APEX Shoulder Mastering Surgical Techniques for Clinical Success-Shoulder Irreparable Cuff

Shoulder Irreparable Cuff
Video Transcription
We're going to be discussing irreparable rotator cuff tears. So that means a rotator cuff tear that's not fully fixable. I'm describing our terms, defining our terms.  All of our disclosures are on the Academy website. These are mine. Here's our esteemed panel. So, you know, typical rules of engagement. You get what you get. Don't get upset.  So don't ask for any extra images that aren't up there. A rotator cuff tear that is not fully repairable, OK? You guys understand that, right? Pretty straightforward.  We have lots of options. And so options besides some of these that are up there. But these are going to be your main options to choose from, unless you really  think outside of the box. Theo, I don't really do any bridging allographs. So you can toss that out there if you would like. That's not going to be what I chose, though, so.  All right, case number one. 56-year-old male, right-hand dominant, left shoulder pain. Really active guy. So he's a retired Marine.  He had an arthroscopic cuff repair in that shoulder in 2005. Did well for 15 years. Felt a pop doing a bench press. Was diagnosed with a recurrent cuff tear.  And this guy is a gym rat. So he's retired. He wants to bench. He wants to do pull-ups. He wants to go to the gym and not have any restrictions.  So some of this is defining expectations, right? So on his physical exam, he's a muscular guy. He's got some atrophy in the back. His active elevation is great.  So he's got full active elevation. He has 40 degrees of passive external rotation with a 40-degree lag sign. And his internal rotation is pretty good.  So he can get up to about T12 in the back. His supra is a little weak. His infra is really weak. And his subscap seems OK. So Rob, what are you thinking right off the bat  with what I've told you? What are you expecting to see? Since it's an irreparable rotator cuff tear, I know I'm not going to be able to repair his infra. I've said too much.  I'm anticipating that this guy has some caries minor chronic dysfunction. And I'm thinking lower trapezius tendon transfer is the surgical option, my main surgical option here.  Next case. Just kidding. Bill, what do you see on x-rays? No tricks here. Anything that concerns you or anything that you, what do you notice on these x-rays  that's important to point out? He has a little bit of a high-riding humeral head, I think. And the fact that he does not have a lot of significant degenerative change  in the glenohumeral joint, I think, are the key points. Yep. Agreed. So little proximal migration humerus. He's got kind of some chronic changes on the undersurface of his acromion.  So maybe some of this has been going on for a while. And can you see those, Theo? Yeah. Sorry, that left one's kind of dark.  So you have a coronal cut, an axial cut, and a sagittal cut. This is all you get. Describe kind of what kind of cuff tear you're dealing with here.  Yeah, so I think, I mean, yeah, that's right, irreparable. Yeah, they got all the. Tell me what in your mind on examined imaging makes you know this is not a cuff tear  that I can fix arthroscopically. Yeah, so I mean, he's very immediately, in the first view, very immediately retracted. So the edge of his tendon is at the level of the glenoid.  And I don't really see any muscle there. Looking at the kind of going all the way, jumping over the kind of sagittal views on the far right, a lot of atrophy.  I mean, Dr. Burkhart would always make the point that sometimes in a really big tear, that just reflects the medialization. It's just like in a healthy traumatic tear,  that can be probably good for somebody there. That can be medial retraction, a healthy muscle. But in him, we know it's chronic.  And then his sort of subscap looks like some tendinopathy. A lot of times, the MRIs kind of under-image these. So the radiologist will read it as intact.  If you look closely, you see some signal changes there. It's sort of gray, not dark. But a lot of times, there's an upper edge tear there. And then on the kind of posterior cuff,  also doesn't look totally healthy. Yeah, and it looks like, I guess, describe that level of atrophy.  Would you consider that grade four atrophy, especially if it's infraspinatus? Yeah, the infra actually looks worse than the supra there, which is usually it's the other way around.  But yeah, I mean, it's probably more fat than muscle there. Yep. I think the thing I like the best, and I know you were going to say, is that Terry's minor. I like seeing that.  Yeah. Because that kind of opens up the door to a lot of other things that are going to work for the shoulder. Stand up for me and point that out to everyone,  just to make sure they see it on the screen right behind your head. Oh, yeah, right here. Big, fat Terry's minor. Big old Mr. Knish. Yeah. So nice, healthy Terry's minor.  Yes, that's right. Rob, we kind of touched on this already. What kind of things on physical exam do you look for to determine, before you even see imaging,  if you think you're dealing with a repairable cuff or an irreparable cuff? I mean, exam for irreparability, I don't think matters that much to me,  except just that planning for what your options are. If they have really severe external rotation dysfunction, you've got to be able to deal with that in the case of irreparability.  So if they have hornblowers, if they have big lags, external rotation deficiency, you just have to note it and plan for managing that. Yeah. So my guess for this, I mean, what  I would guess about this guy is that, in his prior cuff repair, his infrared didn't heal. Maybe his super did. He's obviously had chronic infraspinatus deficiency  for a long time, because his Terry's minor is so big. And maybe he just ruptured his biceps tendon with whatever just happened.  The back of his rotator cuff has been bad for a long time, so. And this guy is a good deltoid, so he has a well-compensating issue. Yeah, so I mean, I wouldn't automatically  be going to surgery with this guy. Maybe he's not going to be able to repair his infraspinatus. Maybe he can get over whatever just happened. Yeah.  So let's assume that now it's 12 weeks, and he's been in physical therapy for eight weeks. And he still can't lift like he was lifting at the gym.  And he knows he's got a tear, because he's seen his MRI report. And he wants something done. So if you guys are unfamiliar with the Rohy score,  ooh, that's really big, this was published in the Journal of Sports Medicine in 2019. And which of these factors, we know we're not doing a primary cuff repair in this guy,  and he wants something done. Which of these factors do you consider in what our options are, in terms of a transfer, an SCR, a balloon, going straight to a reverse?  Bill, which of these factors do you consider in a case like this? Well, I think part of this is kind of your own beliefs play a role in this as well, right? For sure.  You have all the science here. But I think the reality, for me, it's going to be the lack of external rotation and the lack of muscle.  And me, personally, I've never been a big believer  in doing SCR. So I want a dynamic way to do this. So for me, that's a tendon transfer, regardless of what. This is healing. I'm not worried about cuff healing.  I'm worried about restoring function. Yeah. Do you worry at all about your graft healing, whatever your graft is? That's kind of the reason I'm bringing this up.  Because if you're going to do an SCR or a tendon transfer, you are asking something to heal to that tuberosity.  Yes, the answer, yes. Yes, I worry about that. Perfect. Perfect. Terrible question. Yeah, Theo, anything different? When do you consider doing a bridging graft?  Do you consider doing a bridging graft? So I actually did some early in my practice. And I have not done them recently. But kind of leading up to this meeting,  I was going through some of the old arthroscopy journal podcasts. And Ivan Wong, who's doing some good work up in Canada and also a SCOE alum, has published some very good  results with bridging allografts for these partial repair plus bridging allografts. And so it sort of made me think I need to start reconsidering that again for some of these. Yeah.  And when you guys do use the Rohy index for, say, for a primary repair, do you have a cutoff that you look at in your mind? Is there a number that if you're,  do you calculate the Rohy score or do you just consider those variables? It's kind of like the ISIS score for shoulder instability. We know what's bad.  So if you're aware, if they're over 70 and they have a big tear, higher failure rate, is there a number you consider in your head? Here, I'll just do this.  So one that I've heard is seven. Yeah, I think it's like a Spidey Sense Rohy score. Yeah, I was going to say seven. But it's not something I do for every case,  but sort of these questionable cases. And it's like I'm trying to fine tune my decision making. I'll do the calculation and just see if it sways me one way or the other. Yeah.  But it's function. It's pain level. It's all those type of things are going to play a role in here. I mean, I think we all kind of know that these patients are  going to have a difficult time healing their cuffs. But I don't think they have to fully heal their cuffs for some of the patients.  Just get better with a simple arthroscopic surgery. To me, it's do you do, and when you get into these situations, is it reverse? Is it tendon transfer?  Or is it just a simple arthroscopy? And that, to me, is more patient defined than Rohy score defined. Yep, I agree. And I think the take home message  is no one knows what the right score is. If the Rohy score is four or less, they do well. If it's over 10, they do really bad. So somewhere in the middle is you  take all these factors into consideration that if they're over 70 with a big tear and bad atrophy, a primary cuff repair is probably not going to heal.  One more comment on the bridging graft. I mean, it is essentially kind of like what you're doing with the lower trap. You're just tendon transferring the cuff by extending it out.  But he's probably not an ideal candidate because his infra is so atrophied. So bad. Yep. So what are you going to do in this guy, Rob? You've already said.  Yeah, I mean, I think that lower trap is theoretically the right thing to do because he's muscle tendon unit deficient. And that gives you some chance of restoring that for infra.  I bet he would have some, I mean, just guessing, I bet he would have some repairable supraspinatus. And you could do Larry's biceps posting technique.  Or you could maybe do some stuff more anteriorly to get some primary repair. But I think the infraspinatus is gone. Yep. Bill, would you offer him a reverse? No. No, no.  No, this guy gets a lower trap. So here's his diagnostic scope. So we're in his left shoulder. We're viewing from lateral. So this is his infraspinatus.  You can see it's really thin and wispy and really retracted and fibrotic and scarred in. And there's just not a whole lot there. Does this change anyone's plan? No.  So it's important to have an intact subscap. So to do a tendon transfer, you either want an intact subscap or a repairable subscap. So this guy had an upper subscap tear.  So we fixed that with an anchor. And then we did a lower trap transfer. And this is something we can look at in the lab. I make a horizontal incision over the scapular spine.  And then in the medial third, you release the lower trapezius tendon. And you can put some tag stitches in it and then mobilize it superficial and deep.  And then I bring it in under the infraspinatus and then repair that over the top. So you can pass a tag stitch from your posterior incision into the joint.  You make an accessory intralateral cannula to pull that through. And then the big downside with the lower trapezius transfer  is you need to use an Achilles tendon allograft because the lower trap tendon won't work. So we whip stitch  an Achilles graft and then here we're bringing it in and this is a knotless anchor going into the  anterior greater tuberosity to hold it down and then I do a triple loaded anchor in the posterior  greater tuberosity where I kind of want it its line of pull to be and then with those sutures  I pass one through the graft and one through the infraspinatus so I'm trying to repair the  infraspinatus over the top of it to maybe get some natural stuff. So there's our graft coming in  and then there's a triple loaded anchor in the back of the tuberosity in the posterior tuberosity  that's the crack out sutures going to the knotless anchor in the front  and then here I've passed mattress sutures through the infraspinatus and through the graft so I've  tried to repair the infraspinatus back up over the top and then if you do have a repairable supraspinatus you can tie that back to the Achilles tendon so you can try and get some  kind of pull if the supraspinatus is decent if you can't get it all the way over you can do a  side to side to the Achilles graft try and get a little line of pull and then when you rotate the  arm you can see that it actually moves so that's the Achilles sewn into the lower trap there and  on the post-op x-ray it actually re-centers the humeral head so it immediately drops the humeral head down so you kind of get that subacromial spacer effect from the balloon  just by it sitting on the tuberosity so the it's important to tell your patients the rehab is long  for these you know you keep them in a brace for eight weeks and you don't start any strengthening until 12 weeks do you guys use an actual gunslinger I started using the gunslinger  and now I've gone to a big wedge pillow like the bottom picture I I use the DJO quadrant okay I  know we're not supposed to use trade names but I use the DJO quadrant brace that's what Eric Wagner  uses and switch to that it's actually really good it has a lot of adjustability and it's pretty  comfortable I'll say anecdotally for me this is the worst part of taking care of these patients  and I feel like it's like the most important part is immobilizing them and not they always  they always come in with their arm flopped across the front of them and it's like what what was I  what have I done you know with my hours of surgery with them so and another interesting point that I'll make it bossom obviously is Elisan is the one who's like tried to popularize  this the most he puts these people in a brace and he tells them you may not take it off for  eight weeks for any reason no showering no I mean he's like really seriously immobilizes them that  is brutal yeah so but I feel like it's hard to get that to heal if you don't do that and keep  them in external rotation because you're asking an allograft to heal in two places so I think that's  an underappreciated part of getting this to work a lot of a lot of this a lot of the regular slings  like this one at the bottom here they'll they'll come with a 30 15 30 degree abduction pillow and  then you can get the way you can get a wedge that's addition to it and I combine both of those  so they actually sit like that because I there's no better way to have patients not come back to  see you again is to start putting people into they hate it you can't even get through a door yeah yeah nobody will come back and see you again after that so you got to do something  in the middle you got to maximize your rehab but you've got to make it so that it's functional  yeah or they'll come back but they're not wearing it at all or with a different even a different  shirt on right you know all right yeah how many folks in the audience have done a tendon transfer for an irreparable cuff tear hand raise few yeah how many folks still do scr  yep so those are all options how about balloons subacromial balloon how many people have  experience with a subacromial balloon yeah a lot more interesting huh so this is this guy at six  months so he's back in the gym and he's happy so it did it restored his external rotation it's funny  if you watch his face here because I'm like showing him I'm like here now do this do this  and he's totally confused and what he's supposed to be doing but he was happy and I think it restored his active motion he's still weak overhead but he's back at the gym lifting and  he's happy so as you guys mentioned Bassamel Hassan has championed this and they've shown that it can reverse external rotation pseudoparalysis and will a binder who's next door  published this 90 percent of patients had improvements in all outcomes 90 percent of patients pseudoparalysis was reversed and this study a couple years ago compared lower trap to  lat dorsi and found that the lower trap actually did better than the latissimus dorsi so it's  technically easier and at least in this study did better rob yeah I think it's safer to learn than  latissimus because it's a subcutaneous dissection although there's some trickiness to it but I just  these people that want strength with these cuff division shoulders I just tell them you're not  gonna have normal strength no matter what we do I mean I think that this is probably better than  nothing and it's probably better than scr you know if it heals and everything like that but  but the lower trapezius muscle tension is a third of the infra and then biomechanically and then  you're losing a grade strength theoretically by tendon transfer principles so they're not going  to be normal again and I think it's really important for them to know that because a lot  of them are guys like this guy who want that and you know you just can't I just never for me I never  promised them no you gotta drink the back your shoulder is never going to be normal it's never  going to be what you want it to be okay next case 65 year old male retired male veteran with right  shoulder pain he's had it for years slowly worsening he's had extensive non-op management  now he wants to do something about it so he's still got pretty good motion he doesn't have any  lag signs but he's got weakness of super and infra and his subscap seems okay so theo anything  catch your eye anything you're concerned about here yeah so he's superiorly migrated looks like  the chromium humoral interval is a bit narrowed reactive changes on the acromion maybe the superior maybe a little bit of arthritic wear eccentrically on the glenohumeral joint  agreed joint doesn't look too bad okay rob here's your mri okay he's got a thin thin super and for  it's very retracted subscap looks fine on that cut that you've shown us terry's minor looks maybe a  touch hypertrophied supra's atrophied or medial eyes q3 guttale a3 super 34 and when you get a  cut like this this is the most medial cut on his sagittal mri and it doesn't go far enough yeah i  mean i try to repeat the mri no i just look at you almost always get coronals yeah sometimes you'll  get axial t1 so i just spin through those i don't know if that's any good but you know i tried it i  mean somebody who hasn't had surgery before what was the chronicity on this years he hasn't five  years worsening pain and weakness oh yeah i mean he's got a chronic rotator cuff tear obviously but  you know i try to look for muscle and try to give them the benefit of the doubt and i try to give  them an and a repair a primary repair this is an irreparable case so we already know it's  irreparable but i wouldn't discount a primary rotator cuff repair if i what if it wasn't high  tension because even if it structurally fails the patient's probably still going to do well  in this age group with his teres minor so what would you do he wants something i would scope him  and have a backup plan i would send him for a backup plan of probably a dermal reconstruction  or maybe a balloon in this case maybe balloon might be interesting option for him because  not full motion no way it's got full motion and pain weakness balance cuff good yeah he'd be a  reasonable balloon can depending on this kind of social situation i think yeah what are you going  to tell him so his so i want to make sure i heard this right so his the procedure he's got  some it's mostly for pain is that his yeah but he's weak overhead yeah he's got pretty good active  motion so probably his biggest complaint is pain but he says like it's weak but it hurts so he's  one i mean i agree with everything rob said but he's one that i might even send for like a super  scapular nerve block and see whether or not there's any entrapment because i'm going to do something  with this guy if his problem is pain i want to see what i can do the best to treat all that stuff so  if he would respond to a you know a nerve block super strong guided super scapular nerve block  that helped significantly with this he's allergic to cortisone i would use lidocaine that's good  allergic to lidocaine also okay so i so i wouldn't so okay and markane i did not do that but that is  okay enough of you he has no other eo  yeah i mean i you know he tell us it's irreparable but i i kind of agree i think with with rob i mean  he may this may be somebody who you can advance some of that and you know do a partial repair i think larry published like midterm results on that here's your diagnostic scope  so we're viewing from lateral again you know it's not as bad as the last guy it's got that  that you could use too looks like larry wants to know how much abduction you're in right now  30 90 it's 90 degrees  up here it's fine it's fine all right does this uh okay so now rob you said you were going to  scope and make another assessment yeah so what are you doing right now that looks that's pretty  terrible i'd probably debride it a little more and do it and that infra looks worse than i expected  it to look honestly i thought his infra was going to look no it's a chronic i mean it's a chronic  cuff tear it's you know i would yeah this so a sedentary guy i mean this is somebody who he's  going to do fine whatever you do you know if he's sedentary and whatever you can do anything here  okay he's got a balanced cuff he needs pain relief so here we go we're pulling on it  i said same thing as theo that biceps looks tasty so i took a page out of larry's book  and we released his transverse humeral ligament transferred his biceps to the center of the  tuberosity and then repaired everything over the top and uh because he had a really husky biceps  it was huge you know and so i did like in larry's technique video left it attached to the superior  labrum released the transverse humeral ligament so i could pull it all the way out i put a double  loaded anchor about a centimeter behind the bicipital groove i did not cut it distal i left  it intact distally anchored it down then i put a triple loaded anchor just behind that and i pulled  up his infraspinatus and did a side-to-side repair and he did all right he did not do great  i mean he got his motion back and he's happy but he's still weak you know so this may have  been pushing the envelope a little bit but i think that that is your point is well taken like he did  better and he was happy he's like doesn't hurt anymore but i'm still kind of weak up here  but um it saves a reverse for if he fails in 10 years i don't know what do you think larry  is this uh is this cuff too crappy to do this technique yeah it's uh i use it for all comers in  this if i'm in the operating room because you're in this kind of clinical situation where you're  going to try to scope it and see what you have then i'll do this repair and i'll move the biceps  just like you did and secure it there the biceps is very thick graft it's on average six and a half  millimeters in diameter which is much thicker than any kind of sr scr graft or whatever and it's alive  and it's cheap and it's fast so i think in this clinical situation what are your options right and i think this is what i would have done personally and and he probably my patient  would have been a lot stronger but you need to re-watch my video maybe it had been good plug  so here's larry's here's larry's technique so this is on a tech so you can search this and watch  and see how to do it correctly you can see all the screw-ups that i made and this was a systematic  review where they looked at 113 patients and they all got better so follow-up between 6 and 40 months  and they showed improvements in all their pros above the minute minimally significant mcid  minimally help me out rob minimal clinical significance yeah thank you so they all improved over their mcid so i think that this is a good option to keep in mind when you have an  intact bicep so just like larry said earlier i'm a biceps killer but since this technique i don't  cut the biceps right away leave it and maybe you can use it and if you don't need it you can always cut it later any parting thoughts from our panel  perfect thank you to our panelists
Asset Caption
Moderator: Michael O’Brien, M.D.
Panel: William Ciccone, M.D., Robert Hartzler, M.D., Theodore Shybut, M.D.