How should this irreparable cuff tear be treated? - Revealed

  A 58 year old woman with type II diabetes presented with several year history of pain and weakness of the right shoulder. This started while she wasworking as a stocker grocery distributorship following lifting heavy bins of hominy and other produce. On one occasion she noted an audible pop. At evaluation she had passive elevation of 140 and active elevation of 80 degrees. She had grade three strength of elevation, grade four strength of external rotation and grade 5 strength of internal rotation. There was palpable crepitus on active and passive shoulder movement. 

Her images at the time of presentation are shown below.

Her symptoms did not respond to 2 months of PT.

After discussion of the alternatives, including superior capsular reconstruction, biologic patches, tendon transfers and reverse total shoulder arthroplasty, the patient elected to have smooth and move: an outpatient fifteen minute open procedure performed through an anterior deltoid split without sacrifice of acromial or coracoacromial ligament integrity with excision of the hypertrophic bursa, resection of the ragged ends of the torn tendons, and resection of the prominent aspects of the uncovered greater tuberosity followed by a manipulation to assure full range of passive motion. 

At surgery the findings of the MRI were confirmed. The undersurface of the coracoacromial arch was smooth.  The long head tendon of the biceps and subscapularis were intact; no biceps surgery was performed. 

After surgery she was encouraged to perform range of motion exercises and to return to active use of her shoulder immediately. 

At six weeks after surgery she returned for routine followup, reporting that her preoperative pain was relieved by the afternoon of surgery and had not returned. She was able to return to full use of her shoulder. 

A video of her active motion at her 6 week visit is shown here.

In contrast to the alternatives, this procedure is inexpensive, allows immediate post operative return to function, and does not preclude subsequent procedures in the unusual circumstance of recurrent symptoms. 

For this woman, the smooth and move was a wise choice.

Great horned owl

Ravenna Park, Seattle

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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).

How should this irreparable cuff tear be treated?

 A 58 year old woman with type II diabetes presented with several year history of pain and weakness of the right shoulder. This started while she wasworking as a stocker grocery distributorship following lifting heavy bins of hominy and other produce. On one occasion she noted an audible pop. On evaluation she had passive elevation of 140 and active elevation of 80 degrees. She had grade three strength of elevation, grade four strength of external rotation and grade 5 strength of internal rotation. There was palpable crepitus on active and passive shoulder movement. 

Her images at the time of presentation are shown below.

Her symptoms did not respond to 2 months of PT.

What would be your suggested treatment?

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

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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).

Can a subacromial balloon do this?

 A 57 year old man with rheumatoid arthritis on methotrexate and Humira presented with pain, crepitance and weakness of the left shoulder coming on after doing pushups. His symptoms did not respond to 12 weeks of physical therapy. Of note he had a reverse total should on the contralateral side for irreparable cuff tear.

On examination he had active and passive elevation to 140 degrees, but pronounced crepitance and discomfort on active motion.

His AP radiograph showed a narrowed acromiohumeral interval.

 

After discussion of the alternatives, he elected a smooth and move procedure. A preoperative MRI was not obtained.

At surgery hypertrophic bursa and an irreparable supraspinatus tear were identified along with an irregular prominence of his tuberosity at the supraspinatus insertion site. The remainder of his cuff was intact. 

After one hour in the recovery room he was dressed and ready for discharge with full, smooth and comfortable active elevation.

Comment: The smooth and move is a conservative surgical procedure that can be offered to patients with irreparable cuff tears and retained active elevation. It preserves the coracoacromial arch. It does not include the implantation of balloons or patches. It enables immediate resumption of active elevation and all activities as tolerated. Finally, it does not burn bridges to subsequent procedures should they become necessary.

Comments welcome at shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link


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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). 

Irreparable cuff tear in a 62 year old woman.

A recent American Shoulder and Elbow Surgeons journal club (link) discussed some options for the management of symptomatic refractory irreparable rotator cuff tears. The faculty discussed the a variety of surgical options, their cost and their effectiveness.

Our approach to patients with irreparable cuff tears has remained consistent for the last three decades: starting with a good trial of directed Jackins rehabilitation exercises to first optimize shoulder flexibility 

and next to gradually build strength.

we continue to be impressed with the effectiveness of this program, irrespective of the size of the cuff defect.

For patients who have active elevation of the arm above 90 degrees but who continue to have limiting stiffness and pain, we consider the simple, low cost, low risk procedure known as the "smooth and move" . A recent example of the rapid return of function following of this procedure can be seen here.

Here's another recent example of an irreparable cuff tear in a 62 year old woman.

After a trial of the Jackins exercise program she had regained motion her her shoulder, but still had painful, function-limiting crepitus of the shoulder.

With this result from her Simple Shoulder Test

She asked to proceed with a smooth and move procedure at which time we found an irreparable supraspinatus tear with a large lateral flap, intact biceps tendon, intact subscapularis and infraspinatus and smooth undersurface of her coracoacromial arch.

We debrided her hypertrophic bursa and the flap, smoothed her tuberosity, preserved her biceps tendon and performed a manipulation under anesthesia. No patches or bioactive agents were used. 

She resumed her active motion and strengthening exercise program immediately after surgery = minimal down time.

At six weeks after surgery she returned for a post op check and demonstrated strong full and comfortable elevation of her arm, reporting that she had returned to work.

Comments welcome at shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link


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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). 

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


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link


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Follow on facebook: https://www.facebook.com/shoulder.arthritis
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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).

Innovation, balloons and irreparable cuff tears

I hope you enjoy the Hidden Brain as much as I do. 

A recent post Do less. points out that the human drive to invent new things has led to pathbreaking achievements in medicine, science and society. But our desire for innovation can keep us from seeing one of the most powerful paths to progress: subtraction. Sometimes the best way forward involves removing, streamlining and simplifying things.

One of the examples given is that while training wheels on a kid's bike seem like a good innovation, it enabled the child to ride without learning to balance.

It turns out that a better way to teach a kid to ride is to subtract the pedals and training wheels and - voila - the balance bike.

I'm also a big fan of the ASES podcast. A recent program,  Balloon vs. Tuberoplasty, reviewed options for managing irreparable rotator cuff tears, including superior capsular reconstruction, subacromial balloons, partial repairs, tendon transfers, and "biologic" tuberoplasty. The panel concluded that while there were "non-inferiority" studies and case reports, no surgical procedure was the clear favorite. As an example, a recent case series, Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Demonstrates Improved Shoulder Functionality and High Revision-Free Survival Rates at Minimum 5-Year Follow-up, combined debridement with the placement of a subacromial balloon in 61 patients. 10 were lost to follow-up over 3 years. Of the remaining 51, 9 were lost at the latest follow-up.  17% required revisions within two years. Constant-Murley total scores increased significantly (27 to 69). 10% were highly satisfied, 48% were satisfied, and 43% were dissatisfied.

The podcast concluded with Justin Griffin saying, "There may be a future where we figure out a way to retrain the deltoid in the setting of a massive cuff tear that does not require any procedures." - an example of innovation by subtraction.

Many shoulders with chronic irreparable cuff tears (including my own) are comfortable and functional.  For patients with chronic irreparable cuff tears and problematic weakness, there is the opportunity to use a simple exercise to retrain the deltoid, which is the primary source of shoulder power no matter what other treatments are considered.

Patients with irreparable cuff tears can have painful subacromial crepitus, which can be identified by placing the examiner's finger just anterior to the acromion while the shoulder is moved in rotation and elevation. As mentioned in the ASES podcast, many surgical procedures have been advocated for such a patient, yet there are very few studies that compare these methods with each other. 

The authors of Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age network meta-analysis to analyze comparative studies of surgical treatment options for massive irreparable cuff tears - without glenohumeral arthritis or pseudoparalysis -  in patients <70 years of age. The treatments included debridement; arthroscopic bridging graft; arthroscopic partial repair; superior capsular reconstruction; long head of biceps augmented superior capsular reconstruction; InSpace balloon placement; tendon transfer; and reverse shoulder arthroplasty.

A total of 23 studies met the inclusion criteria, with 1178 patients included in the analysis. The mean weighted age was 62.8 years; 48.2% were men, mean follow-up was 28.9 months. There were no significant differences between groups in regard to sex or age. 

The treatments were ranked using the the P-score - an estimate of the likelihood that the investigated treatment is the ideal method for an optimal result for each of the different outcome measures, where 0 is least effective and 1 is most effective.

Unfortunately most studies did not evaluate treatment with simple debridement in comparison to more complex procedures. However for studies that did, debridement had the highest P-score, as shown below.



Forrest plot for Constant Score:

Forrest plot for range of active forward flexion:

This network meta-analysis found that simple debridement was the most effective procedure in significantly improving Constant score and active flexion for individuals with massive irreparable cuff tears when it was compared to other more complex surgical modalities. 

Comment: Debridement is a component of most procedures performed for irreparable cuff tears. Debridement alone subtracts away the other possible surgical elements (balloons, grafts, partial repair). It has the important advantages of not requiring any post-surgical down time and of not burning bridges for other procedures should it not yield the desired result. Furthermore it is the least costly in comparison to grafts, balloons, and partial repairs and avoids the possible complications of these procedures. 

We refer to our approach to debridement as the "smooth and move procedure" emphasizing the goals of smoothing the articulation between the coracoacromial arch and the proximal humerus and initiating passive and active motion following the procedure. We have found this procedure to be effective not only as a primary procedure for patients with irreparable cuff tears, but also as a revision procedure for patients with failed prior attempts at surgical reconstruction.

Elements of this technique include (1) preserving the integrity of the deltoid and coracoacromial arch, (2) preserving the long head of the biceps unless it is frayed or dislocated, (3) removing hypertrophic bursal tissue, (4) trimming the rough edges of the reaming cuff, (5) resecting the prominent portions of the greater tuberosity, (6) manipulating the shoulder to eliminate any capsular tightness, and (7) starting motion exercises immediately after surgery.

The surgical technique and the outcomes of two patients having the smooth and move after failed cuff reconstruction attempts is shown in this link.

Two publications present the outcomes for this procedure:

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

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

Comment to shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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). 

Irreparable rotator cuff tear in an active man

A sixty year old active man presented with incapacitating pain and weakness of his right shoulder after two prior rotator cuff repair attempts. He was unable to sleep comfortably because of shoulder pain. On examination he had painful, crepitant active elevation above 90 degrees.

His MRI showed supraspinatus tendon retraction to the level of the glenoid and a chronic subscapularis tear.

He elected to proceed with a smooth and move procedure (see this link). At surgery his supraspinatus and subscapularis were found to be irreparable. The upper third of his intraspinatus was deficient.

Immediately after surgery he started active and passive range of motion exercises.

At nine months after surgery he came by for a followup, reporting that he was sleeping comfortably and demonstrated the active motion shown in the images shown below with his permission.

Comment: There are many reported approaches to irreparable supraspinatus and subscapularis cuff tears, including a subacromial balloon, a superior capsular reconstruction, a biologic graft, tendon transfers, partial repairs and reverse total shoulder (see this article by our current shoulder fellow, Mihir Sheth  link). The smooth and move procedure provides a safe, inexpensive, minimally invasive procedure with minimal postoperative downtime that can be effective in shoulders without pseudo paralysis and without significant arthritis (see this link and this link).

You can support cutting edge shoulder education that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
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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).

Subacromial Balloon Spacer - what is the evidence supporting the value of this innovation to patients with irreparable cuff tears?

Rotator cuff tears are one of the most common conditions of the shoulder. While many patients can accommodate the progressive age-related deterioration of the cuff with no or minimal symptoms, others have disabling symptoms and loss of function. Surgical management of symptomatic rotator cuff tears is commonly performed. For those tears that are not durably reparable, surgical options include (1) subacromial smoothing with debridement of hypertrophic bursa and the non-functioning margins of the tendon, possible biceps surgery, and manipulation as necessary to address glenohumeral stiffness, (2) partial repair, (3) superior capsular reconstruction, (4) reverse total shoulder and (5) the recently introduced Stryker InSpace subacromial balloon spacer. The InSpace device is a saline-filled biodegradable balloon that is inserted surgically in the space between the humerus and the acromion. In theory this device helps maintain the gap between the acromion and the humerus, and reduces friction.
The balloon received Food and Drug Administration (FDA) clearance in the USA in July, 2021, with approximately 29,000 devices having been implanted outside the USA before this.



The question is, in patients with symptomatic, irreparable rotator cuff tears, does adding a subacromial balloon spacer to debridement alone improve shoulder pain and function above what is achieved with debridement alone?

While small published case series have suggested encouraging clinical results, others have reported poor results or cases of inflammation and pain. For this reason, the authors of Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial conducted a novel, efficient, adaptive clinical trial to assess the clinical effectiveness of a subacromial spacer balloon for people with symptomatic irreparable tears of the rotator cuff. This article was summarized in In Symptomatic Irreparable Rotator Cuff Tears, Adding a Subacromial Balloon Spacer to Debridement Resulted in Worse Shoulder Pain and Function at 12 Months.

The study was conducted by surgeons in 24 hospitals in the United Kingdom and included 117 patients (mean age, 67 years; 57% men) who had irreparable rotator cuff tears with disabling symptoms (pain and loss of function) and unsuccessful nonoperative management, and in whom surgery was warranted. Patients with reparable cuff tears, arthritis, pseudoparalysis, and subscapularis deficiency were excluded.

Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Using concealed allocation, patients were randomized to balloon spacer plus debridement (n = 56) or debridement alone (n = 61). Patients in the balloon spacer group received the Stryker InSpace balloon inserted by subspecialty-trained shoulder surgeons after arthroscopic debridement of the subacromial space and biceps tenotomy. Participants and assessors were masked to group assignment. Masking was achieved by using identical 1.5-cm lateral portal incisions for both procedures, blinding the operation note, and a consistent rehabilitation program offered regardless of group allocation.

The study was designed to have 90% power providing a robust answer to the clinical question.

The primary outcome was shoulder-related pain and function as measured by the Oxford Shoulder Score at 12 months. Secondary outcomes included the Western Ontario Rotator Cuff Index, EuroQol-5 Dimensions-5 Levels (EQ-5D-5L), and adverse events at 12 months. 97% of patients completed follow-up for the primary outcome. The primary outcome was the Oxford Shoulder Score at 12 months.

Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The study was designed to be terminated either for convincing evidence of a lack of benefit (futility) or for strong clinical benefit (efficacy). This exposes fewer people to risk of harm in the trial itself, as well as preventing harm or high costs for people having the treatment in the wider community. Having both futility and efficacy stopping rules allow a study to report early if an intervention is ineffective. Recruitment to this study was stopped when the predefined boundary for futility was crossed.

As seen in the figure and table below, in patients with symptomatic irreparable rotator cuff tears, adding the InSpace balloon to debridement only resulted in worse shoulder pain and function. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design –4·2 [95% CI –8·2 to –0·26];p=0·037) favoring debridement alone.












The adverse events for the two groups are shown below.




The authors concluded that for patients with symptomatic irreparable rotator cuff tears, adding a subacromial balloon spacer to debridement resulted in worse shoulder pain and function at 12 months.

Another recent study, InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears A Multicenter, Single-Blinded, Randomized Controlled Trial concluded that the outcomes of the InSpace implant were not superior to those of partial repair for the treatment of patients with irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis.









Recently, the authors of Outcomes of Subacromial Balloon Spacer Implantation for Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis reviewed the published evidence on the value of this procedure. Non of these authors had financial conflicts of interest related to the balloon.

Their review found 28 studies that were eligible for inclusion. 17 reported adequate pre- and postoperative data (mean and measure of variance) and thus were included in the meta-analysis.

894 shoulders (886 patients) had a mean age of 67.4 years (range, 61.7-76.2) with average follow-up of 30.4 months (range, 12-56). All patient reported outcomes and range of motion improved significantly from the preoperative baseline.  Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%), synovitis (0.6%) and infection (0.8%). 5% of patients required salvage reverse shoulder arthroplasty.

Most of the identified reports of balloon implantation included other procedures performed at the same surgery, procedures which by themselves lead to improved shoulder comfort and function for patients with irreparable cuff tears: biceps surgery, partial or medialized cuff repair, and debridement. 

Comment: Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit the ability to interpret the available evidence. As a result the value of balloon implantation in comparison to currently accepted treatment strategies is unknown. In order to determine the true efficacy of the balloon, studies must compare outcomes of balloon placement to an identical control without balloon placement.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
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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)