Tuesday, June 21, 2016

Irreparable rotator cuff tears - is 'partial repair' helpful?

Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up.

These authors recognize that patients with massive irreparable rotator cuff tears can have retained overhead elevation, but may have complaints of pain.

They treated 34 patients with preoperative active forward elevation >120° and no evidence of glenohumeral arthritis. In each case there remained a portion of the cuff that was not mobile and able to be fully repaired to the tuberosities.

The surgical treatment included at least five elements: (1) bursectomy, (2) d├ębridement of tendon delaminations, (3) aggressive releases and slides, (4) acromioplasty, and (5)   'partial' rotator cuff repair ("a low-tension repair of as much of the rotator cuff as could be advanced to the tuberosities") and biceps tenotomy.  Patients then had a 3 month post surgical rehab starting with a sling for 6 weeks.

Patients were followed up clinically and radiographically. 28 patients had a minimum of 5 years of follow-up. Failure was defined as an American Shoulder and Elbow Surgeons score of <70, loss of active elevation >90°, or revision to reverse shoulder arthroplasty during the study period.

The patient’s radiographs were graded on the basis of the Hamada stage with a comparison between
the preoperative radiograph and the last follow-up radiograph (grade 1, the acromiohumeral interval (AHI) is >6 mm; in grade 2, the AHI is <5 mm; in grade 3, the AHI is <5 mm with acetabularization of the acromion; grade 4 represents grade 3 with the addition of degenerative changes of the glenohumeral joint.

Patients demonstrated improvements in average preoperative to postoperative American Shoulder and Elbow Surgeons scores (46.6 to 79.3 [P < .001]) and Simple Shoulder Test scores (5.7 to 9.1 [P < .001]) along with decrease in visual analog scale for pain scores (6.9 to 1.9 [P < .001]). The patients lost an average of 14 degrees of forward elevation (168° to 154° [P = .07]), external rotation (38° to 39° [P = 1.0]), or internal rotation (84% to 80% [P = 1.0]) was identified; 36% of patients had progression of the Hamada stage. The failure rate was 29%; 75% of patients were satisfied with their index procedure.

The authors point out that this was a retrospective study with no imaging to show whether or not the 'partial repair' had healed.

Comment: In this study several procedures were included in the surgical management: a biceps tenotomy, a bursectomy, a cuff debridement, soft tissue releases a subacromial decompression, and an attempt at a partial cuff repair. Without comparing MRI or sonographic imaging of the cuff before and at followup, one cannot know if the integrity of the cuff was improved, i.e. if the attempted repair had any effect on the outcome.

In our practice, we are reluctant to attempt partial cuff repair because (1) the quality and quantity of the tendon to be repaired are usually poor and (2) after a partial repair the approach to rehab is conflicted: should one move the shoulder to prevent adhesions or should one immobilize the shoulder (as was done in this study) to optimize the chances of healing. We are also reluctant to perform an acromioplasty, especially in cuff deficient shoulders, (1) because it can weaken the shoulder (as reported here) and (2) because of the risk of creating anterosuperior escape as shown below (note that three of the 2 followed up patients in this series required a subsequent reverse total shoulder).

Instead we manage massive symptomatic rotator cuff tears with preserved active elevation and no arthritis with the smooth and move procedure, which allows immediate post operative function as well as active and passive range of motion exercises - as discussed in this link, this link and this link