posterior and anterolateral portals while internally and externally rotating the extremity (Fig. 5.23). The arthroscope may also be inserted into the glenohumeral joint space to examine the repair from the articular perspective.
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
FIG. 5.24
Step 7 • Once the repair is completed, attention is then turned to the acromioplasty. An acromioplasty is performed only in the presence of an acromial spur; it is not necessarily a routine part of the procedure. • The borders of the acromion are defined using the thermoablation device. The acromial spur is exposed while taking care to preserve the deep deltoid fascia (Fig. 5.24). • An acromioplasty is then performed using a 4.85-mm oval burr, removing only enough bone to reveal the native acromion and to assure a flat undersurface (Fig. 5.25). • The shaver is then used to complete the bursectomy and to remove any loose osseous fragments from the acromioplasty.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients who undergo massive rotator cuff repair are managed with a standard postoperative rehabilitation regimen: • Weeks 1–6: sling immobilization, waist-level activities of daily living, elbow/wrist/ hand motion, no reaching/lifting/pulling/pushing. • Weeks 6–8: discontinue sling, begin passive ROM • Weeks 8–10: begin active-assisted ROM and active ROM • Weeks 10–12: begin progressive strengthening • While healing rates of massive rotator cuff tears have been historically low, particularly in older patients with more aggressive rehabilitation, these patients are often still able to achieve favorable clinical outcomes (Galatz et al., 2004; Gerber et al., 2000; Harryman et al., 1991; Sugaya et al., 2007). • Complications are rare with arthroscopic repair of massive rotator cuff tears. As discussed above, perhaps failure to heal is the most common complication. In addition, these patients may encounter stiffness, particularly when managed with a conservative rehabilitation regimen consisting of prolonged immobilization. Late stiffness can be treated with judicious use of corticosteroid injections and, in refractory cases, with arthroscopic lysis of adhesions.
EVIDENCE Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojanl C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg [Am]. 2007;89:747–57. In this study, 68 patients who underwent arthroscopic biceps tenotomy or tenodesis for the treatment of massive irreparable rotator cuff tears were retrospectively reviewed at a minimum of 2 years after surgery; 78% of patients were satisfied. The mean Constant score improved from 46.3
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FIG. 5.25
STEP 7 CONTROVERSIES
• Controversy exists regarding single-row versus double-row repair. Double-row repairs have demonstrated enhanced biomechanical properties and restoration of the native footprint with compression of tendon to bone over a larger surface contact area. • Effects of single-row versus double-row repair on healing and clinical outcome are varied and inconclusive, though improved postoperative structural integrity has been demonstrated with double-row techniques (Charousset et al., 2007; Park et al., 2008; Sugaya et al., 2005). • Increased cost of double-row repair is a disadvantage. • The authors prefer a double-row repair in younger patients in whom anatomic healing will likely have a greater effect on outcome and satisfaction.
STEP 7 EQUIPMENT
• 4.75-mm SwiveLock SP suture anchor (Arthrex; Naples, Florida) • Arthroscopic suture cutter • 4.85-mm arthroscopic bur • 5.0-mm arthroscopic shaver
STEP 7 PEARLS
• Avoid excessive bone removal. • Protect the deltoid from injury.
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears
STEP 7 PITFALLS
• Excessive bone removal, injury to the deltoid, and resection of the coracoacromial ligament could lead to iatrogenic anterior-superior instability. • In the presence of an os acromiale, an acromioplasty is deferred to avoid destabilizing the fragment. • If one is concerned about the security of the repair or likelihood of successful healing, one should consider deferring the acromioplasty to preserve the coracoacromial arch, which serves as a restraint to anterosuperior escape.
POSTOPERATIVE PEARLS
• Adequate pain control is necessary to allow patients to progress with prescribed therapy. • Cold therapy is useful in pain control and postoperative comfort.
POSTOPERATIVE PITFALLS
• Overly aggressive initial therapy may risk early repair failure.
POSTOPERATIVE CONTROVERSIES
• Conclusive evidence does not yet exist to support any specific rehabilitation protocol. Earlier protocols relied on early motion to avoid stiffness associated with open procedures. • These authors have moved to a more conservative rehabilitation program because of the low rate of healing after repair of massive rotator cuff tears. Furthermore, stiffness may be less of a concern in the context of arthroscopic repair.
to 66.5. There was no difference in outcome between the tenodesis and tenotomy groups. Cosmetic deformity occurred in 62% of patients, but none was symptomatic after tenotomy. Atrophic teres minor, pseudoparalysis, and severe cuff tear arthropathy were associated with worse clinical outcomes. (Level III evidence). Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Sur Am. 2005;87(6):1229–40. This study was one of the first to show decreased healing after rotator cuff repair in patients over the age of 65 years. Sixty-five shoulders with chronic rotator cuff tears were evaluated for outcomes and tendon integrity after repair. Absence of healing was associated with decreased strength. Patients over the age of 65 had a 43% chance of healing. Charousset C, Grimberg J, Duranthon LD, Beilaiche L, Petrover D. Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair? A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment. Am J Sports Med. 2007;35:1247–53. This prospective investigation compared patients who underwent arthroscopic single-row or doublerow rotator cuff repair with minimum postoperative follow-up of 2 years using Constant scores, patient satisfaction, return to work, and postoperative computed tomography (CT) arthrogram to assess repair integrity at 6 months. There was no significant different in Constant scores between groups, with improvement in pain, activity, and strength in both groups. In addition, there was no difference in subjective satisfaction or return to work. While no statistically significant difference was detected in the incidence of “watertight” repairs on CT arthrogram (77.4% for double row, 60% for single row), there was a significantly higher incidence of “anatomic” footprint restoration in the double-row group. (Level II evidence). Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8:599–605. This study examined 41 patients undergoing shoulder surgery with CT and MRI to establish whether these methods were comparable in assessing rotator cuff fatty infiltration and to establish a relationship between fatty infiltration and rotator cuff muscle atrophy. The study concluded that CT and MRI had excellent interobserver reliability, although the latter demonstrated superior reliability. The correlation between CT and MRI was fair to moderate, and a relationship between fatty infiltration and atrophy was established. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg [Am]. 2004;86:219–24. In this study, 18 patients who had complete arthroscopic repair of a tear measuring greater than 2 cm in the transverse dimension were evaluated at a minimum of 12 months and at 2 years after surgery. Seventeen of 18 patients demonstrated recurrent tears. Despite this lack of healing, clinical improvement was noted in certain patients at 12 months, including American Shoulder and Elbow Surgeons (ASES) scores greater than 90 points in 13 patients, improved functional outcome scores in 16, resolution of pain in 12, and improved motion with elevation above shoulder level in all 18. Clinical outcomes declined somewhat at 2 years, including ASES scores and forward elevation. (Level IV evidence). Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg [Am]. 2000;82:505–15. This study prospectively evaluated 27 patients who underwent open repair of massive rotator cuff tears at a minimum of 2 years postoperatively with imaging and clinical evaluation. Overall, patients demonstrated improvement in the Constant score, ROM, and pain; and 63% of tendons demonstrated healing on final evaluation. Patients with recurrent tears demonstrated clinical improvement, albeit less than in those patients with intact repairs. Fatty infiltration was found to be irreversible, and muscle atrophy was only somewhat reversible in intact supraspinatus repairs. (Level IV evidence). Harryman 2nd DT, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen 3rd FA. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg [Am]. 1991;73:982–9. In this study, 105 patients who underwent open rotator cuff repair were retrospectively reviewed at a minimum of 2 years postoperatively with imaging and clinical evaluation. Eighty percent of isolated supraspinatus tears successfully healed on ultrasound, whereas 50% of larger tears healed. Increased prevalence of recurrent tears was found in older patients and those who had undergone previous attempted repair. Most patients reported pain relief and satisfaction postoperatively, regardless of the status of the repair. However, patients with an intact repair demonstrated better function, ROM, and strength. Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg [Am]. 2009;91:1405–13. In this study, 117 patients with rotator cuff tears, both symptomatic and asymptomatic, were prospectively evaluated with plain radiographs and ultrasound. Proximal humeral migration was greater
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears in symptomatic tears, as well as those tears that involved the infraspinatus. For symptomatic tears greater than 175 mm, pain and tear size have a significant effect on proximal migration. However, tear area was determined to be the most important predictor of proximal humeral migration. (Level II evidence). Keener JD, Wei AS, Klm HM, et al. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome. J Bone Joint Surg [Am]. 2010;92:590–8. This study retrospectively reviewed 21 patients who underwent revision arthroscopic rotator cuff repair at a minimum of 2 years after surgery. These patients demonstrated improvement in pain, Simple Shoulder Test scores, ASES scores, forward elevation, and ER. Forty-eight percent of patients demonstrated healing on postoperative ultrasound examination, including 70% of those with single-tendon tears and 27% of those with supraspinatus/infraspinatus tears. Patient age and number of torn tendons had a negative correlation with postoperative repair integrity. Those patients with intact repairs demonstrated higher Constant scores and improved scapular-plane elevation. (Level IV evidence). Le BTN, Wu XL, Lam PH, Murrell GAC. Factors predicting rotator cuff retears: an analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med. 2014;42(5):1134–1142. In a retrospective study of 1000 patients, the retear rate was 17% 6 months after surgery. Retears occurred in 27% of full thickness tears and 5% of partial thickness tears. Factors associated with retears are age at the time of surgery and tear size, both the AP and medial-lateral dimensions. Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair. J Bone Joint Surg [Am]. 2007;89:1770–6. This study retrospectively reviewed 53 patients with isolated supraspinatus tears at a minimum of 24 months postoperatively. Overall, patients demonstrated improvement in the Constant score regardless of repair integrity. Seventy-five percent of patients demonstrated healing on final evaluation. Patients with recurrent tears demonstrated diminished abduction strength and decreased Constant scores. Preoperative fatty infiltration of grade 2 or more, supraspinatus atrophy, and age all were found to be associated with recurrent tears. Neither progression nor reversal of fatty infiltration or atrophy was observed in healed tears. However, recurrent tears demonstrated progression of both of these characteristics. (Level IV evidence). Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus: new anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg [Am]. 2008;90:962–9. This cadaveric study of 113 shoulders sought to define the insertional footprint of the posterosuperior rotator cuff tendons, and discovered the footprint of the supraspinatus to be smaller, and that of the infraspinatus to be larger, than previously thought. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of singleand double-row repairs in rotator cuff tears. Am J Sports Med. 2008;36:1310–6. This investigation compared patients who underwent single-row and double-row arthroscopic rotator cuff repair. These patients were evaluated at a minimum of 22 months with ASES and Constant scores, as well as a Shoulder Strength index. Overall, all outcomes improved in both groups with no statistically significant difference between groups. However, when large and massive tears (>3 cm) were examined separately, the double-row group demonstrated superior results compared to the single-row group. (Level II evidence). Park MC, Elattrache NS, Tibone JE, Ahmad CS, Jun B-J, Lee TQ. Part I: footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007a;16(4):461–8. Park MC, Tibone JE, Elattrache NS, Ahmad CS, Jun B-J, Lee TQ. Part II: biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a doublerow repair technique. J Shoulder Elbow Surg. 2007b;16(4):469–76. These studies established the biomechanical and physical characteristics for the transosseous equivalent repair commonly used in practice. The first evaluated the contact area of the tendon to the native footprint of the rotator cuff tendon insertion on the greater tuberosity, and the transosseous repair better approximated the anatomic footprint. The second study compared the transosseous equivalent repair to a double row technique, and the transosseous repair improved ultimate failure strength but did not differ in stiffness or gap formation. Sugaya H, Maeda K, Matsuki K, Morüshi J. Functional and structural outcome after arthroscopic fullthickness rotator cuff repair: single-row versus dual-row fixation. Arthroscopy. 2005;21:1307–16. This investigation compared patients who underwent single-row and double-row arthroscopic rotator cuff repair. These patients were evaluated at a minimum of 2 years postoperatively with UCLA and ASES scores, as well as with MRI to assess structural integrity. Although all patients demonstrated improvement in outcome scores, with no statistically significant difference among groups, structural integrity did differ. Significantly more subjects in the single-row group demonstrated insufficient thickness and recurrent defects in the rotator cuff repair. Subjects with large to massive tears demonstrated a higher incidence of recurrent defects in the single-row group compared to the double-row group (44% versus 29%, respectively). (Level III evidence).
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PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears Sugaya H, Maeda K, Matsuki K, Morüshi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg [Am]. 2007;89:953–60. In this study, 86 patients who underwent arthroscopic double-row rotator cuff repair were evaluated prospectively at a minimum of 2 years postoperatively. Overall, all clinical outcome scores, including Japanese Orthopedic Association (JOA), UCLA, and ASES scores, improved on final evaluation. Eighty-three patients demonstrated healing on MRI, including 95% of small and medium tears and 60% of large and massive tears. Patients with a recurrent major defect demonstrated diminished outcome scores and strength, while those with a recurrent minor defect demonstrated no functional compromise. (Level IV evidence). Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg [Am]. 2004;86:708–16. In this study, 71 patients who underwent shoulder arthroscopy were prospectively studied to examine the relative accuracy of ultrasound in evaluating the rotator cuff relative to MRI and arthroscopy. Ultrasound demonstrated accuracy comparable to MRI with regard to identifying a rotator cuff tear and distinguishing partial-thickness and full-thickness tears, as well as determining the dimensions of the tear. (Level 1-1 evidence).