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Mobilization of Rotator Cuff for Repair

- Discussion: (RTC menu)
    - mobilization is often required for massive tear;
    - simply closing extensive tear will not suffice if atrophied muscles are not contracting adequately and if excessive tensions placed on repaired cuff cause reinjury;
    - repair of good quality rotator cuff tissue is esp important in achieving an optimal result;
    - repairing attenuated, scarred, frayed, or fibrillated cuff tissue contributes to risk of failure, no matter how well tear closure is performed;
    - convergence repair
            - ref: Arthroscopic Repair of Large U-Shaped Rotator Cuff Tears Without Margin Convergence Versus Repair of Crescent- or L-Shaped Tears.

- Technique of Mobilization and Repair:
    - initial intra-articular release;
           - rotator cuff mobilization starts with an intra-articular release; 
           - need to recreate pouch that is normally present superior to glenoid labrum between undersurface of rotator cuff and superior or posterosuperior
                    portion of the lateral aspect of glenoid neck  (between 2 and 10 o'clock);
          - determine if the rotator cuff is attached by scar tissue to the superior part of the labrum
          - bring in cautery device from the anterior portal and define the interval between the labrum and the rotator cuff
          - release adhesions between undersurface of cuff and superior portion of glenoid labrum, starting from anterior and progressing toward posterior;
          - this will recreate the normal medial gutter between the rotator cuff and the capsule and the capsule/labrum;
          - this will release theadhesions and allow tension-free mobilization
          - careful to avoid dissection more than 2 cm medial to the glenoid edge to avoid neurovascular injury
          - ref: Arthroscopic Rotator Cuff Repair with Interval Release for Contracted Rotator Cuff Tears

    - cuff mobilization: 
           - when mobilizing the rotator cuff, it is first useful to pass a "traction" suture through the muscle (using a Kessler type stitch); 
           - this allows the cuff to be pulled forward under tension without damaging the muscle; 
           - place a blunt right angle retractor underneath the acromion and to apply traction to the forearm inorder to widen the exposure; 
           - surgeon can then pass his finger above and below the muscle, freeing up adhesions; 
           - superior capsular release: (see rotator interval)
                    - superior capsular release and rotator interval-coracohumeral ligament release is performed when needed to allow a low-tension reduction of
                             supraspinatus tendon to its anatomical position;
          - in repairing large RCT, additional length to obtain closure of gap may be gained by making parallel incisions on both sides of contracted tendon;
          - that is between supraspinatus & infraspinatus tendons posteriorly and between supraspinatus and subscapularis tendons anteriorly,
                    and by dividing capsule of shoulder joint at its reflexion onto internal surface of the rotator cuff;
    - dissection of the supraspinatus:
           - supraspinatus is ensheathed w/ in supraspinatus fossa by dense fascia from which some of the fibers take origin;
           - incision along scapular spine to release muscle encounters this supraspinatus fascia, which must be incised before muscle belly can
                     be lifted from fossa in preparatoin for its mobilization;
           - dense fascia of supraspinatus is incised and stripped w/ an elevator;
                  - suprascapular artery and nerve are protected by muscle unless dissection is inadvertently carried into muscle fibers;
           - suprascapular artery and nerve are protected from surgical trauma by supraspinatus, provided that digital dissection is confined to
                  spine of scapula and the floor of the fossa;
           - supraspinatus tendon is closely blended w/ underlying capsule and synovial tissue of the shoulder;
                  - this connention is divided before the muscle can be advanced;
     - anterior slide:
             - coracohumeral ligament (see rotator interval)
                    - ligament may be scarred down to the base of the coracoid which keeps the supraspinatus in a retracted position;
                    - by releasing the rotator interval and the coracohumeral ligament from the base of the coracoid may allow up to 1.5 cm of increase tendon excursion;
                    - ref: Arthroscopic release of the rotator interval and coracohumeral ligament: An anatomic study in cadavers.
     - posterior slide:
             - posterior release is performed in the interval between supraspinatus and infraspinatus, aiming toward the base of the scapular spine      
             - supraspinatus and infraspinatus are pulled laterally (away from the suprascapular nerve) while the surgeon releases the interval
             - suprascapular artery and nerve are protected from surgical trauma by supraspinatus, provided that digital dissection is confined to
                        spine of scapula and the floor of the fossa;
             - need to pulls the tendon that we are cutting further away from the nerve and is an added measure of protection for the nerve;
             - references:
                        - Arthroscopic repair of large rotator cuff tears using the interval slide technique
                        - Anatomy of the posterior rotator interval: implications for cuff mobilization
                        - Arthroscopic repair of massive, contracted, immobile tears using interval slides: clinical and MRI structural follow-up.
- additional techniques:
     - convergence repair
     - if gap in supraspinatus still cannot be closed, incision is extended thru AC joint, excising anterior corner of acromion together w/ 1 cm portion of clavicle;
     - retraction of cut end of clavicle & of divided trapezius will expose much of underlying supraspinatus muscle, allowing suture of even large tears
              of rotator cuff w/o tension after supraspinatus release and advancement;
     - modest debridement of the end of the tendon should expose sufficient healthy tissue for attachment by one of several techniques;
     - consider accepting cuff defect, suturing tendon to point of tension & then suturing tendon's edges to cancellous bone;
     - appropriate for triangular-shaped tear, w/ its longest portion parallel to tendon fibers & relatively narrow base perpendicular to tendon
              fibers and near the tendon insertion; 
      - references:
              - Anatomy of the posterior rotator interval: Implications for cuff mobilization 

- References:

Advancement of the supraspinatus muscle in the repair of ruptures of the rotator cuff.

Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears.

Mobilization and Repair Techniques for the Massive Contracted Rotator Cuff Tear: Technique and Preliminary Results

Techniques to Mobilize and Repair a Retracted Rotator Cuff Tear 

Electromyographic evaluation after primary repair of massive rotator cuff tears

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity.