A 61 year old women with an irreparable cuff tear

A recent post, Innovation, balloons and irreparable cuff tears, reminded us that (1) rotator cuff integrity was not necessary for satisfactory shoulder function and (2) many treatments for irreparable cuff tears (superior capsular reconstructions, bioinductive grafts, subacromial balloons, tendon transfers, reverse total shoulder arthroplasty) can be more costly, have a longer recovery periods, and have higher complication rates without yielding superior outcomes than simple debridement in appropriately selected cases.

In patients having symptomatic irreparable cuff tears but with retained active elevation above the horizontal, we consider a smooth and move procedure: removing hypertrophic bursa and degenerated cuff remnants, smoothing any tuberosity prominence, manipulation to eliminate any capsular tightness, and preserving the coracoacromial arch and all functional cuff elements (including the long head tendon of the biceps unless it is frayed or unstable). No partial repair is attempted. (see Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation and Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

Here is an example from earlier this month. A 61 year old woman had chronic activity-limitng pain in her right shoulder. She answered "no" to all 12 of the Simple Shoulder Test questions

    

Her shoulder examination is shown below. Her supraspinatus was too painful to test. 

Her MRI showed a severely degenerated supraspinatus tendon with an irreparable tear.

Her symptoms did not respond to a course of physical therapy.

After discussion of the non-operative and surgical options, she elected to proceed with a smooth and move procedure. 

At surgery, the degenerated supraspinatus tendon was irreparable. It was debrided. The subscapularis and infraspinatus were intact. The intact biceps tendon was preserved.  The undersurface of the coracoacromial arch was smooth; it was preserved. The uncovered tuberosity prominence was smoothed.  The shoulder was manipulated for a full range of motion. No implants were used.

The patient began active assisted flexion immediately following the procedure without surgeon-imposed restrictions. She returned to the office three weeks after surgery with comfortable active elevation >150 degrees. 

Her three week Simple Shoulder Test responses and her active elevation are shown below.

While the smooth and move is not a perfect solution for irreparable cuff tears and while it is not applicable in all such cases, it does have the advantages of effectiveness, low cost, low complication rate, simple rapid rehabilitation, and leaving the door open for additional surgeries in the uncommon event that they become indicated.

Comments welcome at shoulderarthritis@uw.edu


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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).