Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3470-y
SHOULDER
Decision‑making in massive rotator cuff tear André Thès · Philippe Hardy · Klaus Bak
Received: 3 July 2014 / Accepted: 2 December 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V. Keywords Rotator cuff/injuries · Shoulder joint/patophysiology · Rotator cuff/surgery · Shoulder pain/surgery
involving complete rupture of at least two rotator cuff tendons [33]. Posterosuperior and anterosuperior are two most common tear types seen. The prevalence of massive tears reported in the literature has ranged from 10 to 40 % of all RCT [6]. With chronicity of the tear, tendons retract, and muscles atrophy with associated fatty infiltration, thus rendering the tear irreparable or with unfavourable results, even if repaired. RCT is said to be irreparable if preoperative imaging studies show tendon retraction to the glenoid edge and stage 3 and stage 4 fatty infiltration or muscular atrophy. The tear might also be judged irreparable preoperatively if tendons cannot be reinserted to their footprints despite mobilization and soft tissue release.
Physical examination Definition Rotator cuff tears (RCT) exceeding 5 cm were historically described as massive RCT [21]. The size of the individual, and in turn, the size of the overall tendon was not taken into consideration. However, more recently they have been defined and widely accepted as tears
A. Thès (*) Hôpital Ambroise Paré – APHP, 9, Avenue du Général de Gaulle, 92100 Boulogne–Billancourt, France e-mail: [email protected] P. Hardy Hôpital Ambroise Paré – APHP, Boulogne–Billancourt, France K. Bak Teres Hospitalet Parken, Copenhagen, Denmark
Patients with chronic tears exhibit variable limitations in active and passive shoulder motion. Stiffness after rotator cuff tear is common, and it may affect postoperative prognosis in some patients. Stiffness has been shown to be more common in posterosuperior and post-traumatic tears. Postoperative stiffness limited to the first 2 months seems to be of no importance to the end result [69] and seems to be rare after arthroscopic repair [24]. Supraspinatus weakness, checked with Empty Can Test (arm in 90° abduction, 30° horizontal adduction, and 90° internal rotation, elbow extended, thumb pointing towards floor, patient resists downward pressure from examiner, positive if pain or weakness appears), is usually almost always present. In patients with posterosuperior tears, external rotation is weakened. The external rotation lag sign (ERLS) is performed in the sitting position with the arm at the side, the shoulder abducted 40° and the elbow flexed to 90° and
13
arm is externally rotated to maximum. If the patient cannot actively hold this position, infraspinatus and supraspinatus are likely to be torn. The specificity of this test can be improved after a subacromial lidocaine injection, whereas sensitivity of drop arm test and ERLS is decreased [4]. Hornblower’s test (performed with elbow flexed at a right angle and the arm abducted and externally rotated to 90°) helps identify teres minor involvement, while showing inability to actively hold this position. In patients with anterosuperior tears, significant weakness of the subscapularis will be noted. The Gerber’s liftoff Test mainly evaluates the lower subscapularis muscle, while Bear Hug Test and Belly Press Test assess upper muscle belly. In addition to these, patients may also demonstrate increased passive external rotation. Internal rotation lag sign is more sensitive and as specific as a lift-off test and magnitude of the lag correlated with the size of the rupture (as well for ERLS) [44]. Pathology of the long head of biceps (LHB) should be assessed with bicipital groove tenderness and resisted flexion of the arm with the elbow extended and the forearm supinated (Speed’s test). Hypotrophy in the suprascapular and infrascapular fossae should be looked as well as deltoid muscle atrophy and function. Suprascapular neuropathy is often found in massive RCT [22]. The compression of the nerve at the suprascapular notch is said to be caused by tendon retraction and/or dynamic nerve stretching and following pinching of the nerve at the notch, and sometimes by compressive lesion in suprascapular fossa (ganglia [75], scapulae fracture [26]). The symptoms include pain relieved by a local anaesthetic injection at the suprascapular notch, muscle atrophy, and a positive Lafosse test [51]. Magnetic resonance imaging (MRI) hypersignal in supra and infraspinatus and electrophysiological exploration modifications may be present too [51].
Imaging Various aspects to be assessed with radiologic investigations include the shape of the acromion, proximal migration of humeral head, grade of cuff tear arthropathy and osteoporosis. A complete evaluation includes an anteroposterior view both in glenohumeral (GH) and scapular planes, an outlet view, and an axillary view. Bigliani [7] classified three types of acromion morphology seen on an outlet view and type 3 was correlated with RCT [85]. Nevertheless, there are many concerns with this classification as it has poor intra- and interobserver agreement [71]. The Critical Shoulder Angle, evaluated on an anteroposterior radiograph, is associated with RCT when greater than 35° [62].
13
Knee Surg Sports Traumatol Arthrosc
Acromiohumeral interval (AHI) is the distance measured between the humeral head and undersurface of the acromion on a true anteroposterior view with the shoulder in neutral rotation. The normal range is 7–14 mm. AHI of 3 of supraspinatus, FDI of infraspinatus >2, coronal oblique tear distance >31 mm and sagittal oblique tear distance >32 mm) to be correlated with incomplete repair. Mobility of the tendon, however, is best assessed during arthroscopy.
Factors to be considered in deciding the management of massive RCT Massive RCT can be acute or chronic. It is very important to assess the history of symptoms, as it plays a vital role in the treatment strategy. Acute massive RCT, usually seen in young patients following a significant traumatic event, is usually not associated with muscle atrophy and tendon retraction and thus amenable to better chances of direct tendon to bone repair. In chronic rotator cuff tear, common in elderly individuals, patients usually experience an insidious onset of gradually worsening pain and weakness in the involved shoulder. Associated tendon retraction and muscle atrophy makes repair difficult. However, at times, such patients may have a functional RCT, presenting only because of recent appearance of pain, wherefore pain relief is the primary concern. Tendonitis of the LHB may be the most important source of pain in these patients. Though it is difficult to stratify patients according to age and to define approach to treatment, it cannot be denied that age is an important biological factor affecting the healing of the cuff tendon. Various studies have shown direct correlation between age and poor outcome following rotator cuff repair (RCR) [20, 84]. Physiological age also defines the demands, activity level and requirements of the patient. Impaired healing in chronic smokers should also be taken into consideration while planning treatment [78].
Management options There is increasing evidence that treatment of RCT should be individually tailored with respect to tear size, the aetiology and the patient’s age and demands. A treatment algorithm (Fig. 1) for the management of RCT is suggested, and below the current treatment options and their evidence are reviewed.
Non‑operative treatment Non-operative treatment is considered in older patients, with low functional demands and relatively few symptoms and/or who refuse or are unfit for surgery. Various nonoperative approaches include activity modification, local steroid injections and physiotherapy. Physiotherapy aims to relieve stiffness, if any and improve strength of the shoulder muscles. Other goals of therapy include re-education of muscle recruitment, scapular stabilization, coordination of muscle co-contraction and improvement of proprioception [67]. Structured deltoid rehabilitation program helps to improve the overhead abduction [56]. Zingg et al. [92] reported of 19 patients of Massive RCT treated conservatively. A satisfactory shoulder function was maintained at 4-year follow-up. The role of subacromial injections is controversial, although it may help relieve pain and facilitate physical therapy Failure of non-operative treatment over a period of around 6 months in chronic tears and around 6 to 8 weeks in acute traumatic tears should be considered for operative treatment.
Arthroscopic rotator cuff repair In spite of high re-tear rates following surgical repair of massive tears, various studies have shown better clinical outcomes with open or arthroscopic complete repair of massive RCT compared with non-operative or other surgical approaches [11, 33, 92]. Arthroscopic RCR is a preferred modality, especially in acute traumatic tears in young symptomatic patients with high functional demand (Fig. 3a). Early repair in traumatic tears is advised as delayed repair can lead to difficulties in surgery and fewer good results [43]. Arthroscopic evaluation for reparability of the cuff should be done with an assessment of the tendon retraction and elasticity and condition of the remnant tendon (Fig. 2c, d). Double row and suture bridge repair have lower re-tear rates in massive RCT [61]. Various methods to help complete repair have been described. These include margin convergence, single and double interval slides, biceps tendon augmentation and patch graft. [48, 57, 65, 74] The procedure should be combined with additional procedures such as subacromial decompression, acromioplasty and biceps tenotomy/tenodesis, if required.
Subacromial decompression Complete repair of the massive cuff tear may be limited by tendon retraction, poor tissue quality, muscle
13
Knee Surg Sports Traumatol Arthrosc
Symptomatic massive rotator cuff tear Clinical diagnosis X-ray (AP-view in neutral rotation) MRI/MRA
Chronic
Glenohumeral arthritis - non-operative treatment - if failure RSA +/- TT (LDF: if positive Horn Blower Sign, status of the Teres Minor)
Traumatic - in some cases nonoperative treatment - review at 6- 8 weeks
No Glenohumeral arthritis Non-operative treatment for 6 months - if failure: surgery AHD > 7mm SAD + BT + RCR (sometimes impossible, partial repair, TT) AHD< 7 mm: SAD+BT AHD < 4 mm RSA or LDF
Arthroscopic repair - always to be preferred before RSA or LDF - MRI (size of the tear, retraction, fatty iniltration, muscle atrophy) only to evaluate how dificult the repair will be, and to assess prognosis in terms of tendon healing - Age is not a key factor for the decision of a RCR
Fig. 1 Treatment of massive rotator cuff tear algorithm. MRI magnetic resonance imaging, MRA magnetic resonance arthrogram, RSA reverse shoulder arthroplasty, TT tendon transfer, LDF latissimus
dorsi flap, AHD acromiohumeral distance, SAD subacromial decompression, BT biceps tenotomy/tenodesis, RCR rotator cuff repair
atrophy and fatty degeneration. In 1992, Burkhart et al. [13] fluoroscopically imaged 12 shoulders of massive RCT and described three kinematic patterns. Stable fulcrum is the situation with a tear of the superior rotator cuff, where the intact anterior and posterior cuff provided a suspension bridge for coupled deltoid and cuff action on the shoulder. With this biomechanical model, they proposed that certain RCT in older individuals may be adequately treated with debridement and decompression, without repair. In 1995, Rockwood et al. [76] performed tendon debridement, subacromial decompression with anterior acromioplasty and resection of coracoacromial (CA) ligament in 53 shoulders with irreparable rotator cuff tear, which showed significant improvement in pain, function and range of motion, at the average follow-up of around 6 years. Gartsman [32] reported improved shoulder function in 79 % of patients treated with open debridement and decompression for irreparable RCT. However, he also reported them to be inferior to those with RCR. Zvijac et al. [93] and Kempf et al. [46] noted substantial deterioration in
pain relief, strength and functional outcome for short periods of time after arthroscopic debridement. The ideal patients for achieving improved functional status on subacromial decompression are patients with intact anterior and posterior cuff, which provide a stabilizing effect on the humeral head and permit the deltoid muscle to provide abduction force to the shoulder joint. Preoperative relief with a subacromial injection is a favourable prognostic finding for improvement after this operation. The patients need to be explained that the procedure is not to improve the existing strength of the cuff muscles, but to provide symptomatic relief. The procedure can also be ideal for an elderly patient with low functional demand, whose primary concern is relief of pain. Klinger et al. [50] identified preoperative superior humeral migration, presence of subscapularis tear, glenohumeral arthritis and decreased range of motion, as negative prognostic factors for the procedure. The procedure involves subacromial and subdeltoid bursectomy, debridement of the torn edges of the cuff tendon, with or without the removal of the intraarticular portion of the biceps tendon, depending upon its
13
Knee Surg Sports Traumatol Arthrosc Fig. 2 a Cuff tear arthropathy. b MRI showing retracted supraspinatus tendon retracted to the glenoid edge. c Arthroscopic view showing a L-shaped massive cuff tear. d Arthroscopic view of a U-shaped massive cuff tear
Fig. 3 a Arthroscopic repair with a suture anchor. b Arthroscopic partial repair with a side-to-side suture. c Reverse shoulder arthroplasty
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condition. Excision of the acromioclavicular (AC) joint or just it’s under surface can be performed if the AC joint is symptomatic on cross-body adduction. There is concern about the preservation of the CA ligament as it provides superior restraint to the humeral head in cases of irreparable RCT. Excision of the CA ligament may lead to anterosuperior migration of the humeral head, thus decreasing the AH interval and progression to cuff tear arthropathy in the non-stiff shoulder. The subacromial decompression, however, may be more complete after visualizing the anterior part of the acromion by releasing the CA ligament, and it also seems to reform or to reattach after resection or release [5].
LHB tenotomy Patients with a chronic rotator cuff tear frequently have anterior shoulder pain attributed to pathology of the long head of the biceps [83]. The stabilizing role of LHB on the glenohumeral joint has been supported or refused by various biomechanical, electromyographic (EMG) and in vivo studies [47, 54, 77, 89, 91]. Different pathologies of the LHB tendon seen with rotator cuff lesions include tendinitis, instability and partial or complete tear. In massive cuff tears, LHB is very often responsible for pain because it becomes entrapped between the proximally migrated humeral head and the acromion. So in cases of irreparable RCT, removal of intra-articular portion of the LHB has been proposed. This can be achieved either by biceps tenotomy or by tenodesis of the LHB in the bicipital groove. Biceps tenotomy or tenodesis can help improve postoperative shoulder motion due to alleviation of pain in cases where pain is the reason for decreased shoulder use and motion. However, it seems to have no major role in improving joint mechanics. In a retrospective study of 68 patients with irreparable RCTs treated arthroscopically with biceps tenotomy or tenodesis by Boileau et al. [8], 78 % patients were satisfied with the results. They reported an improvement in Constant score without significant loss of acromiohumeral distance (average 1.1 mm) or progression to glenohumeral arthritis. However, they contraindicated the procedure in cases of pseudoparalysis of the shoulder and severe rotator cuff arthropathy. Similarly, Walch et al. [87] in a study of 307 arthroscopic tenotomies in cases of irreparable RCT, presented improvement in Constant Score with 87 % patient satisfaction. Again there was no significant decrease in the AHI (average 1.3 mm) or accelerated progression to GH arthritis, at around the 5 years of follow-up. However, Klinger et al. [49] in a study of 41 patients of irreparable RCT treated with debridement with or without tenotomy showed no additional advantage of biceps tenotomy over improved function and shoulder scores.
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Knee Surg Sports Traumatol Arthrosc
In addition, various disadvantages of tenotomy have been proposed that include loss of biceps strength, cosmetic Popeye deformity and superior migration of the humeral head. The cosmetic deformity with distal migration of the LHB has been reported to be common with incidence ranging from 3 to 70 %. Also, the loss of strength is historically described to be of 20 % each for forearm supination and elbow flexion. Biceps tenodesis has been widely studied and described to deal with these problems associated with biceps tenotomy. However, considering the higher age in this group of patients and the dramatic relief from severe pain, cosmetic deformity and decreased strength are usually not bothersome to the patient. When comparing tenotomy with tenodesis in cases of RCR, De Carli et al. [18] showed that the Popeye sign associated with LHB tenotomy had no correlation with the final clinical outcome. Persistent pain from LHB may be more likely to have a more negative functional consequence than the absence of the LHB [82].
Suprascapular nerve release Release of the suprascapular nerve at the suprascapular notch remains controversial. Costouros et al. [22] showed reversal of suprascapular neuropathy after massive posterosuperior tears repair in seven patients. Mallon et al. [59] found similar results with postoperative EMG studies showing renervation potentials. Lafosse et al. [51] found no difference between cuff repair plus suprascapular nerve release and cuff repair alone.
Tuberoplasty and reverse arthroscopic subacromial decompression Having identified the role of the coracoacromial arch and coracoacromial ligament in providing anterosuperior stability to the head of the humerus, Fenlin et al. [29] in 2002 described procedure called tuberoplasty. They advised open resection of the exostosis of the greater tuberosity, to achieve smooth congruent acromiohumeral articulation and reported 95 % satisfactory results in 19 patients, with a minimum of 27 months of follow-up. They discouraged the use of this procedure in cases with pseudoparalysis of cuff muscles. Scheibel et al. coined the term reversed arthroscopic subacromial decompression (RASD) for the procedure that includes arthroscopic debridement of the subacromial space and glenohumeral joint, arthroscopic tuberoplasty, with or without biceps tendon tenotomy. Both Scheibel et al. and Verhelst et al. [80, 86] reported satisfactory midterm results with respect to pain relief, functional recovery and patient satisfaction following RASD. They noticed a decrease in the acromiohumeral distance
Knee Surg Sports Traumatol Arthrosc
postoperatively, which they, however, attributed to biceps tenotomy. In a retrospective analysis of 32 patients with at least 24 months of follow-up, Lee et al. [52] showed satisfactory results in 81 % patients operated with concomitant acromioplasty and tuberoplasty. Better clinical outcome is associated with preservation of preoperative AH interval and continuity in inferior scapula-humeral line. However, none of the studies could support that the positive result seen after the procedure was attributed exclusively to tuberoplasty, as it was also accompanied with bursectomy and treatment of biceps tendon. Currently these procedures are used only rarely in standard clinical practice.
Sub‑acromial spacer Senekovic et al. [81] introduced a novel technique by implanting a biodegradable spacer into the subacromial space after subacromial decompression. The aim of this device is to reduce the subacromial friction during shoulder movements. Twenty patients with massive irreparable RCT were implanted during a shoulder arthroscopy procedure. After a 3-year follow-up, a sustained benefit was observed especially in pain reduction. Constant score improved from 33.4 to 65.4 points.
Partial repair Although the above procedures can be helpful in elderly low-demand patients with a balanced rotator cuff, they fail to provide the strength required by young demanding patients. Burkhart [14], in his historical paper in 1991, proposed that the rotator cuff can be functional if the anterior and posterior forces are balanced and coupled with deltoid function. Massive RCT can be managed with creation of this force couple. This can be achieved by partial repair of the massive cuff tear, opening new horizon in the management of massive irreparable RCT [15]. Various studies have emphasized the importance of stable fulcrum kinematics and force coupling around the shoulder as the most important factor prediction outcome in rotator cuff repair, over mere closing of the hole in the tendon [15, 45]. In patients with posterosuperior or anterosuperior tears, repair of infraspinatus or subscapularis, respectively, can help achieve a biomechanically stable cuff (Fig. 3b). Burkhart et al. [17] showed satisfactory results in 13 of 14 patients with irreparable RCT managed with open partial repair at an average follow-up of around 21 months. The average UCLA score improved from 9.8 preoperatively to postoperative value of 27.6. The mean active elevation improved 90.8° following surgery. Duralde
et al. [25] in a retrospective study of 24 partial open rotator cuff repairs showed a 92 % patient satisfaction. There was a significant improvement in anterior shoulder elevation and pain relief. They noted no postoperative arthritis or reduction in the AHI. Porcellini et al. [73] treated 67 patients (mean age 47 years) with massive irreparable cuff tears by arthroscopic partial cuff repair. There was a significant improvement in the mean Constant score at the 3-year follow-up. There was no reduction of AHI in any of the patients; however, they cautioned limited utility of this procedure in patients with preoperative AHI of less than 5 mm. Arrigoni et al. [2] reviewed the results of 26 massive contracted immobile tears treated with functional repair of the cuff using an interval slide technique. After a mean follow-up of 39 months, the mean DASH (disabilities of arm, shoulder and hand) score was 20.9 (0.83–59.1) with a low residual level of pain. They stated that this technique improves markedly the quality of life without precluding more invasive consequent solutions. Thus partial cuff repair (open or arthroscopic) helps achieve improved symptomatic and functional results in cases with irreparable cuff tears. It may also help to maintain the AHI, avoiding progression to osteoarthritis. However, partial repair has no role in cases where the subscapularis or infraspinatus tears are irreparable or deltoid function is impaired. Its use in cases with AHI of
SHOULDER
Decision‑making in massive rotator cuff tear André Thès · Philippe Hardy · Klaus Bak
Received: 3 July 2014 / Accepted: 2 December 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V. Keywords Rotator cuff/injuries · Shoulder joint/patophysiology · Rotator cuff/surgery · Shoulder pain/surgery
involving complete rupture of at least two rotator cuff tendons [33]. Posterosuperior and anterosuperior are two most common tear types seen. The prevalence of massive tears reported in the literature has ranged from 10 to 40 % of all RCT [6]. With chronicity of the tear, tendons retract, and muscles atrophy with associated fatty infiltration, thus rendering the tear irreparable or with unfavourable results, even if repaired. RCT is said to be irreparable if preoperative imaging studies show tendon retraction to the glenoid edge and stage 3 and stage 4 fatty infiltration or muscular atrophy. The tear might also be judged irreparable preoperatively if tendons cannot be reinserted to their footprints despite mobilization and soft tissue release.
Physical examination Definition Rotator cuff tears (RCT) exceeding 5 cm were historically described as massive RCT [21]. The size of the individual, and in turn, the size of the overall tendon was not taken into consideration. However, more recently they have been defined and widely accepted as tears
A. Thès (*) Hôpital Ambroise Paré – APHP, 9, Avenue du Général de Gaulle, 92100 Boulogne–Billancourt, France e-mail: [email protected] P. Hardy Hôpital Ambroise Paré – APHP, Boulogne–Billancourt, France K. Bak Teres Hospitalet Parken, Copenhagen, Denmark
Patients with chronic tears exhibit variable limitations in active and passive shoulder motion. Stiffness after rotator cuff tear is common, and it may affect postoperative prognosis in some patients. Stiffness has been shown to be more common in posterosuperior and post-traumatic tears. Postoperative stiffness limited to the first 2 months seems to be of no importance to the end result [69] and seems to be rare after arthroscopic repair [24]. Supraspinatus weakness, checked with Empty Can Test (arm in 90° abduction, 30° horizontal adduction, and 90° internal rotation, elbow extended, thumb pointing towards floor, patient resists downward pressure from examiner, positive if pain or weakness appears), is usually almost always present. In patients with posterosuperior tears, external rotation is weakened. The external rotation lag sign (ERLS) is performed in the sitting position with the arm at the side, the shoulder abducted 40° and the elbow flexed to 90° and
13
arm is externally rotated to maximum. If the patient cannot actively hold this position, infraspinatus and supraspinatus are likely to be torn. The specificity of this test can be improved after a subacromial lidocaine injection, whereas sensitivity of drop arm test and ERLS is decreased [4]. Hornblower’s test (performed with elbow flexed at a right angle and the arm abducted and externally rotated to 90°) helps identify teres minor involvement, while showing inability to actively hold this position. In patients with anterosuperior tears, significant weakness of the subscapularis will be noted. The Gerber’s liftoff Test mainly evaluates the lower subscapularis muscle, while Bear Hug Test and Belly Press Test assess upper muscle belly. In addition to these, patients may also demonstrate increased passive external rotation. Internal rotation lag sign is more sensitive and as specific as a lift-off test and magnitude of the lag correlated with the size of the rupture (as well for ERLS) [44]. Pathology of the long head of biceps (LHB) should be assessed with bicipital groove tenderness and resisted flexion of the arm with the elbow extended and the forearm supinated (Speed’s test). Hypotrophy in the suprascapular and infrascapular fossae should be looked as well as deltoid muscle atrophy and function. Suprascapular neuropathy is often found in massive RCT [22]. The compression of the nerve at the suprascapular notch is said to be caused by tendon retraction and/or dynamic nerve stretching and following pinching of the nerve at the notch, and sometimes by compressive lesion in suprascapular fossa (ganglia [75], scapulae fracture [26]). The symptoms include pain relieved by a local anaesthetic injection at the suprascapular notch, muscle atrophy, and a positive Lafosse test [51]. Magnetic resonance imaging (MRI) hypersignal in supra and infraspinatus and electrophysiological exploration modifications may be present too [51].
Imaging Various aspects to be assessed with radiologic investigations include the shape of the acromion, proximal migration of humeral head, grade of cuff tear arthropathy and osteoporosis. A complete evaluation includes an anteroposterior view both in glenohumeral (GH) and scapular planes, an outlet view, and an axillary view. Bigliani [7] classified three types of acromion morphology seen on an outlet view and type 3 was correlated with RCT [85]. Nevertheless, there are many concerns with this classification as it has poor intra- and interobserver agreement [71]. The Critical Shoulder Angle, evaluated on an anteroposterior radiograph, is associated with RCT when greater than 35° [62].
13
Knee Surg Sports Traumatol Arthrosc
Acromiohumeral interval (AHI) is the distance measured between the humeral head and undersurface of the acromion on a true anteroposterior view with the shoulder in neutral rotation. The normal range is 7–14 mm. AHI of 3 of supraspinatus, FDI of infraspinatus >2, coronal oblique tear distance >31 mm and sagittal oblique tear distance >32 mm) to be correlated with incomplete repair. Mobility of the tendon, however, is best assessed during arthroscopy.
Factors to be considered in deciding the management of massive RCT Massive RCT can be acute or chronic. It is very important to assess the history of symptoms, as it plays a vital role in the treatment strategy. Acute massive RCT, usually seen in young patients following a significant traumatic event, is usually not associated with muscle atrophy and tendon retraction and thus amenable to better chances of direct tendon to bone repair. In chronic rotator cuff tear, common in elderly individuals, patients usually experience an insidious onset of gradually worsening pain and weakness in the involved shoulder. Associated tendon retraction and muscle atrophy makes repair difficult. However, at times, such patients may have a functional RCT, presenting only because of recent appearance of pain, wherefore pain relief is the primary concern. Tendonitis of the LHB may be the most important source of pain in these patients. Though it is difficult to stratify patients according to age and to define approach to treatment, it cannot be denied that age is an important biological factor affecting the healing of the cuff tendon. Various studies have shown direct correlation between age and poor outcome following rotator cuff repair (RCR) [20, 84]. Physiological age also defines the demands, activity level and requirements of the patient. Impaired healing in chronic smokers should also be taken into consideration while planning treatment [78].
Management options There is increasing evidence that treatment of RCT should be individually tailored with respect to tear size, the aetiology and the patient’s age and demands. A treatment algorithm (Fig. 1) for the management of RCT is suggested, and below the current treatment options and their evidence are reviewed.
Non‑operative treatment Non-operative treatment is considered in older patients, with low functional demands and relatively few symptoms and/or who refuse or are unfit for surgery. Various nonoperative approaches include activity modification, local steroid injections and physiotherapy. Physiotherapy aims to relieve stiffness, if any and improve strength of the shoulder muscles. Other goals of therapy include re-education of muscle recruitment, scapular stabilization, coordination of muscle co-contraction and improvement of proprioception [67]. Structured deltoid rehabilitation program helps to improve the overhead abduction [56]. Zingg et al. [92] reported of 19 patients of Massive RCT treated conservatively. A satisfactory shoulder function was maintained at 4-year follow-up. The role of subacromial injections is controversial, although it may help relieve pain and facilitate physical therapy Failure of non-operative treatment over a period of around 6 months in chronic tears and around 6 to 8 weeks in acute traumatic tears should be considered for operative treatment.
Arthroscopic rotator cuff repair In spite of high re-tear rates following surgical repair of massive tears, various studies have shown better clinical outcomes with open or arthroscopic complete repair of massive RCT compared with non-operative or other surgical approaches [11, 33, 92]. Arthroscopic RCR is a preferred modality, especially in acute traumatic tears in young symptomatic patients with high functional demand (Fig. 3a). Early repair in traumatic tears is advised as delayed repair can lead to difficulties in surgery and fewer good results [43]. Arthroscopic evaluation for reparability of the cuff should be done with an assessment of the tendon retraction and elasticity and condition of the remnant tendon (Fig. 2c, d). Double row and suture bridge repair have lower re-tear rates in massive RCT [61]. Various methods to help complete repair have been described. These include margin convergence, single and double interval slides, biceps tendon augmentation and patch graft. [48, 57, 65, 74] The procedure should be combined with additional procedures such as subacromial decompression, acromioplasty and biceps tenotomy/tenodesis, if required.
Subacromial decompression Complete repair of the massive cuff tear may be limited by tendon retraction, poor tissue quality, muscle
13
Knee Surg Sports Traumatol Arthrosc
Symptomatic massive rotator cuff tear Clinical diagnosis X-ray (AP-view in neutral rotation) MRI/MRA
Chronic
Glenohumeral arthritis - non-operative treatment - if failure RSA +/- TT (LDF: if positive Horn Blower Sign, status of the Teres Minor)
Traumatic - in some cases nonoperative treatment - review at 6- 8 weeks
No Glenohumeral arthritis Non-operative treatment for 6 months - if failure: surgery AHD > 7mm SAD + BT + RCR (sometimes impossible, partial repair, TT) AHD< 7 mm: SAD+BT AHD < 4 mm RSA or LDF
Arthroscopic repair - always to be preferred before RSA or LDF - MRI (size of the tear, retraction, fatty iniltration, muscle atrophy) only to evaluate how dificult the repair will be, and to assess prognosis in terms of tendon healing - Age is not a key factor for the decision of a RCR
Fig. 1 Treatment of massive rotator cuff tear algorithm. MRI magnetic resonance imaging, MRA magnetic resonance arthrogram, RSA reverse shoulder arthroplasty, TT tendon transfer, LDF latissimus
dorsi flap, AHD acromiohumeral distance, SAD subacromial decompression, BT biceps tenotomy/tenodesis, RCR rotator cuff repair
atrophy and fatty degeneration. In 1992, Burkhart et al. [13] fluoroscopically imaged 12 shoulders of massive RCT and described three kinematic patterns. Stable fulcrum is the situation with a tear of the superior rotator cuff, where the intact anterior and posterior cuff provided a suspension bridge for coupled deltoid and cuff action on the shoulder. With this biomechanical model, they proposed that certain RCT in older individuals may be adequately treated with debridement and decompression, without repair. In 1995, Rockwood et al. [76] performed tendon debridement, subacromial decompression with anterior acromioplasty and resection of coracoacromial (CA) ligament in 53 shoulders with irreparable rotator cuff tear, which showed significant improvement in pain, function and range of motion, at the average follow-up of around 6 years. Gartsman [32] reported improved shoulder function in 79 % of patients treated with open debridement and decompression for irreparable RCT. However, he also reported them to be inferior to those with RCR. Zvijac et al. [93] and Kempf et al. [46] noted substantial deterioration in
pain relief, strength and functional outcome for short periods of time after arthroscopic debridement. The ideal patients for achieving improved functional status on subacromial decompression are patients with intact anterior and posterior cuff, which provide a stabilizing effect on the humeral head and permit the deltoid muscle to provide abduction force to the shoulder joint. Preoperative relief with a subacromial injection is a favourable prognostic finding for improvement after this operation. The patients need to be explained that the procedure is not to improve the existing strength of the cuff muscles, but to provide symptomatic relief. The procedure can also be ideal for an elderly patient with low functional demand, whose primary concern is relief of pain. Klinger et al. [50] identified preoperative superior humeral migration, presence of subscapularis tear, glenohumeral arthritis and decreased range of motion, as negative prognostic factors for the procedure. The procedure involves subacromial and subdeltoid bursectomy, debridement of the torn edges of the cuff tendon, with or without the removal of the intraarticular portion of the biceps tendon, depending upon its
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Knee Surg Sports Traumatol Arthrosc Fig. 2 a Cuff tear arthropathy. b MRI showing retracted supraspinatus tendon retracted to the glenoid edge. c Arthroscopic view showing a L-shaped massive cuff tear. d Arthroscopic view of a U-shaped massive cuff tear
Fig. 3 a Arthroscopic repair with a suture anchor. b Arthroscopic partial repair with a side-to-side suture. c Reverse shoulder arthroplasty
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condition. Excision of the acromioclavicular (AC) joint or just it’s under surface can be performed if the AC joint is symptomatic on cross-body adduction. There is concern about the preservation of the CA ligament as it provides superior restraint to the humeral head in cases of irreparable RCT. Excision of the CA ligament may lead to anterosuperior migration of the humeral head, thus decreasing the AH interval and progression to cuff tear arthropathy in the non-stiff shoulder. The subacromial decompression, however, may be more complete after visualizing the anterior part of the acromion by releasing the CA ligament, and it also seems to reform or to reattach after resection or release [5].
LHB tenotomy Patients with a chronic rotator cuff tear frequently have anterior shoulder pain attributed to pathology of the long head of the biceps [83]. The stabilizing role of LHB on the glenohumeral joint has been supported or refused by various biomechanical, electromyographic (EMG) and in vivo studies [47, 54, 77, 89, 91]. Different pathologies of the LHB tendon seen with rotator cuff lesions include tendinitis, instability and partial or complete tear. In massive cuff tears, LHB is very often responsible for pain because it becomes entrapped between the proximally migrated humeral head and the acromion. So in cases of irreparable RCT, removal of intra-articular portion of the LHB has been proposed. This can be achieved either by biceps tenotomy or by tenodesis of the LHB in the bicipital groove. Biceps tenotomy or tenodesis can help improve postoperative shoulder motion due to alleviation of pain in cases where pain is the reason for decreased shoulder use and motion. However, it seems to have no major role in improving joint mechanics. In a retrospective study of 68 patients with irreparable RCTs treated arthroscopically with biceps tenotomy or tenodesis by Boileau et al. [8], 78 % patients were satisfied with the results. They reported an improvement in Constant score without significant loss of acromiohumeral distance (average 1.1 mm) or progression to glenohumeral arthritis. However, they contraindicated the procedure in cases of pseudoparalysis of the shoulder and severe rotator cuff arthropathy. Similarly, Walch et al. [87] in a study of 307 arthroscopic tenotomies in cases of irreparable RCT, presented improvement in Constant Score with 87 % patient satisfaction. Again there was no significant decrease in the AHI (average 1.3 mm) or accelerated progression to GH arthritis, at around the 5 years of follow-up. However, Klinger et al. [49] in a study of 41 patients of irreparable RCT treated with debridement with or without tenotomy showed no additional advantage of biceps tenotomy over improved function and shoulder scores.
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Knee Surg Sports Traumatol Arthrosc
In addition, various disadvantages of tenotomy have been proposed that include loss of biceps strength, cosmetic Popeye deformity and superior migration of the humeral head. The cosmetic deformity with distal migration of the LHB has been reported to be common with incidence ranging from 3 to 70 %. Also, the loss of strength is historically described to be of 20 % each for forearm supination and elbow flexion. Biceps tenodesis has been widely studied and described to deal with these problems associated with biceps tenotomy. However, considering the higher age in this group of patients and the dramatic relief from severe pain, cosmetic deformity and decreased strength are usually not bothersome to the patient. When comparing tenotomy with tenodesis in cases of RCR, De Carli et al. [18] showed that the Popeye sign associated with LHB tenotomy had no correlation with the final clinical outcome. Persistent pain from LHB may be more likely to have a more negative functional consequence than the absence of the LHB [82].
Suprascapular nerve release Release of the suprascapular nerve at the suprascapular notch remains controversial. Costouros et al. [22] showed reversal of suprascapular neuropathy after massive posterosuperior tears repair in seven patients. Mallon et al. [59] found similar results with postoperative EMG studies showing renervation potentials. Lafosse et al. [51] found no difference between cuff repair plus suprascapular nerve release and cuff repair alone.
Tuberoplasty and reverse arthroscopic subacromial decompression Having identified the role of the coracoacromial arch and coracoacromial ligament in providing anterosuperior stability to the head of the humerus, Fenlin et al. [29] in 2002 described procedure called tuberoplasty. They advised open resection of the exostosis of the greater tuberosity, to achieve smooth congruent acromiohumeral articulation and reported 95 % satisfactory results in 19 patients, with a minimum of 27 months of follow-up. They discouraged the use of this procedure in cases with pseudoparalysis of cuff muscles. Scheibel et al. coined the term reversed arthroscopic subacromial decompression (RASD) for the procedure that includes arthroscopic debridement of the subacromial space and glenohumeral joint, arthroscopic tuberoplasty, with or without biceps tendon tenotomy. Both Scheibel et al. and Verhelst et al. [80, 86] reported satisfactory midterm results with respect to pain relief, functional recovery and patient satisfaction following RASD. They noticed a decrease in the acromiohumeral distance
Knee Surg Sports Traumatol Arthrosc
postoperatively, which they, however, attributed to biceps tenotomy. In a retrospective analysis of 32 patients with at least 24 months of follow-up, Lee et al. [52] showed satisfactory results in 81 % patients operated with concomitant acromioplasty and tuberoplasty. Better clinical outcome is associated with preservation of preoperative AH interval and continuity in inferior scapula-humeral line. However, none of the studies could support that the positive result seen after the procedure was attributed exclusively to tuberoplasty, as it was also accompanied with bursectomy and treatment of biceps tendon. Currently these procedures are used only rarely in standard clinical practice.
Sub‑acromial spacer Senekovic et al. [81] introduced a novel technique by implanting a biodegradable spacer into the subacromial space after subacromial decompression. The aim of this device is to reduce the subacromial friction during shoulder movements. Twenty patients with massive irreparable RCT were implanted during a shoulder arthroscopy procedure. After a 3-year follow-up, a sustained benefit was observed especially in pain reduction. Constant score improved from 33.4 to 65.4 points.
Partial repair Although the above procedures can be helpful in elderly low-demand patients with a balanced rotator cuff, they fail to provide the strength required by young demanding patients. Burkhart [14], in his historical paper in 1991, proposed that the rotator cuff can be functional if the anterior and posterior forces are balanced and coupled with deltoid function. Massive RCT can be managed with creation of this force couple. This can be achieved by partial repair of the massive cuff tear, opening new horizon in the management of massive irreparable RCT [15]. Various studies have emphasized the importance of stable fulcrum kinematics and force coupling around the shoulder as the most important factor prediction outcome in rotator cuff repair, over mere closing of the hole in the tendon [15, 45]. In patients with posterosuperior or anterosuperior tears, repair of infraspinatus or subscapularis, respectively, can help achieve a biomechanically stable cuff (Fig. 3b). Burkhart et al. [17] showed satisfactory results in 13 of 14 patients with irreparable RCT managed with open partial repair at an average follow-up of around 21 months. The average UCLA score improved from 9.8 preoperatively to postoperative value of 27.6. The mean active elevation improved 90.8° following surgery. Duralde
et al. [25] in a retrospective study of 24 partial open rotator cuff repairs showed a 92 % patient satisfaction. There was a significant improvement in anterior shoulder elevation and pain relief. They noted no postoperative arthritis or reduction in the AHI. Porcellini et al. [73] treated 67 patients (mean age 47 years) with massive irreparable cuff tears by arthroscopic partial cuff repair. There was a significant improvement in the mean Constant score at the 3-year follow-up. There was no reduction of AHI in any of the patients; however, they cautioned limited utility of this procedure in patients with preoperative AHI of less than 5 mm. Arrigoni et al. [2] reviewed the results of 26 massive contracted immobile tears treated with functional repair of the cuff using an interval slide technique. After a mean follow-up of 39 months, the mean DASH (disabilities of arm, shoulder and hand) score was 20.9 (0.83–59.1) with a low residual level of pain. They stated that this technique improves markedly the quality of life without precluding more invasive consequent solutions. Thus partial cuff repair (open or arthroscopic) helps achieve improved symptomatic and functional results in cases with irreparable cuff tears. It may also help to maintain the AHI, avoiding progression to osteoarthritis. However, partial repair has no role in cases where the subscapularis or infraspinatus tears are irreparable or deltoid function is impaired. Its use in cases with AHI of
