Diagnosis and treatment of anterosuperior rotator cuff tears

Nineteen of 407 patients who underwent rotator cuff repair surgery over a 6 -year period were found to have a tear of the subscapularis in combination with the supraspinatus and infraspinatus tendons. Nine of these patients ha d an unsuccessful prior surgery which failed to recognize the extent of the subscapularis component. Surgical repair of the subscapularis tendon requi red a deltopectoral approach, and repair of the supraspinatus and infraspin atus components of the tear could only be accomplished through this approac h in 4 patients. In the remaining 15, an extended superior approach was req uired to mobilize and repair the supraspinatus and infraspinatus tendons. I n all cases, the biceps tendon was either torn or severely degenerated requ iring tenodesis. At a mean Follow-vp of 40 months (range 24 to 75 months), subjective results were excellent in 5 patients, good in 3, Fair in 4, and poor in 7. The modified Constant score improved to a mean of 69% (range 23% to 130%), compared with a preoperative mean of 38% (range 23% to 100%). Ph ysical findings positive for subscapularis insufficiency persisted in 14 of 19 patients. A significant correlation (P < .05) was found between a lower Constant score and duration of symptoms longer than 6 months as well as an appearance of severe fatty degeneration and atrophy of the subscapularis m uscle on magnetic resonance imaging. We conclude that anterosuperior rotato r cuff tears are an infrequent configuration that may require surgical repa ir through an extended approach combining deltopectoral mobilization of the subscapularis with transdeltoid mobilization of the supraspinatus and infr aspinatus. Repair before 6 months of symptoms is associated with a better f unctional outcome and is the result of less involution of muscle and tendon tissue.