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Bridging reconstruction for massive rotator cuff tears


OVERVIEW

Chapter synopsis

  • Management of massive irreparable rotator cuff tears is challenging, and bridging reconstruction of the rotator cuff with acellular human dermal matrix allograft is a viable solution with good short-term to medium-term results being reported in the literature. In this chapter, we will review the surgical technique for arthroscopic bridging reconstruction of a rotator cuff tear.

Important points

  • Proper patient selection is important for successful results, and bridging should be avoided in patients with severe stiffness and glenohumeral arthritis.

  • This procedure requires advanced arthroscopic skills and has a steep learning curve.

Clinical and surgical pearls

  • Accurate graft sizing with a calibrated probe

  • Always retrieving the suture shuttle posterior and parallel to the previous suture and avoid crossing the sutures

  • Passport cannula at the lateral portal for graft passage

  • Proper debridement of the greater tuberosity to optimize biology for graft healing

  • Proper graft folding with Short-Tailed Interference Knots (STIK) sutures inside before inserting to the joint

Clinical and surgical pitfalls

  • Improper sizing technique for the graft may lead to over tensioning or under tensioning of the graft.

  • Failure to retrieve the suture shuttle posterior and parallel to the previous suture may lead to suture tangling and graft entanglement during insertion.

Video available

  • : Arthroscopic anatomic bridging reconstruction of a massive rotator cuff tear using acellular human dermal allograft

Introduction

Rotator cuff tears are the most common source of shoulder pain and disability in the general population. Rotator cuff tears are commonly classified as small, medium, large, and massive according to their sizes. Although there is no consensus on the definition of massive rotator cuff tears, tear sizes ≥5 cm are widely accepted in this category. Massive rotator cuff tears constitute 40% of all cuff tears and represent a challenging problem for orthopedic surgeons. Massive rotator cuff tears are usually associated with degenerative changes, including fatty infiltration, muscle atrophy, and tendon retraction. These changes result in a high potential for irreparability and high re-tear rates.

Various options are available to bridge the gap in irreparable cuff tears. Non-anatomic repair such as tendon transfer are challenging procedures. , Other options include anatomic bridging reconstruction (BR) of rotator cuff tears or non-anatomic superior capsular reconstruction (SCR) using different types of grafts, including autografts, allografts, xenografts, and synthetic patches. ,

BR restores the anatomical continuity of the rotator cuff to the tuberosity and limits superior migration of the humeral head with promising short- to mid-term outcomes. A recent systematic review conducted by Lin et al. showed that BR has better results than SCR with greater mean differences in Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Score (ASES), Visual Analog Scale (VAS) scores, and external rotation. It also showed that allograft has better clinical outcome scores than autograft for BR. However, no study has directly compared outcomes of BR versus outcomes of SCR.

In this chapter, we present an all-arthroscopic technique for the BR of chronic irreparable massive rotator cuff tears, as described by Snyder. Our graft choice for BR is acellular human dermal allograft (AHDA), which has better biological and biomechanical properties than other graft types.

Preoperative considerations

History

  • Usually, chronic progressive symptoms with pain and weakness of abduction and external rotation

  • Can have acute pain after lifting a heavy object or falling down for acute on chronic tear

  • Pain is mostly at the anterolateral aspect of the shoulder and radiating to the deltoid insertion

  • Pain is exacerbated by overhead activities

  • Night pain usually present

  • Weakness with overhead activity

Physical examination

  • Supraspinatus and infraspinatus atrophy

  • A decrease in active shoulder range of motion

  • Positive Drop arm test for a massive supraspinatus tear

  • Positive external rotation lag sign for a massive infraspinatus tear

  • Positive Hornblower sign for severe teres minor tear

  • Positive belly press test and a bear hug test for subscapularis tear

  • Be wary of crepitus of glenohumeral joint and anterosuperior escape with humeral head that becomes prominent anteriorly with an elevation of the arm

Imaging

  • Shoulder radiography with anteroposterior (AP), lateral, and axillary view ( Fig. 27.1 )

    Fig. 27.1, Pre-operative X-ray of the left shoulder which is used to evaluate the glenohumeral joint for superior head migration and arthritis of the glenohumeral joint. (A) Anteroposterior view; (B) Lateral view; (C) Axillary view.

  • Magnetic resonance imaging (MRI) ( Fig. 27.2 )

    Fig. 27.2, (A) Pre-operative MRI showing a large rotator cuff tear; (B) the pre-operative MRI is important to evaluate the subscapularis, and the patient is preferred to have intact or at least repairable subscapularis (orange arrow) ; (C) usually the sagittal oblique plane of MRI is used to assess the rotator cuff muscle belly and fatty infiltration.

Although evaluation of the muscle atrophy and fatty infiltration on the preoperative MRI is helpful for the prognosis of BR, they are not absolute contraindications for the procedure as successful results are still possible. On the other hand, advanced glenohumeral osteoarthritis and static superior head migration is an absolute contraindication for BR and should be carefully evaluated in the preoperative shoulder radiography.

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