The Hip: Preservation, Replacement and Revision

Assessment of Rotator Cuff Tear

Discussion:  - anatomy of rotator cuff 

 - Assessment of Cuff Tear: 
    - partial tear
    - crescent tear
          - single tear pattern
          - minimal medial retraction
          - allows straight forward repair
    - U shaped tear
          - crescent-shaped tear with  significant central medial retraction (medialization can approach glenoid rim)
          - requires convergence repair;
    - L shaped tear and reverse L shaped tear
          - similar to U-shaped tears, but there also is longitudinal split posteriorly anteriorly, resulting in the posterior leaflet retracting posteriorly and medially;
          - posterior leaflet needs to be reduced anatomically; 
          - anterior cable:
                   - The biomechanical relevance of anterior rotator cuff cable tears in a cadaveric shoulder model.

    - massive rotator cuff tear 
          - reestablishment of the rotator cable;
                 - refers to anterior and posterior attachments of rotator cuff;
                 - fibers from coracohumeral ligament which transversely span distal attachments of supraspinatus and infraspinatus tendons in a curving arc;
                 - cable helps distributes the forces throughout the rotator cuff tendon;
                 - anterior cable attachment has a significant concentration of forces under rotation.
                 - need to repair cable reattachment prior to any margin convergence as well since it brings the supraspinatus out to proper length;
                 - with cuff tears extending anterior enough so that there is no remaining cuff attachment lateral to the biceps, then the anterior cable is disrupted;
                 - need to repair the most anterior portion of the supraspinatus with an anchor adjacent to the articular surface of the humeral head
                            just lateral and posterior to the biceps;
                 - this may convert a large tear into a U-shaped tear;
 
- Open Assessment:
   - after exposure, tear in rotator cuff must be identified, although this may be difficult if reactive bursal changes are present;
           - freeing bursa from scar allows one to recognize normal tendon and to continue tissue dissection in the same plane over torn area;
    - rotator cuff size is best described by surface area and by muscle compliance rather than a simple linear measurement;
    - posterior cuff will be brought into operative field by extending and internally rotating the shoulder - which is acomplished by pinning
           patient's arm between OR table and surgeons hip while it is positioned in full exernal rotation; 
    - assessment of size of rotator cuff tear:
           - infraspinatus insertion zone was identified by laying the two branches of the forceps over the scapular spine so that the forceps were in line with the fibers of the cuff;
           - fibers coming from a level inferior to the scapular spine are infraspinatus fibers;
           - teres minor insertion was identified by locating its insertion on the respective tubercle, which lies inferior and slightly medial to infraspinatus insertion

- References:
      - Anatomic reduction and next-generation fixation constructs for arthroscopic repair of crescent, L-shaped, and U-shaped rotator cuff tears.
      - Arthroscopic Rotator Cuff Repair
      - ROTATOR CUFF TEAR: ARTHROSCOPIC TREATMENT
      - Rotator cuff repair: Current concepts and applications
      - Arthroscopic Repair of Large U-Shaped Rotator Cuff Tears Without Margin Convergence Versus Repair of Crescent- or L-Shaped Tears



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, January 19, 2015 3:49 pm