Friday, September 23, 2011

Rotator Cuff 13 - Full thickness rotator cuff tears - repair

Full thickness rotator cuff tears are treated by secure reattachment to bone, provided there is sufficient quantity and quality of tendon for a robust attachment with the arm at the side. The goal is to have a smooth distribution of load that is continuous across both the repaired and intact tendon so that disproportionate force concentration on the repair is avoided. Because there is often a loss of tendon substance, repair to bone relatively shortens the tendon. The ability of the muscle to be extended laterally to accommodate for this shortening is limited by (1) the attachment of the capsule to the tendon on one hand and to the glenoid labrum on the other and (2) the attachment of the coracohumeral ligament to the tendon of the supraspinatus and subscapularis laterally and the coracoid medially. Thus, unless the tear is acute, it may be necessary to release the coracohumeral ligament from the coracoid.

 and to release the capsule from its attachment to the glenoid labrum

so that the muscle and tendon can be drawn out further laterally to the insertion. Without such releases the repair may be under undue tension and at risk for failure. After the releases have been performed and after any scar has been dissected from the humeroscapular motion interface, traction sutures are placed in the tendon edge. If good quality tendon can be brought close to its normal insertion site with the arm in adduction, a robust repair can be carried out.

The ideal reattachment technique has the following properties:

(1) yields a smooth upper surface which can articulate congruously with the intact undersurface of the coracoacromal arch 

and avoids knots or tendon edges on the upper aspect of the repaired cuff where they could rub under the coracoacromial arch 

(2) excludes joint fluid from the repair site and accommodates some slippage in the sutures and knots without separation of tendon from bone

(3) creates a secure isometric junction between the tendon and bone spreading the load among numerous sutures 

(4) can accommodate weakened bone at the greater tuberosity

(5) can be accomplished without sacrificing acromion, the acromioclavicular joint, or the deltoid origin 

If there is insufficient quantity and quality of tendon to reach the tuberosity with the arm at the side, consideration can be given to moving the insertion site up to 1 cm medially on the humeral articular surface. If a robust repair cannot be performed, the priority shifts from repair to achieving the smoothest possible upper aspect of the proximal humerus for articulating with the undersurface of the coracoacromial arch. Often the head is translated superiorly because of the loss of the spacer effect of the superior cuff tendon and secondary erosion of the superior glenoid lip

This situation may call for smoothing of the upper aspect of the residual cuff as well as recession of the tuberosities if they are prominent so that the surface presented by the proximal humerus to the coracoacromial arch is smooth – we refer to this as a “smooth and move,” the goal of which is to convert the upper aspect of the proximal humerus into a smooth convexity that articulates congruously with the concave undersurface of the coracoacromial arch. Because the procedure is performed through a deltoid-on approach, no postoperative restrictions are placed so that the patient can move the joint actively immediately after surgery. We have found that when the cuff will not reach to a reasonable insertion site, abducting the shoulder so that repair can be achieved

and then ‘protecting’ the arm in abduction

tends to lead to cuff insertion failure when the arm is brought down to the patient's side.


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