2021 ISAKOS Biennial Congress Paper
All-Arthroscopic muscle advancement repair technique for massive postero-superior rotator cuff tears
Andrew Ker, MBChB, BSc (Hons), FRCSed (T+O), Brisbane, QLD UNITED KINGDOM
Jashint Maharaj, MBBS, MPHTM, Brisbane, QLD AUSTRALIA
Bart-Jan Jd Veen, MD, Enschede NETHERLANDS
Kenneth Cutbush, MBBS, FRACS, FAOrthA, Spring Hill, QLD AUSTRALIA
Ashish Gupta, MBBS, MSc, FRACS, Brisbane, QLD AUSTRALIA
Shoulder Surgery QLD Reserach Institute, Brisbane, QLD, AUSTRALIA
FDA Status Not Applicable
All-Arthroscopic muscle advancement technique for massive cuff tears allows for tension-free repair and low re-tear rates
The purpose of this study was to present an all-arthroscopic muscle advancement technique to repair massive postero-superior rotator cuff tears and to examine functional and clinical outcomes.
Re-tear rates remain high following repair of massive rotator cuff tears. Retraction and delamination result in poor tendon quality and increased tension on the repair. These tears are often deemed irreparable due to a high failure rate. In this case, younger patients are often managed with tendon transfers or superior capsular reconstruction, whereas elderly patients are recommended reverse shoulder arthroplasty. This technique modified the open Debeyre-Patte procedure and the arthroscopy-assisted muscle advancement procedure reported by Morihara et al. This all-arthroscopic technique of muscle advancement allows a tension-free tendon repair in massive retracted rotator cuff tears.
Our technique involved sequential arthroscopic release of the supraspinatus and infraspinatus muscles. Muscle slides consisting of the release of the medial attachment to the scapula border and preservation of fascial attachments to rhomboids and deltoid to full muscle advancement were utilized in patients with irreparable postero-superior cuff tears depending on the extent of retraction and chronicity of the tear. Identification and preservation of the neurovascular pedicles (suprascapular nerve) to each muscle were performed. This allowed advancement of the tendon to its footprint, permitting tension free tendon repair. Tendon repair technique addressed the deep tendon layer with a Lasso loop, followed by a tied medial row taken to a knotless lateral row.
55 patients underwent this repair technique, with a mean follow up of 11 months (range 6-24 months). All patients had pre-operative Magnetic Resonance Imaging (MRI) scans confirming massive retracted rotator cuff tears to the rim of the glenoid (Patte Grade 3) and muscle fatty infiltration as classified by Goutallier et al. Follow-up MRI scans were performed to assess tendon healing. Clinical outcomes were evaluated comparing pre- and post-surgical Constant Murley scores and pain VAS.
MRI showed that 51 out of 55 (93%) repairs were healed, with a re-tear rate of 7%. The mean Constant Murley scores improved from 48 ± 16 pre-operatively to 80 ± 13 (p<0.05). VAS scores improved from a mean of 4 ± 2 pre-operatively to 1±2 post-operatively. 5 patients underwent further surgery: 2 patients to remove prominent hardware, 1 patient for release due to stiffness and 2 patients for reverse shoulder arthroplasty.
In our series, the clinical outcomes of the all-arthroscopic muscle advancement technique showed a low re-tear rate. Significant improvements in shoulder function and pain were noted. This technique is an alternative to non-anatomical procedures, such as superior capsular reconstruction and tendon transfers.