- 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.
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