Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including débridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.Level of EvidenceReview Article.     

Latissimus dorsi tendon transfers for rotator cuff deficiency

Purpose:

Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency.

Materials and Methods:

At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation.

Results:

Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05).

Conclusion:

Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term.

Level of Evidence:

Level 4.     

Lattisimus dorsi transfer forirreparable rotator cuff insufficiency

Irreparable rotator cuff insufficiency is a difficult problem with few options. Debridement, local or distant tendontransfers have all been attempted with mixed results. Transfer of the lattissimus dorsi tendon is a reasonable option that should be considered.     

Treatment of massive irreparable rotator cuff tears using dermal allograft bridging reconstruction

AimsVarious options are available for treating massive irreparable rotator cuff tears, but all have their own limitations and no gold standard currently exists. Our aim was to report on outcomes of bridging repair with a dermal allograft for symptomatic massive irreparable rotator cuff tears where primary or partial repair was not possible.Patients and methodsWe prospectively reviewed 22 patients who underwent an open interposition bridging repair with an allograft (GraftJacket) sutured medially to the residual rotator cuff stump and laterally to the footprint with suture anchors. Mean age at time of surgery was 59 years (range 53–66 years). The Oxford Shoulder Score, pain visual analogue scale and range of motion were compared pre-operatively and at mean follow up of 2.8 years. All patients had a postoperative MRI scan.ResultsThere was a significant improvement in mean Oxford Shoulder Score from a pre-operative score of 14.2–34.3 points (p < 0.01) at final follow up. Pain VAS score improved from 6.6 points to 2.8 points (p < 0.05). Significant improvements in range of motion were also seen. Postoperative MRI scans showed a retear in 8 patients (36%), but the retear size was smaller and an improvement in outcomes maintained at final follow up.ConclusionOpen dermal allograft bridging repair for massive irreparable rotator cuff tears can lead to satisfactory outcomes and delay the need for a reverse shoulder arthroplasty.     

Dynamic ultrasonography to evaluate coracoacromial ligament displacement during motion in shoulders with supraspinatus tendon tears

We evaluated coracoacromial ligament (CAL) displacement during motion in shoulders with supraspinatus tendon tears by dynamic ultrasonography (US). Twenty subjects with unilateral, full‐thickness supraspinatus tendon tears (SST group) and 20 subjects with intact supraspinatus tendons (control group) underwent dynamic US. The CAL displacement in their bilateral shoulders was measured in the transverse US view during passive and active shoulder abduction and internal rotation (SAIR). In the SST group, the CAL displacement was significantly greater in the affected shoulders than in the intact ones (1.9 mm ± 0.8 mm vs. 1.5 mm ± 0.5 mm, p = 0.01) during passive SAIR, but was not significantly different between the shoulders (1.7 mm ± 0.7 mm vs. 1.7 mm ± 0.4 mm, p = 0.81) during active SAIR. In the control group, no difference in the CAL displacement between the shoulders was noted during passive and active SAIR. Thus, dynamic US revealed greater CAL displacement in shoulders with supraspinatus tendon tears than in intact ones during passive SAIR. Dynamic US may help to detect abnormal kinematics in shoulders with such injury. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1430–1434, 2012     

Partial cuff debridement for irreparable defects of the rotator cuff

The treatment of massive rotator cuff tears can pose a difficult problem for the unprepared orthopaedic surgeon.There are many ways to treat massive rotator cuff tears, and one viable option is debridement with acromioplasty. For this form of treatment to be successful, the surgeon must choose his patient carefully. This report will focus on patient selection, biomechanics, and postoperative rehabilitation. A thorough understanding of rotator cuff tear biomechanics is needed when treating a massive tear; thorough physical and radiological examinations will help the orthopedist understand the biomechanic characteristic of the patient's tear. A tear that is balanced in both the transverse and coronal planes is stable and functional and will do well with debridement. Conversely, a tear that is unbalanced in either the transverse or coronal planes is unstable and nonfunctional and will not do well with simple debridement. Nonfunctional tears demand an attempt at rotator cuff tendon repair to restore balance to the cuff, making the tear functional. Debridement of a functional tear can be successfully performed with arthroscopic or open technique. Preservation or reconstruction of the coracoacromial (CA) arch is important because it adds anterosuperior stability to the shoulder with a massive rotator cuff tear. Postoperative rehabilitation is as important as the surgery itself and will also be emphasized. Many surgeons have had success with debridement of massive rotator cuff tears; however, as with any procedure, proper understanding of the pathology and proper patient selection is paramount to obtaining a successful result.     

关节镜下肱二头肌长头肌腱转位治疗不可修复巨大肩袖撕裂的研究进展

目的综述关节镜下肱二头肌长头肌腱(long head of biceps tendon,LHBT)转位治疗不可修复巨大肩袖撕裂的研究进展。方法查阅近年来国内外关节镜下不同方式LHBT转位治疗不可修复巨大肩袖撕裂的相关文献,并进行总结分析。结果关节镜下LHBT转位是一种治疗不可修复巨大肩袖撕裂的有效方法,目前主要采用断近端、两头断、断远端及不切断4种方式。临床研究表明上述方式均能取得良好疗效,但远期疗效有待进一步随访明确。结论关节镜下LHBT转位治疗不可修复巨大肩袖撕裂手术简便、有效,患者损伤小、术后恢复快,但对术者技术要求较高,需严格把握手术适应证。     

Arthroscopic debridement of massive rotator cuff tears: negative prognostic factors

Introduction The purpose of this study was to identify the factors that may lead to poor outcomes after arthroscopic debridement in massive rotator cuff tears.Materials and methods Thirty-three patients (10 women and 23 men) with massive, irreparable rotator cuff tears underwent arthroscopy by a single surgeon. The preoperative diagnosis was based on the clinical examination and MRI. Their mean age was 69 years (range 62–79 years), and the average follow-up was 31 months (range 24–46 months). If indicated, the performed arthroscopic debridement included acromioplasty, debridement of the cuff, resection of the distal part of the clavicle or tenotomy of the long head of the biceps. In 28 cases (85%) acromioplasties and in 6 cases (18%) biceps tenotomies were performed, 2 of which were a single tenotomy without any associated acromioplasty. One patient had been managed with concomitant resection of the distal part of the clavicle.Results The Constant and Murley Score improved by a mean of 30 points, from a mean of 37 points (range 21–52) preoperatively to a mean of 67 points (range 31–82) at the time of follow-up. Some 82% of the patients were satisfied with the procedure. The result was considered unsatisfactory because of inadequate pain relief in 4 shoulders, because of limited active abduction in 1 and because of limited external rotation in 1. A poor outcome was associated with a complete tear of the subscapularis tendon in 6 patients. The radiological study showed no significant narrowing of the subacromial space.Conclusion Our early results suggest that arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands. However, its long-term consequences remain to be evaluated by studies with lengthy follow-up. Prognostic factors that may lead to a negative outcome are preoperative superior migration of the humeral head, presence of subscapularis tear, presence of glenohumeral arthritis and decreased range of motion.     

Biceps tendon properties worsen initially but improve over time following rotator cuff tears in a rat model

Damage to the biceps tendon is often seen in conjunction with rotator cuff tears. However, controversy exists regarding its role in the shoulder and its optimal treatment. A previous study determined that biceps tendons were detrimentally affected in the presence of rotator cuff tears in the rat model and this damage worsened over time. However, whether this damage progresses at later time points to provide a chronic model is unknown. The objective of this study was to determine the changes in the biceps tendon in the presence of a cuff tear over time. Our hypothesis was that histological, compositional, organizational, and mechanical properties would worsen with time. We detached the supraspinatus and infraspinatus tendons of 48 rats and evaluated these properties at 1, 4, 8, and 16 weeks postdetachment. Properties worsened through 8 weeks, but improved between 8 and 16 weeks. We therefore conclude that biceps tendon changes in this model are not truly chronic. Additionally, it has been shown that infraspinatus properties in this model return to normal by 16 weeks, when biceps properties improve, indicating that earlier repair of one or more of the rotator cuff tendons may lead to resolved pathology of the long head of the biceps tendon. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:874–879     

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.     

Reconstructive surgery for massive rotator cuff tear

Surgical Principles The rotator cuff is repaired with transosseous sutures if possible. If the defect is too large for direct repair, local muscle or tendon transfers are used. An anterior acromioplasty with resection of the coraco-acromial ligament is performed in every case. In absolutely irreparable tears the authors recommend an open or arthroscopic debridement combined with an anterior acromioplasty and a resection of the lateral end of the clavicle. Should a cuff tear arthropathy exist, shoulder replacement or an arthrodesis should be considered. Revised Version from: Operat. Orthop. Traumatol. 4 (1992), 161–178 (German Edition).     

Results of reconstruction of massive irreparable rotator cuff tears using a fascia lata allograft

Background:Despite the advances in surgical treatment options, massive rotator cuff (r-c) tears still represent a challenge for orthopedic surgeons. This study assesses the effectiveness of fascia lata allograft in reconstruction of massive and irreparable r-c tear and to evaluate the healing and functional outcomes.Results:Postoperative constant score increased from 32.5 preoperatively to 88.7 postoperatively. The most important was the pain relief from 2.4 preoperatively to 14.1 postoperatively and range of motion. The results of the MRI were not reliable, but the ultrasound was satisfactory. Finally, there was no infection or rejection of the graft in any of the patients.Conclusions:Despite advances in surgical methods, there is still not a universally accepted treatment for massive and irreparable rotator cuff tears, because the standard methods have dubious results, with excessive retear rates and poor outcomes, necessitating the need for new repair strategies. We documented significant clinical improvement using fascia lata allograft in the repair of massive irreparable r-c tear, acting as scaffold to bridge the defect, enhancing the healing at the repair site.