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CURRENT CONCEPTS
A diagnostic arthroscopy is performed using standard anterior and posterior portals next. Old portal sites can be used for arthroscopy if they are in the right location. Close attention should be paid to the long head of the biceps (LHB) insertion and the intraarticular and intertubercular portion of the biceps tendon (Fig. 3). We have a low threshold to perform tenotomy during revision surgery if there are any signs suggestive of tendonitis or significant tear (as a primary procedure or for later tenodesis; Fig. 4). Subscapularis tendon tears are less common compared to the posterosuperior cuff tears but they are often missed or misdiagnosed as just fraying of the upper rolled edge. The medial and lateral part of the subscapularis footprint should be meticulously examined (Fig. 5). If there is a subscapularis tear that requires repair, it is performed next. An anterolateral portal is required as an accessory working portal for arthroscopic subscapularis repair (Fig. 6). Extensive tears of subscapularis are addressed by open technique. We also prefer to perform intra articular release between the undersurface of the cuff and capsule over the glenoid and debride the rotator cuff footprint on the greater tuberosity via the intra articular portals. Chondral wear or damage on the humeral head or glenoid should be documented. Loose suture material or implants are removed. If there is any sign suggestive of infection, multiple synovial and rotator cuff biopsy specimens should be obtained and send for culture and sensitivities.
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After performing a diagnostic arthroscopy and intra articular work, we proceed to the subacromial space and establish a lateral portal, which is utilized to perform a subacromial bursectomy and revision acromioplasty if necessary (Fig. 7). Fibrous bursal tissue or adhesions tethering the RC to the acromion and deltoid are carefully debrided without causing damage to the deltoid and the rotator cuff. The basic principles of arthroscopic rotator cuff repair should be followed during revision posterosuperior rotator cuff repair and includes tendon mobilization, tear pattern recognition, foot print preparation and performing a tension free repair. The morphology of the tendon tear, the size and the mobility of the torn rotator cuff are analyzed.
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At this stage one of few options exists. First, if the tendon tissue quality is good and there is a sufficient RC tendon excursion to its native footprint, we prefer a transosseous equivalent double row repair with a suture bridge construct to increase the contact area of the tendon at the footprint for healing (Fig. 8). Second, if tension free repair is not possible due to limited RC excursion, soft tissue releases are performed. This includes the intra articular release of the undersurface of the cuff over the glenoid and the anterior and posterior interval slides, which are performed from the subacromial portals. Once enough mobilization of the RC tendons has been achieved we proceed with the transosseous equivalent double row repair. Third, if the tendon excursion is limited and tendon cannot be brought to the lateral footprint despite adequate soft tissue releases, we perform a single row repair with medialization of the tendon on the footprint.
Friable RC tissue that is not able to hold sutures, presence of severe RC tendon tissue loss (musculotendinous tendon tears), massive rotator cuff tears and tendons with poor excursion despite adequate soft tissue releases are intra operative indicators that a revision RCR will fail. This situation represents a decision dilemma for the surgeon. A partial repair of the torn tendon can be performed and includes the use of margin convergence (side to side repair) and repair of the reducible component of the cuff to the footprint (Fig. 9). Some patients surprisingly do well for a significant period of time with this treatment, a fact that many orthopaedic surgeons have experienced in their practice but the exact understanding of this phenomenon is not available. It is suggested that the restoration of the anteroposterior force couple with these limited or partial repair provides stability and relieves pain. Arthroscopic distal clavicle, if necessary, is performed after the rotator cuff repair has been accomplished (Fig. 10).
ISAKOS NEWSLETTER 2015: Volume I 37