Original ArticlesDiagnosis and treatment of anterosuperior rotator cuff tears*
Introduction
Massive tears of the rotator cuff have been described anatomically as lesions that have a maximum diameter of more than 5 cm7, 9 and functionally as tears that involve 2 or more tendons.50 The majority of literature regarding the diagnosis and treatment of massive rotator cuff tears focuses on lesions of the supraspinatus and infraspinatus tendons. Such tear patterns can be termed posterosuperior rotator cuff tears, and the operative management of these lesions has been well described.1, 3, 13, 17, 28, 52 This type of massive tear should be distinguished from a tear pattern that involves complete rupture of the subscapularis in combination with either the supraspinatus alone or the supraspinatus and infraspinatus. This pattern defines an anterosuperior rotator cuff tear.15, 39
On the basis of the combined experience of several European centers, Nové-Josserand and coworkers39 have stated that anterosuperior rotator cuff tears are sufficiently distinct in their clinical presentation and prognosis as to merit separate consideration of their diagnosis and treatment. To date, however, there have been only a few brief clinical reports,31 chapters,39, 49 and personal communications15, 21 regarding the anterosuperior pattern of a massive rotator cuff tear. Favorable results can be achieved with repair of isolated tears of the subscapularis tendon12, 20, 40; however, limited information exists regarding surgical management of a complete subscapularis tear that is accompanied by a supraspinatus and infraspinatus tear. The purpose of this article is to report the senior author's experience, over a 6-year period, with the operative management of this pattern of rotator cuff tearing.
Section snippets
Material and methods
Of 407 rotator cuff repairs performed from 1991 through 1996, 19 had a tear that included the subscapularis in combination with the supraspinatus (5 patients) and the infraspinatus (14 patients). The study group included 17 men and 2 women with a mean age of 58 years at the time of treatment (range 36 to 72 years) (Table I).Seven patients were younger than 50 years. Fourteen cases involved the dominant arm, and 6 cases were reported as work-related. Seventeen patients could relate the onset of
Results
In one patient, the axillary artery was injured during dissection and mobilization of the subscapularis tendon. This injury was immediately repaired with fine monofilament suture with no postoperative sequela. No other surgical complications occurred.
The mean duration of follow-up was 40 months (range 24 to 75 months) (Table III).No difference in subjective or objective results existed between patients who had prior surgery and those without prior surgery. Subjective results were graded as
Discussion
The 19 patients reported in this paper represent only 4% of all patients who underwent operative repair or a torn rotator cuff during the 6-year period of this study. Furthermore, 9 of these patients had prior rotator cuff repair surgery that failed. Therefore, recognition of this kind of tendon injury appears to be poor, and repair carries a poor prognosis.**
It is likely that the infrequency of this pattern of rotator cuff tendon tear renders it easily missed or misdiagnosed without
References (54)
- et al.
Surgical management of complex irreparable rotator cuff deficiency
J Arthroplasty
(1991) - et al.
Operative repair of massive rotator cuff tears: Long-term results
J Shoulder Elbow Surg
(1992) - et al.
Coracoacromial ligament: a comparative arthroscopic and anatomic study
Arthroscopy
(1995) - et al.
Lag signs in the diagnosis of rotator cuff rupture
J Shoulder Elbow Surg
(1996) - et al.
II: Anterosuperior humeral displacement: limitation by the coracoacromial arch [abstract]
J Shoulder Elbow Surg
(1996) - et al.
The coracoacromial ligament: is it the appendix of the shoulder [abstract]?
J Shoulder Elbow Surg
(1996) - et al.
Fatty degeneration in the supraspinatus msucle after rotator cuff tear
J Shoulder Elbow Surg
(1996) - et al.
Release and reattachment of the coracoacromial ligament: a cadaveric study
J Shoulder Elbow Surg
(1997) - et al.
Single-tendon tears of the rotator cuff: evaluation and treatment of subscapularis tears and principles of treatment for supraspinatus tears
Orthop Clin North Am
(1997) - et al.
Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval
J Shoulder Elbow Surg
(1994)
Coracoacromial pressure recordings in a cadaveric model
J Shoulder Elbow Surg
Operative treatment of failed repairs of the rotator cuff
J Bone Joint Surg Am
Strength of fixation with transosseous sutures in rotator cuff repair
J Bone Joint Surg Am
Strength of fixation with transosseus sutures in rotator cuff repair
J Bone Joint Surg Am
The Shoulder
Tears of the rotator cuff. Instructional Course Lectures
Subscapular muscle transposition for repair of chronic rotator cuff tears
Surg Gynecol Obstet
Rotator cuff disease of the shoulder: current concepts review
J Bone Joint Surg Am
Age-related recovery of shoulder function after injury
A clinical method of functional assessment of the shoulder
Clin Orthop
Traumatic tears of the subscapularis tendon: clinical diagnosis, magnetic resonance imaging findings, and operative treatment
Am J Sports Med
Repair of the rotator cuff: end-result study of factors influencing reconstruction
J Bone Joint Surg Am
Excursion of the rotator cuff under the acromion: patterns of subacromial contact
Am J Sports Med
Rotator cuff tears including the subscapularis
Massive, irreparable tears of the rotator cuff: results of operative debridement and subacromial decompression
J Bone Joint Surg Am
Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff
Clin Orthop
Isolated rupture of the subscapularis tendon
J Bone Joint Surg Am
Cited by (299)
Primary Rotator Cuff Bridging Reconstruction Shows Better Clinical and Radiographic Results Than Revision Bridging Reconstruction
2024, Arthroscopy, Sports Medicine, and RehabilitationWhen and how much does the muscle strength recover after arthroscopic superior capsular reconstruction?
2024, Journal of Shoulder and Elbow SurgeryMassive rotator cuff tears with short tendon length can be successfully repaired using synthetic patch augmentation
2023, Journal of Shoulder and Elbow SurgeryArthroscopic Subscapularis Repair With Preserved Biceps Anatomy
2023, Arthroscopy Techniques
- *
Reprint requests: Jon J. P. Warner, MD, Harvard Shoulder Service, Partner's Department of Orthopaedic Surgery, Massachusetts General Hospital, Professional Office Building, Suite 403, 275 Cambridge Street, Boston, MA 02114 (E-mail: [email protected]).