Monday, October 3, 2011

Rotator Cuff 14 - Partial thickness rotator cuff tears - cuff curettage

Here is the detailed description of a procedure (in the form of an operative note) that we've found successful for the management of partial thickness cuff tears that have not responded to a program of stretching. We refer to it as cuff curettage.

DIAGNOSIS:
Partial thickness cuff tear involving the deep surface of the anterior supraspinatus near the tuberosity and the bicipital groove - ICD9 CODE 726.1.

PROCEDURE:
Rotator cuff exploration, lysis of adhesions, resection of bursal tissue, curettage of partial thickness cuff tear – CPT CODE 23405.

INDICATIONS:
The patient has functionally significant pain on elevation of the shoulder. The symptoms have not responded to a program of stretching exercises even though the range of motion is now full. The shoulder continues to manifest a positive supraspinatus tendon sign, i.e., pain on active isometric elevation in the plane of the scapula at 90 degrees of elevation while the arm is in slight internal rotation.  There is minimal atrophy of the supraspinatus and a slight local depression in the tendon near its insertion.

Cuff imaging tests reveal thinning of the supraspinatus tendon due to a partial thickness deep surface tear near its anterior insertion without retraction of the tendon.

Knowing the alternatives as well as the risks of infection, neurovascular injury, excessive stiffness, pain, weakness, irreparability, re-rupture, and the need for revision surgery, the patient desires to proceed with rotator cuff surgery. The patient understands that this surgery will probably consist of curetting the cuff lesion so that its tenuous attachments are released, but could also possibly include a rotator cuff repair if the tear is essentially full thickness and if the cuff tendons are of sufficient quantity and quality, and possibly include a smooth and move without repair if a large irreparable cuff lesion is encountered. The patient recognizes the goal of this procedure is to release weakly attached tendon fibers and understands that it cannot be expected to completely restore normal comfort and function to the shoulder. And lastly, the patient understands his/her critical role in the post surgical rehabilitation.

FINDINGS:
Examination under anesthesia reveals a slightly diminished range of motion and a slight palpable thinning of the cuff near the supraspinatus insertion to the greater tuberosity.

Surgical findings include mild scarring in the humeroscapular motion interface as well as bursal thickening. There is a partial thickness, deep surface defect involving the anterior supraspinatus tendon. The other aspects of the cuff tendons are of good quality and the long head of the biceps and the subscapularis are intact. The undersurface of the coracoacromial arch is smooth.

OPERATION: 
Under satisfactory anesthesia the patient is placed in a low beach chair position. The entire forequarter is carefully prepped and draped in the usual sterile fashion with the arm free to be moved.


The shoulder is approached through a superior incision in the skin line crossing the anterior corner of the acromion





The ‘deltoid-on’ approach is used



The deltoid tendon of origin running between the anterior and lateral thirds of the deltoid is identified and split longitudinally, leaving half of the tendon on either side of the split; no deltoid is detached from the acromion. This split is carried down to the sub deltoid bursa, which is divided in line with the deltoid split. The total length of the deltoid split is limited to 4 cm from the acromion. 


The humeroscapular motion interface is mobilized by blunt finger dissection. A small self-retaining retractor is inserted into the split.   The humeroscapular motion interface is mobilized beneath the coracoid muscles until the axillary nerve can be palpated medially on the front of the subscapularis. The interface is dissected laterally until the axillary nerve can be palpated laterally as it exits the quadrilateral space.

The thickened subacromial/subdeltoid bursa is excised.



This dissection provides excellent exposure of the rotator cuff. The thinned area of the cuff can be identified by palpation, even though the bursal side of the tendon is intact.






A small 000 curette is inserted through the thinnest part of the cuff without making a cuff incision.



The curette is felt to scrape against the uncovered bone from where cuff has been torn. This area is curetted from the anterior to the posterior extent of the tendon detachment until secure cuff insertion is encountered at either end.


On withdrawing the curette only a small puncture in the cuff is present, so no closure of this defect is needed. If the defect had been through most of the cuff thickness so that the tendon insertion was severely weakened, the detachment would have been completed and a formal repair would have been carried out.


Full motion of the glenohumeral joint is assured by gentle manipulation. The acromion is palpated while the shoulder is put through a complete range of motion to verify the absence of any crepitance. The undersurface of the coracoacromial arch is palpated to assure its smoothness. If there is a prominence that encroaches on the cuff, it is smoothed with a pinecone burr without jeopardizing the integrity of the coracoacromial arch.

Formal "acromioplasty" is avoided to preserve the coracoacromial concavity as well as to minimize the risk of adhesions and of weakening the deltoid origin.

Hemostasis is seen to be excellent. The wound is thoroughly irrigated. The deltoid origin is intact at the conclusion of the case. The deltoid split is closed side-to-side-to-side with absorbable sutures.



A standard subcutaneous and subcuticular skin incision is carried out followed by the application of sterile tape closures and sterile dressings.



The patient is returned to Recovery Room in satisfactory condition, with the arm in continuous passive motion.





POSTOPERATIVE PLAN:

Our postoperative plan is for the 140 degrees of flexion/40 degrees of external rotation full motion active program, including stretches in forward flexion, external rotation, up the back, cross body, as well as internal rotation in abduction. There is no need for protection in that there has been no cuff repair and that the deltoid has only been split along its fibers. Forward elevation can also be assisted using a pulley. The ranges of motion are charted on a wall chart twice daily; the patient is discharged when the assisted range of motion goals are achieved.

Strengthening exercises will be started at six weeks after surgery when the shoulder is completely comfortable.



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