More Information on Rotator Cuff Surgery.
Last updated Wednesday, January 26, 2005
Figure 13 - Active flexion as a function of cuff integrity at followup Figure 14 - Ability to perform activities of daily living as a function of cuff integrity at followup Figure 15 - Active flexion of the shoulders in which the repaired cuff was intact Results of treatment
Patients are usually pleased with the results of cuff surgery. Yet it
may be difficult to determine what aspect of the treatment program is
responsible for the improvement.Cuff integrity and quality of result of surgery It is known that many patients with deficient cuffs are surprisingly
comfortable and functional and, therefore, never undergo surgery. It is
also known that the tissue encountered at surgery is not infrequently
insufficient to allow a durable repair, yet the patient is improved
after surgery. These observations bring up the question of the
relationship of cuff integrity to the quality of the result after cuff
surgery. To help answer this question, we undertook a study of 105 of
our own surgical repairs of chronic rotator cuff tears in 89 patients
at an average of five years postoperatively. The patients' ages at the
time of repair averaged 60 years (range 32 to 80). Eighty-six (82%) of
the shoulders had no prior attempt at repair of the cuff.
In all of the surgeries an anterior-inferior acromioplasty was
carried out. The involved tendon or tendons were mobilized as
necessary. A bony trough was created in the humerus to reattach the
mobilized tendons. The site of reattachment was usually in the sulcus
adjacent to the humeral articular surface. In some cases the trough was
placed somewhat more medially, if after mobilization the tendons did
not reach their original anatomic attachment without undue tension when
the arm was at the side. The cuff was protected from active use for
three months postoperatively.
We correlated the functional result with the integrity of the cuff,
as determined by expert ultrasonography. Expert ultrasonography was
selected because of its superior accuracy to cost ratio and
practicality.
We characterized the status of the cuff at surgery and at follow-up
in terms of the integrity of the different tendons. No patient who had
a partial thickness tear repaired had a full thickness retear. In 80
percent of shoulders with repaired full-thickness supraspinatus tears,
the cuff was found to be intact at follow-up. Only 57 percent of cuffs
that had tears involving both the supraspinatus and infraspinatus were
intact at an average follow-up of six years. Less than one-third of the
cuffs which had tears involving all three major tendons were intact
after repair at an average of four years of follow-up. It is evident,
therefore, that the rotator cuff is more likely to develop a secondary
defect after the repair of a large tear. This may be a reflection of
the age of the patient, the quality of the tissue, the quantity of
tissue, the effect of tendon mobilization on tendon viability, or the
greater difficulty in getting healthy tendon securely implanted in bone
when there is a major deficiency in the cuff.
Patients were generally satisfied with the results of surgery, even
when expert sonography showed that the cuff was no longer intact. This
result indicates that patient satisfaction is not a reliable indication
of cuff integrity.
Shoulders with intact repairs at follow-up had the greatest range of
active flexion as compared to those with large recurrent defects (see
figure 13). These patients also demonstrated the best function in
activities of daily living. Where the cuff was not intact, the degree
of functional loss was related to the size of the recurrent defect (see
figure 14). These results indicate that integrity by ultrasound
correlates with cuff function.
Patients with intact repairs of large tears had just as good
function as did those with intact repairs of small tears. We found an
overall greater incidence of recurrent defects in shoulders with repeat
repairs. However, shoulders with intact cuffs after repeat repairs
functioned as well as did those with intact primary repairs (see figure
15).
From this study we concluded that the integrity of the rotator cuff
at follow-up (and not the size of the tear at the time of repair) is
the major determinant of the outcome of surgical repair. An intact
repair of a recurrent tear is likely to yield a result comparable to
that of an intact repair of a primary tear. Likewise, intact repairs of
large tears yield results comparable to intact repairs of small tears.
The chances of the repair of a large tear remaining intact, however,
are not as good as those for a small tear. Older patients tended to
have larger tears and to have a higher incidence of recurrent defects.
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