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Wheeless' Textbook of Orthopaedics

Open Repair of Supraspinatus / Infraspinatus Tear   

 - Rotator Cuff Tear - Discussion: 
     - arthroscopic repair techniques
     - clinical outcomes of repair
     - indications for RTC tear:
             - shoulder pain (especially night pain);
             - symptoms which cause loss of function or quality of life;
             - failure of NSAIDS and formal physical therapy;
             - failure of series of marcaine / steroid injections;
             - full passive ROM pre-op is necessary for a successful operation (rule out frozen shoulder);
     - relative contra-indications:
             - superior migration of humeral head (which indicates massive rotator cuff tear);
                   - as noted by Gartsman GM (1997), all patients w/ radiographic superior migration of the humeral head had a poor result;
             - deficient deltoid, subscapularis, and/or teres minor (either by clinical exam or by MRI) are more likely to lead to poor results;

  - Acromioplasty and Subacromial Dissection:   
 
    - w/ a potential irrepairable cuff tear, consider leaving the CA ligament intact;
     - incision is then deepened to expose subacromial bursa, allowing limited view of underlying rotator cuff;
     - exposure may be improved by elevating acromion w/ small right angled retractor distracting humeral head downward, &
              resecting CA ligament (which is accompanied by acromial branch of thoracoacromial artery); 

     - controversies: Do we always need a subacromial decompression?
               - Goldberg BA, et al, the authors evaluated on shoulder function at a minimum of 2 years after 27 full thickness RC repairs were done
                       w/o deltoid detachment, acromioplasty, or section of CA ligament;
              - 8 of 12 individual Simple Shoulder Test functions were significantly improved after the procedure;
              - there also was a significant improvement in the Short Form-36 comfort, physical role function and mental health scores;
              - RTC w/o acromioplasty avoids possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon
                       scarring to cancellous undersurface of the acromion;
     - references:
              - Improvement in Comfort and Function After Cuff Repair Without Acromioplasty
              - Open rotator cuff repair without acromioplasty.
              - Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes.
              - Débridement of Partial-Thickness Tears of the Rotator Cuff without Acromioplasty. Long-Term Follow-up and Review of the Literature

- Surgical Exposure:
        - 
references:
               - Atrophy of the deltoid muscle following rotator cuff surgery.
               - Arthroscopically Assisted Mini-Deltopectoral Rotator Cuff Repair


- Cuff Repair Considerations: 
 
    - assessment of cuff tear:  (see management of massive rotator cuff tear); 
     - mobilization of rotator cuff: 
     - restoration of the foot print
     - rotator cuff repair techniques:
 
- Additional Considerations: 
  
  - arthroscopic repair techniques
    - distal clavicle excision: (w/ concomitant arthrosis);
    - greater tuberosity debridement:
           - prominent tuberosity can be excised if there is further impingment;
    - biceps tendon:
           - w/ obvious pathology of the long head of the biceps, consider proximal release of the tendon w/ or w/o tenodesis; 
           - reference:
                  - To detach the long head of the biceps tendon after tenodesis or not: outcome analysis at the 4-year follow-up of two different techniques.

- Deltoid Repair:
    - both the superficial and deep fascial layers of the deltoid must be included in the suture repair of the deltoid to the acromion (thru acromial drill holes);
    - consider using a Mason-Allen stitch thru the deltoid muscle;           
    - reference:
            - Arthroscopically Assisted Mini-Deltopectoral Rotator Cuff Repair             

- Post Op Care:
    - with rotator cuff tears, passive range of motion may begin on day 1, and active assist exercises at week four;
    - consider early active assited elevation and external rotation in the supine position; 

- Complications of Rotator Cuff Surgery: 
       - Prevention of shoulder stiffness after rotator cuff repair.


Clinical and Structural Results of Open Repair of an Isolated One-Tendon Tear of the Rotator Cuff.

  - Older References




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

Last updated by Clifford R. Wheeless, III, MD on Tuesday, February 12, 2013 7:08 pm