A cap is defined as non-repairable when it:
– can not be anatomically repositioned at its normal insertion zone (bone tuberosity of the humerus)
– and / or when the muscle related to the broken tendon can no longer function (major fatty degeneration with more fat than muscle, see dedicated chapter)
This can be done before any intervention on the shoulder or after a failure of repair or healing of one or more tendon of the cap.
Indeed regardless of the technique or the surgeon responsible for an intervention of tendon repair of the cap, no guarantee can be made concerning the healing and therefore the final and durable repair of this cap.
Medical treatment (functional)
If this statement is made, in the aftermath of a first intervention or not, the functional and medical treatment must be carried out in a precise and prolonged way if it allows an improvement of the function of the shoulder.
If rehabilitation, based on the decoaptation of the humeral head and the strengthening of the deltoid, reduces pain and restore functional amplitudes, surgical abstention is the rule.
In the event of failure of functional treatment, three types of surgical management exist in our practice:
- tenotomy / tenodesis of the long biceps,
- tendon transfers
- and the inverted shoulder prosthesis.
Factors to specify a surgical indication:
– The existence of an unbroken long biceps tendon and explaining some of the pain
Clinically, if a Popeye muscle is present (see page breaking of the long biceps) it unfortunately signs the rupture of the long biceps tendon.
If not and / or in case of intervention already carried out on the shoulder, it is essential to know if the tendon is continuous (ultrasound, arhroscanner, MRI) and if a gesture has been made on this tendon (cut simply = tenotomy or else fixed on the humerus = tenodesis see dedicated page).
If the tendon is uninjured and can explain all or part of the pain, tenotomy-tenodesis of the long biceps can be a simple and effective way to relieve a painful shoulder whose cap is not repairable. This gesture must remain isolated without the acromion (acromioplasty) being flattened, otherwise the initial discomfort may be aggravated (favors the rise of the humeral head).
– The patient’s age
in the young patient (before 60 years) we will try to avoid at most a shoulder prosthesis
– The clinical situation after rehabilitation,
a painful shoulder but with full active joint amplitudes is possible if tendon transfer is possible whereas the ‘pseudo-paralytic’ shoulder (without active movement possible) is almost exclusively a reverse shoulder prosthesis if we want to improve function (associated or not with tendon transfer).
The inverted shoulder prosthesis can treat all cases but is the only recourse in case of pseudo-paralytic shoulder except isolated or combined loss of external rotation which is not well restored by the prosthesis alone and requires a associated tendon transfer.
– The state of the subscapularis in case of non-repairable rupture of the postero-superior cuff (supra and / or infraspinous tendon)
In the case of functional subscapularis muscle (uninjured or repairable tendon), tendon transfers may function.
In theory, tendinous transfers can replace a tendon that can not be repaired by another whose function is close or synergistic (works at the same time with the broken tendon). In practice, these tendon transfers make it possible to recover some of the active movements lost but above all make them less painful and functional for a sedentary life (without sustained activity …).