REPAIR
OF
OF
RUPTURES With
a Note
on Advancement
J. DEBEYRE, Although
ruptures
of the
ROTATOR
THE
D.
rotator
of the Supraspinatus
and
PATTE
OF
CUFF
cuff
E. ELMELIK, of the
SHOULDER
Muscle
PARIS,
shoulder
THE
FRANCE
have
long
been
recognised
cause of pain and disability, they have always been a source of disappointment because of the difficulties of diagnosis and of surgical treatment. Rupture injuries as dislocation or contusion of the shoulder, that cause immediate pain are
easily
recognised,
of
power
when
as
doing
the
The the
2)
arm
at other
times
is abducted
the
symptoms
and
are
laterally
insidious
rotated
and
in simple
first
present
everyday
as a loss
actions
such
hair.
diagnosis
clinical
(Fig.
but the
as a
to surgeons from such and stiffness,
can
examination can
be
used;
be confirmed arouses entry
easily
suspicion of
by arthrography, of a rupture.
either
into
the
which Gas
should
bursa
subacromial
be done
1) or a radio-opaque
(Fig.
confirms
the
whenever liquid rupture.
I FIG. I FIG. 2 Figure 1-Air arthrograph in a patient of 75 years with a rupture of the cuff. The intra-articular air has penetrated into the bursa which it fills. The subacromial space is a single empty synovial cavity. There has been a complete detachment of the whole of the cuff. This is often seen in old people. Figure 2-Arthrograph with opaque fluid in a patient of 53 years with a ruptured cuff. The opaque fluid has entered the subacromial bursa, but only to a small extent. There is a rupture of the anterior border of the supraspinatus-which occurred at the time of a dislocation.
Arthrography
is essential
before
of the typical clinical findings, Arthrography is reliable. arthrography operated 36
upon
suggested through
operation; and the Only
in
rotator three
it. Two of these the delto-pectoral
one
of
cuff was explorations
shoulders route,
had which
our
patients
it was
omitted
found to be intact. showed no rupture
because
even
though
a long-standing disability and gives an exposure inadequate THE
JOURNAL
OF
BONE
AND
JOINT
were to
SURGERY
REPAIR
exclude
a rupture
faulty the
with both
technique,
confirmed
that
inferior
have
there
for which
The
latter
operated
was
only
and
The
no
ROTATOR
third
the subacromial
rupture.
On
supraspinatus
method be
those
decided who
by
have
bursa
the
doubt
had
had
been
was
and
of
results
cuff
but,
A later
shoulder
fissure
on
it would
the
technique
indications in
through
arthrograph
a small
first,
the correct the
intact
arthrography;
(Fig. 3). problems:
second,
a comparison
an
after
37
SHOULDER
injected.
in one
located
exploration raises two
here,
OF THE
hand,
other
tendon
is offered
CUFF
without
and
by a superficial general of rotator cuff tears
a new
can on
OF THE
certainty.
of the
surface
RUPTURES
the joint
been recognised Surgical treatment
repair,
OF
not
of the
for operation.
patients
who
have
been
not.
FIG.
3
Arthrograph in a patient of 56 years who had severe pain and loss of power; there is a partial rupture of the supraspinatus tendon, indicated by the fact that there is no filling of the subacromial bursa, but only an additional image superimposed on the superior part of the joint cavity. This is caused by an incomplete rupture of the inferior wall of the cuff.
TECHNIQUE
The
classical
incision
gives
approaches
only
to the
a restricted
view
shoulder of
the
acromion process, and provides access subacromial superior approach damages which is so functionally important to impossible
because
The
initial
muscle
may
retraction.
to close voi..
gap
47B,
this NO.
are
either
be wide,
cuff
and
Because
gap 1,
OPERATION
obtain region
of
insufficient
access.
the
tuberosity
greater
The
delto-pectoral
obscured
by
the
only to the humeral insertions of the cuff. The the insertion of the middle part of the deltoid muscle the shoulder. Suture of the ruptured cuff is often
of its extent.
of the
Ruptures
OF
and FEBRUARY
to
exploration reinsert 1965
the
limited it always
to the supraspinatus increases considerably
is usually tendon
without
delayed
or extend to the other parts. in the course of time from
for some
excessive
months
tension.
it is often From
1951
impossible to
1959
we
38
J. DEBEYRE,
explored of
seventeen
limited
extent
the
of
four
gap;
and
Since above
the
muscle whole
a
new
of
the
origin
seven
was
the
for
can
supraspinatus
laterally,
stiffness The
of
margin
of
breadth
short
of
by
the
scapula.
the its
be found,
done
good
soon
probably
access,
because
because
of
enough-between
with
good
knee
spine
the
one
functional
be
seen, the
acromion.
and
results
the
whole
whole
shoulder
minor
can
from
its
is elevated
approach
The
fossa;
from
closure of the
the
tuberosities
When
the
from
supraspinatus
be explored. muscle
necessary can
then
be
5
FIG.
7
of the operation. of
a
forearm
wide
gap.
This
in Volkmann’s
technique
contracture
is
and
analogous
of the
to
quadriceps
joint.
the
with
operation.
of the
incision
it curves An
backwards, joint
fibres
shoulder
margin
insertion. and
the The
scapula;
its outer
acromio-clavicular
upper
and teres
a postero-superior
the
FIG.
prone
beyond scapular
with of
6
lies
outwards
The
not
despite
4
fiexors
during
fingers’ obliquely
the
used
and muscle
permitting the
patient
manipulated
could
to be effected,
been
Stages
of
tear
operation
osteotomy
subscapularis
FIG.
advancement
the
E. ELMELIK
impossible,
the
has and
insertion
the
FIG.
advanced
AND
reinsertion
technique scapula
to
of
of
Twice proved
a satisfactory
1960
insertion
only
PATTE
shoulders.
spine
from
the
the
seven
I).
reinsertion
in
allow
of the
(Table
in eight
months-to
in five
to
shoulders
access;
D.
(Fig.
and
the
deltoid
of the
posterior
are
so
that
a finger’s
the
arm
breadth
can
above
be the
freely
superior
backwards over the acromion and extends two 4). The trapezius muscle is divided one centimetre
osteotomy leaving
of the
supported is made
the
acromion
anterior segment
split
is done,
segment continuous
downwards THE
with
from JOURNAL
transversely
connected
their OF
BONE
the
to the
spine
insertion AND
JOINT
and
clavicle of
into SURGERY
the
the
REPAIR
acromion, the the osteotomy the
bursa
depends When the
sufficient
to
a few
stitches
large,
with
care
to
even
to the
this in
the
The
with and
retracted
and In
limbs
(Fig.
COMPARISON
OF
7).
Closure
APPROACHES
RESULTS
WITH
THE
SHOULDER
FOR
On
the
of
a small
bone
and
other
it is it by
if the
from
its
the anatomy tendon can
The
tear to join
hand,
is elevated
Fortunately end of the
trapezius
DIFFERENT
be
gap
fossa
is
with
of the region reattached,
muscle
is sutured
SURGICAL
ROTATOR
Number Approach
the
to a degree
I
THE
TO
cuff.
is simple.
TABLE
uncovered
closure
muscle
(Fig. 6). proximal
found
through
of the
supraspinatus
blood supply this way the
case
allows
stitches
39
SHOULDER
retractor is inserted to keep ligament is divided and
are
5). tendon
U-shaped
the
OF THE
tuberosities
(Fig.
posterior
CUFF
A self-retaining The coraco-acromial
humeral
two
edges,
long-standing
a
being avoided. widely open.
tendon
the nerve manoeuvre.
ROTATOR
of the rupture the supraspinatus
anterior
widely
OF THE
is opened.
on the extent elasticity of
attach
preserve
permits
RUPTURES
circumflex nerve of the acromion
subacromial
which
OF
CUFF
TEARS
of operations
Delto-pectoral subacromial
or
T
1 ransacromia
1951-1959 No
and
the
is at
needed.
of the
angles
found
Reinsertion
possible
is begun
in this
2
8
-
.
7
44
Total
operations
.
17
46
Total
satisfactory
.
5
41
the
are line
drain
six weeks
2
.
impossible
until
approximated.
of
pull
is placed
A thoraco-brachial
to
.
Reinsertion
deltoid
to
A suction
profuse.
four
fibres
right
tear
of
in the
plaster
the
position
kept
has
two
plane
with
and
fossa,
the
arm
recovered for
osteotomy formal
where
abducted,
good
up vigorously
of the
muscles
supraspinatus
spica,
patient
and
The
these
bleeding
in the
or four
aclomion is not
is always
is applied
power
three
of the osteosynthesis and
deltoid.
rather
retained
for
Re-education
months.
RESULTS
We
have
used
this
forty-six ruptures three shoulders, close the gap. of the results, satisfactory from the for
some
20
or
30
good
work
category
co-operation VOL.
47B,
were excellent, and complete
were NO.
and
; twice no of the
degrees
of
and
1,
were
outward
satisfied.
dissatisfied. but with
in the
ensuing
of the
greatest
FEBRUARY
1965
three
have
been
rupture was supraspinatus
able
to repair
found. was
all the
In twentynecessary to
so that for the purpose of analysis I). Of the forty-one patients with
that is, with almost complete freedom from pain recovery of power and range of movement except rotation; eleven had good results and twelve were
In the latter, despite marked though the range of abduction
resumed
shoulders
discovered advancement
Two patients have not been followed up, forty-four patients can be considered (Table
unchanged and they were third month after operation the
on forty-eight
of the cuff that were that is in 50 per cent,
results eighteen time of operation
improved. incomplete, had
exposure
reduction was over
Three
patients
Most good re-education months.
importance.
of pain, 100 degrees; were
recovery nine
failures;
of
of these
the
movement twelve
functional
results could be recognised from a further proportion of patients The
quality
of this
treatment
and
was patients
state
was
about came
the into
the patient’s
40
J.
Mobility-The patients
improvement had
a normal
range
at the extremes. After from 160 to 180 degrees. the
range
of
abduction
the
other
five
had
good
DEBEYRE,
results.
In
the
AND
of abduction
is shown but
not
a normal
increased;
the
of
frequently 90 degrees
OF
ABDUCTION
slight,
the
improvement
AND
Number
Before
operation
12
2
19
2
44
.
AFTER
-
operation
11
27
4
.
patients
had
attached
this reason sometimes with
infraspinatus
6
and
44
nevertheless constant when this
suggests
that
regained full abduction. there was a complete it might
be helpful
The rupture to reinsert
Two patients have, in fact, had combined reinsertion of both muscles; both but only one recovered a near-normal range of lateral rotation. of the pain is usually spectacular (Table III). Twenty-nine of the forty-four
complete
freedom
more
the subjective found to be the
-
44
tendon,
Lateral some
operation
9
Total.
why
__________
After
.
.
the best results. which explains
of patients
------
29
Intolerable
40 to 60 degrees
considerable.
OPERATION
2
.
but
all had
44
.
Continual
and
Ill
AND
with apparently absent lateral rotation of lateral rotation stayed practically
patients
satisfied
.
failures,
operation
0-60
Some
the
After
60-90
None.
be
of patients
6
Before
to
_______
6
of pain
four
control
OPERATION
90-120
Number
involved
AFTER
II
TABLE
which
even with improved,
3
Amount
poor
operation from
was
120-160
BEFORE
the
example,
23
PAIN
that muscle also. had good results Pain-The relief
for
4
Total
only
and
considered
after
Normal
-
operation
power
II
BEFORE
Rangeindegrees
patients limitation
were
and
persisted was often
Before
patients had ranges of abduction by the operation. In eight patients
was
patients
II.
diminished
three
before
TABLE RANGE
much
these,
of abduction
thirty
Some limitation of rotation rotation with the arm abducted
ELMEL1K
in Table
with
improvement
remaining
E.
however, twenty-three had mobility reduced
range
In six patients
of abduction.
PATTE
of abduction,
operation. No patient was
D.
operation
from
importance
pain, to the
ten
had
relief
result, so important better than the objective there
were
four
who
less and of pain
only than
in
an operation result. Out
had,
objectively, THE
five were to
JOURNAL
not
improved to of
improved. movement.
improve twenty-five
very OF
poor BONE
function, patients
The For was very
results. AND
JOINT
SURGERY
REPAIR
That
all the
excellent with
the the
ill
OF
ruptures
of the
exposure.
When
forty-eight
operated
number
RUPTURES
of good
cuff
on
results
assessed
more
critically.
have
been
operated
upon
as in the
more
than
four
ROTATOR
were
the
patient
even is
justifiable because
matters
possible
to
cent),
Over
the
last
years
ten
tendinitis
had
seventeen
after injury reason for
years,
because
operation when clinical evidence
our
satisfactory
patients
were
easier from
TO
though
three
times
Recent with
and
Rupture
of the
Extensive
rupture
Twenty-one limited excellent
THE
between
fifty
.
Of
the
ruptures
cuff
Of
(85 per
cent)
twenty
OF
seventy
patients
but
with
; of twenty-four
twelve had satisfactory and duration of the lesion
EXTENT
and
being
two
patients
were
it
degenerative
patients
with
results (50 per were important
rupture The IV).
cent).
(Table
IV THE
LrsI0N
AND
TYPE
OF
OPERATION
of patients
suture
suture .
supraspinatus
alone
were
treated
by
advancement
of
the
supraspinatus
muscle
simple
suture,
lesions. one was
there
Of these, a failure.
produced
excellent, with
four
improved
combined
and
one
supraspinatus
seven
infraspinatus
tears,
by advancement of the supraspinatus had an excellent result. advancement of both supraspinatus and infraspinatus, had an improvement 30 to 140 degrees but has no outward rotation and no relief of pain. advancement
of the supraspinatus
being ten had Twelve
satisfactory ruptures, quite good
a failure. and
treated
Obviously
two
.
with
of the
by
four
to
confirmed by The age of
(58 per cent), four were improved and one was a failure. Eleven extensive by repair of the supraspinatus only after advancement of the muscle, gave
results,
made
.
of the muscle
treated
was
supraspinatus
.
of
attempt
after operation. degenerative changes-when
gaps with little retraction, which are evidence of recent results, six had good results, four were improved and
ruptures results treated
ofthe
supraspinatus with of the muscle
after advancement
results ruptures
repair
isolated rupture simple suture .
after advancement
recent many
the diagnosis has been only may be incorrect.
Number Lesion
improvement the
as
no
of the
are compared
to be a marked even
previously
the rehabilitation injury or from
difference.
results
periarthritis, The extent
RELATED
because
OPERATION
TABLE RESULTS
is seen
two
FOR
some
with no preceding this is not clear.
I) there
was
to 1959
old.
the patient the rupture, whether
differentiate-makes
1951
to 63 per
last
of
be closed
cent
months
Most
younger of the
could on from
(Table
41
SHOULDER
operated
then
to recommend a diagnosis on
little.
older. The The etiology
OF THE
29 per
INDICATIONS
It is only arthrography,
CUFF
discovered
patients
since
(from
been
ruptures
that
the seventeen
have
repair
OF THE
does
the
The
not give the best functional
one
other,
which
was
treated
by from
in abduction improvement.
Only thirteen patients have abduction to 140 degrees or more with freedom from pain, but nine have kept or regained normal outward rotation. This, and the absence of any sign of nerve degeneration by electromyography, indicates that the transposed muscle maintains its ability VOL.
to contract. 47 B,
NO.
1,
The FEBRUARY
operation 1965
does
not,
therefore,
merely
supply
padding
to the subacromial
42
J.
region.
The
sooner
simple
suture
gives
an
Unfortunately injury with with
function
the
DEBEYRE,
operation
a better
PATTE
is done
the
AND
better
E.
ELMELIK
the
result;
also
rehabilitation
effects of an untreated by arthrography the
rupture shoulder
In elderly
shoulder
only.
patients
depends upon the diagnosis being confirmed six months physiotherapy to cause improvement. pathology,
surgical
technique.
rupture
requiring
one
are not yet known. After often regains satisfactory in four
but with almost normal, painless movement, and many have only slight functional disability, will improve
and do not need operative treatment. Because halfofthe patients of the cuff obtain a good functional result spontaneously,
of local
a small
result.
the long term a rupture confirmed
rupture of the cuff by arthrography,
D.
because
the
continuity
cuff
can
a degenerative
who have sustained the indication for
by arthrography Operation is not of the
has
of these, discovered with physiotherapy a rupture operation
and the failure contra-indicated
always
be restored
of four to for reasons with
this
new
SUMMARY
1. The shoulder 2.
In
and 3.
results of operation have been reviewed. seventeen
mediocre In the
4.
It
patients
acromion access
Most
was
muscle the
is suggested
to respond
with
delto-pectoral
classical
a superior
process
supraspinatus
surgical
the
patients
rupture
route
of the
rotator
cuff
to
give
poor
fossa
and
found
was
of the access
results.
forty-six
divided of
patients
in sixty-three
proportion that
when
have
been
along
to give
in order
to
of good
to physiotherapy, of the patients
approach
found
a case
enable results
of
the
excellent
rupture
wide has of
repair
should
referred
to us by
Professor
and
gaps
been
operative
supraspinatus
access
the
to
to permit
lateral
closed.
With
be
the
through advancement
this
improved
doubled. cuff,
confirmed
by
arthrography,
fails
be undertaken. S. de S#{232}ze,to whom
THE
JOURNAL
OF
we are most
BONE
AND
grateful.
JOINT
SURGERY
