Shoulder and Elbow cases partial-thickness rotator cuff tears

A 70-year-old, right-hand-dominant woman returns to clinic complaining of persistent, right shoulder pain. She has been clinically diagnosed with a chronic, degenerative rotator cuff tear of her right shoulder. Despite 2 months of consistent physical therapy, injections, and NSAID use, she has worsening pain and weakness. She takes no medications, is otherwise healthy, and is a retired accountant. Her examination shows no obvious atrophy of the supraspinatus or infraspinatus. She has 140 degrees of active shoulder flexion and abduction compared to 160 and 180 with the contralateral side, normal passive range of motion, a positive Neer impingement sign, a positive Hawkins test, as well as pain and weakness with Jobe test. The rest of the examination is normal. Plain radiographs are normal. MRI of the right shoulder shows a tear of the supraspinatus with minimal retraction, no atrophy, and no fatty infiltration. The patient is scheduled for arthroscopy.

If during diagnostic arthroscopy, the tear is determined to be a partial-thickness tear that is 5 mm deep, how would you now treat this patient?

1. Arthroscopic rotator cuff debridement

2. No further operative intervention at this time and an additional trial of physical therapy, NSAIDs, and corticosteroid injection

3. Arthroscopic rotator cuff repair

4. Mini-open rotator cuff repair

5. No further treatment

 

Discussion

The correct answer is (C). Although treatment algorithms are debated, a generally accepted rule is that with chronic, rotator cuff tears, if the tear does not respond to a

trial of conservative treatment, operative treatment is warranted. For partial-thickness tears, the type of operation that should be performed is often controversial. One useful decision-making tool for patients with partial-thickness tears is the Ellman classification.

The Ellman classification differentiates between bursal-sided tears (Ellman classification B) and articular-sided tears (Ellman classification A), and also between those that are less than 3 mm in depth (Ellman classification I), between 3 and 6 mm in depth (Ellman classification II), and greater than 6 mm in depth (Ellman classification III). If a tear is bursal-sided and less than 3 mm in depth (BI), this can be treated with arthroscopic debridement of the tear (Answer A). If it is bursal-sided and greater than 3 mm in depth (BII as in this patient or BIII), this should be treated with arthroscopic rotator cuff repair (Answer C). In addition, subacromial decompression should be considered with all bursal-sided tears, and acromioplasty should be performed if the patient has a type II or type III acromion or has anterior acromion bone spurs. If the tear is articular-sided and less than 6 mm (Ellman classification AI or AII), this can be debrided. If the tear is articular-sided and greater than 6 mm in depth (Ellman classification AIII), this should be repaired. Subacromial decompression and acromioplasty may not be necessary in the case of articular-sided tears. Refer to Table 2–1 and Figure 2–10 for a summary of the Ellman classifications and the indicated surgical treatment after failure of conservative treatment.

 

Table 2–1 SUMMARY OF ELLMAN CLASSIFICATION TEARS AND THEIR TREATMENTS

 

Ellman Classification	Articular or Bursal Sided?	Depth (mm)	Treatment
AI	Articular	<3	Debridement
AII	Articular	3–6	Debridement
AIII	Articular	>6	Repair
BI	Bursal	<3	Debridement
BII	Bursal	3–6	Repair
BIII	Bursal	>6	Repair

Data from From Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg. 2006;14(13):715–725.

 

 

 

Figure 2–10 Potential treatment algorithm for partial-thickness rotator cuff tears. (Reproduced with permission from Shi LL, Mullen MG, Freehill MT, et al. Accuracy of Long Head of the Biceps Subluxation as a Predictor for Subscapularis Tears. Arthroscopy 2015;32(4):615-619.)

 

An additional trial of physical therapy, NSAIDs, and corticosteroid injections (Answer B) would be inappropriate in this case. If the patient failed to improve with this therapy the first time, it is unlikely that a second course of conservative management would be valuable. In these circumstances, operative treatment is warranted and the type of operation should be decided as described above.

A mini-open rotator cuff repair (Answer D) can be performed with similar long-term outcomes as arthroscopic repair, but arthroscopic repair has the potential for faster, short-term recovery postoperatively and is preferred.

Offering the patient no further treatment (Answer E) would be inappropriate in this case because an operation would be helpful in alleviating her pain and restoring function.

It should be noted that with chronic, rotator cuff tears, advanced imaging should not be acquired until after conservative management has failed. The only indication for early advanced imaging would be to differentiate the diagnosis from either infection or tumor. If conservative management cannot manage the patient’s symptoms, then an MRI should be obtained to characterize the tear in order to help with operative planning. With acute tears – where there is a clear traumatic mechanism preceding symptoms – obtaining an MRI immediately is justifiable because surgery within 3 weeks of injury has much better outcome than surgery done after the first 3 weeks.

In the above patient, if during diagnostic arthroscopy, the tear is determined to be a full-thickness tear, how would you now treat this patient?

1. Arthroscopic rotator cuff debridement

2. Additional trial of physical therapy, NSAIDs, and corticosteroid injections

3. Arthroscopic rotator cuff repair

4. Mini-open rotator cuff repair

5. No further treatment

 

Discussion

The correct answer is (C). All full-thickness rotator cuff tears that fail conservative treatment and can be repaired arthroscopically should be repaired arthroscopically. They should not be debrided (Answer A).

An additional trial of physical therapy, NSAIDs, and corticosteroid injections (Answer B) would be inappropriate in this case. If the patient failed to improve with this therapy the first time, it is unlikely that it would work the second time. In these circumstances, operative treatment is warranted and the type of operation should be decided as described above.

A mini-open rotator cuff repair (Answer D) can be performed with similar long-term outcomes as arthroscopic repair, but arthroscopic repair has the potential for faster, short-term recovery postoperatively and is preferred.

Offering the patient no further treatment (Answer E) would be inappropriate in this case because an operation would be helpful in alleviating her pain and restoring function.

Which of the following findings is indicative of a subscapularis tendon tear?

1. High riding humeral head on plain radiographs

2. An empty intertubercular groove on MRI

3. Posterior shoulder dislocation

4. A type III acromion

5. Medial scapular winging

 

Discussion

The answer is (B). As the four layers of the lateral rotator interval insert onto the lesser tuberosity of the humerus, they form the “reflection pulley” that forms a sling around the tendon of the long head of the biceps before it enters the bicipital (intertubercular) groove. A tear of the upper part of the subscapularis can disrupt this reflection pulley and destabilize the biceps tendon, allowing it to sublux or even

dislocate out of its groove, usually in a medial direction. If this happens, the intertubercular groove will be empty on MRI. Often, a “pulley sign” will also be seen on MRI when this occurs. This is when contrast material extravasates extra-articularly just over the superior border of the subscapularis tendon on axial images (see Fig. 2–11).

 

 

 

Figure 2–11 Axial T1 MRI. Left: an empty intertubercular sulcus, positive pulley sign (straight black arrow on left), and dislocated biceps tendon (curved black arrow). Right: fraying subscapularis tendon (arrow). (From Lyons RP, Green A. Subscapularis tendon tears. J Am Acad Orthop Surg. 2005;13(5):353–363.)

 

A high riding humeral head on plain films (Answer A) is associated with a massive rotator cuff tear and is the first sign of progression to cuff tear arthropathy that is seen on plain film.

Anterior, not posterior, shoulder dislocations (Answer C) are associated with subscapular tendon tears.

A type III acromion (Answer D) has been shown to be associated with rotator cuff tears of the supraspinatus, not the subscapularis.

Medial scapular winging (Answer E) results from dysfunction of the serratus anterior muscle, most commonly due to iatrogenic injury to the long thoracic nerve, which innervates the serratus anterior.

What is the best initial treatment for a healthy, 40-year-old patient with an acute subscapularis tendon tear?

1. Pectoralis major tendon transfer

2. Trial of conservative management for 6 weeks

3. Subscapularis tendon repair

4. Biceps tenodesis

5. Latissimus dorsi tendon transfer

Discussion

The correct answer is (C). Because of the acute nature of the tear, immediate surgical repair of the torn subscapularis tendon is indicated. Early surgical repair within 6 months of injury of acute tears is associated with better functional outcomes that repair after 6 months of injury. Waiting could lead to muscle atrophy, fatty infiltration, and retraction; all of which make surgery more challenging and worse outcomes. For these reasons, a trial of conservative management (Answer B) would be inappropriate.

A pectoralis major tendon transfer (Answer A) is one option to fix a torn subscapularis, but it is reserved for tears that are irreparable. Repair of the native subscapularis has better outcomes than using a tendon transfer. A biceps tenodesis (Answer D) may be performed along with a subscapularis tendon repair, but it will not treat the main problem, which is a torn subscapularis tendon. A latissimus dorsi tendon transfer (Answer E) is used for irreparable tears of the posterosuperior rotator cuff (supraspinatus and infraspinatus) in certain patients. However, no tendon transfer would be used in an acute, repairable tear of the rotator cuff.

During arthroscopy of a patient with a chronic subscapularis rotator cuff tear, the superior glenohumeral ligament (SGHL) is noted to be avulsed off of the glenoid. What intra-articular landmark can be used to identify the superolateral border of the tear?

1. Comma sign

2. ALPSA lesion

3. Terry–Thomas sign

4. Sulcus sign

5. Piano key sign

 

Discussion

The correct answer is (A). When a chronic, retracted subscapularis tendon tear is present, the superolateral border of the tear can be identified by a comma-shaped ligamentous structure that exists at this border. This is composed of an avulsed superior glenohumeral ligament blending with the coracohumeral ligament and is called the comma sign (see Fig. 2–12).

 

 

 

Figure 2–12 Comma sign, indicating the superior border of a chronic, retracted subscapularis tendon tear. G, glenoid; H, humerus; SSc, subscapularis; M, medial sling of biceps (comma); *, junction of medial sling of biceps and subscapularis tendon. (Redrawn from Burkhart SS, Lo IKY. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14(6):333–346.)

 

ALPSA lesion (Answer B) is an anterior labral periosteal sleeve avulsion. It occurs when there is an injury to the anterior labrum that causes it to be pulled off of the glenoid. In this pathology, when the labrum comes off it takes with it part of the periosteum covering the anterior glenoid.

A Terry–Thomas sign (Answer C) is when, on AP wrist x-ray, there is an enlarged space between the scaphoid and lunate and is a sign of a scapholunate dislocation.

A sulcus sign (Answer D) can be found with shoulder instability. On physical examination, if downward traction is put on a shoulder with the arm at the side, a depression can be found between the acromion and the humeral head, indicating ligamentous laxity of the shoulder.

A piano key sign (Answer E) can signify distal radioulnar joint (DRUJ) instability. If the distal ulna protrudes dorsally at the DRUJ, can be translated volarly on examination, springs back dorsally after released from volar translation, and is more impressive than the contralateral wrist, this is a positive piano key sign.

 

Objectives: Did you learn...?

 

Classify and surgically treat partial-thickness rotator cuff tears?

 

 

 

Surgically treat full-thickness rotator cuff tears? Recognize the significance of an empty bicipital groove? Treat an acute subscapularis tear?

 

Recognize a comma sign?