Arthroscopic approach may serve as less invasive treatment option
Arthroscopic partial rotator cuff repair may benefit patients with large and massive rotator cuff tears, according to data presented at the annual meeting of the Arthroscopy Association of North America by Stephen C. Weber, MD. Although the results may not approach those of complete arthroscopic repair, the researchers argue that the technique represents a reasonable, low-morbidity, low-cost salvage option for rotator cuff tears that may not be completely repairable.
"Many of us would agree that massive rotator cuff tears continue to be an issue," said Dr. Weber. "Surgical options for such tears are limited, with tendon transfers offering significant perioperative morbidity, while procedures such as interval tendon slides raise concerns about the vascularity of the remaining tendon. And some authors have suggested that partial rotator cuff repair may not show durable outcomes."
Dr. Weber evaluated data on 80 patients who presented with large or massive rotator cuff tears during 2010. Of those, 65 patients had repair of the infraspinatus only, and 15 patients had combined infraspinatus and subscapularis repair. All procedures were performed on an outpatient basis.
According to Dr. Weber, all patients were Thomazeau class 2 to 3 for atrophy, Goutallier class 2 to 4 for fatty infiltration, and Hamada class 1. All patients had undergone attempted primary closure. Interval slides were avoided.
"If solid closure without tension could not be obtained through primary repair, but a portion of the cuff could be reapproximated, we performed a partial rotator cuff repair with acromioplasty and preserved the coracoacromial ligament," Dr. Weber explained.
At minimum 24-month follow-up (mean 40.7 months), Dr. Weber found that good or excellent results were obtained in 88 percent of cases, based on University of California—Los Angeles (UCLA) scores. Simple Shoulder Test (SST) scores averaged 9.54, and Society of American Shoulder and Elbow Surgeons (ASES) scores averaged 82.7. Pain scores displayed greater improvement, while UCLA and ASES functional scores showed less improvement. Average Hamada classification worsened slightly over time, from 1.06 to 1.1, and four patients progressed to Hamada class 3-4, although none progressed more than one Hamada grade. Overall, four patients displayed evidence of vertical migration prior to surgery, while six displayed vertical migration at final follow-up.
"We had no complications," said Dr. Weber, "and that's an important point to keep in mind. In addition, no patient was made worse by the procedure. No patient developed anterosuperior instability, and none developed cuff tear arthropathy. There were three procedures performed after the index partial rotator cuff repair: one had a latissimus dorsi transfer, which was made worse by revision. We had one patient with a dislocated shoulder who was reduced under general anesthesia, with no further surgery and no further instability. And one procedure had to be revised to a secondary partial rotator cuff repair."
At final follow-up, radiography demonstrated no evidence of progressive vertical migration. In addition, 69 of the 80 patients underwent magnetic resonance imaging (MRI), through which the research team found that atrophy was arresting in 52 patients. In addition, 68 percent of patients displayed interval healing of the repaired segment on axial MRI sections.
"The absence of perfect results with any form of surgical treatment suggests that initial nonoperative treatment should be the norm," said Dr. Weber. "Some surgeons have argued that all massive rotator cuff tears can be repaired, but others recognize that some may not be repairable. We find that quality long-term results can be obtained with arthroscopic partial rotator cuff repair for large and massive rotator cuff tears. As the initial procedure, I would favor partial rotator cuff repair over other procedures that may be associated with far more morbidity. However, given the retrospective nature of our data, it's also clear that more prospective, randomized studies need to be conducted in this area."
Dr. Weber has no coauthors on this study. His disclosure information can be accessed at www.aaos.org/disclosure
Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at firstname.lastname@example.org
- Researchers conducted a retrospective study of 80 patients with large or massive rotator cuff tears.
- In all, 88 percent of patients obtained good or excellent results at mean 40.7-month follow-up.
- Pain scores displayed greater improvement, while functional scores showed less improvement.
- No patients experienced complications.