How should we treat massive irreparable cuff tears?

Even though massive irreparable rotator cuff tears are common, the relative effectiveness of the different treatment approaches remains unknown.

The authors of Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age used a powerful tool, 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:

Comment: This network meta-analysis found that simple debridement was the most effective 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. 

While not reported in this study, the cost and complication rates for debridement are lower than for the other procedures; thus, one may conclude that debridement is the most cost effective treatment for these patients based on the currently available evidence.

Our technique for debridement is shown in this link and summarized below.

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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 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
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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).

Spin and the subacromial balloon spacer for massive, irreparable rotator cuff tears.

Spin plays a major role in tennis, basketball, baseball, golf, soccer, cricket, pool, bowling, ping pong, and all other ball sports.

Spin is achieved by applying an unbalanced force to the ball, causing it to rotate in the direction desired by the player.

In publications of clinical research on innovative treatments, positive spin is a frequent form of unbalanced reporting in which beneficial claims are overemphasized while negative findings are minimized, resulting in a biased conclusion that emphasizes the value of the intervention.

The authors of Evaluation of Spin in Reviews of Biodegradable Balloon Spacers for Massive, Irreparable Rotator Cuff Tears list 12 types of spin:

Abstracts are the part of publications most commonly read by surgeons. Spin is most problematic in abstracts, given their brevity and can result in the misrepresentation of a study’s actual findings. 

These authors conducted a search in the PubMed and Embase databases using the search terms: “subacromial balloon”, “subacromial spacer”, “rotator cuff”,  “irreparable”, “systematic review”, and “meta-analysis.” 

A total of 29 studies met their inclusion criteria, of which 10 were reviews or meta-analyses and the remaining 19 were primary studies. The majority of included studies were classified as level IV evidence and only one RCT met this study’s inclusion criteria. 

Spin was highly prevalent in the abstracts of primary studies, systematic reviews, and  meta-analyses discussing the use of the subacromial balloon spacer in the treatment of massive, irreparable rotator cuff tears: spin was identified in 27 of the 29 studies ( 93.1%). Below is a list of the types of spin re-ordered by frequency of occurrence in publications on the subacromial balloon.

Spin commonly served to promote the clinical successes of balloon spacer implantation, often by overlooking confounding factors that may question the accuracy of a study’s findings as shown in the two most frequent types:

Type 3 spin, “Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention”

Type 9 spin, “Conclusion claims the beneficial effect of the experimental treatment despite reporting bias”.

Comment:  To date, there is a lack of high-quality evidence demonstrating superiority of the subacromial balloon spacer in treating massive irreparable rotator cuff tears. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. found that débridement alone outperformed the subacromial balloon spacer for the treatment of these tears.

Similar frequencies of spin are likely to be found in abstracts regarding most other orthopaedic interventions.

Analyzing Spin in Abstracts of Orthopaedic Randomized Controlled Trials With Statistically Insignificant Primary Endpoints found an incidence of 44%.

Evaluation of spin in systematic reviews and meta-analyses of superior capsular reconstruction found least 1 form of spin in all 17 qualifying studies. The most common types of spin were type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") and type 9 ("Conclusion claims the beneficial effect of the experimental treatment despite reporting bias"), both of which were observed in 11 studies (65%). A statistically significant association between lower level of evidence and type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was observed. Interestingly, The Number of Surgeons Using Superior Capsular Reconstruction for Rotator Cuff Repair Is Declining

Readers, reviewers, authors and editors need to be alert to spin in reports of research and consider its presence in efforts to optimize the literature and in the interpretation of current publications, especially those concerning new technologies.

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
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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).

Massive, irreparable cuff tears: what options does the patient have?

By definition, "massive, irreparable rotator cuff tears" are not reparable. Chronic, massive, irreparable cuff tears are common and can range from being asymptomatic to disabling.

It is recognized that for many patients, non-operative management can substantially improve the comfort and function of the shoulder with a chronic massive tear (see Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol). For patients with painful massive, irreparable rotator cuff tears having retained active elevation of the arm, a conservative procedure, the "smooth and move" (see this link),  can provide significant benefit and prompt return to activities without the complexity or the risks associated with more aggressive surgeries 

Some surgeons advocate attempting partial repair of the massive cuff defect. The authors of Massive and irreparable rotator cuff tears treated by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only suggested that partial repair with augmentation using the long head of the biceps would result in a better quality of tendon to bone healing and improved clinical, functional and radiological outcomes for patients with chronic, massive and irreparable rotator cuff tears involving both the supraspinatus and infraspinatus tendons. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the supraspinatus after complete release,

The augmented group consisted of 30 patients whose biceps long head tendon was intact (only minimal redness, fraying and stable proximal attachment) on intraoperative assessment.

The non-augmented group consisted of 30 patients with poor biceps tendon quality, tendon dislocation or absence of the tendon.

As assessed by MRI at one year after surgery, the retear rate for was 43.3% for the augmented group and 73.3% for the non-augmented group. 

In spite of these imaging findings, there were no significant differences between the groups in patients' postoperative shoulder range of motion, strength, Hamada classification, Simple Shoulder Test (SST) scores and postoperative Goutallier scales. The Constant score (CMS) averaged 76.2±0.9 for the augmented group and 70.9±11.5 for the non-augmented group, but this difference failed to reach clinical significance ( the minimal clinically important difference is >10 for the CMS (see Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery)).

Of note, the augmented and non-augmented groups were not comparable. For example, two thirds of the augmented patients were male, whereas less than half of the non-augmented patients were male. The pathologies were different: the augmented patients had intact biceps tendons while the non-augmented patients did not; the size and retraction of the rotator cuff tendons are not reported. Data are not presented on the preoperative strength or range of motion.

Comment:  If we are to be able to discuss management options for our patients with these tears, we will need comparative clinical studies of patients that are similar before treatment is begun. Only in this way will we have the basis for understanding the relative effectiveness of physical therapy, smooth and move, subacromial balloon catheters, superior capsular reconstruction, partial cuff repairs (without and with augmentation) and reverse total shoulder arthroplasty. The need for controlled studies can be seen in this article: Subacromial Balloon Spacer - what is the evidence supporting the value of this innovation to patients with irreparable cuff tears?

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://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).

Pseudoparalysis in massive irreparable rotator cuff tears: what is it and why is it so important?

Patients with massive irreparable rotator cuff tears have widely varying abilities to actively raise their arm. 

Some have quite functional active forward elevation. 

Others have pseudoparalysis, a condition in which the arm can only be passively elevated with assistance from the other arm.

but the arm cannot be actively raised by the patient above the horizontal without assistance.

Patients with massive irreparable rotator cuff tears and pseudoparalysis (as shown in the movie above) may consider reverse total shoulder arthroplasty.

On the other hand, patients without pseudoparalysis may consider simpler, less costly and safer procedures, such as a smooth and move if the shoulder is not arthritic (see this link) and a cuff tear arthropathy hemiarthroplasty if the shoulder is arthritic (see this link and this link).

Because of the clinical importance of pseudoparalysis, the question naturally arises, "are many patients on the borderline of being able to actively elevate their shoulders above the horizontal?", in other words is there a substantial percentage of patients with massive irreparable cuff tears who are "almost pseudoparalytic" or "just barely pseudoparalytic"?

This question can be addressed by data from Pseudoparesis and Pseudoparalysis in the Setting of Massive Irreparable Rotator Cuff Tear: Demographic, Anatomic, and Radiographic Risk Factors. The authors of this paper identified two groups of patients with massive irreparable rotator cuff tears:

The pseudoparalytic group: 79 patients having active forward elevation (AFE) <90 degrees with maintained passive range of motion. The mean (± standard deviation) active forward elevation for this group was 59± 26 degrees.

The non pseudoparalytic group: 50 patients with massive irreparable rotator cuff tears having active forward elevation (AFE) ≥90 degrees. The mean (± standard deviation) active forward elevation for this group was 151± 20 degrees. (p<0.001).

From these means and standard deviations the probable distributions of active forward flexion for the two groups can be determined. The important result is that there was very little overlap between the two groups (see chart below). In other words, most patients with massive irreparable rotator cuff tears were either obviously pseudoparalytic or obviously non pseudoparalytic.   

This bimodal result can be compared to the chart comparing the acromiohumeral distance for pseudoparalytic (4.8±2.7) and non pseudoparalytic (7.6±2.6, p<0.001) shoulders using data from the same study (see below). 

The minimal overlap in active flexion between the pseudoparalytic and non pseudoparalytic groups is striking by comparison to the overlap in acromiohumeral distance. 

  

Comment: This analysis points out that the clinical differentiation of pseudoparalytic and non pseudoparalytic shoulders is usually straightforward, simplifying decision making about the need for a reverse total shoulder arthroplasty (see for example, Reverse total shoulder for everything? How about for cuff tear arthropathy?).

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
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).