Identifying the tear pattern is the key to repairing massive rotator cuff tears

Alternatives to repair include tuberoplasty, biceps tenotomy and suprascapular nerve decompression.

Although massive tears may be the most difficult rotator cuff tears to manage, recognizing the tear pattern and performing appropriate releases can make these procedures less complex and more successful, according to an investigator at Columbia University in New York.

“The real key is to identify the tear pattern and do your releases,” Christopher S. Ahmad, MD, said. “Margin convergence makes it possible for these massive tears to be more like a simple crescent-shaped tear. Do interval slides as you need and remember the other options if all else fail.”

Defining massive tears

In North America, massive tears are defined as those greater than 5 cm, while in Europe, massive tears are defined as tears comprised of two or more tendons, he said. Ahmad noted that MRI is the gold standard for evaluating these tears and can also be used to assess fat infiltration and atrophy which is directly linked to the chance of a retear and functional outcome.

He prefers placing patients in the beach-chair position which allows him to easily appreciate the tear pattern and use multiple working portals. During the surgery, he establishes an accessory lateral portal for visualization and uses posterior, anterior and lateral portals as his working portals.

“Recognizing the tear pattern will allow you to facilitate the repair,” Ahmad said. While the crescent-shaped tears are easy to repair, the U- and L-shaped tears are more difficult to fix, he added.

Check mobility

Assessing mobility from medial to lateral can be frustrating, and Ahmad suggested that surgeons may better understand the tear mobility when checking it from anterior to posterior or posterior to anterior.

To prepare the tuberosity, he removes the soft tissue and abrades the bone. He then places the traction sutures and performs releases.

Surgeons can use a variety of approaches including an anterior interval slide, in which the coracohumeral ligament is divided and the coracoid base is freed. Surgeons using a posterior interval side release the soft tissue connection between the supraspinatus and infraspinatus.

“You have to be careful in this area,” Ahmad said. “This is where the suprascapular nerve and the suprascapular artery are located. It is useful to keep traction as you are doing these releases.”

More surgeons are using margin convergence to convert U-shape tears to crescent-shaped tears, Ahmad said.

“This is a great tool for managing what may be at first glance an irreparable tear,” he said.

To obtain fixation to bone, he puts his anchors through a small stab incision. He does the anterior anchor first, passes the sutures through the rotator cuff and then places the posterior anchor.

When all else fails

Surgeons have several options if they cannot fix the tear including performing a partial repair to recreate the balance of the infraspinatus and teres minor to the scapularis. “If you balance this force couple, you will then be able to achieve some level of pain relief,” Ahmad said.

He added, “There are studies in Europe where a biceps tenotomy in the setting of a massive rotator cuff repair can achieve excellent pain relief.”

Suprascapular nerve decompression is an evolving and exciting area, he said.

“There is interest in doing suprascapular nerve decompressions, and some of the techniques recently presented make it a daunting operation. However, simpler techniques are evolving,” Ahmad said.

He noted that the technique involves resecting the transverse scapular ligament, which may help relieve patients’ pain.

For more information:
Christopher S. Ahmad, MD, associate professor of orthopedic surgery, Columbia University, Center for Shoulder, Elbow and Sports Medicine, can be reached at 622 W. 168th St., New York, NY 10032; 212-305-5561; e-mail: csa4@columbia.edu. He has no direct financial interest in any product or company mentioned in this article.

Reference:
Ahmad CS. Massive cuff tears: Techniques to fix. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.