Sunday, July 15, 2012

The smooth and move in the management of irreparable tears or failed rotator cuff repairs

While there is much emphasis on restoring anatomic integrity of the torn rotator cuff, this is not always in the best interest of the patient, especially if a prior attempt at cuff repair has failed.
We have been pleased with the results of the 'smooth and move' procedure when the cuff tissue is of insufficient quantity or quality to favor a durable repair. This procedure enables immediate mobilization without concern about challenging a fragile repair. We start a full shoulder motion program right away after surgery and progress gentle shoulder strengthening as rapidly as shoulder comfort permits.

I just received a nice followup note from a sixty year old rancher for whom we performed bilateral 'smooth and move' procedures without any attempt to repair his supraspinatus or infraspinatus. While some may have considered 'marginal convergence', a cuff substitute, a latissimus transfer, or even a reverse total shoulder, we felt that none of these were right for this active man who wanted to get back to roping cattle on his ranch.

The right side was done in the fall of 2009. The operative note states:

This rancher has pain and loss of function of his right shoulder. He has had a rotator cuff tear which was treated with a graft jacket. Unfortunately, this became infected and required debridement, leaving him with a stiff, painful shoulder.

There was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. There was minimal evidence of arthritis. The tuberosities were prominent. The undersurface of the coracoacromial arch was smooth. 

Under satisfactory anesthesia, the shoulder was carefully prepped and draped in the usual manner. The shoulder was approached through a superior "deltoid on" approach. The abundant scar in the humeral scapular motion interface was debrided. The previous sutures and graft jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. The subscapularis was identified, freed from scar and reattached anteriorly. The wound was thoroughly irrigated. A manipulation under anesthesia was performed to assure a full range.



A similar procedure was performed on left side for a failed prior repair in the fall of 2011 where the findings were There was abundant scar in the humeroscapular motion interface. The supraspinatus was absent. The subscapularis was absent. The infraspinatus was absent in its upper 1/2. The biceps tendon was absent. The undersurface of the acromion was smooth.There was substantial scar and retained sutures. The deltoid was deficient in the area of the prior surgery.

The abundant scar in the humeroscapular motion interface was lysed.  The prior sutures were removed. The prominences on the humeral tuberosity were resected. The rough edges of the cuff were smoothed. The shoulder was gently manipulated for a full range of motion.The weakened area of deltoid was reinforced by imbrication of  the weakened area with six sutures of #2 Tevdek.

He reports that both shoulders are dramatically improved and that he is back to roping and branding as shown in the photos he shared with us.







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