Atraumatic deltoid rupture with massive rotator cuff tear amenable to primary repair
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Ruptures of the deltoid muscle tendon are rare injuries that are infrequently reported in the literature.
Although these can occur with trauma, prior shoulder surgery or steroid injections, the most frequent presentation of deltoid muscle tendon rupture is atraumatic in nature and typically seen in patients with a history of massive rotator cuff tear (RCT). Superior migration of the humeral head in the setting of massive RCT can lead to impingement of the deltoid between the humeral head and outer facet of the acromion, leading to gradual attritional rupture. Sclerotic changes within the greater tuberosity or local inflammation, such as occurs in conjunction with subacromial bursitis, may increase this risk. Steroid injections to the subacromial space may also play a role in deltoid muscle tendon rupture. Their use may cause muscle weakness, collagen collapse and eventual tendon rupture. The clinical presentation usually consists of shoulder pain and sudden loss of motion accompanied by swelling, ecchymosis and a palpable defect over the deltoid.
Treatment
First-line treatment of partial deltoid tendon tears should be conservative, consisting of a combination of NSAIDs, activity modification and physical therapy upon pain improvement. Although nonsurgical treatments have been described for complete tears in the setting of massive RCTs, range of motion limitations are of concern. For patients who fail conservative therapy and elect for surgery, deltoid repair with or without reverse total shoulder arthroplasty are potential treatment options. Although one case report by Arnold K.L. Tay and colleagues described a good outcome following RSA without deltoid repair, this is often avoided as the injured deltoid will compromise eventual functional outcome. This article describes our technique for primary repair of an acute, atraumatic rupture of the anterior and middle deltoid heads.
The patient is a 73-year-old right-hand dominant woman with a history of right shoulder RCT that is chronic and massive. She presented with worsening right shoulder pain, weakness and ecchymosis without an inciting traumatic event or strenuous activity. Physical exam was remarkable for strength deficits reflective of rotator cuff (external lag and drop arm sign) and deltoid insufficiency, as well as a defect of the deltoid muscle overlying the anterolateral (AL) corner of the acromion. MRI revealed a rupture of the anterior deltoid head, a large hematoma and showed effusion, in addition to a preexisting massive RCT (Figure 1). Due to pain and functional limitations, the patient was indicated for surgical repair of a ruptured deltoid.
Source: Young W. Kwon, MD, PhD
Surgical technique, approach
After anesthesia, the patient is placed in the beach chair position for the surgical procedure. A longitudinal incision is made that extends from the coracoid process past the AL corner of the acromion by about 4 cm. Although it was thin and tenuous, it was noted the fascia that overlies the anterior and lateral portions of the deltoid was intact. At the time of fascial incision, a large fluid collection and hematoma were seen and evacuated.
The glenohumeral joint is evaluated. We confirmed there was a massive RCT involving the supraspinatus, infraspinatus and upper subscapularis tendons, and retraction medial to the glenoid rim. The tendons could not be mobilized for repair. Upon further inspection of the deltoid, it was noted the middle and anterior heads of the deltoid were avulsed from their origins. In addition, they were retracted both distally and posteriorly.
Deltoid repair
To help secure the deltoid muscle, three FiberTape suture tapes (Arthrex) are used. They are passed in a Mason-Allen configuration through the ruptured deltoid tendon, as well as a portion of the fascial flap, for anticipated closure (Figure 2). Blunt dissection is then performed to release any adhesions and mobilize the muscle. This allows for maximal excursion until the time the deltoid can extend enough to reach its acromial origin. Three bone tunnels are created along the AL border of the acromion using a towel clamp. A shuttling suture is used to pass the suture tapes through the tunnels that are created along the anterior half of the acromion in a superior to inferior direction (Figure 3). As the acromial bone tunnels introduce a theoretical risk of acromial fracture, these are placed in a staggered fashion with at least a 1-cm gap.
To minimize the likelihood of bone cutout, the sutures are tied over a 2-mm three-hole plate (Stryker) on the superior surface of the acromion with the arm in abduction to reduce stress on the repair (Figure 4). Examination of the shoulder after repair revealed minimal stress at the repair site upon full adduction. The wound is thoroughly irrigated and closed in a layered fashion. A sterile dressing is applied. The arm is placed in a simple abduction pillow in about 30° abduction.
Postoperative rehabilitation
We observed minimal stress across the repair site with the arm in full adduction. Therefore, we immobilized the patient in about 30° abduction with a shoulder abduction pillow. This was changed to a simple sling at the 2-week follow-up. For high stress repairs, we recommend immobilization in an adjustable gunslinger brace with sufficient abduction to remove tension across the repair site. Abduction can then be gradually decreased by approximately 10° to 15° every week for the first 4 weeks to full adduction.
Formal physical therapy starts at 4 weeks focusing on passive and active assisted range of motion only. At 6 weeks, the patient can start active range of motion. At 2 months, gentle strengthening begins with band exercises. At 4 to 6 months, the patient begins a gradual return to daily activity.
- References:
- Alben MG, et al. Case Rep Orthop. 2022;doi:10.1155/2022/1833988.
- Tay AK, et al. J Shoulder Elbow Surg. 2011;doi:10.1016/j.jse.2011.03.013.
- For more information:
- Matthew G. Alben, BS, and Neil Gambhir, BS, are research fellows for the shoulder and elbow department, and Jeffrey S. Chen, MD, is an orthopedic surgery resident at NYU Langone Health Orthopedic Hospital. Young W. Kwon, MD, PhD, and Mandeep S. Virk, MD, are shoulder and elbow surgeons and associate professors in the department of orthopedic surgery at NYU Grossman School of Medicine. They can be reached at 333 East 38th St., New York, NY 10003. Alben’s email: mattgalben@gmail.com. Chen’s email: jeffrey.chen@nyulangone.org. Gambhir’s email: neilgmbhr@gmail.com. Kwon’s email: young.kwon@nyulangone.org. Virk’s email: mandeep.virk@nyulangone.org.
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