This article is more than 5 years old. Information may no longer be current.
Arthroscopic partial-thickness cuff repair can be done without further propagation
Rotator cuff techniques avoid excision of normal tissue, retain anatomy and promote healing.
Click Here to Manage Email Alerts
For orthopedic surgeons who are unhappy with the
traditional approach to partial-thickness rotator cuff repair — tear
completion, followed by repair — transtendon repair and intratendinous
repair for delamination offer other options, according to Christopher S. Ahmad,
MD, of New York’s Columbia University.
“Taking down the tear has been unsatisfying,” Ahmad said during Orthopedics Today New York 2006, A Comprehensive CME Course.
“In the past, symptomatic partial-thickness rotator cuff tears that failed nonoperative treatment were treated surgically with either debridement, subacromial debridement or with conversion of the tear to a complete tear followed by repair,” Ahmad told Orthopedics Today. “Arthroscopic techniques now allow repair of the partial thickness component of the tear without having to complete the tear.”
Despite the technical demands, Ahmad said arthroscopic techniques offer the following advantages:
- The surgeon can achieve suture anchor tendon fixation.
- Excision of normal tissue is avoided.
- There is less rotator cuff involvement in the healing process.
- Normal anatomy is retained.
- Less tension on the repair is incurred.
- Fewer anchors are needed.
Partial-thickness rotator cuff tears are common in younger patients and overhead athletes. They are associated with internal impingement and frequently involve delamination, Ahmad said.
|
|
|
|
|
Images: Ahmad CS |
“When evaluating these injuries, remember that history is important. Is the patient a repetitive overhead athlete? Is the injury the result of acute trauma or is it activity-related pain in an older patient?” Ahmad said.
Subacromial injections
Subacromial injection tests are useful, but Ahmad cautioned surgeons not to overvalue them “because the tearing and the pathology may be on the articular side, and [the patient] may have resolution of the weakness after the injection.”
Nonoperative treatment involves physical therapy, rest, NSAIDs, and intra-articular or subacromial steroid injections, Ahmad said. Patients who fail 3 to 6 months of nonoperative treatment are indicated for surgery.
Patient factors, such as an athlete being in the middle of a season, may demand earlier intervention. Many surgical options exist for partial-thickness rotator cuff tears. Traditionally, surgeons have performed debridement in isolation or with acromioplasty.
Rotator cuff repair, with or without acromioplasty remains an option, and can be done open or arthroscopically.
Surgeons can also perform arthroscopic transtendon repair using either the beach chair or lateral decubitus positions. Ahmad said he prefers the lateral decubitus, but notes that a little bit more abduction is required in this position to deliver this area of the tendon toward the glenoid.
He said that having an accurate anterior portal — one that is slightly proximal and lateral — is critical. The repair begins with tendon debridement and the surgeon should then assess tear depth.
The normal tendon footprint in the medial to lateral direction is about 12 mm and this knowledge can assist in determining percent tearing off the rotator cuff. Before beginning the repair, the surgeon should move into the subacromial space to examine the tendon on the bursal side, Ahmad said.
Avoid tear propagation
The surgeon should place a prolene suture and then perform a bursectomy, removing all the bursal tissue to enhance suture management. The area should also be evaluated to ensure that there is no bursal-side rotator cuff injury.
At this point, the surgeon should debride the footprint and place the anchors via a percutaneous transtendon approach. Ahmad uses needles which minimize iatrogenic injury to the rotator cuff to complete the suture passing.
|
|
Intratendinous repair is indicated in throwing athletes with a natural internal impingement that is related to throwing. Tendon-to-bone repair in these patients would probably fail because of the internal impingement contact they make while throwing.
“The goal for an intratendinous repair is to promote healing and avoid tear propagation,” Ahmad said.
During the procedure, the surgeon reduces the articular side free laminar component toward the tuberosity. The surgeon then places simple sutures through the intact bursal laminar component and torn articular side laminar component. The surgeon ties the sutures in the subacromial space. No suture anchors are required.
For the first 4 postoperative weeks, patients should protect their shoulder in a sling. The patient should begin elbow, wrist and hand exercises on the first day.
In the second week, the patient should begin Codman and Pendulum exercises and active flexion-extension exercises at 6 weeks. The patient can return to full activities at around 4 to 6 months.
“In summary, partial-thickness rotator cuff tears are common, we should be aware of them in the younger patients and in overhead athletes,” Ahmad said. “They can be associated with the internal impingement-type mechanism, and we should be considerate of delamination as a component.”
For more information:
- Ahmad CS. Partial thickness cuff tears — repair in situ or not? Presented at Orthopedics Today NY 2006, A Comprehensive CME Course. Nov. 11-12, 2006. New York.
- Christopher S. Ahmad, MD, assistant professor, orthopedic surgery, Columbia University, Center for Shoulder, Elbow and Sports Medicine, 622 W. 168th St., New York, NY; 212-305-5561; csa4@columbia.edu