Abstract
Background:
Rotator cuff tears after anterior shoulder instability are more common in patients >40 years of age and rare in younger patients where shoulder instability is most common. Although infrequent, little data exist on the evaluation of combined labral and rotator cuff tears in athletes.
Indications:
Combined rotator cuff and labral tears in the young patient population have a high risk of recurrent instability and require unique intraoperative and postoperative considerations. This patient is a Division 1 collegiate wrestler who sustained a 360° labral and full-thickness rotator cuff tear after an acute traumatic anterior shoulder dislocation.
Technique Description:
The lateral decubitus position is utilized and a posterior viewing portal is established along with anterior and accessory lateral portals. The 360° labral tear is first addressed by appropriately preparing the glenoid creating a quality healing surface. Tape sutures are then utilized to perform a knotless anterior labral repair. The superior labrum, anterior to posterior (SLAP) and then posterior labral repair are sequentially performed. The posterior portal is closed with a polydioxanone (PDS) suture to prevent a stress riser in the capsule. The rotator cuff tear is then repaired in a knotless double row configuration after appropriate greater tuberosity preparation.
Results:
Recent studies evaluating athletes with combined rotator cuff and labral pathology who underwent arthroscopic repair reported 90% good to excellent satisfaction with 77% returning to pre-injury level of athletics. Although few studies have evaluated combined labral and rotator cuff repair and concerns with stiffness exist, the current literature and the authors own experience have found good outcomes following single-stage repair.
Discussion/Conclusion:
Combined labral and rotator cuff tears after anterior shoulder dislocation in the young athletic population are rare and can be challenging to treat. Although there is limited data on these combined injuries in young athletic populations, the current literature and authors’ experience support single stage surgical treatment of combined labral and rotator cuff tears which typically result in improved patient reported outcomes and return to sport.
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
This is a video showing an Arthroscopic Repair of a 360° Labrum and Full-Thickness Rotator Cuff Tear After Shoulder Dislocation presented by Dr. James Bradley, clinical professor of Orthopedic Surgery, University of Pittsburgh Medical Center, and head team physician for the Pittsburgh Steelers, along with Michael Nammour, Orthopedic Sports Medicine Fellow.
These are our disclosures.
Our case involves a 20-year-old man with right shoulder pain after a traumatic anterior subluxation or dislocation with spontaneous reduction event during a wrestling match when his opponent landed on his arm during a pinning maneuver. He’s a division 1 collegiate wrestler. He has pain and subjective instability, and he has no previous subluxation or dislocation events.
On examination, he has range of motion, full and symmetric bilaterally. He has 4 out of 5 strength with abduction, internal and external rotations are 5 out of 5. He has a positive Jobe test, and on instability testing, he has a positive apprehension test, relocation test, Kim test, Jerk test, Dpit test, O’Brien test, and Whipple test.
Imaging shows a circumferential labral tear in a 360° pattern with no bony involvement and a near full thickness supraspinatus tear. This circumferential tear pattern involving the superior biceps labral complex would classify this injury as a type 9 slap tear. Rotator cuff tears are known concomitant injuries in patients with anterior shoulder dislocations and have been between 7% and 32% of cases. These tears are more common in patients >40 years of age. 3
Younger patients have a decreased risk of rotator cuff tears but have a higher risk of recurrent instability. With those that are <30 years old have over 90% chance of re-dislocation. This drops to less than 10% after 40 years of age. Little information is known on the clinical outcomes of patients with combined labral and rotator cuff lesions, as they are often left out of studies due to confounding factors.1,5 This is especially true in the young athletic population. 2
In 1 study, 3 Dr. Hawkins evaluated 19 consecutive patients <40 years old with full thickness rotator cuff tears that were treated surgically 84% had acute injury. The most favorable results were found in those with acute glenohumeral dislocation that were treated with concomitant labral stabilization and rotator cuff repair. 3
Another study 5 published in American Journal of Sports Medicine (AJSM) in 2007 looked at 30 patients with combined rotator cuff and labral pathology who underwent combined arthroscopic repair; 16 patients had a Bankart lesion and 14 had superior labrum, anterior to posterior (SLAP) tears. The average age of the population was 48 years old 90% reported satisfaction as good to excellent, 77 returned to pre injury level of athletics, and the best postoperative Ambulatory Surgical Center (ASC) scores were found in those with a Bankart tear. 5
Lee et al 4 published an article in 2020 comparing arthroscopically treated rotator cuff repairs, slap repairs, and combined repairs. This was a retrospective study with 24-week follow-up. The mean patient age was 57 years old. All groups had equal postoperative patient-determined clinical outcomes, and there were no significant differences between the SLAP group and the combined group at any time point. The combined group did have higher range of motion in forward flexion and strength in abduction, internal rotation, and external rotation than the rotator cuff repair only group. Although this study did look at an older population than our patient, it does highlight the fact that these combined injuries can be treated successfully with an arthroscopic procedure in 1 setting.4,6
Now back to our case. For the procedure, the patient was placed in the lateral decubitus position, and a standard posterior portal is established. On diagnostic arthroscopy, you can see the full thickness labral tearing and detachment in the superior, anterior, inferior, and posterior labrum. Splitting of the superior labrum and detachment of the biceps anchor can clearly be seen.
Next, the anterior superior portal is established in an inside-out fashion inferior to the biceps at the level of the superior glenohumeral ligament. We then placed another anterior inferior cannula at the 5-o-clock position, as depicted by this slide. With the camera in the posterior portal and the shaver in the anterior superior portal, you can see the splitting of the superior labrum with detachment of the biceps anchor. A shaver and an arthroscopic biter was used to debride the tissue back to a healthy base.
The supraspinatus revealed full thickness tearing, and the shaver was used to debride this back to a healthy tendon.
Next, the labrum was fully elevated with the arthroscopic elevator. Then, the glenoid bed was prepared with a half-round rasp and slap burr for the labrum repair. A polydioxanone (PDS) suture was passed around the labrum which was then used to shuttle the suture tape. We drilled for our anchor just anterior to the biceps. The suture tape was secured in the anchor with appropriate tension, then the posterior labrum was prepared in a similar fashion to the anterior.
Next, a needle was used to establish a superior posterior lateral accessory portal and a low profile clear 5-mm arthroscopic cannula is placed. This portal is slightly posterior to midline just lateral to the acromion. This portal was then used for the 11-o-clock clock anchor.
Now the PDS passing suture device was used for passing the suture tape just posterior to the biceps in a similar fashion to the anterior labral repair. The sutures are taken out of the posterior lateral accessory portal and the 11-o-clock anchor is placed. The anchor was placed taking care not to over tension the SLAP repair. Two more anchors were placed at the 10 and 9-o-clock positions. A 7-o-clock position portal was then made with the drill guide and a sharp trocar for the knotless suture tack this was drilled and placed around the 6-o-clock position. When using the passing suture, a larger bite of capsule and labrum can be taken on the inferior half of the glenoid. The PDS and blue suture were taken out of the posterior portal and then shuttled around the labrum. The loop suture was also taken out of the posterior portal and used to shuttle the blue repair suture through the knotless mechanism and then the suture is cut flush to the glenoid face.
A second knotless suture tack was placed at the 7-o-clock position. We prefer to use the suture tack anchors for the inferior most portion of the posterior labrum because it can be placed percutaneously through the guide giving us a better angle for placement. We placed 1 final push lock anchor at the 8-o-clock position through our posterior portal. A total of 10 anchors were used for the 360° labral fixation. The posterior portal was repaired with a number 2 PDS suture.
We then turned our attention to the rotator cuff tear which could be better visualized in the subacromial space. The greater tuberosity bed was prepared with a ring curette followed by a power rasp. The medial anchors were drilled and placed for a double row rotator cuff repair. The medial row anchors were placed just lateral to the articular surface. Because the patient had good bones, a tap was used prior to anchor placement. The 4 strands of fiber tape were passed independently. Care was taken to ensure that a good bite of tendon was taken with each pass. A fiber link was placed anteriorly to restore the anterior cable, a punch was used for the anterior of the lateral row anchors. The anterior fiber tapes from the medial row anchors in the anterior fiber link were passed and fixed in the anterior lateral row anchor. A similar fashion was also performed for the posterior lateral row anchor. The final construct shows good compression across the rotator cuff footprint.
For our postoperative protocol, the patient was immobilized in a sling in 30° of abduction for 6 weeks. Active wrist and hand range of motion began postoperative day 1, pendulum exercises at 2 weeks. Passive and active assisted range of motion and a scapula thoracic program can begin at 4 weeks. Resistance exercises can be initiated at 10 weeks postoperatively and return to sport after 6 months when cleared by the physician.
These are our references.
Thank you for your attention.
Footnotes
Submitted November 4, 2022; accepted January 18, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: J.W.A. received research and educational support from Arthrex, Inc. and is a board or committee member for AOSSM and American Shoulder and Elbow Surgeons. J.P.B. receives royalties from Arthrex, Inc. and DJO and is a board or committee member for AOSSM. 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.
