Partial Repair of Rotator Cuff Tears Greater Than Five Centimeters

Stephen J. Snyder M.D.

Surgical Technique

The patient is placed in a lateral decubitus position with arm abducted 35-40* and 10-12 pounds of traction is applied through a shoulder holder. A gel axillary roll is used to protect the opposite extremity and the down extremity is padded with a gel pad over the fibular head to protect the peroneal nerve. The lateral malleolus is also padded in the same manner. These precautions are recommended by the author.

After the shoulder is prepped with Betadine scrub and painted with Betadine solution the skin is cleaned with isopropyl alcohol followed by a degreaser in preparation to use a vi drape. The anatomical landmarks are drawn on the skin. The posterior portal is marked one thumb width inferior to posterior aspect of the acromion in line with the posterior skin fold from the axilla. The posterior portal is infused with 0.5% Marcaine with epinephrine if permitted by anesthesiologist. The author does not distend the shoulder with saline. The trochar sleeve is inserted into the posterior portal directed toward the coracoid process at a 40 degree angle. The posterior rim of the gleno-humeral joint can be palpated with the tip of the trochar by sweeping medial-lateral. A gentle rotation motion with pushing will allow entry into the joint just medial to the origin of the biceps tendon. Once the trochar is in the joint, a 30 degree arthroscope is inserted. Following shoulder distention with a pump system, the joint is examined systematically . The author prefers to visualize the labrum, subscapularis tendon, glenoid, humeral head, and medial biceps tendon: then placing the arthroscope on the lateral side of the biceps tendon, inspect the rotator cuff from inferior to superior. If one desires to debride the rotator cuff from the intra-articular side, an anterior portal must be established to insert the radial resector. Once all the intra-articular inspection and surgery as been performed the arthroscope is retracted to skin level and a sharp trochar with sleeve is butted against the posterior acromion and inserted into the subacromial space with a sweeping motion. The anterior lateral portal is established by placing an eighteen gauge needle under direct vision in the middle of the large lesion. This provides better access for placement of the anchor. The anchors cannot be placed at an optimal angle to the bone if the portal is to far anterior or posterior In some of these massive tears, two portals are required on the lateral side of the shoulder for optimal anchor placement Once the ALP is established, the bursal tissue is removed with a radial resector (4.5mm). The under surface of the coraco- acromial ligament attachment is removed with the radial resector to the anterior edge of the acromion. All bleeding that is encountered during this procedure is controlled with bipolar cautery. The 4.5mm radial resector is used to remove the acromion starting anterior and removing full thickness to the anterior level of the clavicle. Then the acromion is contoured posteriorly to produce a flat surface. If this technique is used to remove the anterior acromion for the right shoulder, the reverse speed should he used so the blade does not cut into the deltoid muscle or fascia. In a left shoulder use the rotation of blade in forward mode.

If there is degenerative disease in the AC joint, the arthroscopic Mumford procedure is performed. A needle is inserted in the posterior aspect of the AC joint, followed by a stab wound and the insertion of the radial resector to remove 7-8mm off the clavicle side and 3-4mm off the acromial side. No burrs are used by the author to do the acromioplasty or arthroscopic Mumford. Use of the radial resector has the advantage of eliminating bone particles and dust which, in the author's opinion creates increased synovial or bursal reaction and may be the cause of stiffness in the shoulder.

Once the bony operation has been completed, the next step is very critical: to expose the entire retracted rotator cuff. The anterior and middle aspects are usually easily exposed, but the posterior aspect presents difficulty in exposure and identification of the true cull. Several reasons for these difficulties are (1) the crowding of instruments, (2 )increased bleeding in the posterior veil of the bursa, and (3) retraction of the cuff. The posterior thickened bursal veil is easily mistaken for cuff. A point of importance is that cuff tissue must be identified so the repair will be successful: failure to make proper identification here will result in a failed repair. After the entire cuff is clearly identified viewing from the bursal side through posterior portal, the assessment of rotator cuff tear pattern must be made. If an "L" or "V" shaped tear is posterior this may allow tendon to tendon repair, but it must be determined if the edges are flexible enough to be approximated. If the edges will oppose, the tendon to tendon suture is placed in the most posterior portion of the tear and suturing proceeds anteriorly. Once the tendon to tendon repair is completed, then a grasper is applied to the remaining non-repaired cuff and the cuff is displaced anteriorly and laterally to determine the fixation site in the bone that does not place the cuff under tension. Holding the cuff at the designated site, the l0Ib weight being used for traction is removed and the arm is adducted to 0 degree. If the grasper can be maintained at the proposed bone site, then the cuff can be repaired to this site with an anchor and will not fail by suture pulling out from the cuff. The above procedure is repeated before each anchor placement until the cuff held by the grasper will not remain in place with arm adducted. This provides the surgeon with endpoint of cuff repair.

The most common tear pattern is the large "oval". This type of tear is evaluated the same as the "L" and "V" patterns but there is no tendon to tendon repair. One must identify the most posterior aspect of the tendon. A grasper is placed on the tendon to determine the amount of flexibility in the tendon for anterior displacement. Then a suture is placed in the posterior portion of the cuff. The author uses #1 PDS. The anchor placement is determined as previously described for selecting a bony site with the arm adducted. After the first posterior suture is in place, the grasper is placed more medial-anterior and pulled anteriorlaterally to select bony attachment by the adduction technique. The endpoint is determined by the above technique. It cannot be overemphasized that the success of partial repair of the rotator cuff is a repair monitored by adduction of the arm. In the opinion of the author, rotator cuff failure after repair is due to excessive tension by the use of large diameter sutures to bony fixation. If the bone site for fixation is adequate then the suture site in the cuff will fail with excessive tension.

Many of these large cuff tears will have an associated frayed flattened biceps as it starts to exit the joint. The author has used this tendon for attachment to the large oval rotator cuff tendons from a posterior and anterior directions. At times the anterior portion of the rotator cuff (supraspinatus) tendon will be attached to the biceps tendon and both attached to the bone by a suture anchor. The author postulates that this prevents anterior and superior migration of the humeral head by creating dynamic combined tendon stabilization.

The defect will remain anteriorly and will vary in size from patient to patient.

Once the partial cuff repair is completed without disruptive tension, the wounds are closed and patient placed in an ultrasling.

Stage Repair

The stage procedure is performed following a partial repair and rehabilitation of 4-6 months. The shoulder must have full range of motion, actively or passively. The stage procedure does not imply that the remaining defect will be closed one hundred percent. Its physiological and mechanical merits are to create a more functional shoulder as determined by the Modified UCLA rating. This rating has 10 additional points: five for normal abduction strength at 90 degrees and five points for normal resistive external rotation with the elbow against the chest and arm externally rotated at 30 degrees. In the author’s experience, this testing evaluates the integrity of the teres minor, infraspinatus and the remaining defect anteriorly.

Surgical Technique

The shoulder is abducted 40 degrees in lateral decubitus position with lOIbs of traction. The anatomical landmarks are identified and the arthroscope is inserted in the posterior portal. The intra-articular inspection is performed with emphasis on the healed partially repaired cuff. This healed portion will be posterior. It is very important to evaluate the remaining defect from the intra-articular side to identify tear size, pattern, and configuration. An example that is commonly seen on the joint side is horizontal tears with redundant cuff. This alerts the surgeon that once in the subacromial space, this cuff tissue must be incorporated in the sutures to have full thickness repair. The arthroscope is placed in the subacromial space and some scar tissue may be found between the rotator cuff and the deltoid muscle fascia. Often the subacromial space will be very spacious. The remaining cuff must be evaluated for flexibility by applying tension with the grasper. The bone bed must be prepared for bleeding bone. The repair still must start posteriorly and proceed anteriorly. The remaining defect may be completely or partially closed. Again, rotator repaired under "hogging the suture to bone" will fail. The author uses #1 PDS with anchor to bone. The biceps tendon may be used to create anterior anchoring or closure of the rotator cuff. This may place rotator cuff to tendon or rotator cuff to tendon and then to bone by anchor. Once the stage procedure has been performed, either complete or partial, the wounds are closed in the usual manner and the patient’s arm is placed in an ultrasling.

The post operative course requires the patient to wear the sling for three weeks with removal of the pillow portion at the end of the first week. Elbow motion is allowed the first post-operative day. At the end of the third week, the patient is instructed to start circumduction and spider climbing exercises for two weeks. At the fifth week the patient is provided with a shoulder kit and emphasis is placed on using the pulley and exercise stick until full motion is attained. The least resistive thera-band is used in range of motion as pain will permit. The patient must have full range of motion with this band and be performing eight repetitions with five sets before progressing to the next resistive thera-band. The author recommends rehabilitation for a minimum of three months and, ideally, for six months. Only 2% of these patients require professional physical therapy.