Rotator cuff tears

Rotator cuff disease is a common cause of pain and weakness in the shoulder. This article examines the anatomy and function of the rotator cuff; and the incidence, pathogenesis, evaluation, treatment and prognosis of rotator cuff tears.     

Resurfacing arthroplasty for contained cuff tear arthropathy

Cuff tear arthropathy has been among the most difficult management problems faced by the shoulder surgeon. Ability to restore motion and alleviate pain has been challenging and has led Neer to coin the term “limited goals” when discussing outcomes of surgery in this group of patients. Over the past 15 years evidence of improved outcomes has been demonstrated with use of the reverse total shoulder prosthetic implant. However, with longer follow-up, a high rate of complication has also been demonstrated with these implants. Furthermore, their utilization significantly affects the local anatomy and takes away a significant amount of native bone stock. In addition, these implants cost in many cases, three to four times the price of a more conventional prosthesis. Not all patients with cuff tear arthropathy have the same degree of pathology. Many patients retain a “captured” humeral head underneath the coracoacromial arch without demonstrating anterior/superior escape and can be managed with a more conventional prosthesis. Indiscriminate use of the reverse prosthesis on all patients with cuff tear arthropathy presents a relatively reckless and irresponsible use of resources while limiting the ability to perform revision in the face of implant failure. Use of a CTA humeral head implant or cup resurfacing in a valgus position provides a seamless covering over the humeral head, which allows smooth seating within a “socket” formed by the coracoacromial arch. Such patients function quite well with excellent pain relief. Should revision ultimately be needed at a later date, a reverse arthroplasty can easily be performed without damage to the existing architecture. Reverse arthroplasty should be reserved for the physiologically older patient with limited demands and anterior/superior escape of the humeral head. Valgus resurfacing should be the procedure of choice in younger, more active patients whose humeral head remains captured within the coracoacromial arch.     

Results of the repair of acute rotator cuff tears is not influenced by tear retraction

Purpose:

This study evaluated retraction in the setting of acute rotator cuff tears and determined its effects on patient outcomes and tendon repair integrity.

Materials and Methods:

A total of 22 patients had surgery within 6 weeks or less from the time of injury. Fifteen of these patients were prospectively followed at a minimum of 2 years; average 40.5 months (range 24-69). Pre-operative objective and subjective outcomes were compared. Tendon repair integrity was assessed with ultrasound at a minimum of 1 year from surgery. The population was stratified into Group 1 (8 patients) with minimal intra-operative medial tendon retraction to the mid-line level of the humeral head and Group 2 (7 patients) with a large medial tendon retraction to the glenohumeral joint or greater.

Results:

The average time to surgery from the onset of symptoms was 27 days (range, 6-42). Post-operative motion increased significantly for external rotation and forward elevation, 77% of patients were pain free, 80% were completely satisfied, and 100% would have the surgery again. Group 1 (small retraction) versus Group 2 (large retraction) showed that post-operative pain levels, satisfaction, range of motion, strength, subjective shoulder value (95.4% vs. 92.3%), Constant Score (80.8 vs. 78.1), and American Society of Shoulder and Elbow Surgeons (96.2 vs. 93.5) scores were not statistically different. Ultrasound showed a tendon repair integrity rate of 87%. 2 patients who did have a re-tear were in Group 2, yet had comparative outcomes.

Conclusion:

In acute rotator cuff tears, equal patient satisfaction, pain scores, range of motion, strength, and outcome measures should be expected with surgical repair despite the level of retraction.

Level of Evidence:

Therapeutic level IV     

Mid-term results of arthroscopic subacromial decompression in patients with or without partial thickness rotator cuff tears

Aim:

To evaluate mid-term outcome in patients who underwent arthroscopic subacromial decompression (ASD) for shoulder impingement syndrome with intact and partially torn rotator cuffs.

Materials and Methods:

A total of 80 consecutive patients (83 shoulders) who underwent ASD for impingement syndrome between 2003 and 2006 were analyzed. Mean age was 57.1 years. Patients’ self-reported Oxford Shoulder Score (OSS) for pain was collected prospectively and was used as an instrument to measure surgical outcome.

Results:

The mean initial and final OSS for patients with an intact rotator cuff was 26.1 and 40.3, respectively, at a mean follow up of 71.9 months (nearly 7 years). The mean initial and final OSS for patients with a partially torn articular sided tear was 22.6 and 41.9, respectively, at mean follow up of 70.7 months. Both groups showed significant sustained improvement (P < 0.0001). The mean improvement of OSS following ASD was statistically greater (P < 0.03) for partially torn rotator cuff group (19.3 points) as compared to those with normal rotator cuff (14.2 points).

Conclusion:

Patients with dual pathology (partial rotator cuff tear and impingement) appreciated a significantly greater improvement following ASD compared to those with impingement alone. Both groups of patients had a similar final outcome at a mid-term follow up.

Level of Evidence:

IV, retrospective study on consecutive series of patients.     

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     

Comparison of debridement versus suture in large rotator cuff tears: long-term study of 64 shoulders

Introduction The goal of this study is to determine whether suturing is superior to non-closure in terms of the subjective long-term outcome in large rotator cuff tears.Materials and methods A total of 64 shoulders with rotator cuff tears of at least 3 cm diameter and followed up for a mean period of 5 years and 8 months were retrospectively examined. The patients medical history, clinical findings, radiographs and Constant scores were studied. Patients whose tears had been closed with an open suture (n=33) were compared with those whose tears had not been closed (n=31).Results Neither the comparison between open suturing and debridement nor that between open and arthroscopic debridement reveal a significant difference with regard to the overall Constant score or the individual parameters.Conclusion These results suggest that in the long-term, suturing of large rotator cuff tears is not superior to debridement.     

Neurohistology of the subacromial bursa in rotator cuff tear

This study was undertaken to identify and quantitate neural elements in the human subacromial bursa. Biopsy specimens of subacromial bursae were obtained from patients with rotator cuff tears and from cadavers of patients with no history of shoulder disorder (controls). We used a modified gold chloride method to characterize neural elements within the subacromial bursa. The population of intrabursal neural elements was calculated by computerized image analysis. The subacromial bursa demonstrated an extensive neural network: four morphological types of mechanoreceptors and many free nerve endings were identified. In general, there was an inverse relationship between the population density of neural elements and the extent of cuff tear. The population density of neural elements of the subacromial bursa associated with massive cuff tear was significantly lower than that observed in control shoulders. With regard to clinical symptoms, a significant correlation was established between the population density of neural elements in the subacromial bursa and shoulder pain at rest. Our investigation strongly suggests that the subacromial bursa is intimately involved in the perception of shoulder pain, providing an anatomical basis for afferent neural input in proprioceptive reflex ares.     

不可修复肩袖撕裂的临床治疗选择

肩袖撕裂是临床最常见的肌肉损伤,其中对于不可修复肩袖撕裂（IRCT）的治疗仍较为困难。目前针对IRCT的治疗方法有：非手术治疗、肩关节清理、部分及完全肩袖修补术、生物补片技术、肌腱转位、肩峰下球囊占位器、反肩关节置换术。由于各项治疗措施的适应证目前尚未达成共识,本文通过检索查阅国内外相关文献,讨论IRCT的各项治疗措施的疗效及相关适应证,为临床治疗提供理论参考。     

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.