Restoration of Large and Massive Rotator Cuff
Tears with Arthroscopic Technique
Andreas X Papadopoulos*, George E Chatzimarkakis and Athanassios Ch Karageorgos
Department of Orthopaedic Surgery, Olympion Medical Center, Patras, Greece
Submission: April 17, 2019;;Published: April 29, 2019;
*Corresponding author: Andreas X Papadopoulos, Department of Orthopaedic Surgery, Olympion Medical Center, Patras, Greece
How to cite this article: Andreas X P, George EC, Athanassios CK. Restoration of Large and Massive Rotator Cuff Tears with Arthroscopic Technique.
Ortho & Rheum Open Access J 2019; 14(1): 555878. DOI:10.19080OROAJ.2019.14.555878
Purpose: The evaluation of the clinical results and the integrity of the tendon reconstruction after arthroscopic treatment of patients with large or massive rotator cuff rupture.
Methods: This is a retrospective study, with a minimum postoperative follow-up of 24 months, of 134 patients (74 men and 60 women, mean age of 58 years), with large or massive rotator cuff tear. They were patients with a rupture of one or two tendons and a subsequent gap of more than 2 cm in the coronary MRI views (C3 and C4 according to Snyder classification), with incidence of a tendon stump at least at the level of the humeral head (stage 2 and 3 according to Patte), without severe osteoarthritis. The surgical technique involved preparation, mobilization, suturing and fixation, in a single row pattern, by means of bone anchors of the tendon abutments at the anatomical insertion site on humerus head neck.
Results: The suture integrity was checked either by ultrasound scanning or magnetic resonance imaging, and on evaluation, the rates of sound healing and partial or full re-rupture incidence were 75%, 12% and 3%, respectively. Clinical results were satisfactory, concerning final postoperative outcome over preoperative pain assessment (mean VAS pain scoring from 6.2 to 0.88), functionality (mean VAS scoring from 4.32 to 8.8) as well as the ASES questionnaires (from 42.3 to 86.2) and the Constant score (from 42.7 to 82.5).
Conclusion: The arthroscopic investigation and treatment of patients with large and massive rotator cuff tear, that meet the criteria for this type of intervention is a minimally invasive and very effective method that provides satisfactory results in terms of pain, functionality and anatomical restoration of the damage.
Level of evidence II
Keywords: Shoulder arthroscopy; Large – massive rotator cuff tear
The way to deal with large or massive rupture of the rotator cuff has been proved in the recent years to be a field of reflection, research and development of particularly demanding surgical techniques. The development of arthroscopic surgery in conjunction with the continuous technological refinement of arthroscopic devices, tools and materials, as well as the better understanding of the biomechanical function and the role of the rotator cuff in centering the humerus head to the glenoid fossae, stimulated the concept of approaching these ruptures with more emphasis to the logic of the ‚anatomical restoration‘ of the tendon damage .
The term „non-repairable lesion“ that very often follows a magnetic resonance imaging report with the stump of the supraspinatus muscle tendon close to the anatomic level of the glenoid, can eventually correspond to a fully or partially repairable anatomic lesion that adequately responds to the functional demands of the rotator cuff tendons [2,3]. Thus, the use of advanced arthroscopic means and techniques for the
relaxation, mobilization and fixation of the tendon stump can prevent the need of more demanding and expensive interventions such as reconstruction with upper capsular substitutes or a reverse total shoulder arthroplasty .
From 2008 to 2016, in our clinic 134 patients with a large or massive rupture of the rotator cuff were treated by the same operative team. They were patients with a rupture of one or two tendons with a subsequent gap of more than 2 cm in the coronary MRI views (C3 and C4 according to Snyder classification), with incidence of a tendon stump at least at the level of the humeral head (stage 2 and 3 according to Patte). In total 74 men and 60 women with a mean age of 58 years, were treated. In 88% of the cases the rupture was of a chronic pattern character with clinical evidence of pain and muscle weakness, while in 12% of the cases the rupture was due to acute trauma. In 18 patients there was a concomitant partial or total rupture of the subscapularis tendon. When selecting patients for this surgical technique, those suffering from advanced shoulder arthritis,
chronic humerus head migration at the level of the acromion
with severe decrease of the subacromial space (Rotator Cuff
Arthropathy), and patients with chronic inability to anterior
abduction of upper limb (pseudo-paralysis) were excluded.
Scheduled hospitalization period was up to 24h. A 10-month
rehabilitation regime was then followed.
Under general anesthesia, the patient is placed on the
surgical table in a ‘beach chair’ position with the head resting
on a special headrest, removing the bed section under the
shoulder area. After prepping and draping accordingly the
shoulder, and the whole upper limb areas with subsequent
placement of a special sterile arthroscopic bed sheet, hand and
distal arm half are kept under appropriate sterile stockinette
and elastic bandage. Then, the connection to the arthroscopic
tower (camera, cold light cable, shaver, arthroscopic diathermy
device) takes place. Intra-articular pressure on the shoulder is
ensured at a constant level (60 - 75 mmHg) via an arthroscopic
water pump distention system. The patient‘s blood pressure is
adjusted by the anesthesiologist and maintained at low levels
(controlled hypotension) by means of intra-arterial recording to
achieve intraoperative hemostasis and clarity of the arthroscopic
field and image.
Initially, the primary posterior intra-articular portal is to be
placed, though which the arthroscopic optic fiber (30 degrees
- 4mm) is inserted and subsequently the glenohumeral joint is
overviewed. Then, an anterior-superior portal is made in the
rotator interval, under the long head of the biceps, under direct
intra-articular vision. The long head of the biceps is given an
overview securing that if eventually deteriorated, an arthroscopic
tenotomy is to be made at its insertion at the level of the upper
pole of the glenoid and its full removal from the articulation
field is to be secured. Capsular release and its relaxation, labral
debridement and chondroplasty are also performed accordingly.
Next step is to check the anatomical integrity of subscapularis
muscle tendon and its insertion upon the lesser tuberosity.
In the unfortunate event of a rupture (partial or total), a reattachment
to the original humeral insertion is to take place.
Initially, an anterior-inferior arthroscopic portal placement is
performed. We then insert an arthroscopic anchor armed with 2
suture filaments and, by means of a specifically designed passer,
sutures are passed through the tendon. By arthroscopic knots,
the tendon stump is then clamped to the region of the lesser
brachial tuberosity, at the point of the bone anchor. Thereafter,
the arthroscope is inserted into the sub-acromial space through
a posterior-lateral portal. Overview of the subacromial space,
as well as clearance and removal of subacromial bursa is then
performed with concomitant revealing of the rotator cuff tendon
remnants (Figure 1a). Acromioplasty then follows, as well as
removal (if necessary) of the eventual osteophytic lateral edge
of the clavicle. Preparation (debris clearance and mild reaming) is thereafter carried out at the area of the anatomical tendon
insertion on humerus (footprint).
Subsequently, the mobility of the tendon struts is checked.
With an arthroscopic tendon grasper, the tendon edge is
pulled and the direction of elasticity and the possibility of reattachment
without exercising excessive tension to the insertion
site (anatomic footprint), is evaluated. In the case of massive
chronic ruptures, the stump of the supraspinatus and/or part of
the subscapularis muscles tendons are unfortunately close to the
glenoid level, a fact that often renders impossible any attempt to
re-approximate them to the point of fixation. In such situations,
tissue mobilization is attempted by means of arthroscopic
diathermy and specially designed rasps, under direct vision
through the arthroscope, beneath the tendon stump and
between the tendon and the upper glenoid pole, until the base
of the coracoid apophysis (coraco-brachial ligament release). If
the tendon stump is adequately mobilized, its mobility and the
morphology of the tissue deficit are then re-evaluated.
If again the tendons margin lips cannot be easily approached
at the fixation point (large U-defects), side to side margins
convergence is attempted. In this way, by using 2-4 simple
sutures, we can reduce the tendon deficit by more than 50% (to
reproduce a smaller U deficit). Entering the arthroscope through
the lateral subacromial portal, polyclonal non-absorbable
sutures through the posterior and the anterior tendon margins
(U limbs) are passed by the tendon passer. Knots locking, and
convergence are done in turn, in an inside-outwards pattern to
achieve the convergence of U tissue margins (Figure 1b-1e).
Finally, we place 1 to 3 non-metallic bone anchors loaded
with 2 or 3 non-absorbable sutures in the anatomical tendon
insertion on humeral head (or slightly inwards - medialization
up to 10 mm). By using the special tendon passer, each suture
passes through the free edge of the tendon stump. Beginning the
suture passage medially (infraspinatus or teres minor muscles
area) moving laterally, an attempt is made to alternately place
single and double (mattress) sutures in a single row. The final
knot locking is performed following the same manner. The
desirable surgical outcome is the convergence (full or partial)
of the tendon deficit, without tissue tension (Figure 1f). The
shoulder position during the whole suturing phase is to be kept
neutral (without abduction). The operation is completed by
suturing arthroscopic cutaneous portals with single nylon 3-0
sutures and the upper limb is then placed in suspension while
on light abduction.
During arthroscopic examination, degeneration changes
of biceps brachii long head tendon were detected in almost
all cases and arthroscopic tenotomy at the glenoid level was
carried out in all cases that automatic rupture had not preceded.
Acromioplasty and clearance of the subacromial space was
as well performed in all patients, while removal of the lateral
clavicular head due to degenerative issues occurred in 38% of
the cases. The mean length of the medio-lateral tissue deficit
was 3.8 cm. Margin convergence by means of lateral suture
placement was done in 48 patients (35.8%). Partial close of the
deficit was achieved in 22 patients (16.4%).
Minimum follow-up regimen of patients was 24 months. In
terms of suture integrity (by Ultrasound or MRI Scan), healing
rates, as well as partial or full re-rupture rates were 75%, 12%
and 3%, respectively. As for clinical outcomes, there was a great
improvement over preoperative pain assessment (mean VAS
pain score from 6.2 to 0.88), functionality (mean functionality
VAS score from 4.32 to 8.8) as well as the ASES questionnaires
(from 42.3 to 86.2) and the Constant Score (from 42.7 to 82.5).
Active anterior elevation improved on average from 148.6 to
170.8 degrees, while the average enhancement of active external
rotation was 15.3 degrees.
The gradual disruption of the rotator cuff tendons integrity,
because of a chronic impingement syndrome, can lead to
anatomical destruction and functional deficiency of one or
more of the rotator cuff tendons. This results in both muscle
insufficiency and gradual fatty infiltration of the corresponding
muscle, whose tendon is disturbed, but also results in the general
disruption of the stability and concentricity of the shoulder joint
at the glenoid level. An intact rotator cuff constitutes a powerful
glenohumeral stabilizer concentrating the humeral head to the
glenoid [5,6]. Progressive migration of the humeral head towards
the acromion and subsequent occlusion of the subacromial space
because of a large tissue deficit and functional deficiency of 2 or
more rotator cuff tendons leads to mechanical disturbance of the
range of motion, deltoid muscle disfunction, pseudo-paralysis
and rotator cuff arthropathy [7,8]. Arthroscopic reconstruction
of the large rotator cuff ruptures is becoming one of the most
demanding surgical techniques that has been developing with
continuous technical variations in the last few years trying to
provide with functional solutions to a major anatomical and
functional impairment of the shoulder joint .
The ideal goal of a surgical intervention in a middle aged
or older but functional patient without evidence of severe
osteoarthritis in the shoulder joint, who suffers from a large and
possibly unrecoverable damage to the rotator cuff, is to achieve
a painless and functional shoulder with a large and active
range of motion. The development of knowledge, materials and
arthroscopic technique renders this aim feasible in most cases by
performing purely arthroscopic surgery and by applying surgical techniques greatly limiting the need for more open surgical
procedures such as tendon transfers, use of tendon substitutes
and eventual shoulder replacement surgery . This often
seems quite impossible and difficult to assess preoperatively
with imaging methods. Thus, in many cases, reverse shoulder
arthroplasty or tendon transfer is selected from the outset,
with the well-known rates of early or delayed post-operative
complications. However, the arthroscopic investigation of
the remaining rotator cuff usually reveals possibilities for
an anatomical restoration at a rate sufficient to achieve, first
the maintenance of the external rotation and, secondarily,
the focusing of the humeral head on the glenoid fossae, fact
that ensures the ideal biomechanical conditions allowing the
application of the deltoid forces and thus movement of the hand
over the shoulder level .
In cases where, during the initial arthroscopic control, the
tendon stump is quite inelastic and stiff and cannot be attracted
gently to the area of the anatomic fixation, release around
the tendon needs to be performed. This procedure becomes
particularly effective when the release extends to the base
of the coracoid process, between the supraspinatus tendon
stump and glenoid, performing a cross-section of the coracobrachial
ligament. This can also be combined with interval
slides, which were quite popular since the 1990s [10-13], but
subsequently appeared to lead (especially the posterior interval
slide between supra- and infra-spinatus) to tendon perfusion
disorder, ischemic necrosis and re-rupture in the first post-op
semester [14,15]. Therefore, it is also considered by us to be
effective and safe for the tendon viability to mobilize the tendon
stump by sectioning and, thus, loosening of the coraco-brachial
ligament at the base of coracoid process, without additional
interval slides, technique that provides satisfactory mobility to
the tendon without disturbing its perfusion.
Assessing and evaluating the mobility of the tendon
stump after its release, is crucial and vital for taking the most
appropriate intraoperative decision on how to converge the
margins of the tendon deficit. For the large U-type deficiencies,
the difficulty or insufficiency of pulling without exercising
excessive tension on the central U part attempting to move it
towards the anatomical footprint point is clearly highlighted.
Burkhart [5,16,17] depicted the mechanical superiority of sideto-
side sutures between the U-legs in relation to the inside to
outside suturing under tension and introduced the term „margin
convergence“ (Figure 2). In this way the length of the rupture
gradually decreases while increasing the cross-sectional area of
the stump. This reduces the tension for the tendon stump to settle
on the bone as the lateral sutures act protectively reinforcing the
tendon stump strength [18,19]. In theory, this may also increase
the likelihood of healing, as shown by post-operative ultrasound
In cases where despite the tendon mobilization techniques
its length does not meet the requirements for suturing without
tension to the anatomical footprint, if the suturing is performed
under tension re-rupture rate increases . It is preferable and
safer to perform fixation slightly inwards (medialization) by
sutures in a single row without tension, rather than by sutures
in a double row under tension. It appears that fixation of up
to 10 millimeters medially than footprint does not disturb the
biomechanics during the anterior arm elevation [21-23], while
if it exceeds 17 millimeters, there is a negative effect due to
a significant reduction of the lever arm . Therefore, in
cases where the convergence is rather technically demanding,
the inward fixation of up to 10 millimeters is an acceptable
bibliographic option in any reconstructive attempt to fix the
tendon stump under no tension [25,26].
It is, thus, apparent from the literature, a fact we also
realized in the treatment of our patients, that the decision
which method to choose for dealing with large and possibly
unrecoverable ruptures should ultimately be taken, in several
cases, intraoperatively during the arthroscopic investigation.
Only this way can the shoulder surgeon investigate exhaustively
all possibilities of functional anatomical recovery, before
deciding that this is impracticable and thus requires some other
type of surgery. Evolution of arthroscopic technique, materials,
and personal surgical training progress of each surgeon can give
functional results to apparently non-repairable shoulder issues.
Arthroscopic treatment of patients with large and massive
rotator cuff tears that meet the criteria for this type of
intervention is a minimally invasive and at the same time very
effective method that yields satisfactory results in terms of pain,
functionality and anatomical repair of the lesion. The use and
improvement of arthroscopic techniques of tendon mobilization
and release, marginal convergence, and medialized fixation are
useful and documented interventions that facilitate fixation
without tendon tissue tension and lead to the conversion of
difficult and unrecoverable damages to biomechanical and
biologically correct fixations.