By Peter Pollack
ASES Specialty Day symposium examines four common treatments
Current surgical options for treating a massive rotator cuff tear include open or arthroscopic débridement and smoothing, repair, tendon transfers, biceps release, and reverse shoulder arthroplasty (RSA). Several of these approaches were covered during the symposium on “Massive Cuff Tears: A Common Dilemma,” moderated by Joseph P. Iannotti, MD, PhD, as part of the American Shoulder and Elbow Society Specialty Day program.
In the future, more cuff repairs may be performed using bioengineered collagen membranes. Courtesy of Richard J. Hawkins, MD
The ins and outs of cuff repair
Richard J. Hawkins, MD, defined a massive rotator cuff tear as greater than 5 cm in either the coronal or sagittal plane.
“The clinical evaluation should include a look at the physiologic age of the patient, the type of tear (acute or chronic), and symptoms such as reduced range-of-motion (ROM), weakness, and pseudoparesis,” he said. “In making treatment decisions, magnetic resonance imaging (MRI) is probably the most helpful scan, because it can be used to determine the size of the tear, the degree of fatty infiltration into the rotator cuff muscles, and the degree of muscle atrophy.”
Radiographs are helpful in determining the acromiohumeral distance, while coronal and sagittal MRI views can help determine the size of the tear as well as the degree of fatty infiltration.
A tear with a large degree of fatty infiltration is likely to be chronic. Although massive cuff tears can be repaired, several studies have shown that repairs are prone to failure and rarely reverses pseudoparesis, although RSA might. The patient’s age is one of the most important factors in the likelihood for a successful outcome.
Ignore the cuff; treat the biceps
According to Gilles Walch, MD, biceps tenotomy is an alternative to cuff repair. The procedure had been used to treat patients with massive tears and upward migration of the humeral head, when open cuff repair was thought impossible or not desirable because of the patient’s low degree of motivation. His study of 307 patients who had massive cuff tears and were treated with biceps tenotomy between 1988 and 1999 and reviewed with an average follow-up of 5 years (range: 2 to 14 years), only 3 percent (9 patients) required reoperation. Three patients underwent rotator cuff repair; the remaining six patients had RSA.
Subjectively, 86.5 percent of the patients were “very satisfied” or “satisfied” with their outcomes. Functionally, the patients overall showed strong improvements in pain and activities of daily living, but no statistical improvement in mobility and strength.
Additionally, Dr. Walch pointed out that tenotomy does not stop the progression of the natural history of the torn rotator cuff: the natural progressive radiographic changes that occur with long-standing tears remained unaltered.
“Arthroscopic biceps tenotomy can yield favorable clinical results in patients with full thickness rotator cuff tears when repair is not possible or desirable,” said Dr. Walch. He outlined the following indications for tenotomy:
- painful rotator cuff tears with full active and passive ROM
- nonrepairable rotator cuff tears with an acromiohumeral distance of less than 6 mm or fatty infiltration of the muscle greater than stage 2
- unmotivated older patients with low activity
An arthroscopic approach
According to Jeffrey S. Abrams, MD, arthroscopic repair of the rotator cuff should be considered in younger, more active patients with less massive tears, or elderly patients who have sustained a traumatic event that abruptly changed their function. Repair in elderly patients with chronic tears will often result in pain relief and patient satisfaction, but weakness—particularly in rotation—will not improve.
Advantages to arthroscopic repair include a low rate of complication, high patient satisfaction, and retention of other options if the repair is not successful.
Contraindications for arthroscopic repair include fixed superior migration so that the humeral head is touching the acromiom, or higher stages of fatty infiltration. When such changes occur in a muscle, weakness may be inevitable.
Dr. Abrams explained that surgeons should be careful not to detach the coracoacromial ligament when they perform arthroscopic decompression. Although some controversy exists regarding the benefits of single- or double-row fixation, Dr. Abrams pointed out that the tissue between the anchors is the section that heals. He suggested that offset fixation using posterior, anterior, medial, and lateral anchors may be the best configuration to reattach a rotator cuff to its footprint.
He also agreed that the biceps can be part of the problem, particularly when it is out of its groove. He suggested placing the tendon over the top of the repair and sewing it to the posterior margin.
In his study of arthroscopic repair on 290 shoulders (201 large tears, 89 massive tears), 88 percent of patients reported pain relief, and 85 percent saw improvements in active motion. Strength, however, remained fair.
Reversing the shoulder
For Mark A. Frankle, MD, RSA is a viable treatment option if nonsurgical treatment isn’t successful in nonarthritic patients with massive rotator cuff tears and in patients who have pseudoparesis with less than 90 degrees of elevation and whose cuffs are unlikely to heal if repaired.
Although the patient’s age is the most predictable factor in determining which cuffs are likely to heal, the following additional factors must also be considered: anterosuperior escape, fatty infiltration of cuff, a history of poor healing or previous failed cuff repair, and comorbidities such as smoking. Patients with these risk factors are more likely to be treated with RSA.
About 10 percent of Dr. Frankle’s RSA patients have a massive cuff tear with minimal or no osteoarthritis. Those candidates generally fall into one of three categories: patients who have pseudoparesis without dislocation (escape), but with multiple comorbidities; patients who have pseudoparesis with clinically evident—but not radiographically evident—escape; and patient who have pseudoparesis with escape that is both clinically and radiographically evident.
A study of 70 patients (71 shoulders) who had RSA between 1999 and 2006 found that ROM improved for all patients. Across the study, 45 percent of patients reported “excellent” satisfaction, and another 44 percent reported “good” or “satisfied.” Of the 3 mechanical complications, 2 patients reported “excellent” satisfaction, and the other reported “satisfactory” after revision.
Options for rotator cuff repair continue to expand. In the future, surgeons may be able to use bioengineered collagen membranes to create tissue scaffolds, employ human growth factors such as bone morphogenetic proteins and platelet-derived growth factors, or achieve tissue engineering using stem cells or gene transfer.
References to the studies cited and disclosure information for the panelists can be found in the online version of this article, available at www.aaosnow.org
Peter Pollack is a staff writer for AAOS Now. He can be reached at firstname.lastname@example.org
May 2009 Issue
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