Orthopedic Teaching Cases 2023, Jan, 18 | 12:00 am

Shoulder and Elbow cases massive, irreparable rotator cuff tears

A 70-year-old, right-hand-dominant woman presents to clinic with right shoulder pain and weakness. She has had progressive weakness and severe pain with overhead motions for the last several years to the point where she is no longer able to reach overhead. She endures severe night pain as well. Conservative treatment with physical therapy, NSAIDs, and corticosteroids used to help but do not anymore. She is otherwise healthy and takes no medications. On examination, she has visible atrophy of the supraspinatus and infraspinatus muscles. She has very limited active flexion and abduction of 30 degrees, external rotation of 10 degrees, and internal rotation to T12. She has full passive range of motion (ROM) with positive Neer, Hawkins, and Jobe test; a positive drop arm test; and a positive external rotation lag sign. The rest of the examination is normal. Plain films are normal. An MRI reveals a massive rotator cuff tear involving the supraspinatus and infraspinatus. The supraspinatus and infraspinatus both show signs of minimal atrophy, minimal fatty infiltration, and retraction to the glenoid.

During arthroscopy, it is confirmed that the patient has a massive and immobile tear with a small part of the anterior supraspinatus still attached to the greater tuberosity. What technique will likely need to be used in order to repair the rotator cuff to the greater tuberosity?

  1. Anterior interval slide

  2. Posterior interval slide

  3. Krackow stitch

  4. Double-bundle reconstruction

  5. Marginal convergence

 

Discussion

The correct answer is (A). Massive and immobile tears can be either U-shaped or longitudinal. These can sometimes be repaired using an anterior or posterior

interval slide technique. In an anterior interval slide technique, there is some anterior portion of the supraspinatus still attached to the greater tuberosity laterally and rotator interval anteriorly. The greater tuberosity attachment can be incised and the rotator interval attachment can be detached by incising the coracohumeral ligament. In a posterior interval slide technique, there is some posterior portion of the supraspinatus still attached to the infraspinatus. This can be detached by incising the interval between the supraspinatus and infraspinatus (Answer B). These interval slide techniques decrease the tension and improve lateral mobilization, allowing the supraspinatus to be more easily repaired to the greater tuberosity. The posterior leaf of the tear is then brought together with the anterior leaf through marginal convergence, leaving you with a small crescent-shaped tear that can be repaired to the greater tuberosity (see Fig. 2–16).

 

 

 

Figure 2–16 Massive, immobile rotator cuff tear and repair using anterior interval slide followed by marginal convergence. SS, supraspinatus; IS/TM, infraspinatus/teres minor; RI, rotator interval; CHL, coracohumeral ligament; Sub, subscapularis. (Redrawn from Burkhart SS, Lo IKY. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14(6):333–346.)

 

Crescent-shaped tears are not retracted much medially, can be mobilized laterally relatively easily, and thus can be relatively easily repaired to humeral bone (see Fig. 2–13).

 

 

 

Figure 2–13 Crescent-shaped rotator cuff tear and repair. SS, supraspinatus; IS, infraspinatus. (Redrawn from Burkhart SS, Lo IKY. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14(6):333–346.)

 

U-shaped tears can be repaired using marginal convergence (Answer E). U-

shaped tears have an apex that extends further medially, usually to the edge of the glenoid in the sagittal plane, and this part cannot be mobilized all the way to the greater tuberosity. Because of this lack of mobility, these tears have to be repaired using marginal convergence, which is essentially zipping up the U from the apex toward the greater tuberosity using side to side sutures to bring together the anterior and posterior leaves of the U-shaped tear. In performing this marginal convergence, you essentially are converting a U-shaped tear into a crescent-shaped tear that can be relatively easily mobilized to the greater tuberosity, allowing it to be repaired (see Fig. 2–14).

 

 

 

Figure 2–14 U-shaped rotator cuff tear and repair using marginal convergence. SS, supraspinatus; IS, infraspinatus. (Redrawn from Burkhart SS, Lo IKY. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14(6):333–346.)

 

Finally, an L-shaped tear resembles a tear that can be thought of as partially a crescent-shaped tear and partially a U-shaped tear. One leg of the L is the more mobile, less retracted, crescent-shaped tear which transitions into the other leg of the L, a less mobile, more retracted part of the tear which mechanically and visually resembles a U-shaped tear. The retracted U-shaped part, like a normal U-shaped tear, must be repaired using marginal convergence. Then the remaining crescent-shaped part, like a normal crescent-shaped tear, can be mobilized laterally and repaired to bone (see Fig. 2–15).

 

 

 

Figure 2–15 L-shaped rotator cuff tear and repair using marginal convergence. SS, supraspinatus; IS, infraspinatus; RI, rotator interval; CHL, coracohumeral ligament; Sub, subscapularis. (Redrawn from Burkhart SS, Lo IKY. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14(6):333–346.)

A Krackow stitch (Answer C) is a locking stitch that can be used in various tendinous repairs, including Achilles’ tendon repairs. This type of stitch is not used in rotator cuff repairs.

A double-bundle reconstruction (Answer D) is a type of ACL reconstruction. This type of reconstruction is thought to more closely mimic the mechanics of a native ACL.

If in the same patient the MRI showed fatty infiltration of the supraspinatus and infraspinatus to the point where there was an equal amount of fat and muscle, which of the following would be the best treatment if the patient also had significant concomitant glenohumeral arthritis?

  1. Hemiarthroplasty

  2. Total shoulder arthroplasty

  3. Latissimus dorsi tendon transfer

  4. Arthroscopic rotator cuff repair

  5. Reverse total shoulder arthroplasty

 

Discussion

The correct answer is (E). Given that her rotator cuff has atrophied and has fatty infiltration to the point where there are equal parts fat and muscle, this is considered an irreparable rotator cuff tear. Repair should not be attempted because of poor outcomes following repair (see last two paragraphs of this discussion below). A reverse total shoulder arthroplasty is an alternative to repair that should be used in cases of massive, irreparable rotator cuff tears. It is a semi-constrained prosthesis that restores function in patients with massive rotator cuff tears by constraining a concave humeral cap inferior to a semispherical glenoid component (glenosphere). This creates an inferior force-couple and a fulcrum that replaces the stabilizing function of the infraspinatus maintaining a center of rotation around which the shoulder can move. This allows the deltoid to abduct and flex the shoulder without causing the humerus to migrate superiorly and about the acromion. In an elderly patient with a massive, irreparable rotator cuff tear (as in this patient), a reverse total shoulder arthroplasty is the procedure of choice.

It should be noted that reverse total shoulder arthroplasty is also the procedure of choice in patients with cuff-tear arthropathy (aka rotator cuff arthropathy). Characteristics of cuff-tear arthropathy include superior migration of the humerus due to a massive rotator cuff tear, glenohumeral joint destruction, subchondral osteoporosis, and humeral head collapse (see Fig. 2–17). A reverse total shoulder

arthroplasty in this case serves the purpose of eliminating pain caused by glenohumeral joint arthritis while restoring functional motion and is the procedure of choice in patients with cuff-tear arthropathy.

 

 

 

Figure 2–17 X-rays of a patient showing evidence of cuff tear arthropathy. The humerus is migrated superiorly, the glenohumeral joint is destroyed, there is subchondral osteoporosis, and the humeral head is collapsed. (From Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007;15(6):340–349.)

 

A hemiarthroplasty (Answer A) was previously the procedure of choice for cuff-tear arthropathy until the reverse total shoulder prosthesis was developed. A hemiarthroplasty reliably relieves pain, but it does not restore function as well as the reverse total shoulder. Also, if the patient had a previous coracoacromial ligament release or anterior deltoid detachment, they are at risk for anterosuperior escape of the humeral head after hemiarthroplasty.

A total shoulder arthroplasty (Answer B) is contraindicated in the case of cuff-tear arthropathy because of glenoid component loosening. If a glenoid component is used in this patient, the superior translation of the humeral head component on the glenoid component could cause it to loosen and rock, producing a “rocking-horse” glenoid component.

A latissimus dorsi tendon transfer (Answer C) would be a good option if this patient still had a normal glenohumeral joint and were young (less than 50 years old). But this patient has cuff-tear arthropathy, so his glenohumeral joint is destroyed. Performing a latissimus dorsi tendon transfer might restore some range of motion, but the patient would still have pain from arthritis in his shoulder.

An arthroscopic rotator cuff repair (Answer D) would be a poor choice in this patient given the characteristics of her tear. With massive rotator cuff tears, Goutallier et al. showed that the degree of fatty degeneration of the infraspinatus correlated directly with the time between onset of shoulder pain and the rotator cuff

repair (meaning people who waited longer to present and undergo surgery had more fatty degeneration of their infraspinatus tears), with the loss of active external rotation of the shoulder both pre- and postoperatively (meaning that more fatty degeneration predicts less function before and after repair), and with a higher rate of repair failure (meaning that more fatty degeneration predicts greater risk of operative failure). They also did not find any reversal of infraspinatus fatty degeneration after rotator cuff repair.

In addition, Goutallier et al. formulated a classification system for rotator cuff tears that is helpful in determining whether a massive rotator cuff tear is reparable or not based on fatty degeneration. Progressive atrophy and fatty degeneration occurs as the length of time the rotator cuff has been torn increases. The fat to muscle ratio is used in the Goutallier classification. The cause of this atrophy and degeneration is not fully understood but is likely due to a combination of loss of mechanical tension of the muscle and muscle denervation.

This classification was originally based on CT imaging but is now applied to MRI imaging and uses sagittal oblique views at the most lateral slice in which the scapular spine is continuous with the scapular body. There are five categories that range from stage 0 to stage 4. A classification of stage 0 is normal, stage 1 is some fatty streaks, stage 2 is more muscle than fat, stage 3 is equal amounts of fat and muscle, and stage 4 is more fat than muscle. This patient’s rotator cuff tear involves the supraspinatus and infraspinatus, and both have atrophied to the point of having equal amounts of fat and muscle, giving her tear a Goutallier classification of stage 3 (see Table 2–2 and Fig. 2–18). As a general rule, if there is stage 3 or 4 fatty atrophy, rotator cuff repair will not be successful and a reverse total shoulder or tendon transfer would be a better operation.

 

Table 2–2 GOUTALLIER CLASSIFICATION

 

Goutallier Classification

Description

Stage 0

Normal

Stage 1 Minimal fatty streaks

Stage 2 Significant amount of fatty streaks but more muscle than fat Stage 3 Equal amounts of fat and muscle

Stage 4

More fat than muscle

Data from Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty infiltration and rotator cuff atrophy. J Am Acad Orthop Surg. 2013;21(10):613–623.

 

 

Figure 2–18 Three different patients showing different stages of fatty degeneration with Goutallier stages. Higher stages are predictive of worse outcomes after rotator cuff repair. SS, supraspinatus; IS, infraspinatus; TM, teres minor; Sub, subscapularis. (From Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty infiltration and rotator cuff atrophy. J Am Acad Orthop Surg. 2013;21(10):613–623.)

 

If a patient had the same tear but was a healthy, active 50 year old with no glenohumeral arthritis, which of the following choices would be the best treatment?

  1. Latissimus dorsi tendon transfer

  2. Arthroscopic rotator cuff repair

  3. Subscapularis tendon transfer

  4. Trapezius tendon transfer

  5. Reverse total shoulder arthroplasty

 

Discussion

The correct answer is (A). In young, active patients with a massive, irreparable rotator cuff tear without glenohumeral arthritis, a tendon transfer is the most reasonable option to attempt to restore function of the shoulder. In a tear involving the supraspinatus and infraspinatus, the posterior and inferior force-couples in the transaxial and coronal planes, respectively, are out of balance because of the involvement of the infraspinatus in both of those. Because of this, the humerus cannot be dynamically stabilized in the glenoid during active movement of the shoulder. The most popular way to restore this in a young, healthy patient is through a latissimus dorsi tendon transfer in which the insertion of the tendon is transferred from the humeral shaft to the greater tuberosity (see Fig. 2–19). This creates a new posterior and inferior force-couple and creates an external rotation force.

 

 

Figure 2–19 Latissimus dorsi tendon transfer on a right shoulder viewed from superiorly with anterior being the left side of the image. Top: final appearance. Bottom: final sutures being thrown through the latissimus dorsi. (From Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21(8):492–501.)

 

It should be noted that due to the differences in the length and force vector magnitude and direction between the infraspinatus and latissimus dorsi, the force couple is not perfectly restored, and thus the shoulder after a tendon transfer never works as well as with a successful repair of the native cuff. The latissimus force vector is much more vertical and greater in magnitude than the infraspinatus. This transfer thus has variable results in restoring function. Factors associated with poor outcome include subscapularis dysfunction, deltoid dysfunction, osteoarthritis of the glenohumeral or acromioclavicular joint, and loss of teres minor function, none of which are present in this patient.

An arthroscopic rotator cuff repair (Answer B) would be a poor choice in this patient given the characteristics of her tear. The degree of fatty degeneration of the rotator cuff in this case puts the patient at risk for poor outcomes after rotator cuff repair.

A subscapularis tendon transfer (Answer C) has been used by some orthopedists

to attempt to restore an inferior force couple and abduction force by transferring the superior portion of the subscapularis more superiorly to the greater tuberosity. It would likely not be a successful procedure in this patient, though, because there would still be a lack of posterior and inferior force-couple due to the torn infraspinatus. The transfer would help to make up for the loss of function of the supraspinatus abduction force but would not help with the loss of the infraspinatus.

A trapezius tendon transfer (Answer D) is used by some orthopaedic surgeons with good success in restoring external rotation for brachial plexopathy and has some renewed interest in general, but it has not been reported in the literature as a surgical technique for rotator cuff tears and is not as popular as the latissimus dorsi transfer. The inferior trapezius force vector is similar in magnitude and direction to the infraspinatus, so using this transfer makes good biomechanical sense, but other issues exist such as the need to use an Achilles tendon allograft to bridge the distance between the trapezius tendon and the greater tuberosity.

A reverse total shoulder arthroplasty (Answer E) restores range of motion in a shoulder with an irreparable rotator cuff, but it has significant limitations of lifting activities and a higher risk of needing revisions in younger patients like this 50 year old. The goal of surgery in this young, active patient would be to increase function of his shoulder without the limitations of a reverse total shoulder arthroplasty.

If this patient had been diagnosed with a chronic, irreparable tear of the subscapularis and had failed a trial of physical therapy, corticosteroid injections, and NSAIDs, what would be the most reasonable next step in treatment?

  1. Subscapularis tendon repair

  2. Biceps tenotomy

  3. Pectoralis major tendon transfer

  4. Reverse total shoulder arthroplasty

  5. Supraspinatus tendon transfer

 

Discussion

The correct answer is (C). When the native rotator cuff is irreparable, using a tendon transfer is the next step. Since the force vector of the pectoralis major muscle is similar to that of the subscapularis, this tendon can be used as an effective tendon transfer, restoring internal rotation and humeral head centering and compression. The surgery is performed by detaching the pectoralis major from its humeral insertion and moving the insertion to the lesser tuberosity. The tendon of

the pectoralis major can run anterior to the conjoined tendon or can be transposed posterior to the conjoined tendon but anterior to the musculocutaneous nerve. This latter method more closely replicates the force vector direction of the subscapularis, but has not been shown to lead to better outcomes (see Fig. 2–20). A latissimus dorsi tendon transfer is also sometimes used for irreparable subscapularis tendon tears.

 

 

 

Figure 2–20 Pectoralis major tendon transfer. Left: partial tendon transfer. Right: complete tendon transfer. Both use a subcoracoid approach. (From Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21(8):492–501.)

 

Subscapularis tendon repair is by definition impossible since this is an irreparable subscapularis tendon tear (Answer A). A tenotomy of the long head of the biceps (Answer B) would likely be performed as a part of the tendon transfer surgery, but would not by itself help in restoring function. A reverse total shoulder arthroplasty (Answer D) is used for massive, irreparable rotator cuff tears of the anterosuperior rotator cuff but not for subscapularis tears, as in this question. A supraspinatus tendon transfer (Answer E) is not a surgery that has been described for irreparable subscapularis tendon tears.

If the patient presents with concerning signs and symptoms of wound infection 1 month after reverse total shoulder surgery but cultures are negative, what is the most likely causative organism?

  1. Staphylococcus aureus

  2. Streptococcus pyogenes

  3. Propionibacterium acnes

  4. Pseudomonas aeruginosa

  5. Trichophyton rubrum

 

Discussion

The correct answer is (C). This bacterium is the most common cause of delayed or indolent infections of surgical wounds. Cultures are often negative because it takes a long time, about 14 to 21 days for it to grow out on cultures. Staphylococcus aureus (Answer A), Streptococcus pyogenes (Answer B), and Pseudomonas aeruginosa

(Answer D) are some bacterial causes of acute wound infections but would likely present within a week or two of surgery and would likely grow out on cultures. Trichophyton rubrum (Answer E) is a fungus that is the leading cause of ringworm and is not commonly a cause of surgical wound infection.

 

Objectives: Did you learn...?

 

 

Surgically repair full-thickness rotator cuff tears based on tear shape? Treat massive, irreparable rotator cuff tears based on patient age?

 

Treat a massive, irreparable subscapularis tear?

 

Identify the cause of a delayed surgical wound infection of the shoulder?