Friday, February 12, 2016

Rotator cuff tears - what to do if they are irreparable?

Long-term outcome of tuberoplasty for irreparable massive rotator cuff tears: is tuberoplasty really applicable?

These authors report on 16 patients who underwent arthroscopic tuberoplasty for symptomatic irreparable massive RCT without pseudoparalysis. Patients were a mean age of 64 years (range, 43-80 years) at the time of the operation, and the mean duration of follow-up was 98 months (range, 84-126 months).

At the last follow-up, the visual analog scale score for pain during motion had decreased to 2.3 from a preoperative mean of 6.9 (P < .001). The mean University of California at Los Angeles and Constant scores improved from 10.3 and 37.9 preoperatively to 27.2 and 59.2, respectively, at the last follow-up (P < .001 for both). 

The mean acromiohumeral interval changed from 5 mm preoperatively to 4 mm at the last follow-up. Only 1 patient underwent revision surgery.
The authors concluded that arthroscopic tuberoplasty is a good option for relieving pain and improving functionality in nonpseudoparalytic patients with painful irreparable massive RCT.

Comment: Currently there is enthusiasm for treating massive irreparable cuff tears with marginal convergence, superior capsular reconstructions, patch grafts, and reverse total shoulders. These authors demonstrate that some patients may be substantially improved with a simpler option that does not require prolonged periods of rehabilitation after surgery.

As Codman pointed out many years ago, the shoulder is a joint with two concentric spheres sharing a common center of rotation: (1) the humeral head articulating in the glenoid socket and (2) the proximal humeral convexity articulating within the coracoacromial arch. The radius of the second is equal to the radius of the first plus the thickness of the cuff and tuberosity. Here is an illustration from his book:

When the cuff is absent, the uncovered tuberosity extends beyond the extended curvature of the humeral surface, disrupting the normally smooth surface of the proximal humeral convexity. As the figure below from Steve Lippitt shows, smoothing of the tuberosity can restore the smoothness of the proximal humeral convexity that articulates with the undersurface of the (hopefully) intact coracoacromial arch.

Our favored procedure for the painful, stiff and crepitant irreparable cuff tear without pseudoparalysis is the smooth and move procedure, which includes tuberoplasty along with a bursectomy, lysis of adhesions, and a gentle manipulation under muscle relaxation.See this link and this link.