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1. Patients with chronic shoulder pain or weakness
with a documented rotator cuff tear that has failed
nonsurgical management (rest, local modalities,
NSAIDs, physical therapy, and judicious subacromial cortisone injections)
2. Acute, traumatic full-thickness rotator cuff tears
3. Partial-thickness rotator cuff tears greater than 50%
Indications for associated acromioclavicular (AC)
joint resection
➣ AC joint tenderness on physical examination
➣ Radiographic changes of AC joint arthritis
➣ Exposure optimization of a retracted supraspinatus
tendon in chronic or massive rotator cuff tears
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Contraindications
1. Active soft tissue or glenohumeral infection
2. Neuropathic joint
3. Chronic axillary nerve injury
4. Failed prior surgical treatment with associated deltoid insufficiency (relative)
5. Degenerative arthritis (relative); consider combining rotator cuff repair with shoulder arthroplasty
6. Patient’s overall medical condition (relative)
7. Parkinson’s disease or other diseases that cause uncontrolled muscle activity (relative)
8. Patient unable to comply with postoperative
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rehabilitation
Preoperative Preparation
1. Physical examination to include assessment of
AC joint tenderness and/or pain with shoulder
adduction
2. Obtain radiographs
a. Anteroposterior (AP) in plane of scapula (true
AP)
b. AP shoulder (check distal clavicle for “spurs”)
c. Axillary view (check for os acromiale, glenohumeral arthritis)
d. Supraspinatus outlet view (assess acromion shape
[types I–III], spinoacromial angle)
e. 25 degree caudal tilt (“Rockwood view”) (optional)
3. Consider magnetic resonance imaging (MRI): helps
evaluate extent (“full” versus “partial” thickness)
of rotator cuff tears, and presence of muscle atrophy or tendon retraction; observe mass effect of
acromion and AC joint on supraspinatus tendon
(impingement).
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Special Instruments, Position, and
Anesthesia
1. Small sagittal or oscillating saw for bone resection
2. 1.6-mm drill bit for deltoid reattachment
3. Small, half-circle curved free Mayo needle, and #2
braided nonabsorbable suture
4. 5-mm round burr and broad flap rasp to “fine-tune”
acromioplasty
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CHAPTER 2Open Rotator Cuff Tendon Repair2 OPEN ROTATOR CUFF TENDON REPAIR 9
5. Semi-sitting or beach chair position.
The patient is
moved as close to the side of the table as possible
while still being stable.
A beanbag-type McConnell
head holder (McConnell Surgical Mfg., Greenville,
TX) or AMSCO “captain’s chair” is useful to secure
and stabilize the head in a safe neutral position.
Care must be taken to pad all bony prominences.
6. The head may be secured gently with a padded strap
or tape across a pad on the forehead. Care must be
taken to avoid the strap or tape from sliding down
over the eyes.
7. The procedure can be done with either general or
interscalene block anesthesia.
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Tips and Pearls
1.
A thorough preoperative evaluation is critical to
a successful rotator cuff repair.
A complete physical
examination, review of plain radiographs, and
MRI provide meaningful information to plan surgery and counsel patients preoperatively.
The size
of tear and the degree of tendon retraction and
muscle atrophy can suggest the degree of difficulty
in attempting to repair the rotator cuff and the
possible need for postoperative abduction brace
immobilization.
2.
Check passive range of motion preoperatively and
under anesthesia. Gentle shoulder manipulation
may be necessary to release capsular adhesions. If
adhesive capsulitis is severe, consider a staged
manipulation and subsequent rotator cuff repair to
minimize post-surgical loss of motion.
3. Mobilization of the rotator cuff tendon along its
superior and inferior surfaces and release of a
contracted coracohumeral ligament is important
to minimize undesirable tension on the tissue
and repair.
4.
Define the anterior and posterior aspects of the
rotator cuff tear and advance and secure these areas
first. This closes the tear and relieves tension on the
repair at the tuberosity.
5.
A secure deltoid repair to the acromion is as important as the rotator cuff repair in restoring shoulder
strength and function.
What To Avoid
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1.
Make sure the patient is properly positioned on the
operating room table. Avoid excessive cervical traction and brachial plexus traction. Ensure proper
padding of all bony prominences to minimize risk
of neuropraxias.
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2.
Avoid fracturing the acromion during either the
acromioplasty or deltoid reattachment.
3.
Do not mistake the flimsy bursal tissue for the rotator cuff tendon and use it in the cuff repair.
4.
Avoid inadequate or insecure repair of the deltoid to
the acromion.
Postoperative Care Issues
1. A sling or abduction pillow is used postoperatively
to protect the rotator cuff repair.
The choice of postoperative protection depends on the type of patient,
the quality of the tendon tissue, the tension on the
sutures, and the adequacy of the cuff and deltoid
repair.
2. Three phases of rehabilitation—time in each stage
depends on tendon quality and assessment of repair.
a. Phase 1. Passive range of motion: includes pendulum saw, and tummy rub exercises
b. Phase 2. Active-assisted range of motion exercises and gentle cuff isometrics
c. Phase 3. Active range of motion and resistance
exercises
Operative Technique
Approach
1.
Position the patient on the operating room table as
outlined above.
2
. Prepare and drape the entire arm and shoulder
girdle “free.”
3.
Carefully outline prominent anatomic landmarks:
coracoid process, clavicle, AC joint, acromion and
scapular spine.
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4.
Draw the planned skin incision with a marker. The
incision should extend 2 in from the lateral aspect
of the anterior third of the acromion toward the lateral tip of the coracoid process acromion halfway
between the anterolateral and posterolateral corners
of the acromion. Place the skin incision in Langer’s
lines that parallel the lateral border of the acromion
(see Fig. 1–1).
5.
If an excision of the distal clavicle is indicated,
move the incision approximately 1 cm medial to
the standard incision (see Fig. 1–1).
6.
Infiltrate the skin and subcutaneous tissue with
1:200,000 concentration of epinephrine.
7.
Incise the skin and subcutaneous tissue down to
the deltoid fascia.
Develop the prefascial plane to
expose the entire anterolateral corner of the acromion and the lateral aspect of the deltoid.
If AC joint excision is planned, dissect further medially to
expose the distal 2 cm of the clavicle.
8.
Split the deltoid muscle in the raphe between the
anterior and middle deltoid.
Begin at the anterolateral corner and extend the dissection distally 2 to
3 cm. The direction of the split is approximately
perpendicular to the skin incision.
Consider placing
a stay suture to avoid injuring the terminal branches
of the axillary nerve (see Fig. 1–2A).
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9.
Starting from the split, release the deltoid subperiosteally along the anterior acromion using an electrocautery. Start several millimeters back from the anterior edge of the acromion (see Fig. 1–2A).
Bovien electrocautery is more effective than sharp dissection for this step.
10.
Release the superficial and deep deltoid fascia. Tag
these with heavy nonabsorbable suture, which aids
retraction and deltoid repair.
Carefully coagulate
the acromial branch of the thoracoacromial artery
that is usually encountered near the anterolateral
acromion between the superficial and deep deltoid.
11.
Completely detach the coracoacromial ligament,
usually along with the deep deltoid fascia, from
its attachment on the acromion (see Fig. 1–2B).
Usually it is not necessary to dissect these out
separately.
12.
Extend the deltoid release past the AC joint. Expose
the distal clavicle when distal clavicle excision is
planned (see Fig. 1–2A).
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13.
Release bursal adhesions with a blunt instrument or
an index finger.
Acromioplasty
14.
Protect the rotator cuff with a blunt retractor, such as
a medium chandler.
Perform an acromioplasty utilizing either a sagittal saw or a sharp osteotome (see
Fig. 1–3A). The wedge of bone excised should be the
full width of the acromion from the medial to lateral.
a. The goal of the acromioplasty is to shape the
acromion so its undersurface is flat from anterior
to posterior and medial to lateral.
After surgery,
the acromion’s undersurface should have a
smooth contour for optimal subacromial contact.
There should be no ridges or sharp spikes of
bone, nor should there be anterior overhang
of the acromion.
b. The deep deltoid fascia attachment to the lateral
acromion can be used as a landmark to judge the
amount of acromion resected.
After an acromioplasty, the acromion should be flush with the
deep deltoid attachment to the lateral acromion.
15.
Use a burr or file to smooth the undersurface of the
acromion.
Rotator cuff repair
16. Identify the subacromial bursa and perform a complete subdeltoid bursectomy. Fully rotating the arm
exposes the rotator cuff tendons.
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17.
Assess the size of the rotator cuff tendon tear, the
precise rotator cuff tendon anatomy, the shape of
the tendon tear, the tendons involved, the degree
of tendon retraction, the anterior and posterior
extent of the tear, and the quality of the tendon
available for repair.
18.
Tag the torn edges of the rotator cuff with heavy
nonabsorbable suture. Assess the need for mobilization of the tendon.
19.
Several methods are useful in mobilizing the rotator
cuff
a. Release and excision of the subacromial and subdeltoid bursa
b. Release of the coracohumeral ligament, which is
a thick band of tissue between the coracoid
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