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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.

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