More Information on Rotator Cuff Surgery.
Last updated Wednesday, January 26, 2005
Figure 1 - The tendon near the deltoid is split longitudinally Surgical detailsAbout the surgery The goal of cuff repair surgery is to improve the strength and
muscular balance of the shoulder. This operative procedure is
considered when the shoulder demonstrates weakness from a cuff defect
and when there appears to be a substantial chance of achieving a
durable functional repair. These conditions are most likely met in a
traumatic tear where a physiologically sound cuff has been torn acutely
by a substantial injury. In this situation, the quality and quantity of
tendon for repair should be excellent. By contrast, with chronic
massive degenerative tears the quantity and quality of the cuff are
less likely to be optimal for surgical repair. In this situation, the
surgeon and the patient must understand preoperatively the potential
limitations imposed by the tissue in the shoulder.
It must be remembered that there are several ways in which surgery
may worsen the function of a cuff-deficient shoulder. These need to be
reviewed before each cuff operation. The most serious is compromise of
the deltoid muscle. The deltoid may be compromised by nerve injury.
This injury may involve the intramuscular motor branches to the
anterior third of the muscle resulting from a too-distal split of the
muscle in the surgical approach. Deltoid denervation may also arise
from axillary nerve injury when searching for cuff tendons laterally
and posteriorly around the quadrangular space. Normally the deltoid has
a strong tendon of origin between its anterior and middle thirds. This
tendon attaches to the anterior lateral corner of the acromion.
Postoperative function of the deltoid may be compromised by failure to
achieve a strong reattachment of this tendon and the anterior muscle
fibers after acromioplasty. This is particularly a problem when a large
anterior acromial resection is performed requiring stretch of the
deltoid for reattachment. Failure of the anterior deltoid origin
devastates the most important motor for shoulder elevation.
Scarring in the humeroscapular motion interface (see Chapter 2)
between the acromion and deltoid and the cuff and humerus can restrict
humeroscapular motion, negating any benefit achieved from restoring
cuff integrity. This complication results from immobilization of the
cuff against the acromion and deltoid after surgery.
Loss of superior stability can result when the coracoacromial arch
is sacrificed without reestablishing stability with a durable cuff
repair. In this situation, deltoid contraction pulls the head of the
humerus anterior superiorly, rather than elevating it. The deltoid
becomes stretched so that the humeral head seems to be just below the
skin. Patients who lose stability and deltoid function are some of the
most unhappy we encounter after previous repair attempts. Primum non
nocere (first of all, do no harm). Surgical technique The cuff is approached though an acromioplasty incision in the skin
lines perpendicular to the deltoid fibers. This incision offers an
excellent exposure and the opportunity for a cosmetic closure,
particularly in comparison with the skin incisions parallel to the
deltoid fibers. Great care is taken to preserve the tendon fibers of
the deltoid origin to permit a strong repair. The deltoid has an
important tendon of origin between its anterior and middle thirds.
Arising from the anterior lateral corner of the acromion, this tendon
is not only the guide to exposure of the cuff, but is also the key to
reattachment of the deltoid origin at the conclusion of the surgery.
This tendon is split longitudinally for 2 cm distal to the acromion in
line with its fibers, taking care to leave some of the tendon on each
side of the split. The split is continued up over the acromion and into
the trapezius insertion. For 1 cm on either side of this split the
deltoid origin is sharply dissected off the acromion, so the strong
bony attachment fibers remain with the muscle. These fibers provide a
strong "handle" on the muscle, so a solid repair can be achieved.
Splitting the parietal layer of the bursa on the deep aspect of the
deltoid provides a view of the rotator cuff. Before a "reflex"
acromioplasty is performed, the quality and quantity of the cuff tissue
are observed to determine the likelihood of cuff reparability.
Hypertrophic bursa and scar tissue are resected to allow a good view of
the cuff tissue. We characterize cuff tears using a simple system based
on the number of tendons torn. In Type 1, only one tendon (almost
always the supraspinatus) is torn. In Type 2, two tendons (usually the
supraspinatus and infraspinatus) are torn. In Type 3, the
supraspinatus, infraspinatus and subscapularis are torn. Type 1 is
broken down into Type 1A-a partial thickness-tear, and Type 1B-the full
thickness tear confined to a single tendon. We judge the quality of the
cuff tissue in terms of its ability to hold a strong pull applied to a
suture passed through its edge. Finally, it is critical to note the
amount of tissue that has been lost. The extent of tissue loss and the
ability of the remaining tissue to hold suture are the major
determinants of cuff reparability.
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