0
    306
    views

    Arthroscopic Transosseus Tunnel Repair for a Large Rotator Cuff Tear

    A 64-year-old male patient who had previously been treated for a partial rotator cuff tear presents with significant anterior shoulder pain in the same shoulder. When an acute retracted large rotator cuff tear is diagnosed, decisions need to be made about non-operative versus operative treatment.

    Authors

    John G. Horneff, MD, and Joseph A. Abboud, MD

    Disclosures

    Dr. Horneff has no disclosures relevant to this article. Dr. Abboud has disclosed that he is on the scientific advisory board for MinInvasive.

    Case Presentation

    A 64-year-old, right-hand-dominant, retired male patient presents with complaints of a painful right shoulder. He states that he was treated non-operatively 6 years prior for a partial rotator cuff tear of the same shoulder.

    He had been doing well until about a week before presenting to the office, when he had a missed swing while playing golf and took a large divot. He says that since then, he has experienced significant anterior shoulder pain that is disrupting his sleep.

    The patient has been taking anti-inflammatory medication by mouth but says that it has provided only minimal relief.

    Medical and Surgical History

    • Gastroesophageal reflux disease
    • Prostate cancer
    • Hernia repair
    • Non-smoker
    • Occasional social alcohol use (glass of wine at parties)

    Physical Examination

    • Height: 6 feet, 5 inches; weight: 185 pounds; BMI: 21.9
    • Atrophy of the supraspinatus/infraspinatus fossa
    • Active range of motion (AROM): Forward elevation: 135°, abduction: 90°, external rotation (0° abduction): 30°, internal rotation (0 degrees abduction): L3 vertebral level
    • Passive range of motion (PROM): Forward elevation: 160°, abduction: 110°, external rotation (0° abduction): 40°
    • Examination maneuvers: Positive Neer test, positive Hawkin’s impingement sign
    • Sensation intact to light touch in axillary, radial, median, and ulnar nerve distributions
    • 5/5 strength in radial, median, ulnar, anterior interosseous, and posterior interosseous nerve distribution
    • 2+ distal radial pulse
    • Full AROM/PROM of the elbow and wrist
    • Shoulder scores: ASES: 56.32, SST: 41.67

    Differential Diagnosis

    • Rotator cuff tendinitis
    • Partial-thickness rotator cuff tear
    • Acute full-thickness rotator cuff tear
    • Chronic rotator cuff tear
    • Biceps tendinitis
    • Glenohumeral osteoarthritis
    • Cuff tear arthropathy
    • Adhesive capsulitis

    Imaging

    Initial anteroposterior (AP) and axillary view radiographs were obtained (Figures 1a-b).

    AP

    • Minimal arthritic changes noted at the glenohumeral joint
    • No significant proximal migration of the humerus in relation to the glenoid

    Axillary

    • Minimal arthritic changes with well-maintained joint space
    • Humeral head well centered in reference to the glenoid vault               

    Figures 1a-b. Preoperative AP (left) and axillary (right) view radiographs.

    An MRI was obtained for assessment of the rotator cuff given the physical examination findings and the minimal changes see on plain radiography.

    Coronal T2-weighted (Figures 2a-b)

    • Complete full-thickness tear of the supraspinatus and infraspinatus tendons, with retraction of about 1 cm medially
    • Minimal arthritic changes

    Axial T2-weighted (Figures 2c-d)

    • Intact subscapularis tendon, with moderate tendinosis
    • Intact long head of the biceps tendon within the bicipital groove, with mild tendinosis.

    Sagittal T1-weighted (Figures 2e-f)

    • Grade 1 Goutallier changes noted in the supraspinatus and infraspinatus muscle bellies
    • Subscapularis and teres minor muscle bulk in satisfactory condition
    • Full-thickness tear about 3 cm in sagittal dimension

    Figures 2a-b. Coronal T2-weighted MRI.

    Figures 2c-d. Axial T2-weighted MRI.

    Figures 2e-f. Sagittal T1-weighted MRI.

    Diagnosis

    • Acute retracted large rotator cuff tear with minimal glenohumeral joint arthritis

    Treatment Options

    Non-operative Treatment

    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Physical therapy
    • Cortisone Injections

    Advantages

    • No risks of surgery
    • Can begin treatment immediately
    • No need for immobilization

    Disadvantages

    • Decreased success of treatment with increased age and tear size
    • NSAIDs side effect profile (ie, gastric bleeding)
    • Decreased tendon tissue quality with multiple cortisone injections
    • Potential for tear to continue to increase in size and result in cuff arthropathy

    Surgical Treatment: Rotator Cuff Repair with Bone Anchor Placement

    Advantages

    • Commonly performed procedure
    • Preserves native glenohumeral articular surfaces
    • Minimally invasive arthroscopic technique with decreased chance of perioperative and postoperative complications

    Disadvantages

    • In general, decreased healing rates with large/massive and chronic tendon tears compared with small and acute tears
    • Costs of multiple anchors in larger tears
    • More foreign material implanted when using anchors versus transosseous repairs
    • Long rehabilitation

    Surgical Treatment: Rotator Cuff Repair with Transosseus Suture Tunnels

    Advantages

    • Preserves native glenohumeral articular surfaces
    • Reestablishes the tendon footprint
    • Potentially allows for full return to activity if the tear heals
    • Cost benefit for larger tears compared to anchor repair. The tunneler device costs approximately $700, with each cartridge costing $100 per tunnel (total cost: $1000). Comparatively, a transosseus-equivalent repair with anchors would require 4 to 6 anchors at a cost of $300 per anchor (total cost: $1200-$1800).

    Disadvantages

    • May be technically more difficult than anchor placement
    • May require longer operative time for some surgeons
    • Potential for suture cutout in poorer quality bone (ie, advanced age, osteoporosis, tuberosity cysts), although grommets are available to help minimize cutout in poor bone

    Procedure

    The patient agreed to undergo arthroscopic transosseus tunnel rotator cuff repair.

    • After receiving an interscalene nerve block, the patient was placed in the beach chair position at 90° of elevation, with the arm in a McConnell arm positioner. He received general anesthesia for the procedure.
    • A standard posterior superior arthroscopic portal was established for placement of the arthroscope into the glenohumeral joint.
    • An anterior superior instrumentation portal was made under direct visualization.
    • Systematic diagnostic evaluation of the glenohumeral joint was performed. The subscapularis and long head of the biceps tendons were found to be intact (Figure 3a). The rotator cuff demonstrated a full-thickness tear of the entire supraspinatus and part of the infraspinatus tendons, with retraction of about 1.5 cm (Figure 3b). The teres minor tendon was intact. There was no evidence of glenohumeral arthritis (Figure 3c).
    • The arthroscope was redirected to the subacromial space and a lateral portal was established under direct visualization to allow preparation of the subacromial space with an arthroscopic shaver and electrocautery.
    • Bursectomy, coracoacromial ligament release, and acromioplasty were performed.
    • Attention was turned to the torn rotator cuff tendon, which was debrided back to a healthy tissue margin.
    • Releases were performed to establish maximal tendon mobility, including release of subacromial adhesions and the rotator interval.
    • The tendon footprint on the greater tuberosity was decorticated to increase chances of healing.
    • A posterolateral portal was created for viewing with the arthroscope.
    • A spinal needle was placed off the edge of the lateral acromion to localize medial tunnel hole placement.
    • An arthroscopic awl was used to create medial holes.
    • An arthroscopic bone tunneler was used to create bone tunnels via the lateral portal (Figure 4). The lateral portal was expanded to about 8 mm to accommodate the tunneling device.
    • A medial needle guide placed into medial hole and tunneler was held in place to allow correct placement of a lateral hole.
    • The needle was fired to capture the looped wire suture passer from the lateral hole.
    • The wire loop was retrieved out of the lateral portal to pass 3 sutures from medial to lateral in the tunnel.
    • A total of 3 transosseus tunnels were created from anterior to posterior. Three non-absorbable, high-strength braided composite sutures were placed in each tunnel.
    • The sutures were shuttled through the rotator cuff in an anterior to posterior fashion with an arthroscopic suture passer through the cuff tendon tissue.
    • Sutures were tied in a simple fashion via a working cannula established in the lateral portal.    
    • Portal sites were closed with a non-absorbable monofilament suture in figure-of-8 fashion.

    Figure 3a. Arthroscopic view of the subscapularis tendon.

    Figure 3b. Arthroscopic view of the full-thickness supraspinatus and infraspinatus tear from the subacromial space.

    Figure 3c. Arthroscopic view of the glenohumeral articular surfaces.

    Figure 4. Arthroscopic bone tunneler device.

    Postoperative Management

    0-4 Weeks

    • Use of a sling for comfort, non-weight-bearing
    • Arm use allowed for light tasks (eating, writing, hygiene).

    4-8 Weeks

    • Out of the sling except for uncontrolled environment
    • Formal physical therapy begun with Phase 1 stretching (passive range of motion)
    • No lifting heavier than the weight of a coffee cup.

    8-12 Weeks

    • Physical therapy advanced to Phase 1 and 2 stretching (PROM and AROM initiated)
    • Running allowed

    12 Weeks

    • Physical therapy advanced to Phase 1 strengthening with weight-lifting restriction of 5 pounds

    Patient Course

    At 1 week after surgery, the patient’s portal incisions were healing well and his pain was minimal.At 8 weeks after surgery, the patient continued to do well.

    • PROM
      • Forward elevation: 130°
      • Abduction: 80°
      • External rotation (0° abduction): 30°

    At 6 months, the patient continued to do well with minimal pain. His incisions were well healed. He continued to do well with physical therapy, and he was back to full activity with racket sports.

    • AROM
      • Forward elevation: 155°
      • Abduction: 90°
      • External rotation (0° abduction): 50°
      • Internal rotation (0° abduction): T7 vertebral level

    At 2 years after surgery, he continued to demonstrate a good outcome. He had no complaints and was very satisfied overall.

    • AROM:  Forward elevation: 160°, abduction: 90°, external rotation (0° abduction): 50°, internal rotation (0° abduction): T7 vertebral level
    • ASES shoulder score: 100
    • SST shoulder score: 100

    Author Information

    John G Horneff, MD is a fellow in shoulder and elbow surgery at The Rothman Institute, Philadelphia, Pennsylvania. Joseph A Abboud, MD is a board-certified shoulder and elbow surgeon with The Rothman Institute and an associate professor of orthopaedic surgery at Thomas Jefferson University, Philadelphia, Pennsylvania.

    Shoulder Reconstruction Section Editor, Rothman Institute Grand Rounds

    Luke S. Austin, MD