Selection and De-Selection of Treatment Options For Massive Cuff Repairs
Selection and De-Selection of Treatment Options For Massive Cuff Repairs
By Jon J.P. Warner, MD, Edward H. Yian, MD, and Phillipe Clavere, MD
Open repair of rotator cuff tears has been a time-tested technique based on fundamental principles. Neer originally proposed 4 major objectives: cuff defect closure, elimination of impingement lesions of the coracoacromial arch, deltoid muscle preservation, and early rehabilitation without disrupting the repair.1 With recent arthroscopic technology advancements, the decision between open and arthroscopic repair has become less clear. The selection of the appropriate mode of treatment, however, is critical in optimizing patient outcome and involves consideration of preoperative, intraoperative, and postoperative factors.
Preoperative
Patient expectations of outcomes must be tempered with associated factors. One must consider the overall disability that includes the quantity of pain, functional limitations, and overall goals. Comorbidities such as muscle spasticity, seizure disorders, and diabetes mellitus can all affect the end result. In addition, both clinical and biomechanical studies have shown that well-compensated function can still remain despite the presence of a large cuff tear.
The quality of both the deltoid and rotator cuff influences the prognosis for success. Deltoid function contributes up to 60% of strength in abduction and elevation. Poor outcome has clearly been associated with deltoid detachment co-existing with a rotator cuff tear. Furthermore, the extent of atrophy and fatty degeneration within the muscle bellies of the torn tendons is associated with the overall tendon quality and elasticity. Overall shoulder function and external rotation strength have been correlated by Goutallier and colleagues with the degree of fatty degeneration and muscle atrophy.2 This atrophy and fatty degeneration is believed to be irreversible, despite surgical treatment. Similar observations have been made with magnetic resonance imaging, particularly with T1 oblique sagittal images medial to the coracoid process. Evidence of severe atrophy and fatty degeneration indicates that restoration of pre-injury biomechanics will not be possible, and other options, such as tendon transfers, may be needed. In massive tears with decreased acromiohumeral intervals or chronic anterosuperior lesions, arthroscopic subacromial debridement may be an option, primarily for pain relief.
Evaluation of preoperative range of motion is imperative. If passive range of motion is significantly limited in a patient with a large cuff tear, then both adhesive capsulitis and rotator cuff tear must be treated. With massive tears, Warner has had good experience (unpublished data) with staged arthroscopic capsular release and subsequent rotator cuff repair. Smaller tears can be treated with concurrent capsular release, if a strong, stable repair is achieved, to allow for immediate postoperative range of motion. Otherwise, excess strain on the repair can lead to re-tear.
Intra-Operative Considerations
Other factors integral to the success of repair include the quality of the cuff tendon and bone. Patients with chronic tears who have had multiple steroid injections may have poor structural tendon integrity. Gerber and associates have shown that a modified Mason-Allen stitch does not cause tendon necrosis and yields a stronger repair than standard open techniques.3 Osteoporosis of the proximal humerus can compromise the repair strength regardless of the use of suture anchors or even transosseous tunnels. In this scenario, poor bone quality is the weakest link in the chain. The strongest bone lies distal to the greater tuberosity. It is recommended that sutures exit tunnels at least 1-2 cm distal to the greater tuberosity with more than a 1-cm bone bridge and that a cortical augmentation device be used.4 Transosseous simple suture repair is the recommended technique in order to maximize repair site area leading to a potentially stronger repair and increased healing.5
Tendon mobilization and evaluation of structural integrity is essential to characterizing the tear. Chronic tears often have more retraction, tendon involution, loss of structural integrity, and increased stiffness from scarring and fatty degeneration. Scarred cuff tissue adherent to the acromion underside can be difficult to differentiate from bursal tissue. The inflamed bursal tissue, as well as degenerative tendon edges, must be excised to provide a healthy, vascularized tendon edge. Both intra-articular and extra-articular releases must be performed to maximize tendon mobility, including rotator interval and perilabral releases. The amount of tendon delamination must be recognized and appropriately repaired to restore tendon structure. This can often be very difficult to evaluate arthroscopically. Lamination defects treated either by resection or by interlaminar repair have been shown to fare equally, regardless of repair technique.6 These defects have been found to be more common in cuff tears less than 5 cm in size. Lastly, deficient cuff tissue can be augmented with surrounding soft tissues (eg, biceps tendon) to reinforce the deficient tissue.
Postoperative Considerations
Patient noncompliance with early active range of motion can lead to failure of the repair, while a lack of early passive range of motion can lead to shoulder stiffness. Overall patient health and comorbidities should be considered in deciding appropriate rehabilitation needs. An elderly patient with limited functional goals would be ill suited for a latissimus tendon transfer, while a young laborer would require more than a cuff debridement.
Conclusion
Proper decision-making requires a consideration of all patient factors. Management options vary from nonsurgical treatment to partial repair to arthroscopic or open repair to tendon transfers. While these patients are often debilitated due to chronic pain and altered shoulder mechanics, a satisfying and predictable functional outcome can be achieved with the appropriate treatment. n
Dr. Warner is Director at Harvard Shoulder Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Mass. Drs. Yian and Clavere are Fellows.
References
1. Neer CS. Cuff Tears, Biceps Lesions, and Impingement In Shoulder Reconstruction. Philadelphia: WB Saunders; 1990:41-142.
2. Goutallier D, et al. Fatty muscle degeneration in cuff ruptures. Clin Orthop. 1994;304:78-83.
3. Gerber C, et al. Experimental rotator cuff repair. A preliminary study. J Bone Joint Surg Am. 1999;81:1281-1290.
4. Caldwell GL, et al. Strength of fixation with transosseous sutures in rotator cuff repair. J Bone Joint Surg Am. 1997;79(7):1064-1068.
5. Apreleva M, et al. Rotator Cuff Tears: The effect of the reconstruction area on three-dimensional repair site area. Arthroscopy. 2002;18(5):519-526.
6. Sonnabend DH, Watson EM. Structural factors affecting the outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11:212-218.
Open repair of rotator cuff tears has been a time-tested technique based on fundamental principles. Neer originally proposed 4 major objectives: cuff defect closure, elimination of impingement lesions of the coracoacromial arch, deltoid muscle preservation, and early rehabilitation without disrupting the repair.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.