Sunday, March 16, 2014

Atraumatic cuff tears: an intrinsic age-related degenerative process

The authors of Research Zeroes in on Pathogenesis of Rotator Cuff Disease received the 2014 Ann Doner Vaughan Kappa Delta Award.

These authors observed that non-traumatic rotator cuff tears result from degenerative changes in the tendon that progress in size over time in association with fatty degeneration of the attached muscle. At a certain stage, these changes become irreversible.

They conducted a longitudinal, prospective follow-up study of a cohort of 262 patients with asymptomatic full or partial thickness rotator cuff tears that were incidentally discovered contralateral to a symptomatic cuff tear by routine ultrasound examination.

The findings indicated that rotator cuff disease develops in an age-related, bilateral, degenerative way; approximately 40 percent of rotator cuff tears increase in size over as few as three years due to an intrinsic, degenerative process, rather than the previously held belief that tears develop due to acromial “impingement”.

In this study, tears commonly started about 1.5 cm posterior to the biceps tendon—and then propagated in both posterior and anterior directions. Loss of the anterior supraspinatus tendon attachment correlated with fatty degeneration. Proximal migration of the humeral head was much more likely to occur once the tear reached a specific threshold: tears wider than 1.5 cm at the humeral insertion were more likely to have superior migration, tears that extended to the bicipital groove and through the anterior supraspinatus tendon were more likely to have altered kinematics.

The authors recommend that patients younger than 60 years with small or medium-sized tears that are significantly painful should be given strong consideration for early surgical intervention in hopes of preventing progression in tear size and development of fatty degeneration. They noted that rotator cuff repair is much less likely to lead to tendon healing in patients who are 63 years and older; early surgical intervention does not provide much clinical advantage in these patients for which there is concern for healing.

Comment: The recognition that cuff tearing is an intrinsic progressive degenerative process, rather than related to subacromial ‘impingement’ is important. This recognition is consistent with the lack of evidence that acromioplasty is an important part of treatment of rotator cuff disease. Furthermore the recognition that cuff failure is a degenerative process suggests that at some point the tendon and associated muscle will degenerate to the point that attempting surgical reattachment of the degenerated tendon to bone is unlikely to result in a durable repair.

What remains to be established is whether reattachment of a tendon early in the process of degeneration will reverse the degenerative process.
As H.L.McLaughlin stated in 1962, "the wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis."
It has yet to be demonstrated that suturing degenerated tendon results in improvement in the quality of the tendon.
Bottom line: it matters if the cuff fails because of tear or wear

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