RECURRENT ANTERIOR SHOULDER INSTABILITY CAUSED BY MASSIVE ROTATOR CUFF TEARS

Abstract

Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.