Diagnosis and treatment of anterosuperior rotator cuff tears

Abstract

Nineteen of 407 patients who underwent rotator cuff repair surgery over a 6-year period were found to have a tear of the subscapularis in combination with the supraspinatus and infraspinatus tendons. Nine of these patients had an unsuccessful prior surgery, which failed to recognize the extent of the subscapularis component. Surgical repair of the subscapularis tendon required a deltopectoral approach, and repair of the supraspinatus and infraspinatus components of the tear could only be accomplished through this approach in 4 patients. In the remaining 15, an extended superior approach was required to mobilize and repair the supraspinatus and infraspinatus tendons. In all cases, the biceps tendon was either torn or severely degenerated, requiring tenodesis. At a mean follow-up of 40 months (range 24 to 75 months), subjective results were excellent in 5 patients, good in 3, fair in 4, and poor in 7. The modified Constant score improved to a mean of 69% (range 23% to 130%), compared with a preoperative mean of 38% (range 23% to 100%). Physical findings positive for subscapularis insufficiency persisted in 14 of 19 patients. A significant correlation (P <.05) was found between a lower Constant score and duration of symptoms longer than 6 months as well as an appearance of severe fatty degeneration and atrophy of the subscapularis muscle on magnetic resonance imaging. We conclude that anterosuperior rotator cuff tears are an infrequent configuration that may require surgical repair through an extended approach combining deltopectoral mobilization of the subscapularis with transdeltoid mobilization of the supraspinatus and infraspinatus. Repair before 6 months of symptoms is associated with a better functional outcome and is the result of less involution of muscle and tendon tissue. (J Shoulder Elbow Surg 2001;10:37-46.)

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.