Mobilization of Rotator Cuff for Repair

- Discussion: (RTC menu)
    - mobilization is often required for massive tear;
    - simply closing extensive tear will not suffice if atrophied muscles are not contracting adequately and if excessive tensions placed on repaired cuff cause reinjury;
    - repair of good quality rotator cuff tissue is esp important in achieving an optimal result;
    - repairing attenuated, scarred, frayed, or fibrillated cuff tissue contributes to risk of failure, no matter how well tear closure is performed;
    - convergence repair
            - ref: Arthroscopic Repair of Large U-Shaped Rotator Cuff Tears Without Margin Convergence Versus Repair of Crescent- or L-Shaped Tears.

- Technique of Mobilization and Repair:
    - initial intra-articular release;
           - rotator cuff mobilization starts with an intra-articular release; 
           - need to recreate pouch that is normally present superior to glenoid labrum between undersurface of rotator cuff and superior or posterosuperior
                    portion of the lateral aspect of glenoid neck  (between 2 and 10 o'clock);
          - determine if the rotator cuff is attached by scar tissue to the superior part of the labrum
          - bring in cautery device from the anterior portal and define the interval between the labrum and the rotator cuff
          - release adhesions between undersurface of cuff and superior portion of glenoid labrum, starting from anterior and progressing toward posterior;
          - this will recreate the normal medial gutter between the rotator cuff and the capsule and the capsule/labrum;
          - this will release theadhesions and allow tension-free mobilization
          - careful to avoid dissection more than 2 cm medial to the glenoid edge to avoid neurovascular injury
          - ref: Arthroscopic Rotator Cuff Repair with Interval Release for Contracted Rotator Cuff Tears

    - cuff mobilization: 
           - when mobilizing the rotator cuff, it is first useful to pass a "traction" suture through the muscle (using a Kessler type stitch); 
           - this allows the cuff to be pulled forward under tension without damaging the muscle; 
           - place a blunt right angle retractor underneath the acromion and to apply traction to the forearm inorder to widen the exposure; 
           - surgeon can then pass his finger above and below the muscle, freeing up adhesions; 
           - superior capsular release: (see rotator interval)
                    - superior capsular release and rotator interval-coracohumeral ligament release is performed when needed to allow a low-tension reduction of
                             supraspinatus tendon to its anatomical position;
          - in repairing large RCT, additional length to obtain closure of gap may be gained by making parallel incisions on both sides of contracted tendon;
          - that is between supraspinatus & infraspinatus tendons posteriorly and between supraspinatus and subscapularis tendons anteriorly,
                    and by dividing capsule of shoulder joint at its reflexion onto internal surface of the rotator cuff;
    - dissection of the supraspinatus:
           - supraspinatus is ensheathed w/ in supraspinatus fossa by dense fascia from which some of the fibers take origin;
           - incision along scapular spine to release muscle encounters this supraspinatus fascia, which must be incised before muscle belly can
                     be lifted from fossa in preparatoin for its mobilization;
           - dense fascia of supraspinatus is incised and stripped w/ an elevator;
                  - suprascapular artery and nerve are protected by muscle unless dissection is inadvertently carried into muscle fibers;
           - suprascapular artery and nerve are protected from surgical trauma by supraspinatus, provided that digital dissection is confined to
                  spine of scapula and the floor of the fossa;
           - supraspinatus tendon is closely blended w/ underlying capsule and synovial tissue of the shoulder;
                  - this connention is divided before the muscle can be advanced;
     - anterior slide:
             - coracohumeral ligament (see rotator interval)
                    - ligament may be scarred down to the base of the coracoid which keeps the supraspinatus in a retracted position;
                    - by releasing the rotator interval and the coracohumeral ligament from the base of the coracoid may allow up to 1.5 cm of increase tendon excursion;
                    - ref: Arthroscopic release of the rotator interval and coracohumeral ligament: An anatomic study in cadavers.
     - posterior slide:
             - posterior release is performed in the interval between supraspinatus and infraspinatus, aiming toward the base of the scapular spine      
             - supraspinatus and infraspinatus are pulled laterally (away from the suprascapular nerve) while the surgeon releases the interval
             - suprascapular artery and nerve are protected from surgical trauma by supraspinatus, provided that digital dissection is confined to
                        spine of scapula and the floor of the fossa;
             - need to pulls the tendon that we are cutting further away from the nerve and is an added measure of protection for the nerve;
             - references:
                        - Arthroscopic repair of large rotator cuff tears using the interval slide technique
                        - Anatomy of the posterior rotator interval: implications for cuff mobilization
                        - Arthroscopic repair of massive, contracted, immobile tears using interval slides: clinical and MRI structural follow-up.
- additional techniques:
     - convergence repair
     - if gap in supraspinatus still cannot be closed, incision is extended thru AC joint, excising anterior corner of acromion together w/ 1 cm portion of clavicle;
     - retraction of cut end of clavicle & of divided trapezius will expose much of underlying supraspinatus muscle, allowing suture of even large tears
              of rotator cuff w/o tension after supraspinatus release and advancement;
     - modest debridement of the end of the tendon should expose sufficient healthy tissue for attachment by one of several techniques;
     - consider accepting cuff defect, suturing tendon to point of tension & then suturing tendon's edges to cancellous bone;
     - appropriate for triangular-shaped tear, w/ its longest portion parallel to tendon fibers & relatively narrow base perpendicular to tendon
              fibers and near the tendon insertion; 
      - references:
              - Anatomy of the posterior rotator interval: Implications for cuff mobilization 

- References:

Advancement of the supraspinatus muscle in the repair of ruptures of the rotator cuff.

Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears.

Mobilization and Repair Techniques for the Massive Contracted Rotator Cuff Tear: Technique and Preliminary Results

Techniques to Mobilize and Repair a Retracted Rotator Cuff Tear 

Electromyographic evaluation after primary repair of massive rotator cuff tears

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity.

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

Last updated by Data Trace Staff on Monday, October 28, 2013 12:30 pm