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?

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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 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) débridement 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. 

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