All-Arthroscopic Muscle Slide and Advancement Technique to Repair Massive Retracted Posterosuperior Rotator Cuff Tears

Abstract

Symptomatic massive posterosuperior rotator cuff tears without glenohumeral joint arthritis and chronic medial retraction often are deemed "irreparable." These patients often are treated with alternative joint-sparing procedures including superior capsular reconstruction or tendon transfer procedures. Open and arthroscopic-assisted muscle advancement techniques allow maximal lateral tendon mobilisation during rotator cuff repair. In this report, we present an all-arthroscopic technique of complete supraspinatus and infraspinatus muscle scapular detachment and advancement in retracted massive posterosuperior rotator cuff tears. This allows for an anatomical tendon footprint reduction and tension-free repair.

Fig 1

(A) Preoperative T2-weighted coronal MRI scan of a right shoulder demonstrating a supraspinatus tendon tear retracted to the level of the glenoid (end of tendon indicated by white arrow). (B) Preoperative T1-weighted sagittal MRI demonstrating grade 3 fatty infiltration of the supraspinatus (white star) and grade 1 fatty infiltration of the infraspinatus (blue star). (MRI, magnetic resonance imaging.)

Fig 2

To perform an all-arthroscopic muscle advancement of a retracted posterosuperior rotator cuff tear, the patient is positioned in beach chair position using an open-backed shoulder positioner table attachment and draped allowing surgical access to the midline posteriorly. (A) Superior view of the right shoulder demonstrating surface anatomy and arthroscopy portals used (Typical portals used include A, B, C, D, E, S, ISP and MSS portals). (B) View of the posterior shoulder surface anatomy and arthroscopy portals used. The medial scapular spine (MSS) portal is made 2 cm medial to the medial angle of the scapular spine allowing detachment of the medial insertion of both the supraspinatus and infraspinatus muscles to facilitate maximal lateral excursion of each tendon.

Fig 3

Arthroscopic image of a right shoulder viewing from the C portal demonstrating a retracted tear of the posterosuperior rotator cuff tendons (supraspinatus and infraspinatus) to the level of the glenoid. The deep layer and superficial layer of the supraspinatus tendon are defined and the mobility of the tendon for repair to its humeral footprint is assessed using an. arthroscopic grasper. Here, the tendon cannot be reduced to the humeral head. (DL, deep layer; G, glenoid; HH, humeral head; SL, superficial layer.)

Fig 4

Arthroscopic image of a right shoulder viewing from the C portal. While one is performing lateral advancement of the posterosuperior rotator cuff muscles to repair a retracted tear, an SSN release is performed to prevent traction injury to the nerve. First, the suprascapular nerve scissors (SSN scissors) are introduced from the S portal and the TSL is identified. The suprascapular nerve is found under the TSL. (SSN, suprascapular nerve; TSL, transverse scapular ligament.)

Fig 5

Arthroscopic image of a right shoulder viewing from the C portal after release of the SSN. The SSN scissors are introduced through the S portal and positioned under the TSL. The TSL is then released using the SSN scissors to free the SSN and vessel. (SSN, suprascapular nerve; TSL, transverse scapular ligament.)

Fig 6

Illustration of a right shoulder demonstrating the interval between the supraspinatus (SSP) and infraspinatus (ISP) tendons that is identified just lateral to the scapular spine. The SSN and vessel are found under the musculotendinous junction at this point and protected before elevation of the SSP and ISP muscles from their respective scapular fossae. (SSN, suprascapular nerve.)

Fig 7

Viewing medially from the lateral C portal in a right shoulder, the supraspinatus muscle is elevated sharply from its bony fossa on the scapula to facilitate lateral tendon advancement. A coblator is introduced through the D portal and slid down the scapular spine under the supraspinatus to elevate the muscle. A separate retractor is introduced through the S. portal retracting the supraspinatus muscle (not in view). (SS, scapular spine; SSP, supraspinatus; SSP fossa, supraspinatus fossa.)

Fig 8

In a right shoulder viewing medially from the lateral C portal, the infraspinatus muscle is elevated sharply from its bony fossa on the scapula. A coblator is introduced through the ISP portal and slid down the scapular spine from above to elevate the infraspinatus muscle. (ISP, infraspinatus; ISP fossa, infraspinatus fossa; SS, scapular spine.)

Fig 9

Posterior view of a right shoulder. To facilitate maximum lateral excursion of the supraspinatus and infraspinatus tendons allowing a tension-free rotator cuff repair, the medial attachment of each muscle is released from the medial border of the scapula. The medial scapular spine (MSS) portal is created making a 2-cm vertical incision medial to the medial angle of the scapular spine. The portal is made no more than 2 cm medial to the medial angle to avoid injury to the spinal accessory nerve, typically found 4 cm medial to the medial angle. From this portal, a Cobb elevator can be inserted to bluntly dissect off the medial attachment of the supraspinatus muscle superior to the scapular spine and the medial attachment of the infraspinatus muscle inferior to the scapular spine. Here, the Cobb elevator has been introduced laterally under the infraspinatus muscle to ensure a full release from the bony fossa.

Fig 10

(A) Drawing of the posterior scapula in a right shoulder showing full elevation of the supraspinatus (SSP) and infraspinatus (ISP) muscles from the scapula using a Cobb elevator through the medial scapular spine (MSS) portal. (B) The superficial fascial attachments of the supraspinatus and infraspinatus muscles are left intact and the muscles can then be advanced laterally up to 4 to 5 cm, facilitating a tension-free rotator cuff repair in the presence of a retracted posterosuperior tear.

Fig 11

Drawing of a right shoulder demonstrating a double row rotator cuff repair following lateral muscle advancement. (A) Sutures are passed through the deep tendon layer using a Lasso loop technique, as well as the superficial layer and tied medially. (B) Sutures are then taken laterally using a suture bridge configuration to a lateral row of knotless anchors.

Fig 12

(A) Arthroscopic view of a right shoulder viewing through the C portal. Following lateral muscle advancement, the supraspinatus (SSP) and infraspinatus (ISP) tendons have been reduced over their anatomical footprint on the greater tuberosity and repaired. (B) Six-month postoperative T2-weighted coronal right shoulder magnetic resonance imaigng scan of the same patient shown in Figure 1, demonstrating healing of the supraspinatus tendon over its anatomical footprint (white arrow).