Arthroscopic Extreme Medialized Repair for Massive Rotator Cuff Tear: Resection of Cartilage and Subchondral Bone Over the Top of the Humeral Head

Rotator Cuff Footprint Medialization: Indications and Technique

When attempting to repair a large, retracted rotator cuff tear, the orthopaedic surgeon can use several techniques such as capsular release and interval slides that can aid in achieving a low-tension repair and thus allow the best environment for healing. One less commonly used strategy is medialization of the greater and lesser tuberosity anatomic rotator cuff footprint. Previous studies have shown that increased tension across the bone-tendon interface decreases healing rates. Medialization effectively decreases the repair tension by reducing the distance from the tendon to its insertion point. As a result, we commonly apply some degree of footprint medialization even for repair of some small- or medium-sized tears if intraoperative assessment shows that reapproximation of the rotator cuff tissue to the anatomic footprint may lead to excessive tension. The purpose of this article is to share our indications and to describe our technique for medialization of the rotator cuff footprint insertion.

The effect of medial shift of supraspinatus tendon on the glenohumeral joint motion-a cadaveric study

PURPOSE

Full-thickness retracted massive supraspinatus tears are a challenge for arthroscopic surgeons where multiple options for treatment exist, but medializing the attachment is a relatively easy procedure for which a decision can be taken intraoperatively. We investigate the viability of MATERIAL AND METHODS: Ten freshly thawed cadavers were taken and dissected. The supraspinatus tendon was resected, and then its attachment was progressively medialized. The range of motion (abduction, internal and external rotation) was recorded and compared. As a result, we noted a statistically significant decrease in abduction, internal and external rotation with progressive medialization of the supraspinatus insertion.

CONCLUSION

Medialized repair of the supraspinatus can be performed only to an extent beyond which it compromises glenohumeral motion. We noted a statistically significant decrease in ROM with even a 3 mm medialization of the tendon, but the acceptable medialization has to be determined on a case-to-case basis.

Repair of Massive Rotator Cuff Tear With Medialization and Balloon Spacer Insertion

Retracted massive rotator cuff tears can be challenging to repair. Reduction of the retracted tendon to the native footprint may result in a repair with excessive tension. Repair under excessive tension predisposes to increased tendon retear rates. Footprint medialization involves securing the tendon medial to the anatomic footprint, resulting in decreased tension during repair. Several surgical adjuncts can also be employed to reinforce such tears so as to reduce the risk of retear. The aim of this Technical Note is to describe a surgical technique of rotator cuff repair with medialization of the footprint combined with a balloon spacer insertion.

Extreme Medialized Repair for Challenging Large and Massive Rotator Cuff Tears Reveals Healing and Significant Functional Improvement

PURPOSE

To evaluate range of motion, muscle strength, clinical outcomes, and radiographic results of the extreme medialized procedure on rotator cuff tears that were initially irreparable.

METHODS

From arthroscopic rotator cuff repair cases performed at our institution (June 2017 and August 2020), we retrospectively reviewed cases in which the rotator cuff was (1) unable to be withdrawn to the greater tuberosity, (2) repaired using the extreme medialized procedure, and (3) followed up for a minimum of 2 years. Patients with a history of previous surgery were excluded. Preoperative and postoperative scores were used for clinical evaluation. Imaging evaluation used 2-year postoperative magnetic resonance (MR) images.

RESULTS

Sixty-four patients met the criteria; mean age 68.2 ± 7.9 (range 51-82) years; mean follow-up period 26 ± 2 (24-37) months. Tear size: 45 ± 7.1 (30-70) mm in medial to lateral diameters, 40 ± 9.3 (30-60) mm in anteroposterior diameter; suture anchor number: 5.5 ± 1.2 (4-8). The visual analog scale score (50.7 to 11.8), the University of California, Los Angeles, score (12 to 31), constant score (45 to 31), and the American Shoulder and Elbow Surgeons score (53 to 31) at the final follow-up improved compared with preoperative values (all P < .0001). Preoperative and postoperative changes in range of motion also showed improvement in anterior elevation (107° to 151°, P < .0001), abduction (100° to 154°, P < .0001), external rotation (41° to 47°, P = .0238), and internal rotation (L1 to Th10, P < .0001). Muscle strength was also improved in abduction (from 1.9 kg to 5.0 kg, P < .0001) and external rotation (from 3.5 kg to 7.7 kg, P < .0001). MR imaging evaluation revealed 2 cases (3.1%) of retears that fell into type 4 Sugaya classification.

CONCLUSIONS

Extremely medialized repair of large and massive tears not able to be repaired using conventional techniques led to improved clinical outcomes compared to preoperative conditions.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Editorial Commentary: Extreme Medial Repair of Massive Rotator Cuff Tears With Atrophy Warrants Caution: Robbing Peter to Pay Paul

Medialization of the rotator cuff insertion as a technique to manage massive rotator cuff tears has been described for decades. However, "extreme medialization" as a means to manage massive rotator cuff tears with significant atrophy warrants caution. Nonanatomic reconstruction almost always carries a price. Biomechanical studies show extreme medialization results in significant and obligate restriction of motion, and it is difficult to imagine how extreme medialization would allow normal clinical motion without substantial scapulothoracic compensation. Similarly, obligatory loss of strength could be expected. Based on the current evidence, I will not indicate this technique for my own patients at the present time.

Medialized Rip-Stop Convergence Technique for Retracted Rotator Cuff Tears

Attempts to restore the anatomical footprint during rotator cuff repair for retracted, relatively immobile tears can be difficult. In some cases, it can lead to excessive tension of the repair. Previous studies have noted improved clinical outcomes when repair tension is not excessive, and medialization of the anatomical footprint has been suggested as a technique that can help surgeons repair large, retracted tears without excessive tension and achieve improved clinical outcomes. Of note, excessive tension when restoring the rotator cuff tendon to the anatomical footprint is not limited to large, retracted tears. In some cases, restoring small- and medium-sized tears to the anatomical footprint also can lead to excessive tension. Therefore, it is not uncommon for the authors to employ some degree of footprint medialization even for repair of small- or medium-sized tears if repair to the anatomical footprint will lead to excess tension. The purpose of this article and video demonstration is to provide instruction for a reproducible rotator cuff technique using a medialized single-row rip-stop construct combined with convergence.