Overview
Rotator cuff injury was first discovered and named by Smith in 1834, but did not attract much attention until Codman and Akerson pointed out in 1931 that it was an important cause of shoulder pain and made preliminary studies on its diagnosis and treatment, and then many scholars began to conduct a lot of research on this disease. Rotator cuff injury is one of the most common shoulder disorders in middle-aged and elderly people, which can cause shoulder pain and serious shoulder dysfunction, and its incidence accounts for about 17% of shoulder lesions and 41% in Nobuhara, Japan, which seriously affects the quality of life of middle-aged and elderly people.
Rotator cuff tears are a common cause of shoulder pain, limited motion and dysfunction. Rotator cuff tears can cause a range of shoulder symptoms and affect the quality of daily life, such as shoulder pain, especially at night so that you cannot sleep; inability to brush your hair; and inability to remove a bra in women. 2008 statistics show that nearly 2,000,000 people in the United States were seen for rotator cuff disease.
Anatomy
The rotator cuff, also known as the rotator cuff, is composed of four short muscles – supraspinatus, infraspinatus, teres minor and subscapularis – that span the top of the shoulder joint, with their tendonous parts fused to each other and tightly connected to the joint capsule, and attach to the greater and lesser tuberosities of the humerus along the upper 2/3 of the anatomical neck.
The rotator cuff is a cuff-like tissue consisting of the supraspinatus, infraspinatus, and infraspinatus muscles attached to the greater tuberosity of the humerus and the subscapularis muscle attached to the lesser tuberosity of the humerus, wrapped around the humerus, above which is the rostral shoulder arch consisting of the acromion, acromioclavicular joint, and rostral shoulder ligament, with the subacromial bursa between them. The rotator cuff plays a role in supporting and stabilizing the shoulder-humeral joint during shoulder motion and maintaining the normal fulcrum relationship between the humeral head and the articular glenoid. Tears of the rotator cuff are a common injury in the shoulder joint, most often occurring in the supraspinatus tendon.
The subacromial joint, also known as the second shoulder joint, is composed of the rostral arch, the rotator cuff, and the humeral tuberosity. Although it does not have a typical joint structure, it should be considered as a joint from a functional point of view, with the large subacromial-subdeltoid bursa being considered as the joint cavity. The rostral arch has a strong bone-ligamentous structure that prevents the humeral head from dislocating upward and backward. The subacromial-subdeltoid bursa lies between the superficial and deep shoulder muscles, and functionally facilitates the smooth abduction of the greater tuberosity of the humerus under the acromion. The subacromial-subdeltoid bursa is important in imaging because it is a specific sign for the diagnosis of a complete rotator cuff tear, as the contrast agent can penetrate through the fissure into the bursa during CT and MR imaging.
Anatomical biomechanics
The rotator cuff is composed of muscle fibers of the supraspinatus, infraspinatus, subscapularis and teres minor muscles that originate from the scapula and attach around the humeral head, mixed with the capsule of the shoulder joint, forming a cuff-like structure at the anatomical neck of the humeral head, which has a supporting and stabilizing effect on the acromioclavicular joint. When the shoulder joint is abducted and lifted, the contraction of the rotator cuff muscles keeps the humeral head fixed on the shoulder pelvis and prevents the strong contraction of the deltoid muscle from causing direct impact of the humeral head with the acromion or rostro-capital arch. The supraspinatus acts as an overhead stabilizer for the humeral head, the infraspinatus and the teres minor act as posterior stabilizers and cause the humerus to rotate externally, while the subscapularis has the role of causing the humerus to rotate internally. The supraspinatus is the most important of the rotator cuff muscles and is the most prone to injury. Another role of the rotator cuff is to maintain a so-called confined joint cavity that helps maintain synovial fluid to nourish the articular cartilage and prevent secondary osteoarthritis.
The concept of rotator cuff gap tears was first introduced by Nobuhara, who believed that the main clinical symptom was shoulder pain during shoulder supination and a feeling of instability in the shoulder joint. Anatomically, the rotator cuff gap is the gap between the supraspinatus tendon and the subscapularis tendon, which is a triangle-like structure in the coronal plane. The medial side of the triangle is the root of the rostral process, and its upper and lower sides are formed by the supraspinatus and subscapularis tendons, respectively, ending laterally at the greater and lesser humeral tuberosities and covering the long head of the biceps tendon in the intertubular sulcus. The rotator cuff gap is the structure bridging the supraspinatus tendon and the subscapularis tendon, and is actually part of the entire rotator cuff structure, and is the weakest part of it, limiting the inferior displacement of the humeral head and external rotation of the shoulder joint. Once injury occurs, the combined force of the supraspinatus and subscapularis muscles during upper arm abduction is weakened, and the humeral head is fixed to the shoulder glenoid with reduced strength, resulting in glenohumeral joint laxity and decreased stability of the shoulder joint.
Etiology and pathogenesis
There are many factors that contribute to rotator cuff injury, including trauma, glenohumeral instability, shoulder-thoracic joint dysfunction, congenital or developmental malformations and degenerative changes. Among them, the degenerative theory and the impingement theory are the most well-known.
(A) Degeneration theory
Lindblom and Palmer studied the rotator cuff by microangiography and found that there was an obvious lack of vascular zone about 1 cm from the supraspinatus stop. This zone is the junction between the branches of the suprascapular and infrascapular arteries from the muscle belly and the branches of the anterior rotator humeral artery from the greater tuberosity. Before the degeneration of the supraspinatus tendon, there is a significant ischemia in this zone. This lack of blood supply causes local ischemia in the tendon and is an intrinsic factor in rotator cuff degeneration and tearing. Since then, some scholars have concluded that the degeneration of the supraspinatus hypovascular zone increases with age, and the myofibrillar tissue becomes necrotic and ruptures, and can be significantly ruptured by minor trauma, which is the degenerative trauma theory. It has been found that the dominant hand side is prone to rotator cuff tears, indicating that excessive wear and tear is a major factor causing rotator cuff injury. Although, trauma is an external factor causing rotator cuff tears, however, for non-degenerative rotator cuffs, trauma generally causes acute massive tears or large nodal avulsion fractures, and only for already degenerative rotator cuffs, trauma causes partial or complete rotator cuff ruptures.
Most tears are the result of rotator cuff wear that occurs with age. Degenerative tears are most commonly seen in the dominant shoulder joint. When one rotator cuff is torn, the likelihood of rotator cuff injury on the other side increases. Factors that affect degenerative or chronic rotator cuff tears are
1. Repeated impingement: Sports such as tennis, rowing, and weightlifting can lead to over-applied injuries. Some other jobs such as window cleaning and mopping can also lead to repeated impingement of the rotator cuff and rotator crest, eventually leading to rotator cuff tears.
2.Reduced blood supply: There is a non-vascular area in the rotator cuff at 10~20mm near the humeral stop, and as we age, the blood supply to the rotator cuff is further reduced, which accelerates the degeneration and tearing of the rotator cuff.
3.Bone superfluous: when age increases, bone superfluous (bone spur) is often formed on the lower surface of the acromion. When the shoulder joint is raised, the bone spur can wear out the rotator cuff, and the repeated wear causes rotator cuff tear.
4. Local anatomical abnormalities: oversized humeral tuberosity, subacromial bursa thickening and fibrosis, rostral shoulder ligament hypertrophy, hooked rotator cuff, etc. will increase rotator cuff wear.
Studies have shown that patients with the following risk factors are more likely to cause rotator cuff tears.
1. Age: Patients over the age of 40 are more likely to develop tears;
2. Exercise patterns: prolonged repetitive heavy lifting or overhead movements such as tennis, painters, carpenters, etc.
(B) The impingement theory
The impingement theory was proposed by Neer in 1972. The rotator cuff tendon between the rostro-capital arch and the greater tuberosity of the humeral head is prone to congestion, edema, degeneration and even rupture due to the collision of the rostro-capital arch when the shoulder joint is abducted and lifted. Kim examined 376 patients with rotator cuff injuries and found that 74% had impingement of the rotator cuff, further confirming Neer’s impingement theory. In these specimens, 73% of the complete rotator cuff injuries had a hooked shape, which led to the conclusion that the shape of the shoulder peak was closely related to the shoulder impingement sign. This autopsy finding was also supported by the X-ray examination of 200 cases of shoulder joint.
Ozaki et al. found that many rotator crest lesions such as trabecular disorders, osteosclerosis, osteochondral atrophy and cystic degeneration occurred on the bursal surface of the rotator cuff through autopsy. Partial or full-thickness fracture of the rotator cuff was not observed in specimens with partial rotator cuff tears below the rotator cuff, i.e., on the articular surface side. Therefore, it is speculated that the subacromial bony changes are secondary to rotator cuff injury, rather than due to subacromial bony degeneration causing rotator cuff injury. Other authors have correlated impingement syndrome and rotator cuff tears and found that rotator cuff tears increased with age, whereas subacromial osteochondral changes did not correlate with age. Harvie et al. recently suggested that genetic factors play an important role in total rotator cuff tears in a controlled study of twin siblings versus the general population.
It is now believed that rotator cuff tears are actually the result of a combination of intrinsic and extrinsic factors, including the lack of vascular zone of the rotator cuff tendon and the specific location and function of the supraspinatus muscle, and extrinsic factors including repetitive use of the shoulder joint, subacromial impingement and various degrees of shoulder trauma.
Clinical manifestations and signs
Rotator cuff injury mainly manifests as neck and shoulder pain, especially nocturnal pain, shoulder weakness, gravel rolling sound can be heard during activity, and pain in the abduction 60°~120° position, which is more common in men over 40 years old.
1. Shoulder pain is an early symptom of rotator cuff rupture: the most typical pain is nighttime pain in the neck and shoulder and “over-the-top” activity pain (when the affected limb is raised above the top of one’s head). In the presence of chronic subacromial bursitis, the pain is persistent and intractable. The pain is sometimes accompanied by radiating pain to the neck and upper extremities, and is aggravated by lying on the affected side, which seriously affects sleep and is very painful for the patient. Pain becomes the main reason for patients to visit the clinic and an important parameter to evaluate the effectiveness of treatment.
2. Weakness of the shoulder joint and atrophy of the supraspinatus, infraspinatus and deltoid muscles. Depending on the site of rotator cuff injury, shoulder joint weakness can manifest as weakness in abduction, weakness in supination or weakness in posterior extension, respectively. Due to the pain and weakness, the active activities of the shoulder joint are limited and the shoulder joint cannot be lifted and abducted, which affects the function of the shoulder joint, but the passive range of motion of the shoulder joint is usually not significantly limited.
3. Pressure pain in the gap between the anterior lower part of the acromion and the greater tuberosity. When the arm is lifted or rotated, a popping sound may be felt or a gravelly sound may be palpated. The distinctive gravelly sound is usually seen in the third stage of impingement sign, especially in complete rotator cuff tears.
4.Pain arc sign is positive. When the affected limb is lifted at 60°~120° in abduction, there is obvious pain in front of the shoulder due to the maximum stress on the rotator cuff.
5.Pendant arm test is positive. Some patients cannot lift the arm actively or cannot hold the upper limb after lifting due to pain.
6.Impact test: pain occurs when the humeral tuberosity impacts with the shoulder peak.
Physical examination
Visual examination
Start from the sternoclavicular joint in front and check the entire clavicle to the acromioclavicular joint laterally;
After examining the acromioclavicular joint and the anterolateral angle of the acromion, check the rostral process, the tuberosity, and the subscapularis stop;
The long head of the biceps tendon in the inter-nodal groove is then examined in the mild abduction and internal rotation position;
In the mild posterior extension and internal rotation position, the greater tuberosity and supraspinatus tendon are examined, and the lateral border of the acromion is also examined;
In external rotation and mild flexion of the shoulder joint, the posterior lateral angle of the acromion and the infraspinatus tendon and the lesser circular tendon below it are examined;
Finally, the posterior scapular gland and the supraspinatus, infraspinatus, and teres minoris muscles above and below the scapular gland are examined.
X-ray examination
X-rays have no direct diagnostic value for rotator cuff injuries, especially for acute tears or early lesions, but are useful for the diagnosis of subacromial impingement when the following X-ray signs are present: (1) low acromion with a hooked or curved acromion; (2) dense or bony subacromial and humeral tuberosities; (3) anterior acromion or acromioclavicular joint, humeral tuberosity decalcification, erosion, resorption or bony densities; (4) Rounding of the greater tuberosity of the humerus, loss of the boundary between the articular surface of the humeral head and the greater tuberosity, and deformation of the humeral head; (5) reduction of the distance between the acromion and the humeral head. The normal acromion-humeral head distance ranges from 1- 37.5 px, less than 1. 0 is narrow, and less than 0. 5 cm suggests an extensive rotator cuff tear. Routine radiographs show superior displacement of the humeral head and deformity of the greater humeral tuberosity in patients with rotator cuff injury with a positive rate of 78% and a specificity of 98%, so it is important to measure the acromion-humeral head spacing. A-H spacing can also be reduced due to complete rupture of the long head of the biceps tendon, loss of downward compression of the humeral head, or due to other dynamic imbalances.
Ultrasonography
Ultrasound diagnosis of rotator cuff tears has been used in clinical practice since the early 80’s. It has the advantages of non-invasive, dynamic observation, repeatability, high accuracy, ability to detect tears of rotator cuff tendons other than supraspinatus; convenient operation, time saving, low cost; ability to diagnose long head biceps tendon disorders at the same time; unique value for postoperative follow-up of rotator cuff tears, etc., and high diagnostic accuracy, with an accuracy rate of 90% reported abroad. The sensitivity of ultrasound in diagnosing rotator cuff tears is 75% and the specificity is 92.3%. Therefore, it is valued by clinical workers and currently accepted by many scholars, especially in epidemiological investigation and postoperative follow-up observation, which has unique value. However, when applying ultrasound to diagnose rotator cuff injury, the operator must be fully familiar with the pathological and anatomical basis of the rotator cuff in order to make a reasonable description of the images, the diagnostic criteria are not easy to grasp, and the diagnostic accuracy is highly dependent on individual operating techniques and experience. According to Brandt, there are 7 ultrasound diagnostic criteria for rotator cuff tears: 1 interrupted echogenicity in the rotator cuff; 2 central strong echogenic zone; 3 no rotator cuff echo; 4 strong echogenic points in the rotator cuff; 5 thinning of the local echogenic area; 6 flat laminar echo; 7 thin hypoechoic shadow.
MRI examination
The normal rotator cuff is homogeneous and hypoechoic on MRI with uniform thickness. In the oblique coronal view, the distal contour of the rotator cuff is set off by the fat on the subacromial-deltoid subacromial bursa surface and by the contrast in the joint cavity. The supraspinatus tendon is sometimes seen as a moderate to high signal area on T1-weighted images approximately 25px from its humeral attachment. This is an artifact due to the so-called “devil’s horn effect”.
The immediate signs of supraspinatus tendon tears include disruption of tendon continuity, recession of the severed end, markedly elevated signal (especially in T2W1), morphologic changes and lacunae, which are more reliable signs of tendon tears.
The results of this group were found statistically to be the best PDFS sequence, the characteristics of proton imaging can show the water signal, which can clearly show the anatomical structures, tendon, muscle belly, muscle gap and subacromial deltoid synovial bursa, without the interference of fat shadow, less artifacts, coupled with the chemical shift sequence, using the different frequencies of fat and water in the tissue, the fat and water can be easily separated, suppressing the fat signal highlighting the water signal, thus enhancing the The display of water molecules within the lesion can clearly and sensitively display subtle rotator cuff lesions uniformly, improving the detection rate and accuracy of rotator cuff lesions. Therefore, PDFS sequence is preferred for rotator cuff lesions, and combined with conventional MRI, it can fully display the pathological changes of rotator cuff.
MRI is currently a more commonly used clinical method to diagnose rotator cuff injuries. It is completely noninvasive, has high soft tissue resolution, and can image in multiple planes, which can more visually observe the rotator cuff tendons and their injuries, so its application prospects are significantly better than those of shoulder arthrography. In particular, conventional MRI is superior to shoulder arthrography for the diagnosis of partial rotator cuff tears, because the presence of partial tears on the bursal side and within the tendon can be determined by changes in rotator cuff morphology and signal. The accuracy of conventional MRI in diagnosing rotator cuff tears has been inconsistently reported. o Evancho et al. reported that the sensitivity of conventional MRI for the diagnosis of total rotator cuff tears was 80%, whereas Singson et al. reported 100% o Iannotti et al. classified rotator cuff injuries according to their MRI pathologic changes: (1) tendinitis: increased homogeneity of tendon signal intensity, but no morphologic changes, with intact subacromial and subdeltoid bursal fat layers. (2) Incomplete rupture: limited increase in tendon signal intensity with morphologic changes, showing discontinuity of the fatty layer of the subacromial and subdeltoid bursae. (3) Complete rupture: Significant increase in tendon signal intensity and significant morphological abnormalities, such as interrupted tendon continuity, retraction of the tendon muscle belly junction, or significant muscle atrophy, increased signal intensity of the muscle, and interrupted or absent subacromial deltoid subacromial bursal fat layer continuity.
MRI shoulder arthrography is a new imaging method to diagnose rotator cuff injury in recent years. Zheng Zhuozhao et al. concluded that MRI rotator cavity imaging has high sensitivity, specificity and accuracy in diagnosing rotator cuff tears or total rotator cuff tears, and can be the preferred method for diagnosing rotator cuff lesions after a comparative study of imaging diagnostic methods for rotator cuff injuries. Combining the features of shoulder arthrography and conventional MRI scans, MRI shoulder arthrography can both visualize the morphology and signal of rotator cuff tendons and evaluate rotator cuff injury more accurately. According to the literature, the accuracy of MRI shoulder arthrography in diagnosing rotator cuff tears can reach 100%.
Arthrography
Arthrography has been used since the 1930s and is the traditional imaging method for diagnosing rotator cuff tears. Arthrography methods include single-contrast contrast imaging and double-contrast imaging, which is a diagnostic method using the principle that the humeral mons arthrographic contrast agent spills into the subacromial bursa or fills the biceps tendon sheath through the ruptured rotator cuff. It can make a diagnosis of full-thickness tears, partial tears of the rotator cuff articular surface, rotator cuff gap splitting and frozen shoulder, and is especially accurate in diagnosing full-layer tears. Different authors have reported an accuracy rate of 90% to 100%. However, shoulder arthrography is an invasive test that requires an X-ray fluoroscopy to guide the puncture into the joint cavity, which is not only radiologically harmful but also prone to misdiagnosis due to technical factors of the puncturer. Kelloran et al. have shown that uneven distribution of contrast in the joint cavity, projection of the biceps tendon sheath to the lateral aspect of the greater tuberosity in external rotation, and injection of contrast into the subacromial bursa can all lead to misdiagnosis. In patients with partial rotator cuff tears, the accuracy of shoulder arthrography is poor.
Treatment
Rotator cuff tears, if left unrepaired, will gradually get larger and can go from a small rotator cuff tear of less than 25px to a large rotator cuff tear of greater than 75px in as little as 1 year. Therefore, for diagnosed rotator cuff tears, if you are too old (>75 years old) or physically unable to tolerate surgery, conservative treatment such as oral anti-inflammatory and analgesic medications, physical therapy, and intra-articular local seal can be considered. Otherwise, surgical treatment is recommended to repair the rotator cuff.
Conservative treatment
Non-surgical treatment is suitable for partial rotator cuff tears, complete rotator cuff tears that do not want to receive surgical treatment, and elderly patients, who are treated with analgesic, hemostatic, dehydrating, and blood-activating drugs, along with local painful point closure, physical therapy, and fixation of the affected shoulder in the abduction, forward flexion, and external rotation position with a cast or abduction frame for 3~4 weeks, followed by functional exercises of the shoulder joint. If conservative treatment for 4~6 weeks still cannot restore the strong and independent abduction of the shoulder joint, then surgery should be considered.
(A) Non-surgical treatment
Non-surgical treatment of rotator cuff injury includes rest, non-hormonal anti-inflammatory drugs, physical therapy, local closure, aspiration of calcified sediment, various exercises to restore muscle strength and comprehensive rehabilitation methods. Most scholars believe that non-surgical treatment is appropriate for patients with short duration of disease (within 3 months), small tears, Neer stage I or older patients with low functional requirements of the shoulder. Due to the wide variation in case selection, evaluation criteria and quality of non-surgical treatment application, the excellent rates of non-surgical treatment reported in the literature range from 33% to 82%. Goldberg reported conservative treatment of 46 patients with full-thickness rotator cuff injuries, in which 59% of the patients showed symptomatic improvement. Bokor et al. performed comprehensive nonoperative treatment in 53 cases of full-thickness rotator cuff tears and achieved a 77% pain relief rate, which increased over time, with 67% of patients experiencing pain relief at 6 years and 81% at 9-year follow-up. A similar conclusion was reached by Bartolozzi et al. after a multifactorial analysis of the follow-up data of 136 patients with rotator cuff injuries treated conservatively: the effect of non-surgical treatment was closely related to the length of follow-up, with the longer the time, the better the effect, and poor outcome was found to be associated with three factors: rotator cuff tear >25px, persistence of symptoms >1 year before treatment, and significant functional decompensation were closely related.
Surgical treatment
Anesthesia and position
General anesthesia with cervical plexus anesthesia is applied with the patient in a semi-recumbent position with the affected shoulder outside the edge of the surgical bed.
Surgical incision
A 5-7 cm long longitudinal incision was made in front of the shoulder, extending upward to the acromioclavicular joint, and the flap was retracted to both sides. 3-4 cm of the tendonous portion of the anterior middle 1/3 junction of the deltoid muscle was incised from the acromion, with careful protection of the axillary nerve. The subdeltoid bursa was opened and the humeral head was moved in all directions to check the extent and degree of the tear, the shape of the tear edge, the mobility of the tendon severed end and the toughness of the tendon tissue.
Repair method
In 15 cases with complete rotator cuff tears, the torn tendon was loosened and trimmed, and a bone groove was cut out in the area of tendon attachment at the medial aspect of the greater tuberosity and lateral edge of the articular surface of the humerus. In two cases of partial rotator cuff tears for which conservative treatment was ineffective, surgical treatment was performed with tendon-bone suture fixation, layered wound closure, and negative pressure drainage. After removal of the fixation, the patient gradually transitioned from passive exercise to active exercise and strength exercise, and the shoulder function was basically restored after 3~6 months.
(B) Surgery
It has been 100 years since Muller (1898) first reported the use of surgery to repair rotator cuff tears. With the continuous improvement of technology and the introduction of arthroscopic techniques, there are now many invasive treatments for rotator cuff injuries. Anatomically speaking, the rotator cuff plays a role in the three-dimensional movement of the shoulder joint. In the coronal plane, the deltoid and the lower part of the rotator cuff (infraspinatus, teres minor, and subscapularis) are a force couple; in the horizontal plane, there is another force couple between the anterior part of the rotator cuff (subscapularis) and the posterior part (infraspinatus and teres minor). The purpose of rotator cuff tear repair is to rebalance these two force couples and restore the stability of the shoulder joint, not just to repair the tear. However, because of the variety of pathological changes in rotator cuff injuries, the overall efficiency reported ranges from 70% to 95% depending on the case selected, the surgical approach and the evaluation criteria. The surgical treatment of rotator cuff injury can be divided into open surgery and arthroscopic surgery.
1.Open surgery treatment
McLuohling repair method This method is to fix the tendon to the bone at the anatomical neck above the greater humeral tuberosity or to bury the proximal stump of the rotator cuff into the bone groove at the anatomical neck and fix it, which is suitable for patients with very few distal stumps or who can no longer undergo direct anastomosis. Neer ( 1972) concluded that rotator cuff injuries are closely related to impingement of the rotator cuff and therefore acromioplasty should be performed at the same time as rotator cuff repair. The acromioplasty consists of excision of the rostral shoulder ligament, thickening of the subacromial bursa, and wedge excision of the anterior inferior part of the acromion until the arm is free of impingement during supination and abduction. Fokter used open surgery to treat 51 patients with total rotator cuff injuries with a mean follow-up of 4 years and a satisfaction rate of 88.2%. The treatment outcome was considered to be significantly related to the size of the tear and the length of surgical treatment after injury, independent of the modality of surgery, the mode of postoperative rehabilitation, and age. The combined application of subacromial decompression and rotator cuff repair acromioplasty in open surgery is the most commonly used method to treat rotator cuff injuries. For patients with huge tears that cannot be repaired by conventional methods, many scholars have applied muscle transposition to obtain better results. karas et al. applied subscapularis transposition posteriorly and superiorly in 20 cases of huge tears (> 125px or more) to treat large supraspinatus tears with muscle atrophy. 85% of the patients were satisfied with the results, but two cases had loss of shoulder elevation and nine cases felt weak during prolonged, repetitive The results indicated that subscapularis transposition is effective in the treatment of large rotator cuff defects, but caution should be exercised in patients requiring excessive supraspinatus horizontal motion. In addition, a procedure like Debeyre’s supraspinatus nudge is performed to repair the defect by peeling off part of the attachment point of its supraspinatus fossa and nudging the muscle outward while preserving the blood supply of the supraspinatus muscle. It is mainly used for patients with large supraspinatus tendon defects.
2.Arthroscopic surgery
Advances in arthroscopic techniques have provided a new treatment method for rotator cuff injuries. Under arthroscopic surveillance, the type of tear can be diagnosed and evaluated, and the injury can also be treated. With a clear view of the structures involved, the procedure appears safer than ever before, avoiding the potentially dangerous complications associated with open surgery, especially for triceps injuries. Since the early 1990s, many scholars have performed arthroscopic treatment of rotator cuff injuries, with reported excellent rates of 80% to 92%. There are three methods of arthroscopic surgery for rotator cuff injuries, namely subacromial decompression-plasty and rotator cuff repair; rotator cuff repair with debridement of the shoulder lesion and small incision assistance; and simple arthroscopic debridement of the shoulder.
Wolf et al. applied arthroscopic treatment of rotator cuff injury followed up for 4 to 10 years, and the satisfaction rate was 94%.Severud compared the efficacy of arthroscopic treatment of rotator cuff injury and small incision treatment of rotator cuff injury, and found that there was no significant difference in long-term efficacy between the two, and the surgical efficacy was not related to the surgical method, but more dependent on the type of injury, while the arthroscopic group had a lower incidence of shoulder stiffness at 6 to 12 weeks. The arthroscopic group had a lower incidence of shoulder stiffness at 6-12 weeks and achieved a better range of motion. Hata compared the use of small incisions with conventional open surgery for rotator cuff injuries. The small incision approach did not lead to postoperative deltoid atrophy, and at 3-month postoperative follow-up, the shoulder scores were significantly higher than in the conventional open group, allowing for earlier recovery. Massoud performed arthroscopic acromioplasty and debridement for 114 chronic small and medium rotator cuff injuries, and 74.6% of patients were satisfied with the results, including 59.3% and 87.5% of patients under 60 years of age and over 60 years of age, respectively, with a significant difference.
Early arthroscopic rotator cuff repair mostly used single-row rivet suture fixation, which gradually revealed some defects over time.Apreleva et al. recently showed that the rotator cuff attachment at the humerus is a complex three-dimensional structure, and because the rivet fixation is point contact, the single-row reconstruction technique is not able to completely reconstruct the normal rotator cuff. Ian proposed the use of a double-row reconstruction technique for rotator cuff repair. The double-row reconstruction technique fixes the rotator cuff stump in two rows: the inner row is fixed to the humeral head near the outer edge of the articular surface, and the outer row is fixed to the outer side of the bone bed at the inner edge of the trap of the greater tuberosity, which allows the entire rotator cuff to be reconstructed, increasing the contact area and improving healing. The double-row reconstruction has increased fixation points due to the addition of a second row of fixation, which increases the initial strength of the reconstructed tissue, reduces the load carried by each rivet, and improves the mechanical strength and function of the repaired rotator cuff, allowing it to heal better at the anatomic point. De Beer et al. treated 58 patients with rotator cuff injuries using a modified double-row reconstruction method with an average follow-up of 15 months and an excellent rate of 90%, and more importantly, ultrasound showed that 89% of the patients had an intact rotator cuff at postoperative follow-up. Millett devised another “mattress style double rivet fixation” method that also increases the area of rotator cuff reconstruction. This method consists of two suture rivets that are fixed independently of each other, and then the two rivets are connected by a suture loop so that the load is distributed over the two rivets, which reduces the failure rate of fixation. It has similar strength compared to other double-row fixation methods and has fewer sutures through the rotator cuff, making it a simple method.
The treatment of massive rotator cuff tears has been controversial since and the management of this condition has included conservative treatment, arthroscopic debridement and or biceps tendon resection, partial repair and tendon transposition. Previously, it was thought that rotator cuff injuries of 10-30 mm could be operated arthroscopically. Large and huge rotator cuff tears should be repaired by open surgery due to supraspinatus tendon retraction, adhesions, and bursal fatigue, and open surgery is preferable to arthroscopic surgery for large and huge tears. However, with the development of arthroscopic techniques, these views have changed, and Lo and Burkhart initially reported the use of arthroscopic repair of large rotator cuff injuries. The procedure involved an anterior dissection of the rostro-humeral ligament and a posterior dissection of the supraspinatus muscle to release the supraspinatus tendon. Significant improvement in pain scores was found at 18 months of follow-up. Bennett reported an arthroscopic repair of a massive rotator cuff injury using the “margin convergence” and “gap shift” approach with a 95% patient satisfaction rate. The satisfaction rate was 88%. With the maturity of arthroscopic technology, it is expected that it will be the future direction of rotator cuff injury treatment, which not only has a wide field of vision and can clarify the cause of the injury, but also has a small trauma and fast postoperative recovery.
Rehabilitation method
In 15 cases with complete rotator cuff tears, the torn tendon was loosened and trimmed, and a bone groove was cut out in the area of tendon attachment at the medial aspect of the greater tuberosity and lateral edge of the articular surface of the humerus, with a depth of about 3 mm. In two cases of partial rotator cuff tears for which conservative treatment was ineffective, surgical treatment was performed with tendon-bone suture fixation, layered wound closure, and negative pressure drainage. After the immobilization was removed, the patient gradually transitioned from passive exercise to active exercise and strength exercise, and the shoulder function was basically restored after 3~6 months.