Treatment of partial tears remains an issue

According to Evan L. Flatow, MD, the treatment of partial thickness rotator cuff tears remains an ongoing area of controversy because orthopaedic surgeons lack evidence-based data that can help in making treatment decisions. “Randomized, prospective studies don’t exist,” says Dr. Flatow. “Even the retrospective studies available aren’t really very well controlled.

“The theory and ideology will suggest treatment rationale a little bit,” he suggests. “If there’s impingement, decompression is needed; for tendon degeneration, resection and repair is indicated; and for altered kinematics, stabilization is required.”

Dr. Flatow’s preference is to perform débridement on younger, more athletic patients, who have an element of instability or internal impingement, a treatable labral lesion, or less than 75 percent of the tendon involved. He suggests débridement and decompression for older patients who have a greater degree of degeneration and only 25 percent to 50 percent of the tendon involved. If more than half the tendon is involved, he prefers to complete the tear and repair it securely to bone, because in his experience with such patients, the repair is technically simple and the tendon rarely retears.

More information is available on the results of repair of full-thickness rotator cuff tears. Studies have found that most patients experience pain relief, but that strength and function depend on the degree of muscle atrophy and repair integrity. Although muscle atrophy may reverse if the repair remains intact, fatty infiltration does not reverse and may even progress.

Some recent studies suggested a higher rate of retear after arthroscopic repair. Dr. Flatow posits the following six “excuses” for this:

• Magnetic resonance imaging and ultrasound “overread” retears
• Surgeon’s skill level (mature and comfortable with an open technique vs. early experiences with arthroscopic skills)
• Immediate arthroscopic repair strength may be lower
• Healing tendon surface area may be smaller
• Patients have less pain and therefore protect the arm less
• Surgeons may tackle harder cases (less morbidity)

Pros and cons of arthroscopic repairs
Although arthroscopic repair of rotator cuff tears has some “cons” (such as the surgical learning curve, resulting swelling, and cost of anchors), these arguments are far outweighed by the “pros.”

Arthroscopic rotator cuff repair gives the surgeon the ability to see both sides of the cuff and to visualize all pathology (such as superior labrum anterior posterior tears, biceps involvement, and osteoarthritis). It also enables easier capsular release and results in less pain and morbidity, smaller scars, and increased range of motion. Most of all, Dr. Flatow points out, “Patients want it.”

Pros and cons of mini-open repairs
Mini-open repairs have a long track record and may provide a more secure repair, but this approach has several drawbacks, including early pain and morbidity, the increased rate of stiffness, damage and thinning of the deltoid, and the fact that “Patients don’t want it.”

Final recommendations
Dr. Flatow provides the following indications for arthroscopic cuff repairs today: “All primary repairs, with the exception perhaps of a few traumatic subscapularis tears, can be treated arthroscopically. But you can do most subscapularis tears—even complete tears—arthroscopically.

“Arthroscopic surgery is also indicated in some revision surgeries—even those with stiffness, impingement, or recurrent tears—if there is good tissue, because it enables the surgeon to do all of the necessary releases,” he continues. “It’s especially indicated in elderly patients who have massive tears, because the morbidity is much less and the surgery can be performed as an outpatient procedure, using a regional block.”

Dr. Flatow offered the following indications for an open cuff repair: “Traumatic subscapularis tears that are stuck to the axillary nerve; some larger retracted tears with good muscle where the patient is overwhelmingly concerned with strength; revision surgery where grafts and tendon transfers are going to be used; and, of course, if there’s coexisting arthritis and a concomitant arthroplasty is planned.”

Disclosure information for Evan L. Flatow, MD, is available on the AAOS Web site at www.aaos.org/disclosure. Peter Pollack is a staff writer for AAOS Now.

Resolving orthopaedic controversies
Whenever two or more orthopaedic surgeons gather, the talk invariably turns to “how did you handle this [condition, surgical approach, complication]?” So it’s no wonder that the “Top Orthopaedic Controversies” course sponsored by the AAOS inspired orthopaedists from across the United States and Mexico to travel to New York City to listen to comments from some of the top surgeons in the field.

Course director Edward Akelman, MD, assembled a stellar faculty to share their experience and expertise on a wide range of orthopaedic controversies, ranging from open vs. arthroscopic treatments for shoulder instability to the value of artificial spinal disks, hip resurfacing vs. hip replacement, and ankle arthroplasty vs. fusion.

AAOS Now staff writer Peter Pollack was also present and, during the next several months, will be summarizing just a few of the many highlights from the course, beginning with two shoulder treatment controversies.