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Arthroscopic Option in cuff tear arthropathy

Authors: S Lichtenberg

References: SECEC, Rome 2005

In cases of beginning cuff tear arthropathy with massive rotator cuff tears and upward migration of the humeral head one can consider arthroscopic surgery to relief the patients’ symptoms.  In order to select the right patient and to perform the right surgical procedure the possible techniques are discussed and the proper patient pointed out.

ACROMIOPLASTY:
It is known that the coracoacromial arch is a passive stabilizer against anterior superior migration of the humeral head in the presence of cuff deficiencies (5, 7) and therefore has to be protected.  A formal arthroscopic sub acromial decompression includes incision or even resection of the coracoacromial ligament and thus weakens this stabilizing mechanism.  Therefore it is not advisable to perform “classic” arthroscopic sub acromial decompression in these patients.  Humeral instability will occur and function will be disastrous.  Smoothing of the under surface of the acromion can be performed.

TUBEROPLASTY (REVERSED ACROMIOPLASTY):
In order to create pain relief the subacromial space has to be decompressed.  Since formal acromioplasty is contraindicated the decompression should be performed on the opposite side, the humerus.  Fenlin et al. (1) showed that with open resecting and smoothing of the greater tuberosity they achieved good pain relief in these patients in 95% by creating a smooth motion under the acromion.  Scheibel et al. (8) performed the procedure arthroscopically and reported 83% of excellent and good results according to the Constant-score.  Arthroscopic tuberosity therefore is a viable option if there is roughness in the subacromial pathway.

DEBRIDEMENT:
Debridement includes the resection of the inflamed synovial, bursa and smoothing of the bone and the tendon remnants.  These “aggressive agents” have to be removed to recover the patients’ status of painlessness (2).  Thus debridement is a mandatory part of the arthroscopic procedure in patients with beginning cuff tear arthropathy.

TENOTOMY OF THE LONG HEAD OF BICEPS (LHB TENOTOMY):
Although the long head of biceps (LHB) is a known humeral head depressor in the cuff deficient shoulder (4) it is also genrator once it became unstable due to large RC tear (3,9).  Tenotomy will relieve the pain generated by the LHB and will cause only minor cosmetic problems.  Comparing tenotomy to tenodesis there were no statistically significant differences reported concerning cosmesis, spasm or anterior shoulder pain (6).  If a biceps tendon is still there in the joint it should be tenotomized.

AC-JOINT RESECTION:
There is no scientific paper concerning the role of the arthroscopic AC joint resection in patients with massive RC tears or cuff arthropathy.  Usually the AC joint in these patients is not a concern in terms of pain.  Even with massive radiological changes in the AC joint the patients do not report on local pain over the AC joint.  This conforms with the fact that in patients with degenerative osteoarthritis an AC joint resection is not performed either.  Furthermore, in patients with a large postero-superior RC tear requiring a latissimus-dorsi-transfer the AC joint is not symptomatic even if the x-ray shows arthritic changes.  It is not advisable to perform neither arthroscopic nor open AC joint resection in order not to compromise the coracoacromial arch.

RECONSTRUCTION OF THE CORACO-ACROMIAL ARCH:
Once the coracohumeral arch is deficient, either by progression of the disease or iatrogenic after failed open RC repair, there is nothing to do arthroscopically anymore.  A possible reconstruction can only be performed in an open technique.  One has to admit that these reconstructions in patients with cuff tear arthropathy are very difficult and do not show promising results.  Wiley (10) reported on 4 patients reconstructing the coracoacromial arch using a bone graft.  Other reports of using soft tissue like Achilles tendon or fascia lata are more anecdotal and should be reserved for young patients with a deficient coracoacromial arch.  Another solution is the use of a reconstruction cap.

INDICATIONS:
The main goal of the arthroscopic procedure is pain relief and not improvement of function, therefore the patient has to be informed about the possible achievement of the operation.  The ideal patient with mild cuff tear arthropathy for arthroscopic surgery shows at least 90° of forward flexion and pain is the leading symptom.  Biomechanics will not be altered, it is a palliative procedure.  On the other hand, if the patient present with a pseudo-paralytic shoulder and seeks for functional improvement arthroscopic surgery in terms of tuberosity, LHB tenotomy and debridement will not meet his needs or demands. 

SUMMARY:
In patients with mild cuff tear arthropathy, pain as the leading symptom and still a good functional range of motion, arthroscopic tuberoplasty, LHB tenotomy and glenohumeral and subacromial debridement is a viable option for temporary or even lasting improvement before other surgical options such as cup arthroscopy or reversed arthroplasty is necessary.

REFERENCES:
1. Fenlin JM, Chase JM< Rushton SA, Friedman BG (2002) Tuberoplasty: creation of an acromiohumeral articulation – a treatment option for massive, irreparable rotator cuff tears.  J Shoulder Elbow Surg 11:136-142
2. Kelberine FM (1997) Arthroscopic treatment in massive irreparable cuff tear.  In Gazielly DR, Gleyze P, Thomas T (eds).  The Cuff.  Paris: Elsevier; 1997 pp. 347-349
3. Kempf JF, Gleyze P, Bonnomet F, Walch G, Mole D, Frank A, Beaufils P, Levigne C, Rio B, Jaffe A. (1999) A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty.  Arthroscopy 15:56-66
4. Kido T, Itoi E, Konno N, Sano A, Urayama M, Sato K (2000) The depressor function of biceps on the head of the humerus in shoulders with tears of the rotator cuff.  J Bone Joint Surg 82-B: 416-419
5. Lazarus MD, Yung SW, Sidles JA, Harryman DT (1996) Anterosuperior humeral displacement: limitation by the coracohumeral arch.  J Shoulder Elbow Surg 5 (Suppl): S7 [abstract]
6. Osbahr DC, Diamond AB, Speer KP (2002) The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis.  Arthroscopy 18: 483-487
7. Pagnani MJ, Deng XH, Warren RF, Torzilli PA, O’Brien SJ (1996) Role of the long head of biceps brachii in glenohumeral stability: a biomechanical study in cadavera.  J Shoulder Elbow Surg 5:255-262
8. Scheibel MT, Lichtenberg S, Habermeyer P (2004)  Reversed arthroscopic subacromial decompression for massive rotator cuff tears.  J Shoulder Elbow Surg 13:272-278
9. Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabo I (2005) Arthroscopic tenotomy of the long head of the biceps in the treatment of the rotator cuff tears: Clinical and radiographic results of 307 cases.  J Shoulder Elbow Surg 14: 238-246
10. Wiley AM (1991) Superior humeral dislocation: a complication following decompression and debridement for rotator cuff tears.  Clin orthop 263: 135

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