- Discussion:
- 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;
- Intra-Articular Release;
- need to recreate the pouch that is normally present superior to the glenoid
labrum between the undersurface of the rotator cuff and the
superior
or posterosuperior portion of the lateral aspect of
the glenoid neck;
- determine if the rotator cuff is attached by scar tissue
to the superior part of the labrum
-
release adhesions between undersurface of cuff and
superior portion of glenoid labrum, starting from anterior
and progressing toward posterior;
- Technique of Mobilization and Repair:
- when mobilizing the rotator cuff, it is first useful to pass a "traction" suture thru 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;
- the surgeon can then pass his finger above and below the muscle, freeing up adhesions;
-
superior capsular release:
- superior capsular release and rotator interval-coracohumeral ligament release is performed when needed to allow a low-tension reduction of the
supraspinatus tendon to its anatomical position;
- in repairing large tear of cuff, 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 the 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
- 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;
- 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
- need to pulls the tendon that we are cutting further away from the nerve and is an added measure of protection for the nerve;- misc techniques:
- 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;
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.
Anatomy of the posterior rotator interval: Implications for cuff mobilization
Mobilization and Repair Techniques for the Massive Contracted Rotator Cuff Tear: Technique and Preliminary Results
