Massive RCT: A “New” approach from an “Old” technique…

Dear CSS Colleagues:


Enclosed is an interesting article which describes a technique for management of Massive RCT…and it is not SCR or Tendon transfer! Ashish Gupta is an innovative and talented surgeon with the courage to try new approaches. His approach is an extension of the original “Supraspinatus Slide” described by Debeyre in 1965. I am including my response to him as well as that of Bassem ElHassan, and also an additional article from work I did on this subject in 1989 when I was doing research at the school of surgery in Paris. I hope you find this of interest.

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Dear JP:


I have been doing muscle slides and advancement for large retracted / irreparable cuff tears for a few years now and it has replaced the need for an SCR or T Transfer for primary cuff ruptures in my practice.

I have done around 70 cases with Patte 3 retraction with Goutalier grade 3 and above.

Our re-ruptuture rate clinically at 1 year and on MRI at 12 months is 4%. We shall be publishing our clinical results by mid-year.

Perhaps another trick in your bag to tackle this difficult problem...

Regards

Ashish


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Hi Ashish:

I read this with interest and in the context of research I did in Paris in 1989 at École de Chirurgie ("School of Surgery"). At the time I had been working at Inselspital in Bern, Switzerland with Christian Gerber. I was supported to go to Paris and do anatomical research on Debeyre’s supraspinatus slide approach which you reference in your article. My study was to look at his muscle slide in the context of Suprascapular Nerve anatomy. This was published in JBJS in 1992. I am enclosing it here.

What we observed was that the SSN tethered the muscle slide and your approach to releasing it makes sense; however, more current knowledge raises several concerns for me.

First, when you move the entire muscle laterally you change the moment arm relative to the joint and effectively reduce the mechanical advantage of the muscle. Second, when a massive RCT leads to muscle trophicity and a Goutallier stage >2, the compliance of the muscle is reduced and the ability for generation of power (according to the Blix curve for muscle fibers) is reduced as well. So, it is hard to understand in such a case how there is improved power with your operation when it is performed in such cases.


Best,


JP Warner


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Dear Ashish,

Hope you and the family are doing very well 😊

Very nice article Ashish (as usual) and well said comments JP.

I have done this technique in the past but not arthroscopically (you are very skilled arthroscopist) and it is rewarding when you see the tendon of the supraspinatus and infraspinatus approaching their footprint without tension.

However, what JP mentioned about the muscle tension/excursion, change of mechanics are correct.

As you know that the rotator cuff, in contrast to muscles that have tendinous origin and insertion (for example the biceps), have very unique origin of their fibers from the fossa of the supraspinatus and infraspinatus. The muscle fibers resting muscle length is what give them their unique strength and power.

When you release all these muscle fibers from their origin allowing the muscle fibers to retract laterally and in turn the tendon to become more lateralized, it will result in muscle resting length shorter than their resting length. The extent of shortening is not known because it depends how much you lateralize the muscle and where the elevated muscle fibers will end up getting scarred on the fossa.

In addition, as JP mentioned the degree of fatty atrophy may impact significantly any remaining power in the elevated muscle.

In the case you showed in your article, if the teres minor is intact, then the advantage of the technique will be to seal the joint with biologic tissues. But the main power will be originating from the subscapularis/teres minor force couple.

I will be interested to see if you have supra/infra/teres minor tear with fatty atrophy and pseudoparalysis, whether this technique works.

To close, I truly hope this pandemic will be over soon so that we can reunite again

Cheers my friend

B 😊

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Gents

Awesome.

Thanks for the comments as always.

JP thanks for sharing your article very impressive.

As I mentioned in our post Muscle slide and advancement is a powerful tool in our armamentarium to tackle this problem. By no means is it a one stop shop operation for every patient and every surgeon as ( advanced arthroscopy skills are needed). I do feels a fills a large void in our ability to perform primary repairs though.


Anatomy

I found some of the same things when I worked in our lab to evaluate the advancement procedure.

Its crucial that the SSN pedicle is released off its attachments to the glenoid. I have highlighted this in the paper. A release of the transverse scapular ligament and the vertical attachments off the supraspinatus and capsule around the glenoid from the coracoid base till 9 O clock is crucial to free the SSN pedicle.

I found in open dissections once the Nerve is released off the glenoid it moves with the muscle belly of the supra and infra.

The only other tether is the nutrient branch to the fossa which is a branch of the Suprascapular artery which needs to be cauterised.


Muscle Releases

Re the relases of the muscle off the bone. I believe thet the procedure slide to a full advancement is incremental in its severity. I begin working laterally and peel off the Infra and supra off the bone and keep assessing the footprint restoration. Used a tensiometer intraop initially to ensure its tension is minimal. In severe cases ( chronic retracted cuffs ) a full advancement is necessary. Now as I work in the plane of the muscle and the bone all the superficial attachments of the muscle belly are left intact. There are strong connections to the deep fascia overlying the infraspinatus- a layer which is in the same plane as trapezius (as Bassem and you have shown us). Secondarily the medial border of the infra and supra under the trapezius the overlying fascia continues with the rhomboids and L scapulae. This fascia is not touched. Thus superficially the fibres all the way from the tendon to the rhomboids are untouched. As the procedure is all arthroscopic we donot dissect all the superficial fascial attachments which are necessary for an open approach. Thus am I really lateralising the muscle perhaps the deeper part of it. Its elongating more than lateralising.


Goutalier Grade: I find that the grading of the fatty infiltration at the level of the coracoid misguides us. As the tear retracts and goes medial we need to assess the grade of artrophy much more medial and this guides me wether an advancement is possible. We have looked at this in our case series and will publish it. Thus for me the traditional goutalier grade is not a good guide. As I dissect more medial I find the quality of the muscle is ok and not scarred. Understandably this procedure cannot be performed if the muscle is completely converted into fat and scar- RSA it is.

I really care about the residual tendon stump length and am guided by Gerbers paper which highlights a stump length of less than 15 mm has a higher rerupture rate.. this I think is completely correct and for me this pt is better suited for a SCR or TT. Thus caution is advised in transtendinous degenrate ruptures and revision cuff repairs.


Re elongation of the muscle and blix curve shifting… I agree The muscle does get elongated perhaps. The MRI data we have post op - its difficult to evaluate this. We have commenced a EMG and elastography study on this will know results in a year. What I have found is that pts regain upto 80% or higher strength back compared to the normal contralateral side. We have strength testing and constant scores on everyone so from a functional perspective they are not weak if the cuff heals.


Pseudo paralysis- Bassem - The 3 failures we had all had pesudoparalysis with static proximal humeral head migration. I had to convert them to RSA and they are happy and PParalysis reverted. Thus I want to ensure that there is no static proximal migration. I tried Buddys technique few years ago to do a complete capsulectomy to restore proximal head migration ( static) but I was not able to centre the head. Dynamic proximal head migration in my experience reverses as the cuff heals or a T is performed.

I will have to look at the data in detail to see howmany pts were pseudoparalytic in my case series before I can give you a reliable answer.


I submitted our manuscript to ASES last year and was rejected. I will try again this year perhaps we get a more favourable response.


JP happy to share with the codman society. Open to comments and criticism. This is the only way for adoption of the technique. Its certainly helped a lot of my patients and I truly believe it will help people worldwide especially in regions where access to RSA is not possible.


Best regards

Ashish



ARTHROSCOPIC MUSCLE SLIDE
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Warner 1992 - Anatomy and relationships
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