Andrew Green
Chronic massive rotator cuff tears present a great treatment challenge. Because of unique pathologic anatomic features, they must be considered distinct from both smaller chronic tears and acute traumatic massive rotator cuff tears. For the purposes of this review, chronic massive rotator cuff tearing implies that there has been long-standing pathology, not necessarily with concurrent symptoms, leading to the presentation of a patient with a massive rotator cuff tear and substantial rotator cuff muscle atrophy. This implies that the tear is difficult to repair primarily, if not sometimes irreparable. With an aging population and increasing functional expectations, it is likely that we will encounter this difficult problem with increasing frequency.
Various treatment options are available including pain management, nonoperative rehabilitation, subacromial debridement, biceps tenodesis or tenotomy, rotator cuff repair, and rotator cuff reconstruction, all of which have some demonstrated efficacy. The goals and expectations of the treatment of this difficult problem must be clearly understood and defined to maximize the outcome. Determining the best treatment for an individual patient with a chronic massive rotator cuff tear can be difficult. There are no randomized prospective studies that compare nonoperative and operative treatment, nor are there any studies that compare the various surgical options. The purpose of this review is to present a current understanding of chronic massive rotator cuff tears and discuss the evaluation and management of patients with chronic massive rotator cuff tears.
Pathogenesis
Etiology and Pathophysiology
The cause of rotator cuff tears has been the subject of extensive debate, and there are several factors that are implicated in the development of rotator cuff tears. Interestingly, the presence of a tear does not a priori render a shoulder symptomatic. Studies of large numbers of patients with symptomatic rotator cuff tears note that the size of a tear does not directly correlate with self-reported symptoms.
The cause of rotator cuff tears is usually categorized as either intrinsic or extrinsic. Intrinsic factors relate to pathology of the rotator cuff muscles and tendons. This includes degenerative changes that occur with aging, tendon overload, and relative hypovascularity of the anterior aspect of the supraspinatus tendon. Extrinsic factors include subacromial impingement, glenohumeral instability, and unstable os acromiale. Patients with chronic massive rotator cuff tears usually do not have a history of significant shoulder trauma. In occasional cases there is a remote history of trauma that may have caused the tearing. The context of the onset of symptoms is an important consideration. Although many patients with chronic massive rotator cuff tears have an insidious onset of symptoms with gradual worsening, some report a more acute onset of symptoms sometimes related to a traumatic event.
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Epidemiology
Patients with chronic massive rotator cuff tears are usually older. This is consistent with the results of studies that demonstrate that there is an increasing prevalence of rotator cuff tears even in asymptomatic individuals with advancing age. Less frequently, younger patients, often males with a history of substantial labor or physical activity involving the upper extremities, present with chronic massive rotator cuff tears.
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TABLE 42-1 Rotator Cuff Tear Size Classification |
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Classification
Rotator cuff tears are usually classified according to the chronicity and size of the tear. The chronicity of a rotator cuff tear can refer to either the duration of symptoms or the duration of pathology. There are several approaches to classifying the size of rotator cuff tears. The most commonly used approach is based on the dimensions of the tear (Table 42-1). Rotator cuff tears can also be classified according to the number of tendons that are involved, with massive tears involving at least two complete tendons. Additionally, the extent of tendon retraction and the tissue quality are important factors that are not generally accounted for by the various size-based classification systems. Nevertheless, muscle quality is especially important in the context of larger rotator cuff tears. Muscle quality can be appreciated on physical examination as atrophy of the spinati muscles, as well as on CT and MR imaging. Based on CT and MR imaging, the rotator cuff muscles are graded as stage 0 (completely normal), stage 1 (some fatty streaks), stage 2 (marked fatty infiltration but more muscle than fat), stage 3 (as much fat as muscle), or stage 4 (more fat than muscle).
Important Points
Diagnosis
Physical Examination and History
Clinical Features
Patients with chronic massive rotator cuff tears typically present with pain and shoulder dysfunction and tend to be older than the average patient with a rotator cuff tear. Less commonly, younger patients present with chronic massive rotator cuff tears. Chronic massive rotator cuff tears can present in three different clinical settings. Although most patients present with an insidious onset of shoulder pain and dysfunction, some present with a history of a previous significant traumatic injury that caused the tear or a recent traumatic event that aggravated an underlying pre-existing rotator cuff tear. Patients with the latter presentation, acute-on-chronic tears, present in two clinical scenarios. The first includes patients with pre-existing chronic symptomatic rotator cuff tearing who sustain an injury that causes an acute extension of the tear. The second group has pre-existing asymptomatic rotator cuff tears and an acute injury that results in the onset of shoulder pain. In either case, there was pre-existing rotator cuff tearing. After an acute traumatic injury, patients may be unable to actively elevate their arm. In some cases there is extensive anterior arm ecchymosis. The important point is that patients who deny pre-existing symptoms but have the typical clinical features of chronic rotator cuff tearing; spinatus atrophy, external rotation weakness, and characteristic plain radiographic findings are likely to have had pre-existing rotator cuff tearing.
The status of the rotator cuff can usually be accurately determined with a detailed physical examination. Any evaluation for shoulder pathology should also include examination of the cervical spine and a focused neurologic evaluation. Cervical spondylosis, stenosis, and radiculopathy can cause shoulder pain that mimics the pain of rotator cuff pathology. Shoulder girdle weakness can also be the result of brachial plexus disorders (Parsonage-Turner syndrome and brachial neuritis, or tumor) or suprascapular neuropathy. Last, the presentation of chronic septic arthritis can mimic a chronic massive rotator cuff tear and should not be forgotten when evaluating patients. Table 42-2lists differential diagnosis disorders.
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TABLE 42-2 Differential Diagnosis for Chronic Massive Rotator Cuff Tear |
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Visual inspection of the patient provides important anatomic information. Several findings are consistent with chronic massive rotator cuff tearing. These include anterior superior subluxation and prominence of the humeral head, infraspinatus and supraspinatus atrophy, and chronic rupture of the proximal tendon of the long head of the biceps. Supraspinatus atrophy is more difficult to detect beneath the trapezius muscle. In many cases massive rotator cuff tears can be detected as a palpable defect at the supraspinatus insertion at the anterior lateral aspect of the shoulder. Swelling owing to subdeltoid synovial fluid can also be present. Deltoid detachment is rare but is usually visible as a defect at the anterior aspect of the origin of the middle deltoid.
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Figure 42-1 The right shoulder has an external rotation lag sign in this patient with a massive rotator cuff tear. A: The arm can be passively externally rotated. B: The patient cannot actively externally rotate the arm. (From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
Active and passive shoulder motion is assessed in scapular plane elevation, external rotation with the arm at the side and in 90 degrees abduction, internal rotation behind the back and at 90 degrees abduction, and across-chest adduction. When motion is assessed, the scapulohumeral rhythm is also assessed. Several studies have noted alterations in scapulohumeral rhythm in the presence of shoulder pathology. Significant loss of passive shoulder motion is uncommon in the presence of a massive rotator cuff tear. Nevertheless, patients can have subtle loss of motion in specific directions that can contribute to symptoms. It is important to recognize shoulder stiffness in the presence of rotator cuff tear for two reasons. First, strength is more difficult to evaluate when there is substantial stiffness. Second, the cause of the stiffness (adhesive capsulitis, capsular contracture, or glenohumeral arthritis) may be the cause of the patient's symptoms. Despite severe rotator cuff deficiency, some of these patients have good elevation strength owing to compensatory deltoid strength. Consequently, many patients with chronic massive rotator cuff tears have full active shoulder elevation. Patients with significant deltoid weakness may be unable to actively elevate their arm.
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Figure 42-2 A: A positive lift-off maneuver in a patient with a subscapularis tendon tear of the left shoulder. B: A positive belly-press test of the left shoulder in the same patient. Note the posterior position of the left elbow. (From Lyons RP, Green A. Subscapularis tendon tears. J Am Acad Orthop Surg. 2005;13:353–363 , with permission.) |
External rotation weakness is characteristic of chronic massive rotator cuff tears. Elevation weakness is a less consistent finding. Some patients have sufficient deltoid strength to mask the absence of supraspinatus strength. The Jobe empty can test, which assesses strength with the shoulder elevated about 90 degrees and internally rotated with the thumb pointing downward, will usually cause pain and elicit weakness. Pain can also be the cause of inability to elevate the arm. A subacromial injection with 10 centiliters (100 mL) of 1% lidocaine can eliminate the pain and allow a better assessment of rotator cuff strength.
Rotational weakness is often easiest to elicit. External rotation weakness and external rotation lag are signs of massive rotator cuff tearing that involves the infraspinatus tendon (Fig. 42-1). An external rotation lag sign is elicited by passively positioning the arm in maximal external rotation. When there is marked weakness, the patient is unable to hold the arm in this position and the hand falls toward the abdomen. The horn blower's sign, inability to externally rotate the elevated arm, also demonstrates severe infraspinatus weakness. Associated subscapularis tearing is less common but may also be present. Patients with chronic atraumatic subscapularis tearing have internal rotation weakness, variable excessive passive external rotation, and a positive lift-off test or belly-press maneuver6 (Fig. 42-2).
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The lift-off test is difficult to perform when there is pain or limited shoulder motion that prevents positioning of the arm and hand behind the back. Unfortunately, subscapularis tears are often overlooked or ignored by inexperienced examiners, both surgeons and radiologists.
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Figure 42-3 True anterior posterior radiograph of a shoulder with a chronic massive rotator cuff tear. Although, there is reduction of the acromial humeral space and the humeral head is elevated relative to the glenoid, there is no glenohumeral arthritis. |
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Figure 42-4 True anterior posterior radiograph of a shoulder with rotator cuff tear arthropathy. There is no acromiohumeral space, there are degenerative changes of the glenohumeral joint, and the greater tuberosity is rounded off. |
Various physical examination maneuvers and signs are performed and assessed to evaluate patients with rotator cuff disorders. Park et al. evaluated eight physical examination tests. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best posttest probability (91%) for full-thickness rotator cuff tears, especially in patients older than 60 years of age.
The combination of a detailed history and thorough physical examination often provides sufficient information to establish a diagnosis of massive rotator cuff tearing. Imaging studies provide information to confirm the diagnosis and assist in treatment selection.
Important Points—Physical Examination
Radiologic Features
Plain Radiographic Evaluation.
A complete evaluation of the shoulder includes a series of five plain radiographs. These views include a true anteroposterior, anteroposterior in internal and external rotation, axillary lateral, and outlet. Although plain radiographs do not visualize soft tissues, they demonstrate skeletal and osseous changes that suggest the presence of rotator cuff pathology and are particularly helpful in assessing patients with chronic massive rotator cuff tears (Fig. 42-3).
Elevation of the humeral head relative to the glenoid and narrowing of the acromiohumeral space are findings that are consistent with long-standing rotator cuff pathology (Fig. 42-4). It has been suggested that an acromiohumeral space <7 mm is consistent with a rotator cuff tear and that when the space is <5 mm, there is a massive tear. Erosion or rounding off of the greater tuberosity (femoralization) is typical of long-standing massive rotator cuff tearing. Similarly, long-standing contact of the greater tuberosity with the acromion can lead to the formation of a facet on the underside of the lateral acromion as well as spurring and excrescences on the greater tuberosity that can be visualized on anterior posterior radiographs. The true anteroposterior and axillary lateral radiographs can also demonstrate glenohumeral arthritis. The axillary lateral view also demonstrates the relative anteroposterior position of the humeral
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head. Anterior subluxation on an axillary lateral radiograph is consistent with anterior superior instability or subscapularis tendon tear. The outlet view is used to demonstrate the acromial morphology.
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Figure 42-5 MRI scans of the right shoulder of a 64-year-old male with a chronic rotator cuff tear. A: T2 coronal oblique image demonstrates the supraspinatus tendon tear, atrophy of the muscle, and fatty replacement in the supraspinatus fossa. The supraspinatus tendon (arrows) is at the glenoid. B: T1 sagittal oblique image demonstrates fatty replacement in the supraspinatus fossa and lipoatrophy of the infraspinatus muscle. (From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
The typical radiographic findings of rotator cuff tear arthropathy include loss of the glenohumeral joint space, elevation of the humeral head, erosion and rounding off of the greater tuberosity, and articulation of the humeral head with the acromion (Fig. 42-4). It is important to recognize the presence of significant glenohumeral arthritis as it is a relative contraindication to rotator cuff repair and reconstruction.
Important Points—Plain Radiographs
Advanced Imaging of the Rotator Cuff.
Historically, arthrography is cited as the gold standard for the diagnosis of rotator cuff tearing. However, newer imaging modalities such as ultrasonography and MRI provide better information and have replaced arthrography as the imaging tests of choice for rotator cuff pathology.
Acceptance of ultrasonography for imaging the rotator cuff has been variable. Centers with extensive experience report high rates of sensitivity and specificity. Other centers are not able to confirm these findings. Although some of the variability is related to inexperience, some is also related to differing diagnostic criteria. More recent technologic advances are encouraging a re-evaluation of the value of ultrasonography for imaging the rotator cuff. This includes use of ultrasound by the examining physician.
Magnetic resonance imaging is the current state of the art for imaging the rotator cuff. It can be highly accurate and demonstrates detailed anatomic information, including tear size and muscle quality. The latter information can help establish the chronicity of the rotator cuff tearing and the potential functional status of the cuff. Goutallier et al, reported that higher grades of presurgical fatty degeneration of the rotator cuff muscles are associated with inferior outcomes.
The coronal oblique magnetic resonance images are primarily used to evaluate the supraspinatus tendon and muscle. The extent of retraction and the size and quality of the supraspinatus muscle can be determined (Fig. 42-5A). Fatty replacement of the supraspinatus muscle in the supraspinatus fossa indicates chronic pathology. The size of the supraspinatus tear in the anterior-to-posterior direction can be assessed by noting the tear on sequential images. The sagittal oblique images demonstrate the anterior-to-posterior extent of tearing as well as the quality of all of the rotator cuff muscles (Fig. 42-5B). The axial images can demonstrate the biceps tendon, as well as subscapularis, infraspinatus and teres minor tearing and muscle quality. Axial T2 images are essential for a complete magnetic resonance imaging (MRI) evaluation of the shoulder.
MRI is also helpful in cases of other less-common disorders that can mimic massive rotator cuff tearing. Specifically, patients with external rotation weakness should be evaluated with MRI. Suprascapular nerve palsy, spinoglenoid notch cysts with compression of the infraspinatus branch of the suprascapular nerve, and cervical spine disorders are examples of such disorders. Myopathic changes on MRI are more consistent with neurologic abnormality.
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MR arthrography is not usually required for routine evaluation of the rotator cuff. However, it can be helpful in imaging the rotator cuff after surgery when it is difficult to differentiate scar tissue from tendon.
Although many studies have confirmed the accuracy of magnetic resonance imaging of the rotator cuff, the specific indications for MRI are rarely addressed. Overuse of MRI is a pervasive problem, and careful clinical evaluation can help to define the appropriate usage of this excellent imaging technique. In most cases the diagnosis of a chronic massive rotator cuff tear can be made with a careful history and physical examination alone. MRI is clearly indicated early in the evaluation of shoulder pain and dysfunction after an acute traumatic injury.
Treatment
The successful outcome of treatment of chronic massive rotator cuff tearing depends on selecting the best treatment option for the specific case at hand. Chronic massive rotator cuff tears present in various patients, and treatment options include nonoperative methods, surgical debridement, repair, and reconstruction. Studies have reported high success rates with each of these approaches. In some cases, more than one of the options may be appropriate. Thus, careful consideration of many factors is important, and treatment should be individualized to the case at hand.
Nonoperative Treatment
Many patients with chronic massive rotator cuff tears can be successfully treated without surgery. The rationale behind nonoperative treatment is that some individuals have asymptomatic rotator cuff tears and never present for evaluation and treatment. Activity modification, oral nonsteroidal anti-inflammatory medications, and corticosteroid injections can help some individuals manage their symptoms. Studies of nonoperative treatment of full-thickness rotator cuff tear note improvement in about 50% to 85% of patients. The duration of symptoms seems to correlate with the long-term success of nonoperative treatment.
Some authors have noted that repeated corticosteroid injections have a detrimental effect on the rotator cuff and articular surfaces. In addition, some studies note a negative correlation between the results of rotator cuff repair and the number of preoperative corticosteroid injections. Other studies suggest that the association is less clear-cut. Injections can be very helpful in the initial phases of physical therapy and rehabilitation. With less pain, patients are better able to participate in a rehabilitation program. Nevertheless, repeated corticosteroid injections should be avoided.
The focus of physical therapy is the restoration of shoulder motion and strengthening of the intact portions of the rotator cuff and the periscapular and deltoid muscles. Passive motion is improved with stretching exercises. Strengthening of the internal and external rotators is best achieved with resisted exercises performed with the arms below chest level. Deltoid strengthening should be initiated in the supine position with the effects of gravity minimized and then progressed to an upright seated or standing position. In addition, scapular muscle strengthening can enhance the function of a weak rotator cuff. There are various techniques for strengthening, including isometric, isotonic, and isokinetic exercises. Strengthening should be progressed gradually and within the patient's comfort level.
Patients with atraumatic onset of pain and with marked spinati atrophy, evidence of chronic rotator cuff tearing, are ideal candidates for nonoperative treatment. In many such cases it is unlikely that the massive rotator cuff tear will be repairable. Thus, nonoperative management should be the first line of treatment.
Operative Treatment
Operative treatment of chronic massive rotator cuff tears encompasses a spectrum of complexity ranging from minimally invasive arthroscopic approaches to major reconstructive surgery. There are advocates for all options but few objective data to guide selection.
Open and Arthroscopic Treatment Without Rotator Cuff Repair
Some authors advocate subacromial decompression and rotator cuff debridement as treatment for massive irreparable rotator cuff tears. The rationale behind subacromial smoothing and rotator cuff debridement includes our knowledge that there are asymptomatic individuals with rotator cuff tears, and the fact that a substantial proportion of patients who have a satisfactory result from a repair of a massive rotator cuff tear have persistent rotator cuff defects after the repair.
Debridement and acromioplasty is best suited for lower-demand individuals. More active individuals who fail nonoperative treatment are probably better served with attempted rotator cuff repair. Some authors report that the results of debridement of full-thickness rotator cuff tears deteriorate with time.
Although most rotator cuff tears are at least partially repairable, in some cases the tear is either not repairable or repair would be unlikely to substantially alter shoulder function. The ideal candidate for debridement is an individual with shoulder pain who has good elevation strength, can actively elevate the arm overhead, and can externally rotate the arm with gravity eliminated. This suggests that there is good shoulder kinematics and that the internal and external rotators are balanced.
Either an open or arthroscopic approach can be used for subacromial debridement. The arthroscopic approach has the advantage of an easier and more rapid rehabilitation because the deltoid origin is preserved. Acromial smoothing as opposed to formal acromioplasty is performed to remove undersurface spurring and rough excrescences. Similarly, the greater tuberosity is smoothed; a so-called reverse acromioplasty arthroscopic subacromial decompression. Thus, the coracoacromial arch is maintained by avoiding an excessive acromioplasty and by preserving the coracoacromial ligament. This helps to prevent loss of the restraint to superior
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humeral head subluxation that the intact coracoacromial arch provides.
Biceps tenotomy or tenodesis is recommended as an adjunct to arthroscopic debridement of chronic massive rotator cuff tears. If there is subluxation or dislocation of the tendon of the long head of the biceps or partial tearing, this can be an effective procedure to alleviate shoulder pain associated with chronic massive rotator cuff tears. In the older patient, arthroscopic tenotomy is a minimally invasive procedure that does not require the postoperative immobilization or protection that a tenodesis requires.
Factors associated with a poor prognosis with arthroscopic treatment of chronic massive rotator cuff tears include preoperative superior migration of the humeral head, the presence of subscapularis tearing or weakness, the presence of glenohumeral arthritis, and decreased range of motion. Most authors point out that although the short-term results of arthroscopic treatment are encouraging, the long-term results often deteriorate.
Rotator Cuff Repair
Many studies and reviews have presented the techniques and the results of rotator cuff repair. Most recent studies of rotator cuff repair have reported successful outcome in 80% to 90% of cases. The traditional goal of rotator cuff repair is to repair the rotator cuff tendons to the proximal humerus and to decompress the subacromial space without disrupting the coracoacromial arch. The role of acromioplasty has been recently questioned, and some authors do not routinely perform it as part of a rotator cuff repair. Repair of chronic massive rotator cuff tears is particularly difficult because of tendon substance loss, retraction, scarring, and poor mechanical properties. Several techniques and maneuvers are used to mobilize the rotator cuff tendons and facilitate the repair. Traditional open techniques, mini-open, and all arthroscopic repairs have been advocated. Determining the feasibility of a repair is of primary importance as not all chronic massive rotator cuff tears are repairable.
Open Rotator Cuff Repair.
A skin incision is made over the top of the lateral third of the acromion in the Langer lines. This is a very cosmetic incision and can be extended anteriorly to permit a deltopectoral approach if required to repair a concomitant subscapularis tear. The skin and subcutaneous tissue are elevated as full-thickness flaps to expose the acromion and the origins of the anterior and middle heads of the deltoid muscle. The anterior deltoid is elevated off the anterior acromion, and the deltoid fibers are split laterally just posterior to the deltoid raphe for about 3 to 4 cm. In doing this, the coracoacromial ligament is released from the acromion but not resected. This approach allows ample access to the subacromial and subdeltoid spaces, as well as the supraspinatus, infraspinatus, and teres minor tendons.
The goal of anterior acromioplasty is to flatten the undersurface of the anterior acromion, decompress the subacromial space, and create a smooth acromial surface, without disrupting the coracoacromial arch. Spurring on the undersurface of the distal clavicle is also removed. Care is taken to avoid excessive resection, especially shortening of the acromion to prevent anterior superior instability.
Subacromial and subdeltoid adhesions are released, and excess bursal tissue can be excised to allow visualization of the rotator cuff tear. Adhesions under the anterior deltoid are often more tenacious and require more formal dissection to clearly visualize the rotator cuff interval and subscapularis tendon.
The subscapularis tendon is inspected for tearing. Tears of the upper third of the subscapularis tendon can often be repaired through this exposure. More extensive tears may require a separate deltopectoral approach. Similarly, the biceps tendon is visualized both within the glenohumeral joint and by pulling the more distal aspect up from the biceps groove.
Next the supraspinatus and infraspinatus tendon edges are identified and traction sutures are placed. In contrast to cases of acute massive tears that can usually be easily mobilized to the tuberosity, additional steps are required to mobilize chronic massive tears. Fascial adhesions superficial to the supraspinatus and infraspinatus muscles are bluntly released. Releasing the rotator cuff interval and the coracohumeral ligament at the base of the coracoid helps to mobilize the supraspinatus tendon. Capsular releases superiorly and posteriorly will also improve mobility (Fig. 42-6). Occasionally, the interval between the supraspinatus and infraspinatus tendons, the so-called posterior interval, is released to allow differential mobilization of the supraspinatus and infraspinatus tendons (Fig. 42-7). The limit of mobilization of the supraspinatus and infraspinatus muscles is determined by the extent to which the suprascapular nerve can be mobilized. The standard anterosuperior approach allows only 1 cm of lateral advancement of the tendons whereas the mobilization of the supraspinatus muscle from the supraspinatus fossa of the scapula permits ≤3 cm of lateral advancement.
Once the rotator cuff is fully mobilized, the insertion site on the proximal humerus is prepared by decorticating the bone just lateral to the articular surface. Tendon reattachment can be accomplished by passing no. 2 braided nonabsorbable sutures through transosseous tunnels or by using suture anchors. Many suture techniques are available. The Mason-Allen suture technique is usually recommended. Augmentation of the bone of the greater tuberosity with small plates or washer-type devices is advocated when there is substantial osteopenia to improve the strength of the suture bone interface
After the rotator cuff repair is completed, the anterior deltoid origin is reattached to the anterior acromion with nonabsorbable sutures passed through drill holes in the acromion. This repair is reinforced with additional nonabsorbable sutures. A secure repair of the deltoid is critical to avoid postoperative deltoid avulsion. Again, the coracoacromial ligament is preserved and essentially reattached to the acromion as part of the deltoid repair.
The rotator cuff should be repairable with the arm at the side. A repair with excessive tension is likely to fail. If this is not possible, a partial repair is performed or rotator cuff reconstruction is considered. Burkhart has espoused the concept of partial repair that re-establishes the cable construct of the rotator cuff. This is in part achieved by repairing the cuff defect side to side. In many cases the infraspinatus can be mobilized laterally and superiorly to be
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repaired to the greater tuberosity. Although some authors have advocated reattachment of the rotator cuff more medially into the articular surface, this is not a widely accepted technique.
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Figure 42-6 A, B: Glenohumeral capsular releases to mobilize the rotator cuff. (From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
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Figure 42-7 Anterior and posterior rotator cuff interval releases to mobilize a large tear of supraspinatus and infraspinatus tendons. A:Dotted lines indicate the releases. B: Supraspinatus tendon mobilized separate from infraspinatus. C: Tendon sutured into place for the repair. (From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
Mini-Open Rotator Cuff Repair.
Mini-open rotator cuff repair combines some of the advantages of arthroscopic and open surgery. Advocates of mini-open rotator cuff repair stress that there is less deltoid morbidity than with an open repair. This claim is controversial. The access through the deltoid split is more limited than with an open repair and may lead to more aggressive deltoid retraction. Consequently, the mini-open technique should be applied carefully when repairing massive tears. Additionally, the rate of postoperative infection appears to be higher after mini-open rotator cuff repair.
Arthroscopic Rotator Cuff Repair.
All-arthroscopic rotator cuff repairs are quickly becoming the preferred technique for rotator cuff repair. As the technique has evolved, it has been applied to larger rotator cuff tears. Although the early functional outcomes appear similar to the outcomes of open repairs, the incidence of persistent or recurrent tear is higher for all-arthroscopic repairs. All-arthroscopic techniques attempt to perform all of the essential steps of an open repair to mobilize and repair the rotator cuff. New techniques are being developed to improve the fixation and tendon apposition.
Partial Rotator Cuff Repair.
Partial rotator cuff repair is an alternative that lies between debridement and complete rotator cuff repair. This generally refers to repair of the infraspinatus. Margin convergence without tendon-to-bone repair is also advocated. It is thought that this restores the anterior-to-posterior stabilizing characteristics of the rotator cuff. Partial rotator cuff repair can be performed with open or arthroscopic techniques.
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Figure 42-8 Subscapularis transfer. A: The upper portion is elevated off of the anterior capsule and transferred superiorly. B: Note that the inferior muscular insertion is left intact. (From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
Postoperative Rehabilitation After Rotator Cuff Repair
The postoperative recovery and rehabilitation is lengthy. The repair is protected with an arm sling or abduction immobilizer for 6 to 8 weeks. Abduction positioning is used to relieve tension on a repair that can be accomplished with the arm at the side, but not to allow repair of an irreparable tear. Passive stretching exercises to regain shoulder motion are begun the day after surgery. After repair of chronic massive tears, passive internal rotation and horizontal adduction are avoided for the first 6 weeks to protect the infraspinatus repair. Light active use and active assisted range of motion is initiated after 6 weeks. Formal strengthening is delayed until 12 weeks after surgery. The overall recovery can take >12 months. Overly aggressive early rehabilitation, especially strengthening, has been implicated as a cause of failure.
Results of Repair of Chronic Massive Rotator Cuff Tear
There are few studies that specifically analyze the results of repair of massive rotator cuff tears. Most studies combine the repairs of a spectrum of tear sizes and find that the results of repair of larger tears are inferior to the results of repair of smaller tears. The results of the repair of chronic massive rotator cuff tears vary. Most patients have significant reduction in pain and some functional improvement. Harryman et al. and Gerber found that repair integrity rather than the original tear size best correlated with the functional outcome of rotator cuff repair. Bigliani et al. evaluated the long-term results of repair of chronic massive rotator cuff tears and reported 85% good and excellent results. Bjorkenheim et al. found that the results of repair of large and massive rotator cuff tears were markedly inferior to the results of repair of smaller tears. Most recently, Jost et al. studied the clinical outcome after failed healing of rotator cuff repairs. They found that the outcome was significantly correlated with the size of the postoperative tear and the extent of fatty degeneration of the infraspinatus and subscapularis muscles. They also found that the size of the tear at follow-up was related to the size of the original tear; larger persistent tears were associated with larger initial tears. Goutallier et al. demonstrated that recurrent tear was greater for tendons whose muscle showed fatty degeneration >grade 1. Fatty degeneration of the infraspinatus or subscapularis muscles had an influence on supraspinatus tendon outcome. Rokito et al. found that all of their patients were satisfied after repair of a chronic large or massive rotator cuff tear, that >1 year was required for restoration of strength, and that the final strength was less than in the contralateral shoulder. Duralde and Bair reported good and excellent results in 67% of patients who had partial rotator cuff repair.
Rotator Cuff Reconstruction
Various approaches have been described to reconstruct irreparable massive rotator cuff tears. These include transfers of the rotator cuff tendons, other muscle and tendon transfers, and tissue and synthetic substitution and augmentation. These procedures attempt to restore the function of the rotator cuff muscles and tendons.
Subscapularis transfer is used to achieve complete rotator cuff repair when repair of the supraspinatus and
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infraspinatus leaves a residual superior defect. The upper third of the subscapularis tendon is separated from the anterior capsule and is then transferred superiorly (Fig. 42-8).
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Figure 42-9 Latissimus dorsi transfer for massive irreparable rotator cuff tear. A: The latissimus dorsi muscle and tendon are dissected. B: The latissimus dorsi tendon is released from the humerus, and sutures are placed into the tendon. C: The tendon is passed inferior to the posterior deltoid and the acromion to the superior wound. D: The transferred tendon is sutured to the edge of the mobilized but deficient cuff edge and the greater tuberosity. (Modified from Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11:321–331 , with permission.) |
Most series do not commonly report using subscapularis transfer. Subscapularis transfer does have the risk of causing internal rotation weakness or internal rotation contracture.
Debeyre et al. first described lateral advancement of the supraspinatus muscle and found that the results of repair of larger rotator cuff tears were improved by this procedure. Ha'eri and Wiley also reported good results with lateral advancement of the supraspinatus muscle. In addition, they found that the muscle was not denervated by the procedure. Although Warner et al. demonstrated that the supraspinatus could be safely mobilized up to 3 cm laterally, formal lateral advancement of the supraspinatus muscle is not widely performed.
Latissimus dorsi transfer is used to substitute for loss of the infraspinatus and supraspinatus tendons (Fig. 42-9). The transfer uses a healthy and strong muscle to restore external rotation and head depression forces that are lost in chronic massive rotator cuff tears. Gerber found that the
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results of latissimus dorsi transfer for massive rotator cuff tear were better if the subscapularis tendon was intact. Iannotti et al. report that patients with better preoperative elevation and external rotator function have better results. Miniaci and MacLeod reported 82% satisfactory results after latissimus dorsi transfer in patients with previously failed operative treatment of massive rotator cuff repair. Other reports have not been as favorable. The results of primary latissimus dorsi transfer appear to be superior to the results of salvage for failed rotator cuff repair.
Other reconstructive procedures have been described but are infrequently reported. These include teres minor transfer, deltoid muscular flap transfer, and trapezius transfer. Although all of these procedures attempt to substitute for the absence of supraspinatus function, they do not address or restore the balance between the anterior and posterior force couples of the rotator cuff.
Tissue substitution or augmentation with material synthetics, autologous and autogenous tissue grafts, and xenograft material has been attempted. The results have been limited, and these techniques are not broadly used. Neviaser et al. reported >80% good and excellent results when they used freeze-dried rotator cuff to repair chronic massive rotator cuff tears. Aside from the potential for foreign body reaction to synthetics or tissue rejection, these techniques do not replace the atrophic and weakened rotator cuff muscles that are typically present with chronic massive rotator cuff tears. Recently, several biologic tissue implants, including xenograft tissue, have been developed to augment rotator cuff repairs. The effect of these implants on outcome is unclear. Despite promising findings in animal rotator cuff repair models, concerns remain about tissue compatibility. Early human clinical studies have not reproduced the same successful findings. Inflammatory reactions after small intestinal submucosal tissue augmentation were recently reported and may be owing to retained cells and DNA.
Glenohumeral Arthrodesis
Glenohumeral arthrodesis is not a commonly performed procedure. Arthrodesis can be performed for painful chronic massive irreparable rotator cuff tears if the goal is a strong, stable shoulder girdle. This may be appropriate for the painful shoulder with anterior superior dislocation because of loss of the coracoacromial arch. However, rotator cuff reconstruction is preferred if the articular surfaces are intact. Otherwise, shoulder arthrodesis may actually result in undesirable loss of upper extremity function below the chest level. Arthrodesis is also difficult to achieve in the typical osteopenic elderly patient who presents with chronic massive rotator cuff tearing. Arntz et al. reported that the results of humeral head replacement for rotator cuff tear arthropathy were better than arthrodesis.
Summary
Chronic massive rotator cuff tears can cause substantial shoulder pain and dysfunction. Several treatment options are appropriate in different clinical settings. Consequently, careful patient evaluation and treatment selection are critically important. Many patients with chronic massive rotator cuff tears can be treated nonoperatively. The goals of surgical treatment must be considered in the context of the individual patient and the complexity of the procedure itself as well as the postoperative recovery and rehabilitation. In some cases, a complete primary repair is possible whereas in others only a partial repair can be achieved. Reconstruction of the rotator cuff is most appropriate for younger, more active patients for whom functional restoration is important. Latissimus dorsi transfer is the preferred reconstructive option for active individuals who are disabled by shoulder pain and weakness of elevation and external rotation and have good deltoid strength. Most of the other reconstructive options have more limited indications and have not been conclusively shown to be superior to debridement procedures. Older, inactive patients, especially those with significant medical comorbidities, are better served by less complicated management approaches that provide pain relief.
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