In patients of average age of 67 years with retained elevation (average >120 degrees), these authors performed arthroscopic rotator cuff repair combined with mini-open supraspinatus and infraspinatus muscle advancement for massive rotator cuff tears (RCTs) in an effort to decrease tension at the repair site.
They evaluated the clinical outcomes and failure rates after this procedure.
Their study included 47 patients diagnosed with chronic massive RCTs, of these, 21 had transosseous equivalent repair only (control group), and 26 underwent transosseous equivalent repair with muscle advancement (study group).
Their study included 47 patients diagnosed with chronic massive RCTs, of these, 21 had transosseous equivalent repair only (control group), and 26 underwent transosseous equivalent repair with muscle advancement (study group).
There was substantial down time after these surgeries: the affected arm was immobilized for 6 weeks in an abduction brace. Passive range of motion exercise commenced from 1 week, active ROM exercise commenced from 4 weeks, and rotator cuff and deltoid muscle strengthening exercises commenced from 12 weeks.
Failure rates were determined by postoperative magnetic resonance imaging. The failure rates were high in in both groups, but lower in the study group than in the control group (23.1% and 52.4%; P = .03). In spite of the observation that the failure rate was twice as high in the control group, there was no difference in the clinical outcomes between the two groups as reflected by the Constant and UCLA scores. Leading one to ask, "does failure matter"?
Comment: The failure rate of repair of massive cuff tears remains high.
In our practice, we discuss the possibility of a smooth and move procedure with patients who have retained elevation and massive tears. This procedure is short, safe and avoids the need for protracted down time after surgery, as described below.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
The typical pathology in these cases is shown in the figure below.
In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.
The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.
The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.
The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable.
They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test
For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.
They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities
They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.
These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.
Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.
While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.
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