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Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Combined Arthroscopic and Open Treatment of Tears of the Rotator Cuff*

GARY M. GARTSMAN, M.D., HOUSTON, TEXAS

An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons

	Introduction

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 
In the last decade, arthroscopy of the shoulder has advanced from a diagnostic tool to an effective treatment option for stage-II impingement (fibrosis and thickening of the tendon), partial-thickness tears of the rotator cuff, and arthrosis of the acromioclavicular joint^{1,3-5,8,11,14}. Full-thickness tears of the rotator cuff have been treated with arthroscopic decompression without repair of the tendon^2-4. However, this procedure does not reliably produce good results, and it is clear that most full-thickness tears necessitate repair.

At present, the technique for decompression of the shoulder and repair of the tendon varies. Some surgeons prefer open repair while others use arthroscopic techniques exclusively. A third option combines arthroscopic and open operative methods. This Instructional Course Lecture will present the rationale and technique of combined arthroscopic and open treatment of partial-thickness and complete tears of the rotator cuff. The treatment of stage-II impingement and massive, irreparable tears will not be covered.

	Rationale of Combined Approach

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 
Full-thickness tears involving the rotator cuff can be treated successfully with traditional open methods. The results have been well documented^15,18. However, this approach is not successful in all patients. In an attempt to improve the outcome, orthopaedists have investigated two areas: the detection and treatment of intra-articular lesions of the rotator cuff and the use of limited operative exposure. Intra-articular lesions of the glenohumeral joint are possible, and it might be beneficial to identify and treat them. These lesions are almost certainly overlooked when an open operative technique is used, as the glenohumeral joint is not well visualized except when there is a massive tear of the rotator cuff. Arthroscopic techniques allow the surgeon to perform a subacromial decompression without detachment of the deltoid. This appears to eliminate the rare but potentially devastating complication of dehiscence of the deltoid.

The theoretical advantages of the combined arthroscopic and open techniques are the diagnosis of coexisting lesions and their possible treatment when the glenohumeral joint is examined, the identification of partial-thickness tears on the articular surface of the cuff, and the evaluation of the subacromial space through the use of small puncture sites. In addition, the deltoid remains attached to the acromion, smaller incisions result in less dissection and less postoperative pain, and appearance is improved. Moreover, the procedure can potentially be done on an outpatient basis and the postoperative rehabilitation may be accelerated.

Options for Operative Treatment
When using a combined approach, the surgeon can choose one of two options for operative treatment depending on the severity of the lesion and on his or her level of skill with arthroscopy of the shoulder. The first option involves arthroscopic evaluation of the glenohumeral joint. Coexisting lesions are identified and treated as appropriate. The arthroscope is then removed, and the rotator cuff is approached through a standard open incision. This technique has the advantages of arthroscopy—that is, it allows intra-articular inspection—and also permits the surgeon to repair the cuff with use of familiar methods. The operative time is minimized with this approach, and the surgeon is able to treat the complete spectrum of rotator cuff disease. The second option involves a greater level of arthroscopic skill. The glenohumeral joint is examined arthroscopically and then the arthroscope is inserted into the subacromial space. A bursectomy is performed if needed to allow visualization of the lesion. If the local anatomy allows, a small open incision is made directly over the lesion and the repair is completed with the open technique. Alternatively, the surgeon can continue with arthroscopic techniques, resecting the coracoacromial ligament and performing an acromioplasty before opening the shoulder. As the surgeon becomes more skilled in arthroscopy of the shoulder, he or she may prepare the repair site on the greater tuberosity and place traction sutures in the edge of the cuff before the shoulder is opened.

The goal of the combined approach is to evaluate both the glenohumeral joint and the subacromial space completely and to allow repair of the torn rotator cuff through a small incision without detachment of the deltoid.

	Partial-Thickness Tears of the Rotator Cuff

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 
Neer originally described three gradations of tears of the rotator cuff¹⁷. Stage I denotes hemorrhage and edema of the tendon; stage II, tendinitis and fibrosis; and stage III, an incomplete or full-thickness tear of the rotator cuff. Most orthopaedic literature has been devoted to the diagnosis and treatment of either stage-II lesions or full-thickness tears^4,14,17. Little has been written regarding partial tears^8-12,20. Two factors seem to be responsible for this. First, most partial-thickness tears occur on the articular surface and are not visualized during open acromioplasty for stage-II impingement; they may not be seen well even if the tendon is split in line with its fibers. Second, when partial tears were noted, they did not fit well into the Neer classification because they represent more damage than a stage-II lesion but cannot be categorized properly as a stage-III lesion.

With the advent and increased use of arthroscopy of the shoulder, partial tears of the articular surface have been described more frequently^6,8-12,20 because the surgeon is able to view the articular surface of the rotator cuff clearly and to measure the damaged area precisely. Various classification systems have been devised to categorize these lesions. The system used in this article was described by Ellman and me⁷; we classified partial-thickness tears according to the depth and anatomical site of the lesion. Tears are noted as being on the articular surface or the bursal surface. Grade-1 lesions demonstrate definite disruption of the tendon fibers but involve less than one-fourth (less than three millimeters) of the thickness of the tendon. Grade-2 lesions involve less than one-half of the thickness of the tendon and are three to six millimeters deep. Grade-3 lesions involve more than one-half of the thickness of the tendon and are more than six millimeters deep.

Lesions of the rotator cuff are diagnosed as partial-thickness tears if there is disruption of the tendon fibers but no full-thickness tear is noted visually or by palpation with a probe or an arthroscopic instrument. Fraying, roughening, abrasion, or discoloration of the synovial lining or the surface of the tendon were not classified as partial-thickness tears.

Preoperative Evaluation
A complete history and a physical examination of the upper extremity and the cervical spine is vital. Elements in the history are reviewed for indications as to the etiology of the tear. Most lesions of this type are secondary to the impingement process, but partial-thickness tears can also be secondary to glenohumeral instability or an episode of trauma. The level of activity desired by the patient should also be noted.

The physical examination documents findings of impingement without regard to the etiology of the tear. Particular attention should be paid to symptomatic glenohumeral translation. The surgeon must be cautious about making definitive conclusions because the examination for instability may be unreliable if the patient is in pain.

Radiographic evaluation is particularly critical for these patients. Anteroposterior, axillary, and scapular outlet radiographs are made and are examined for anterior acromial sclerosis, osteophytes on the anterior aspect of the acromion, and the shape of the acromion. Magnetic resonance images provide additional data on the location and extent of the partial tear.

An operation is indicated for persistent pain that interferes with activities of daily living, work, or sports activities and is unresponsive to a six-to-twelve-month course of non-operative care. Non-operative treatment consists of modification of activity, anti-inflammatory medication, injections of cortisone, and a home rehabilitation program designed to improve or to maintain the range of motion along with exercises to improve strength in the shoulder and scapular muscles.

The surgeon should understand the four essential elements that determine appropriate management of the patient: the etiology of the tear (impingement or instability), the extent of the tear, osseous abnormalities, and the patient's level of activity. A decision-making process that balances the four factors most reliably results in patient satisfaction.

In one study, Milne and I¹² found that the partial-thickness tear was attributable to impingement in eighty-five (77 per cent) of 111 patients, to glenohumeral instability in fourteen (13 per cent), and to direct trauma in twelve (11 per cent). If the tear was caused by instability, an operation that only repairs the tear will not be beneficial. The instability must also be corrected at the time of the operation.

Partial-thickness tears that are secondary to impingement require more complex analysis, and the following are general guidelines. Lower-grade lesions and smaller tears of the rotator cuff may be treated with decompression while more advanced lesions must be repaired. Certain osseous shapes or changes are consistent with extrinsic compression of the tendon. Radiographic findings that suggest that the lesion will respond to operative decompression are a type-III, or hooked, acromion; anterior acromial spurs; and osteophytes in the inferior aspect of the acromioclavicular joint. Patients who have normal osseous anatomy are more likely to have intrinsic lesions and to need repair of the tendon. Less active patients may have a good result with decompression alone while more active patients may need repair of the tendon. The appropriate operative treatment is more clearly defined at the ends of the spectrum. Decompression alone should be successful for the treatment of a grade-1 lesion in a sedentary patient who has a type-III acromion, while repair of the tendon is necessary for a grade-3 lesion in an active patient who has a type-I (flat) acromion. The decision process is more complex in the middle zone—for example, a grade-2 lesion in a weekend recreational athlete who engages in sports requiring overhead activities and who has a type-II (curved) acromion. The surgeon's ability to weigh the involved factors correctly allows for the most successful postoperative course.

Operative Setup

Anesthesia
I use interscalene block anesthesia supplemented with general anesthesia. Regional anesthesia allows decreased use of anesthetic agents, which minimizes postoperative side effects and affords excellent postoperative relief of pain so that the patient can begin physical therapy comfortably. General anesthesia eliminates discomfort as well as unwarranted movement on the operating table.

Positioning of the Patient
I prefer the patient to be in the sitting position as easy access is afforded to the anterior, lateral, and posterior aspects of the shoulder without the need to turn the patient. This is also the position most commonly used for open repair; therefore, the patient does not need to be moved as the surgeon switches from the arthroscopy to the open portion of the operation. Positioning of the upper extremity is facilitated by the use of a McConnell arm-holder (McConnell, Greenville, Texas). This holder allows the upper extremity to be positioned without the help of an assistant and is invaluable for maintaining proper rotation and elevation so that the site of the repair may be brought directly underneath the incision.

Some surgeons use the lateral decubitus position. This position is familiar to most shoulder surgeons who perform arthroscopy, and many are comfortable performing the open portion of the operative procedure with the patient in this position. Either position may be used.

Portals
The acromion and the lateral portion of the clavicle are outlined with a surgical marker. The site of the proposed open incision is also drawn (Fig. 1). Three portals are used. The posterior portal is 1.5 centimeters medial and 1.5 centimeters inferior to the posterolateral acromial border. The posterior portal is made superior to the point of entry used by many surgeons (which is 2.5 centimeters inferior and 2.5 centimeters medial to the posterolateral acromial border) so that the arthroscope enters the subacromial space parallel and immediately inferior to the acromial undersurface. This places the arthroscope at the maximum distance from the greater tuberosity and improves the surgeon's perspective of the tear. The lateral portal is made along the line of the open incision, five millimeters posterior to the anterior acromial border and approximately three to five centimeters lateral to the acromial border (Fig. 2). The axillary nerve can be in jeopardy if the lateral portal is placed more than five centimeters lateral to the acromial border. The lateral portal should allow the cannula to enter midway between the humeral head and the acromion. The anterior portal is placed midway between the acromioclavicular joint and the lateral aspect of the acromion, approximately two centimeters from the anterior acromial margin. Additional portals are rarely necessary as the upper extremity can be rotated to bring various portions of the tear underneath the lateral portal.

View larger version (11K): [in this window] [in a new window]   Figs. 1 through 8: Illustrations of the operative repair. Fig. 1: The posterior portal (PP) and the lateral skin incision (LSN) in the right shoulder. C = clavicle and A = acromion.

View larger version (12K): [in this window] [in a new window]   Fig. 2 The lateral portal (LP) created in line with the lateral skin incision.

Glenohumeral Joint
A blunt trocar and cannula are used to penetrate the glenohumeral joint capsule through the posterior portal. A systematic inspection of all structures is necessary. The surgeon can generally view partial-thickness tears easily as they are most commonly located in the anterior aspect of the supraspinatus. Tears in other locations necessitate changes in rotation and abduction of the shoulder so that the entire tear is visualized clearly.

The surgeon should then establish the anterior portal. The arthroscope is moved anteriorly, and the posterior structures are examined. The arthroscope is then replaced in the posterior portal and a motorized shaver is inserted anteriorly. The partial tear is debrided until the surgeon can determine the dimensions and depth of the lesion. If the lesion is grade 1, the surgeon may remove the instruments, redirect them into the subacromial space, and perform an arthroscopic subacromial decompression with previously described techniques¹¹.

Grade-2 lesions in less active patients or in those who have a type-III acromion may be treated with decompression alone. Grade-2 lesions may be repaired if the patient is active or if the acromial shape is type I or II. If the lesion is grade 3, it is necessary to repair the tendon. The partial tear is then converted into a full-thickness tear by débridement with a soft-tissue shaver. Alternatively, the surgeon may choose to mark the area of the partial tear with a spinal needle placed percutaneously. The entry point for the needle should be in line with the proposed open incision, generally five millimeters posterior to and five millimeters lateral to the anterolateral acromial border. The needle is advanced until it enters the middle of the tear. A number-1 dark blue (for easy visualization) absorbable monofilament suture is passed down the spinal needle until four centimeters of suture are in the joint. A soft-tissue grasping instrument inserted anteriorly holds the suture within the joint as the needle is removed. The arthroscope is then removed from the joint.

Operative Repair
At this point, the surgeon may proceed directly to open repair by making a three to five-centimeter-long lateral skin incision, incising the superficial deltoid fascia and spreading the deltoid fibers (Figs. 3 and 4). The split in the deltoid muscle fibers should begin approximately one centimeter posterior to the anterior aspect of the acromion. If the deltoid split is started at the anterior acromial border, traction applied during operative repair may inadvertently detach the anterior aspect of the deltoid. Acromioplasty and resection of the coracoacromial ligament are performed when there is either radiographic evidence of bone that narrows the subacromial space (a type-III acromion or an anterior acromial protuberance) or arthroscopic findings consistent with impingement, such as fraying or fibrillation of the coracoacromial ligament. The surgeon should then rotate the upper extremity until the full-thickness tear or the marking suture is brought directly into the operative field. The marking suture is removed, and the tendon is debrided until a full-thickness defect is created. The surgeon may then create a trough or a cancellous bed and repair the tendon to bone through tunnels in the bone or with suture anchors (Figs. 5 and 6). The superficial deltoid fascia is reapproximated with absorbable sutures, and the subcutaneous tissue and the skin are closed routinely (Figs. 7 and 8).

View larger version (13K): [in this window] [in a new window]   Fig. 3 The lateral skin incision is deepened.

View larger version (25K): [in this window] [in a new window]   Fig. 4 The tear of the rotator cuff is exposed.

View larger version (27K): [in this window] [in a new window]   Fig. 5 Sutures are passed through the edges of the tendon.

View larger version (28K): [in this window] [in a new window]   Fig. 6 The repaired tear.

View larger version (24K): [in this window] [in a new window]   Fig. 7 The deltoid is reapproximated.

View larger version (12K): [in this window] [in a new window]   Fig. 8 The skin is closed.

Postoperative Rehabilitation
Tears repaired with this technique are generally small (one to three centimeters long). Rehabilitation begins the afternoon of the operation with passive range-of-motion exercises in elevation and external rotation and is continued for six weeks. A sling is worn for protection during this period. Active range-of-motion exercises are started six weeks postoperatively and strengthening exercises, three months postoperatively. A return to full activities is allowed six months after the operative repair.

Results
The reported rate of good and excellent results is 88 per cent (ninety-eight of 111) with this operative technique^12,20.

	Complete Tears of the Rotator Cuff

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 
Combined arthroscopic and open techniques can also be used to treat complete tears of the rotator cuff successfully. Blevins et al. as well as Paulos and Kody reported their experience with this technique. The theoretical advantages proposed by those authors are similar to those for partial tears, the most important being the ability of the surgeon to perform an acromioplasty and a resection of the coracoacromial ligament without detachment of the deltoid, to make a smaller incision, and to evaluate and treat coexisting abnormalities of the glenohumeral joint.

Preoperative Evaluation
An estimation of the size and repairability of the tear is the primary focus of the physical examination. Atrophy of the supraspinatus and infraspinatus muscles, inability to maintain the upper extremity in abduction, and weakness of resisted elevation and external rotation to manual muscle-testing of grade 3 or less are signs of a large tear. As the open approach in the combined technique employs a small incision and visualization is limited, this method is generally not suitable for larger (more than three-centimeter-long) tears or tears that need extensive mobilization. In these situations, the surgeon may elect to use conventional open repair techniques.

Operative Setup
The anesthesia, positioning of the patient, and placement of the portals are identical to those described for partial-thickness tears.

Glenohumeral Joint
Miller and Savoie documented intra-articular abnormality in 74 per cent (seventy-four) of 100 patients who had a mini-open repair and concluded that arthroscopic examination of the glenohumeral joint is useful. However, the clinical importance of the lesions described in that report is unclear. My experience has been that, while abnormalities of the glenohumeral joint were common (137 [69 per cent] of 200 patients) in association with a complete tear of the rotator cuff, most of these abnormalities were minor, with only twenty-five (13 per cent) of the 200 patients having findings of any importance¹³. Taverna and I used three criteria to define a major intra-articular abnormality: a lesion that necessitated operative treatment, that changed the course of the postoperative rehabilitation, or that altereda the expected goals of the procedure.

Three patients were noted to have a severe partial tear of the biceps tendon that was not visible during the subacromial portion of the procedure¹³. All three tears were located within one to two centimeters of the attachment of the biceps to the superior portion of the glenoid. This finding delayed the biceps-strengthening exercises. No patient had a complete tear of the biceps noted during arthroscopy of the glenohumeral joint that had not been identified during examination of the subacromial space.

In our study¹³, lesions involving the cartilage included exposed bone of seven humeral heads. The lesions were all located in the medial aspect of the humeral head, were circular, and averaged thirty millimeters in diameter. Two patients had noticeable areas of full-thickness cartilage loss from the glenoid. No attempt was made to abrade the area of exposed bone. No loss of joint space or other findings consistent with arthrosis were detected on the preoperative radiographs.

Lesions of the labrum included separation in seven patients (anterior and posterior separation of the superior aspect of the labrum in five and a Bankart lesion in two) and a flap tear in three¹³. All of the labral separations were reattached with suture anchors and non-absorbable suture. The patients who had anterior and posterior separation of the superior aspect of the labrum had injured the shoulder during a fall but had no history of locking or catching and no findings on physical examination indicative of glenohumeral instability or the separation. The labral flap tear was located in the anterior-superior quadrant of the glenoid in one patient and anteriorly in two patients; the tears were debrided with a motorized instrument.

Three patients had major synovitis involving the entire shoulder capsule¹³. A complete synovectomy was performed with electrocautery and a motorized shaver after a biopsy specimen was taken. The biopsies demonstrated non-specific inflammatory changes.

Arthroscopy of the glenohumeral joint has a role in the management of patients who have a complete tear of the rotator cuff. It is possible that the identification and treatment of these lesions, previously overlooked with conventional open repair techniques, can improve results.

Operative Repair
After the surgeon completes the glenohumeral portion of the procedure, the arthroscope is repositioned in the subacromial space through the posterior portal. The first goal is to visualize the tear of the rotator cuff accurately and to document its size and shape; therefore, bursa is removed as necessary. If the tear is large (more than three centimeters long) or retracted and is not amenable to repair through a limited incision, the surgeon should halt the arthroscopy and proceed directly to traditional open repair. If the site and size of the tear allow for a repair through the proposed incision, the surgeon has two options: proceed to open repair or, if he or she has advanced arthroscopy skills, continue to perform the operation arthroscopically. The surgeon must remain aware of both the duration of the operation (so that anesthesia time is kept to a minimum) and soft-tissue swelling (so that the open repair is not technically difficult). It is not in the best interest of the patient or the surgeon to perform a combined arthroscopic and mini-open repair that doubles the duration of the operation or that involves an incision that is 90 per cent as long (because of soft-tissue swelling), compared with traditional open methods.

The lateral portal is created in line with the proposed open incision, and an operating cannula is inserted into the subacromial space. Resection of the coracoacromial ligament, anterior partial acromionectomy, and inferior acromioplasty are performed as necessary. Osteophytes on the inferior surface of the lateral aspect of the clavicle are removed with a power burr if they impinge on the rotator cuff, as determined on preoperative radiographic imaging or as observed during the operation. The acromioclavicular joint is resected only if, on preoperative examination, the patient has pain localized to that joint. A traction suture may then be placed through the edge of the tendon. The arthroscopic instruments are removed.

The previous skin marking is used, and a three to four-centimeter-long incision is made. The superficial deltoid fascia is incised, the deltoid fibers are spread with retractors, and the subacromial space is entered. The anterior portion of the middle of the deltoid must be retracted gently. Arthroscopic acromioplasty can weaken the deltoid attachment, and an unrecognized avulsion can substantially compromise function. The tear of the rotator cuff is identified and is repaired with non-absorbable sutures through a bone trough or over a decorticated area of bone with suture anchors. The retractors are removed, the superficial fascia is repaired with absorbable sutures, and the subcutaneous tissue and the skin are closed.

Postoperative Rehabilitation
Tears repaired with this technique are generally small (less than three centimeters long). Rehabilitation begins with passive range-of-motion exercises in elevation and external rotation, starting the afternoon of the operation and continuing for six weeks. A sling is worn for protection during this period. Active range-of-motion exercises are started six weeks after the operation and strengthening exercises, three months after the operation. Full activities are allowed six months after the operative repair.

Results
Blevins et al., in a report on The Hospital for Special Surgery experience, documented an excellent or good result in fifty-three (83 per cent) of sixty-four patients, according to the modified shoulder-rating scale of The Hospital for Special Surgery; fifty-seven (89 per cent) were satisfied with the result. Paulos and Kody reported a good or excellent result in sixteen of eighteen patients according to the rating scale of the University of California at Los Angeles; seventeen patients were satisfied.

	Overview

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 
Open repair of full-thickness tears of the rotator cuff has a documented history of success^15,18. However, not all patients have a successful result after operative intervention. The selection of patients, the severity of the tear, the technique of repair, and the postoperative rehabilitation have a substantial influence on the end result. A technique that combines arthroscopic and open operative repair has the theoretical advantages of identification and treatment of previously undiagnosed lesions of the glenohumeral joint, minimized soft-tissue dissection, preservation of the deltoid attachment, and improved appearance. Whether these theoretical advantages are real will be determined by studies that compare matched series of patients and torn tendons. Two other theoretical advantages do not seem valid. Rehabilitation is not accelerated by the combined approach because the limiting factor is healing of the tear to bone, and this is identical after open and arthroscopic operations. Also, the ability to treat tears of the rotator cuff operatively on an outpatient basis is more dependent on whether regional anesthesia can be used, education of the patient, and economic pressure than on the type of operative method that is used.

The combined arthroscopic and open technique may prove to be the desired method for some surgeons and may serve as a transition from conventional open repair to complete arthroscopic repair for others. It should be stressed that, at present, no ideal repair technique is applicable to all surgeons and all patients. Each surgeon should determine, on the basis of his or her level of arthroscopic proficiency and the type of lesion identified, which operative technique is likely to be most effective.

	Footnotes

 

*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 47, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1998.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Fondren Orthopedic Group, Texas Orthopedic Hospital, 7401 South Main Street, Houston, Texas 77030. E-mail address for Dr. Gartsman: gary@fondren.com.

	References

Top Introduction Rationale of Combined Approach Partial-Thickness Tears of the... Complete Tears of the... Overview References

 

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8. Esch, J. C.; Ozerkis, L. R.; Helgager, J. A.; Kane, N.; and Lilliott, N.: Arthroscopic subacromial decompression: results according to the degree of rotator cuff tear. Arthroscopy, 4: 241-249, 1988.[Medline]
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