Abstract
Background:
Nearly 500,000 rotator cuff repairs are performed annually in the United States. Cysts within the humeral head have been reported to occur in more than half of patients diagnosed with a rotator cuff tear. They are related to age-related degeneration and rotator cuff dysfunction, and may arise from congenital abnormalities.
Indications:
Humeral head cysts may pose technical challenges during rotator cuff repair. Cysts located at the footprint of a planned rotator cuff repair can decrease biological healing capacity and reduce the fixation strength of suture anchors. One treatment strategy to address bone loss secondary to humeral head cysts is to incorporate cancellous allograft bone chips, which provide an osteoconductive scaffold for bone formation.
Technique Description:
Standard arthroscopic portals were established and during arthroscopy, the rotator cuff tear was identified, and tissue was mobilized. The cyst was debrided to healthy, bleeding bone using curettes and an arthroscopic shaver. A 2.5 mL sterile syringe was packed with crushed, cancellous allograft bone chips. The tip of the syringe was removed to allow for a wider aperture to facilitate injection of bone chips. Through an accessory, percutaneous portal just lateral to the acromion, the syringe was inserted into the cyst site, and bone graft contents were injected into the cyst. Pressure was applied to the syringe to impact the bone graft material. The bone chips were impacted with the syringe plunger. Following rotator cuff repair, the patient underwent subacromial decompression, distal clavicle excision, and open sub-pectoral biceps tenodesis with suture anchor fixation.
Discussion/Conclusion:
Greater tuberosity cysts can impose a technical challenge during arthroscopic rotator cuff repair. Incorporation of impacted cancellous allograft bone chips is an efficient, reproducible method to enhance healing of the RTC tendon enthesis.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
The following is a video presentation describing a technique for arthroscopic rotator cuff repair with concurrent bone grafting of a greater tuberosity cyst.
We have no relevant disclosures. The authors’ full list of disclosures is available online at the AAOS website.
In this video, we provide a brief overview of greater tuberosity cysts associated with rotator cuff tears, discuss a case presentation, describe our postoperative management and return-to-sport guidelines, and review published patient-reported outcomes.
Nearly half a million rotator cuff repairs are performed annually in the United States. Cysts within the humeral head have been reported to occur in more than half of patients diagnosed with a rotator cuff tear and may arise from congenital abnormalities and age-related degeneration, and may be secondary to rotator cuff dysfunction.2,4,5 Humeral head cysts can pose technical challenges during rotator cuff repair. 7 Cysts located at the footprint of planned rotator cuff repair can decrease biological healing capacity and reduce the fixation strength of suture anchors. 6 One treatment strategy to address bone loss secondary to humeral head cysts is to incorporate cancellous allograft bone chips, which offer a widely available osteoconductive scaffold for bone formation.
In this case presentation, a 39-year-old right-hand-dominant man presented with 1 week of significantly increased right shoulder pain following an injury while lifting his child. The patient had experienced lower grade pain over the preceding 9 months. At presentation, he rated his pain at 8 out of 10 and his shoulder function as 2% of normal.
Physical examination of the right shoulder was notable for 15° of active scaption, 130° of passive scaption, 15° of external rotation, and internal rotation to L3. Strength assessment of the supraspinatus tendon was limited due to pain; infraspinatus strength was 4+/5. The patient had tenderness to palpation of the bicipital groove and acromioclavicular joint.
Standard shoulder radiographs were obtained and demonstrate maintenance of the glenohumeral joint space and the presence of a large calcium deposit at the insertion of the supraspinatus tendon. Magnetic resonance imaging (MRI) of the right shoulder was obtained to further characterize the calcium deposit and evaluate the integrity of the rotator cuff. Coronal MRI confirmed the presence of a calcium deposit measuring approximately 15 mm × 15 mm with reactive edema within the greater tuberosity of the humeral head.
The greater tuberosity cyst and overlying calcific tendinitis are again visualized on sequential axial images. Proton-dense sagittal MRI sequences demonstrate preservation of rotator cuff muscle bulk. Given the patient’s symptoms and clinical findings, the patient was indicated for arthroscopic excision of calcific tendinitis, rotator cuff repair, subacromial decompression, and biceps tenodesis.
In cases where a greater tuberosity cyst is identified on preoperative MRI, the size and location of the cyst impact whether ancillary steps are needed during the procedure. For small lesions or those located away from the site of planned suture anchor insertion, cysts may not need to be addressed. For larger cysts, crushed, cancellous allograft bone chips are included on the list of supplies to be made available at the time of surgery.
In the operating room, the patient was placed in the beach chair position. 3 Following standard diagnostic arthroscopy within the glenohumeral joint, the arthroscope was introduced into the subacromial space. Following debridement of calcific tendinitis, a full-thickness supraspinatus tear remained.
During routine preparation of the greater tuberosity footprint with an arthroscopic shaver, the quality of the bone can be assessed visually and with tactile sensation of the shaver against the bone. In this case, a 15 mm × 15 mm spherically shaped cyst was identified in the greater tuberosity at the site of planned suture anchor fixation. The cyst was first debrided to healthy, bleeding bone using curettes and an arthroscopic shaver. A burr was avoided to prevent iatrogenic increase in cyst size. The mobility of the rotator cuff tendon was assessed with an arthroscopic grasper to ensure that the tendon could reach the footprint lateral to the cyst. A 5.5-mm triple-loaded PEEK (polyether ether ketone) suture anchor was placed at the base of the cyst. Six suture limbs were passed sequentially through the edge of the torn rotator cuff. The rotator cuff tear measured approximately 18 mm × 18 mm.
Next, a 2.5 mL sterile syringe was packed with crushed, cancellous allograft bone chips. The tip of the syringe was removed to allow for a wider aperture to facilitate injection of bone chips. Through an accessory, percutaneous portal just lateral to the acromion, the syringe was inserted into the cyst site, and bone graft contents were injected into the cyst. Pressure was applied to the syringe to impact the bone graft material. The bone chips were impacted with the syringe plunger.
Attention returned to the rotator cuff repair. Three pairs of medial-row suture limbs were tied sequentially with arthroscopic sliding Weston knots followed by 3 alternating half-hitches to establish 3 medial-row anchor points. Suture limbs were then passed through a 4.5-mm PEEK lateral row suture anchor and fixed at a point 8 mm lateral to the greater tuberosity. Following rotator cuff repair, the patient underwent subacromial decompression, distal clavicle excision, and open sub-pectoral biceps tenodesis with PEEK interference screw fixation.
Three tips and tricks will ensure successful completion of the procedure. First, the greater tuberosity cyst should be adequately debrided of interposed soft tissue to facilitate incorporation of allograft bone graft chips. Second, it is critical to ensure adequate fixation of the suture anchor within bone by applying gradual tension on suture limbs, to confirm anchor stability, prior to passing suture through the rotator cuff. Finally, use of a syringe with its plastic tip removed facilitates insertion of the graft into the defect through an arthroscopic portal.
Postoperatively, patients are immobilized in a sling for 6 weeks with physical therapy beginning 1 week postoperatively. Passive range of motion is initiated 10 to 14 days postoperatively, followed by active-assisted range of motion exercises at 3 to 4 weeks. Active range of motion commences at 5 to 6 weeks. Strengthening exercises are initiated at approximately 3 months postoperatively. Return to sports or full recreational activities is generally expected between 5 and 6 months.
At 6 months postoperatively, our patient’s pain had resolved fully, his range of motion and rotator cuff strength had returned to near normal levels, and his clinical outcome scores reached thresholds for substantial clinical benefit.
Outcomes data following treatment of greater tuberosity cysts associated with rotator cuff tears are extremely limited. In a series of 25 patients who underwent arthroscopic rotator cuff repair in the setting of cysts, Chillemi et al 1 demonstrated satisfactory outcome scores with low complication rates with application of a cylindrical synthetic graft to fill the greater tuberosity cyst.
In conclusion, greater tuberosity cysts can impose a technical challenge during arthroscopic rotator cuff repair. Incorporation of cancellous allograft bone chips is a simple, reproducible method to potentially enhance healing of RTC tendon enthesis.
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Footnotes
Submitted October 10, 2022; accepted January 18, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.F. received Publishing royalties and financial or material support from Elsevier, has Stock or stock Options with iBrainTech, has Stock or stock Options with Jace Medical, also has Stock or stock Options with Sparta Biopharma, is paid as a consultant and received research support from Smith & Nephew and is paid as a consultant and received research support from Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
