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Distal release of the deltoid: An option for symptomatic cuff tear arthropathy
Rotator cuff tear arthropathy is often an incapacitating condition, where chronic pain, fatigue and severe functional impairment (ie, pseudoparalytic shoulder) are the main symptoms.
Its treatment is still controversial. Conservative treatment rarely succeeds. Reverse prosthesis is one of the operative methods designed for truly irreparable chronic massive tears with decentered glenohumeral arthritis, and it is also the preferred treatment.
Copeland and colleagues wrote in 2008 that complication rates of this operation are rather high and not all the patients accept or are able to undergo the procedure. Furthermore, functional results from this kind of prosthesis tend to deteriorate after 7 to 10 years, which persuade us not to use it in patients younger than 70 years.
A new option
As an alternative to the shoulder prosthesis, I have developed and described a new, simple and easy extra-articular procedure — the distal release of the deltoid — at the University of Padua. I have been able to achieve very satisfactory midterm results on 21 consecutive low-demand patients (13 women and eight men; mean age 70.6 years, range 53-78 years) and presented them at the 10th International Congress of Shoulder and Elbow Surgery last September in Costa do Sauipe, Bahia, Brazil.
The purpose of the operation is to reduce subacromial contact pressure (ie, gravitational decompression) and restrict the ascensional force of the deltoid with better centering of the humeral head in relation to the glenoid. We used preoperative MRI in all but two patients to assess the irreparability of the cuff tear and confirmed those findings through a mini-open inspection of the cuff in the same operative session in 7 patients. We obtained a written consent from all the patients: In particular they had to agree to be subsequently treated by a shoulder prosthesis.
We perform surgery using an interscalene brachial plexus block associated with general anesthesia and a laryngeal mask airway. The operative technique includes a longitudinal skin incision of about 6 cm to 7 cm made over the lateral aspect of the arm; fascial division; exposition of the V-shaped insertion of the deltoid to the humeral tuberosity; detachment from bone of the anterior, middle and posterior deltoid using a scalpel; electrocautery; and a periosteal elevator. The radial nerve, running deep between the external and internal heads of the triceps, is protected.
After mobilization of the deltoid, its stump immediately and spontaneously retracts 1.5 cm to 2 cm (0.79 inches) due to muscle reflex/tone. The recessed stump is then sutured in the new position (ie, 1.5 cm to 2 cm proximally to the original insertion) by a strong lax mattress stitch. Finally, we perform hemostasis and suction drainage.
In our study, the patients were usually discharged from the hospital the day after surgery, following removal of the drainage. A postoperative Velpeau bandage remained in place for 4 to 5 days and we used a simple neck sling afterward. We initiated passive mobilization of the shoulder as soon as the patient was free from wound pain, which as usually during first postoperative week. We delayed active motion for 4 to 5 weeks.
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Images: Scapinelli R |
Results of the technique
We evaluated the subjective and objective results using a modification of the UCLA Shoulder Rating Scale. The mean postoperative follow-up was 40 months. There were no complications.
At the follow-up, all but two patients were satisfied with the outcome. The results were graded as excellent in 15 patients, good in three, fair in one and poor in two. Among the two patients with poor results, the cuff tear also involved the subscapularis, and there were major osteoarthritic changes.
The most striking achievements were relief of pain in 19 patients (total pain relief in 16 patients, partial in three) and an improvement in shoulder function, resulting in facilitation of movements (mainly active abduction and elevation) and an improved ability to perform routine activities of daily living.
Muscular strength was slightly or moderately superior to the preoperative status in 15 patients, unchanged in the remaining patients, and it never worsened. No patient required subsequent surgery or regretted not having received a prosthesis.
In half of the patients (11 out of 21) a slight reduction of the upward migration of the humeral head was evident on radiographic controls. No patients experienced an increase of upward migration or substantial worsening of their glenohumeral arthritis.
A beneficial procedure
Distal release of the deltoid seems to be a beneficial procedure for the treatment of intractable and unbearable pain and functional disability of the shoulder in selected elderly patients with rotator cuff tear arthropathy. The operation is quick, less invasive and safe. The positive clinical results reported in this study were at least comparable with those obtained with shoulder prostheses and other more popular salvage procedures, including muscular transfers.
For more information:
- Raffaele Scapinelli, MD, is an honorary professor of orthopaedics and is the past director of the Orthopaedic and Traumatologic Clinic, University of Padua, Italy. He can be reached at Via San Pio X, 15, 35123 Padova, Italy; raffaelescapinelli@libero.it
References:
- Levy O, Webb M, Even T, Venkateswaran B, Funk L, Copeland SA. Arthroscopic capsular release for post-traumatic shoulder stiffness. J Shoulder Elbow Surg. 2008;17(3):410-414.
- Scapinelli R. Distal release of the deltoid: A new treatment option for symptomatic cuff tear arthropathy. #132. Presented at the 10th International Congress of Shoulder and Elbow Surgery. Sept. 17-20, 2007, Costa do Sauipe, Bahia, Brazil.
- Scapinelli R. Distal release of the deltoid for the treatment of symptomatic cuff tear arthropathy : a preliminary report. Techniques in Shoulder and Elbow Surgery. 2005;6:98-107.