Arthroscopic Partial Repair of Irreparable, Massive Rotator Cuff Tears

Abstract

Several treatment options for chronic, massive rotator cuff tears exist, and they include debridement with possible biceps tenotomy or tenodesis, open or arthroscopic partial repair, muscle or tendon transfer, superior capsule reconstruction, synthetic patch augmentation, and reverse total shoulder arthroplasty. The aim of this technique article is to describe our preferred surgical option for irreparable, massive rotator cuff tears with an irreparable supraspinatus, a reparable infraspinatus, and an intact or reparable subscapularis tendon.

Chronic, massive tears of the rotator cuff tendons usually cause atrophy and fatty degeneration of the rotator cuff muscles and painful loss of shoulder function. Several treatment options for chronic, massive rotator cuff tears (RCTs) exist, and they include debridement with possible biceps tenotomy or tenodesis, open or arthroscopic partial repair, muscle or tendon transfer, superior capsule reconstruction, synthetic patch augmentation, and reverse total shoulder arthroplasty (RTSA). Despite all these options, irreparable, massive RCTs are difficult to manage and treat effectively. Partial repair was originally conceived by Burkhart et al.¹ as an open procedure involving the inferior half of the infraspinatus to create a balanced force couple. An arthroscopic modification of this technique was described in 2001,² and it is best used in situations involving massive RCTs with an irreparable supraspinatus, a reparable infraspinatus, and an intact or reparable subscapularis tendon. In fact, if the repair of the supraspinatus tendon is not possible, the reattachment of the subscapularis and infraspinatus tendons provides significant clinical improvement because of restoration of the cable attachment, preservation of rotator cuff function, restoration of balanced force couples, and re-establishment of a stable fulcrum of motion. This technical note describes our arthroscopic partial repair approach to irreparable, massive RCTs (Video 1, Table 1).

Table 1.

Risks and Pearls During Surgery

Surgical Step	Risks	Pearls
Diagnostic arthroscopy	Missing of concomitant long head of biceps tendon lesions	Either tenotomy or tenodesis of the biceps can be performed depending on the age, sex, and functional requirements of the patient.
	Presence of concomitant chondral lesions	Arthroscopic partial repair is contraindicated for patients with grade III or IV chondral lesions according to the Outerbridge classification system.
Mobilization of rotator cuff	Insufficient release leading to false assessment of a tear as “irreparable”	The mobility of the cuff is tested by grasping the edges of the tendons with an arthroscopic grasper.
	Overly aggressive release leading to traction damage to suprascapular nerve	If repair is not possible, alternative techniques should be considered.
	Excessive tension on repair leading to early rotator cuff repair failure	If repair is not possible, alternative techniques should be considered.
Anchor insertion	Anchor pullout due to incorrect anchor positioning	The surgeon can use an 18-gauge spinal needle with an outside-in technique to determine correct anchor positioning.
Suture passage through rotator cuff tendons	Later rotator cuff repair failure	The sutures should be passed 2-3 mm lateral to the musculotendinous junction. Appropriate bursal- and articular-sided tension should be achieved by using a grasper to reduce the tendon and taking differential bites through each leaflet when delamination is present.
Subscapularis release	Vascular and nerve injuries	The surgeon should not proceed medially to the conjoint tendon.
Infraspinatus release	Excessive tension leading to early rotator cuff repair failure	If the tendon cannot be adequately mobilized, then a tendon transfer should be considered.
Postoperative rehabilitation	Postoperative stiffness	The repair should be stable with no tension on it. Physical therapy begins at 4 weeks. The patient should avoid external rotation for the first 4 weeks and internal rotation for the first 6 weeks. Painkillers should be administered.

Surgical Technique

With the patient positioned in the lateral decubitus position with a regional interscalene nerve block, the operative arm is placed in 20° to 30° of abduction and 20° of forward flexion (Star Sleeve Traction System; Arthrex, Naples, FL). The index shoulder is prepared and draped in a sterile fashion. A diagnostic arthroscopy is performed with a 30° arthroscope viewing through a standard posterior portal. A chronic, massive RCT is usually combined with a lesion of the long head of the biceps tendon. Either tenotomy or tenodesis of the biceps can be performed depending on the age, sex, and functional requirements of the patient. Through a standard posterior viewing portal, the posterosuperior cuff tear is also identified (Fig 1). By use of an 18-gauge spinal needle and an outside-in technique, a standard anterosuperior portal is created just lateral to the tip of the coracoid and a lateral portal is created at the midglenoid level in the sagittal plane (Fig 2). The subscapularis tendon tear is evaluated (Fig 3), and its mobility is assessed with a grasper through the lateral portal. At this point, the status of the rotator cuff is assessed and the diagnosis is made. With the arthroscope in the subacromial space through the posterior portal, complete arthroscopic bursectomy and subacromial spur removal with preservation of the coracoacromial arch are performed. After bursectomy, with the arthroscope in the lateral portal, debridement of the nonviable edges of the subscapularis tendon is performed. If necessary, intra- and extra-articular releases are performed to allow for greater mobilization of the tendon. Next, the lesser tuberosity bone bed is prepared through the anterosuperior portal with gentle use of a bone cutter blade (5.5-mm Full-Radius Bone Cutter Blade; Smith & Nephew, Andover, MA) to create a bleeding bed. Afterward, a triple-loaded suture anchor (Healix; DePuy Mitek, Raynham, MA) is placed as medially as possible to the first facet (Fig 4). After anchor insertion, a suture hook (Linvatec, Largo, FL) is preloaded with No. 1 PDS (Ethicon, Somerville, NJ) and introduced through the anterosuperior portal for suturing. The suture hook penetrates the full thickness of the subscapularis tendon from the bursal side toward the articular side. PDS is used to relay the suture limbs of the anchor one at a time, from distal to proximal. Both limbs are tied with simple sliding knots. The torn subscapularis tendon is repaired with full coverage of the footprint on the bursal side (Fig 5).

Fig 1.

Arthroscopic view from the posterior portal in a right shoulder in the lateral decubitus position. A massive tear of the posterosuperior rotator cuff (RC) is visualized. (HH, humeral head.)

Fig 2.

Complete tear of supraspinatus (SSP), infraspinatus (ISP), and subscapularis (SSC) tendons. (TM, teres minor.)

Fig 3.

Arthroscopic view from the posterior portal in a right shoulder in the lateral decubitus position. A tear of the upper third of the subscapularis tendon (SSC) is visualized. (G, glenoid; HH, humeral head.)

Fig 4.

Arthroscopic view from the lateral portal in a right shoulder in the lateral decubitus position. A triple-loaded suture anchor (Healix) is placed as medially as possible to the first facet of the subscapularis (SSC). (HH, humeral head.)

Fig 5.

Arthroscopic view from the posterior portal in a right shoulder in the lateral decubitus position showing a repair of the subscapularis tendon (SSC) with full coverage of the footprint on the bursal side. (HH, humeral head.)

After the anterior cuff repair, we proceed to repair the posterior RCT, with the arthroscope in the posterior portal. From the lateral portal, soft-tissue release and removal of scar tissue are performed with a shaver (Dyonics Shaver; Smith & Nephew) to allow adequate mobility of the tendons to the prepared greater tuberosity. In detail, the mobility of the cuff is tested by grasping the edges of the tendons with an arthroscopic grasper and attempting to pull it laterally to the footprint region as much as possible. An arthroscopic release of the supraspinatus tendon is always attempted before deeming it irreparable. Preparation of the infraspinatus footprint is carried out with a bone cutter blade (5.5-mm Full-Radius Bone Cutter Blade), and a triple-loaded suture anchor (Healix) is placed (Fig 6). Repair of the infraspinatus is performed with a single-row technique (Fig 7) and simple sliding knots proceeding from posterior to anterior using an ExpresSew II Suture Passer.

Fig 6.

Arthroscopic view from the posterior portal in a right shoulder in the lateral decubitus position showing placement of a triple-loaded suture anchor (Healix) for the infraspinatus (ISP) repair. (HH, humeral head.)

Fig 7.

Arthroscopic view from the posterior portal in a right shoulder in the lateral decubitus position showing repair of the infraspinatus (ISP) with a single-row technique. (HH, humeral head.)

At the end of the procedure, the repair can be assessed, first from the posterior portal and then from the lateral portal. The posterior cuff (i.e., infraspinatus) and the anterior cuff (i.e., subscapularis) appear anatomically repaired (Fig 8); the humeral head remains partially uncovered because of the absence of the supraspinatus but is refocused and rebalanced, which is the objective of arthroscopic partial repair.

Fig 8.

Anatomic repair of the posterior cuff (i.e., infraspinatus [ISP]) and the anterior cuff (i.e., subscapularis [SSC]) with the humeral head partially uncovered because of the absence of the supraspinatus (SSP). (TM, teres minor.)

Discussion

Arthroscopic rotator cuff repair techniques have evolved over the past few decades. The arthroscopic RCT partial repair provides orthopaedic surgeons an additional treatment option for an irreparable supraspinatus and reparable infraspinatus with an intact or reparable subscapularis tendon. Originally introduced to obtain a biomechanically sound rotator cuff repair,¹ this technique includes the repair of at least the inferior half of the infraspinatus and all of the subscapularis. This technical note describes arthroscopic partial repair of irreparable, massive RCTs according to the technique later described by Burkhart.²

Modifications of this technique have been subsequently reported, and they include partial repair of the supraspinatus tendon through a margin convergence technique³ or its insertion within the medial footprint.⁴ The principle of margin convergence applied to rotator cuff repair is achieved by side-to-side suture of the cuff tear to converge the free margin of the cuff toward its bone bed. This technique has been shown to reduce strain along the “converged” margin, thereby protecting the tendon-bone repair interface during the critical phases of healing.³ The medialized technique aims to repair, whenever possible, the supraspinatus tendon by inserting the suture anchor within the medial footprint of the greater tuberosity or less than 1 cm medial to the junction between the articular cartilage and the greater tuberosity. This technique has been shown to be effective in terms of recovery of muscle strength and improvement in postoperative outcomes; however, a notable retear rate of 41.7% has to be expected.⁴

It is pivotal to properly clarify the indications for arthroscopic partial repair over other surgical possibilities. The arthroscopic-assisted latissimus dorsi tendon transfer has been proposed as a reasonable solution to restore function and decrease pain in patients with irreparable, massive RCTs.⁵ However, even when arthroscopically assisted, the latissimus dorsi tendon transfer is a challenging and more aggressive procedure compared with arthroscopic partial repair; therefore, it should be indicated when the infraspinatus tendon cannot be repaired. Another treatment option is represented by RTSA; it is frequently used for massive RCTs even in the absence of cuff tear arthropathy. However, uncertainty over the longevity of the prosthesis has been raised and should be taken into account in the treatment of younger patients.⁶ Therefore, we believe that age at surgery and reparability of the infraspinatus tendon should be considered as discriminating factors while choosing between an arthroscopic partial cuff repair and an RTSA. Interestingly, the latter can still be performed to treat failed arthroscopic partial cuff repair. As further procedural alternatives, both patch-augmented rotator cuff repair⁷ and arthroscopic superior capsule reconstruction⁸ have recently been described. Again, the lack of long-term results for these techniques and the consequent concerns about prognoses should be considered. Finally, long head of the biceps tenotomy or tenodesis and arthroscopic subacromial debridement to treat massive RCTs should be purely considered as symptomatic rather than therapeutic surgical options.

In conclusion, if both the anterior cuff (i.e., subscapularis) and the posterior cuff (i.e., infraspinatus) are reparable, arthroscopic partial repair should be performed. A tendon transfer technique can be considered if either the posterior cuff or the anterior cuff is irreparable. RTSA should be preferred in elderly patients (>70 years old) with irreparable, massive RCTs.

Supplementary Data

Video 1

The patient is in the lateral decubitus position with a regional interscalene nerve block. Diagnostic arthroscopy of the right shoulder begins with viewing through a standard posterior portal. The long head of the biceps tendon is missing. A complete rupture of the upper third of the subscapularis, supraspinatus, and infraspinatus is noted. The rotator cuff tear is clearly shown. The subscapularis tendon mobility is assessed with a grasper through the lateral portal. With the arthroscope in the subacromial space through the lateral portal, the lesser tuberosity bone bed is prepared through the anterosuperior portal with a bone cutter blade (5.5-mm Full-Radius Bone Cutter Blade). Afterward, a triple-loaded suture anchor is placed as medially as possible to the first facet. After anchor insertion, a suture hook is used for passing the sutures through the subscapularis. We suggest using a cannula to simplify suture passage and sliding. PDS is used to relay the suture limbs of the anchor one at a time, from distal to proximal, with assessment of the mobility of the subscapularis that is essential to obtain a good repair. All 3 sutures are passed in a similar fashion. Three simple sliding knots are performed. The torn subscapularis tendon is repaired, and the repair appears stable even with dynamic testing, with no tension on it. After the anterior cuff repair, we proceed to repair the posterior rotator cuff tear. With the arthroscope in the posterior portal, preparation of the infraspinatus footprint is carried out with a 5.5-mm Full-Radius Bone Cutter Blade. A second triple-loaded suture anchor is placed at the footprint site. An ExpresSew II Suture Passer is used to pass the sutures through the infraspinatus from medial to lateral. Suture limbs are retrieved through the cannula, and the infraspinatus appears reducible. The same procedure is repeated for the second suture limb. The suture limb is retrieved through the cannula, the ExpresSew II Suture Passer is loaded, and correct positioning for the second suture is identified. All sutures are passed in a similar and easy-to-reproduce fashion. Finally, correct positioning for the more lateral suture is identified, and it is passed using the ExpresSew II Suture Passer. The infraspinatus looks reducible once again. Suture limbs are retrieved through the cannula. Sutures are tied proceeding from lateral to medial. Three simple sliding knots are performed with a single-row technique. The repair appears stable even with dynamic testing, with no tension on it. At the end of the procedure, the repair can be assessed, first from the posterior portal and then from the lateral portal. The infraspinatus and the subscapularis appear anatomically repaired, whereas the supraspinatus appears irreparable. The humeral head remains partially uncovered because of the absence of the supraspinatus but is refocused and rebalanced, which is the objective of our arthroscopic partial repair.