Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

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Full thickness cuff tears

Diagnosis

A full thickness defect of one or more of the cuff tendons can be demonstrated on ultrasonography, arthrography, MRI, arthroscopy or open surgery.

While the diagnosis is not difficult, a number of key factors must be considered in selecting the appropriate treatment for cuff defects.Some defects cannot be repaired, because as McLauglin pointed out they offer only "rotten cloth to sew" (McLaughlin, 1944, McLaughlin, 1962, McLaughlin, 1963, McLaughlin and Asherman, 1951) The recognition that full thickness cuff tears may exist without clinical symptoms (Harryman, Mack, 1991, Matsen, Lippitt, 1994, Milgrom, Schaffler, 1995, Pettersson, 1942, Sher, Uribe, 1995) cautions that cuff defects need not be repaired just because they are there.

Nonoperative treatment

Substantial data are available on the results of nonoperative treatment for full thickness cuff defects. The programs generally include some combination of "compound tincture of time" along with physical therapy, administration of nonsteroidal anti-inflammatory medications, rest, avoidance of precipitating activities, and steroid injections.

Improvement with nonoperative management was noted to be 33 per cent in Wolfgang's series (Wolfgang, 1978), 44 percent in Takagishi's series (Takagishi, 1978), 59 percent in Samilson and Binder's series (Samilson and Binder, 1975) and 90 percent in Brown's series. (Brown, 1949)

Steroid injections do not seem to be a major enhancement to the nonoperative management program. Although Weiss (Weiss, 1981) presented some evidence that patients with arthrographically proven cuff tears are symptomatically improved by intra-articular injections, there is little evidence for a protracted benefit from this method. Other observers found that steroid injections offered no benefit to patients with cuff tears. Coomes and Darlington, (Coomes and Darlington, 1976, Darlington and Coomes, 1977) Lee and colleagues, (Lee, Lee, 1974) and Connolly (Connolly, 1972) compared steroid and local anesthetic injections in patients with tendinitis and tendon tears. They found a small subjective benefit in relief of pain but no effect on function in the steroid-treated group.

There has been a recent resurgence of reports confirming the value of nonoperative management for chronic cuff tears. Bartolozzi et al (Bartolozzi, Andreychik, 1994) studied the factors predictive of outcome in 136 patients with cuff disease who were treated nonoperatively. Mean followup was 20 months (range, 6-41 months). The authors found 66-75% good or excellent results with indication that the clinical result improved significantly as followup duration increased. Prognostic factors that were associated with an unfavorable clinical outcome included a rotator cuff tear over one square centimeter, a history of pretreatment clinical symptoms for over one year duration, and significant functional impairment at initial presentation.

Hawkins and Dulap (Hawkins and Dunlop, 1995)found that over half of patients with full thickness cuff tears treated with a supervised nonoperative program of rotator strengthening exercises obtained satisfactory results at an average of four years followup. Bokor et al (Bokor, Hawkins, 1993) managed 53 patients (average age 62 years) with full thickness cuff tears documented arthroscopically using a program of non-steroidal medications, stretching, strengthening, and occasional steroid injections. At an average of 7.6 years later, thirty-nine of the 53 patients (74%) had only slight or no shoulder discomfort. Of the 28 shoulders presenting within three months of injury, 24 (86%) were rated as satisfactory at the time of latest evaluation. Of the 16 patients who initially had had shoulder pain for over 6 months, only nine (56%) were rated as satisfactory. Most patients showed improvement with regard to their ability to perform activities of daily living. Average active total elevation was 149 degrees compared with 121 degrees at initial presentation. Thirty-two of the 34 patients examined (94%) had evidence of weakness on muscle testing and 19 (56%) had demonstrable muscle atrophy.

Itoi and Tabata (Itoi and Tabata, 1992a) followed 62 shoulders with complete rotator cuff tears which were treated conservatively from 1980 until 1989. The follow-up period averaged 3.4 years. Fifty-one shoulders (82%) rated satisfactory. The overall scores of pain, motion, and function improved significantly. The authors concluded that conservative treatment affords satisfactory results when it is given to the patients with well-preserved motion and strength, although in some cases function may deteriorate with time.

In our own practice we have followup data on 56 patients (23 female, 33 male) with full thickness cuff tears managed nonoperatively. The average age was 61 ± 10 years (range 45-84) and the mean followup time was 25 months. The initial and final responses to the questions of the Simple Shoulder Test are shown in table 1, below.

Table 1

Taken together these results clearly offer encouragement for a trial of nonoperative management for chronic full thickness cuff tears, particularly in cases where the prospect of achieving a durable cuff repair appears doubtful.

Operative treatment

Cuff repair

Patient Selection

Substantial information bearing on the potential reparability of a rotator cuff defect can be obtained from the history along with the physical examination and plain radiographs (see table 2).

Table 2

Acute tears in younger, healthy individuals without prior shoulder disease are more likely to be repairable. Long-standing tears associated with major weakness in older patients carry a poorer prognosis. The prognosis for a durable repair is even worse if the history reveals the administration of local or systemic steroids, smoking, or difficulties in healing previous injuries or surgeries.

These guidelines are derived from our experience, but also are supported by the literature. Postacchini et al (Postacchini, Perugia, 1992) found in a study of 73 cuff repairs, that while seventy-three percent of the cases had satisfactory results, rotator cuff repair is almost always successful in patients with more than 60 degrees of active arm flexion and either small or medium-size tears. Less than two-thirds of the patients with major tears and less than 60 degrees of motion achieved satisfactory results, particularly if there was cuff muscle atrophy.

Watson (Watson, 1985) reviewed the surgical findings in 89 patients with major ruptures of the cuff. He found that all seven patients who had had no local steroid injections had strong residual cuff tissue. Thirteen of 62 patients having one to four steroid injections had soft cuff tissue that held suture poorly; 17 of the 20 patients having more than four steroid injections had very weak cuff tissue; these shoulders with weak cuff tissue had poorer results after surgical repair.

Misamore et al (Misamore, Ziegler, 1995) evaluated 107 consecutive cuff repairs, including 24 patients on Workers' Compensation and 79 who were not. Although other factors such as the age and sex of the patients, the size of the tear of the rotator cuff, and the preoperative strength, pain, and active range of motion of the shoulder were comparable, only 54 per cent of the shoulders covered by Workers' Compensation were rated good or excellent, compared with 92 per cent who were not. Forty-two per cent of the patients on Workers' Compensation returned to full activity, compared with 94 per cent who were not.

Samilson and Binder listed the following most reasonable indications for operative repair of non-acute cuff tears: (Samilson and Binder, 1975)

1. a patient "physiologically" younger than 60 years,
2. clinically or arthrographically demonstrable full-thickness cuff tear,
3. failure of patient to improve under nonoperative management for a period not less than six weeks,
4. patient's need to use the involved shoulder in overhead elevation in his or her vocation or avocation,
5. full passive range of shoulder motion,
6. patient's willingness to exchange decreased pain and increased external rotator
strength for some loss of active abduction, and
7. ability and willingness of the patient to cooperate.

Grana et al (Grana, Teague, 1994) reviewed their experience with 54 patients having open repair of chronic cuff tears. They concluded that pre repair arthroscopic evaluation did not affect the functional outcome, but did increase the cost by about $2000 per patient.

Laboratory studies on repair techniques

Gerber et al (Gerber, Schneeberger, 1994) studied the mechanical properties of several techniques of tendon-to-bone suture employed in rotator cuff repair in cadavers. Two simple stitches failed at 184 N; four simple stitches failed at 208 N. Two Mason-Allen stitches failed at 359 N. These results indicate that in addition to the quality of the bone and the quality of the cuff tissue, the number of sutures and the suture technique affect the load to failure.

Technique of cuff repair

A most important recent study bearing on the technique of cuff repair was published by Zuckerman et al. (Zuckerman, Leblanc, 1991) These authors used a cadaver model to determine the effect of arm position and capsular release on the tension in the repaired tendon as reflected by strain gauges on the greater tuberosity. They found that with repair of supraspinatus-only defects, tension in the repair increased significantly as the arm was lowered from 30 to 15 degrees of abduction. Release of the capsule from the glenoid rim (see figures 51 and 52) significantly reduced the tension at 15 and 0 degrees of abduction. For tears involving the supraspinatus and infraspinatus, abduction of at least 30 degrees was required to reduce tension in the repair. Release of the capsule from the glenoid (figure 52) resulted in a 30% reduction in repair tension when the arm was adducted.

Warner et al (Warner, Krushell, 1992) studied the relationships of the suprascapular nerve to the cuff muscles in thirty-one cadaveric shoulders. The suprascapular nerve ran an oblique course across the supraspinatus fossa, was relatively fixed on the floor of the fossa, and was tethered underneath the transverse scapular ligament. In eighty-four percent of the shoulders, there were no more than two motor branches to the supraspinatus muscle, and the first was always the larger of the two. In eighty-four per cent, the first motor branch originated underneath the transverse scapular ligament or very near it. In one shoulder (3 percent), the first motor branch passed over the ligament. The average distance from the origin of the long tendon of the biceps to the motor branches of the supraspinatus was three centimeters. In forty-eight percent, the infraspinatus muscle had three or four motor branches of the same size. The average distance from the posterior rim of the glenoid to the motor branches of the infraspinatus muscle was two centimeters. The motor branches to the supraspinatus muscle were fewer, usually smaller, and significantly shorter than those to the infraspinatus muscle. The standard anterosuperior approach allowed only one centimeter of lateral advancement of either tendon and limited the ability of the surgeon to dissect safely beyond the neurovascular pedicle. The advancement technique of Debeyre et al., or a modification of that technique, permitted lateral advancement of each muscle of as much as three centimeters and was limited by tension in the motor branches of the suprascapular nerve. In some situations, the safe limit of advancement may be even less. The authors concluded that lateral advancement of the rotator cuff is limited anatomically and may place the neurovascular structures at risk.

Surgical approaches

The surgical approaches to the complete cuff tear vary substantially. These include a saber cut, (Codman, 1911) an anterior approach through the acromioclavicular joint, (Bateman, 1963) a posterior approach, (Debeyre, Patte, 1965) and an "extensile" approach. (Ha'eri and Wiley, 1980) Many authors prefer the anterior acromioplasty approach, taking care to preserve the deltoid attachment and acromial lever arm. (Cofield, 1981, Cofield, 1985, Neer, 1972, Neer and Marberry, 1981) This technique provides excellent exposure of the common sites of lesions--the anterior cuff, biceps groove, undersurface of the acromion, and acromioclavicular joint.

Packer and coworkers, (Packer, Calvert, 1983) reporting on 63 cuff repairs followed for an average of 32.7 months, found that those performed with acromioplasty yielded more pain relief than cuff repair without acromioplasty. If greater access to the supraspinatus is needed, the acromioclavicular joint can be excised. (Neer, 1983) Debeyre and associates (Debeyre, Patte, 1965) described a posterior approach with acromial osteotomy. Ha'eri and Wiley described an approach that is extensile through the acromioclavicular joint to the supraspinous fossa. (Ha'eri and Wiley, 1980)

Repair methods

Operative techniques for repairing full-thickness cuff defects include tendon-to-tendon repair and tendon advancement to bone. McLaughlin (McLaughlin, 1944, McLaughlin, 1962, McLaughlin, 1963, McLaughlin, 1994, McLaughlin and Asherman, 1951)described his approaches to transverse ruptures (reinsertion into bone), longitudinal rents (side-to-side repair), and tears with retraction (side-to-side repair followed by reinsertion of the retracted portion of cuff into the head wherever it will reach with ease with the arm at the side). Although many of his principles are still applied today, most authors would not concur with his use of the transacromial approach or his belief that "distinct benefits are gained by excising and discarding the outer fragment of the divided acromion." (McLaughlin, 1944, McLaughlin, 1963) Hawkins and colleagues used side-to-side repair for small tears and tendon-to-bone repair for larger defects. (Hawkins, Misamore, 1985) Cofield has emphasized the identification of the tear pattern and the use of direct repair and flaps as indicated by the tear pattern. (Cofield, 1982, Cofield, 1985) Nobuhara et al (Nobuhara, Hata, 1994) reviewed, at an average of seven years, one hundred eighty-seven patients (189 shoulders) treated surgically for massive rotator cuff tears using either a tendon-to-tendon repair or the McLaughlin procedure. Ninety-five per cent of the patients were 45 years or older. Excellent or good functional results were attained in 93% of patients. Thirty-three percent of those who underwent tendon to tendon repair complained of pain after overuse compared with only 18% who had the McLaughlin Procedure.

A number of authors have described extensive tendon mobilization or advancement of major tendon flaps to repair large defects. Cofield recommended the transposition of the subscapularis for repair of large cuff defects. (Cofield, 1982) In this technique the subscapularis and the anterosuperior capsule are freed from the anteroinferior capsule, leaving the middle and inferior glenohumeral ligaments intact. The tendon is then transferred superiorly to the anterior aspect of the greater tuberosity. Most patients required postoperative protection in an abduction splint or cast for four to five weeks. These patients, who had severe symptoms of pain and limitation of function preoperatively, had less pain and slight improvement in active motion; 12 of 26 patients gained more than 30 degrees of active abduction, and 4 lost this amount of motion. Two patients disrupted their repair during the acute postoperative period. Of the twenty-six, twenty-five were satisfied with the procedure.

Karas and Giachello (Karas and Giachello, 1996) recently reported their results with twenty patients treated with acromioplasty and subscapularis transfer for massive (>5 cm) tears of the cuff in which direct tendon to bone reconstruction could not be achieved. At a mean of 30 months after surgery, seventeen patients were satisfied. Nine had weakness and discomfort with overhead activities and two had lost active elevation despite relief of pain. The authors found this procedure useful when "traditional" methods of repair were insufficient, but cautioned against its use when patients had full functional elevation preoperatively.

In less than five per cent of his cuff repairs, Neer (Neer, 1983) shifted the infraspinatus and upper half of the subscapularis superiorly to close a defect in the supraspinatus, leaving the lower half of the subscapularis, the teres minor, and the intervening capsule intact. He described the use of a second incision posteriorly for better mobilization of the infraspinatus toward the top of the greater tuberosity. Neviaser and Neviaser (Neviaser and Neviaser, 1982) described the transposition of both the subscapularis and the teres minor to close the defect. Debeyre and colleagues and others described the use of a supraspinatus muscle slide to help close major cuff defects. (Debeyre, Patte, 1965, Ha'eri and Wiley, 1980, Ha'eri and Wiley, 1981) Ha'eri and Wiley (Ha'eri and Wiley, 1981) used the supraspinatus advancement technique of Debeyre; most of their 18 patients achieved satisfactory results.

Latissimus transfers as described for Erb's palsy (Phipps and Hoffer, 1995) have been used to manage large cuff defects. Gerber (Gerber, 1992) reported on sixteen irreparable, massive rotator cuff tears treated with latissimus dorsi transfer and reviewed after an average of 33 months. Pain relief was satisfactory in 94% of the shoulders at rest and in 81% on exertion. Flexion was 83 degrees preoperatively and 135 degrees postoperatively. If the subscapularis was torn and could not be adequately repaired, latissimus dorsi transfer was of no value. In cases with good subscapularis function but irreparable defects in the external rotator tendons, restoration of approximately 80% of normal shoulder function was obtained.

A flap of deltoid has been used to cover cuff defects. Thur and Julke (Thur and Julke, 1995) analyzed the results of shoulder reconstruction using an anterolateral deltoid muscle flap plasty in 100 patients with rotator cuff lesions which were at least 5 x 5 cm in size. Ninety per cent of patients were satisfied. Shoulder function improved significantly, and 72% recovered their strength completely. Most of the patients were able to work after six months. The overall result was good to very good in 83%.

Dierickx and Vanhoof (Dierickx and Vanhoof, 1994) reviewed twenty patients with a painful massive, irreparable rotator cuff tear treated with an open partial acromionectomy and an anterior deltoid muscle inlay flap. After follow-up averaging 12 months, 17 out of 20 patients were satisfied, and the UCLA score improved from an average of 9.35 to an average of 25.7 Active forward flexion improved in 17, and strength of forward flexion improved in 15 patients.

As an alternative approach to surgery for massive tears, Burkhart et al (Burkhart, Nottage, 1994) repaired the margins of the tear to restore force transmission, believing that complete coverage of the defect was not essential. In fourteen patients this procedure led to improvement in active elevation from 59.6 degrees to 150.4 degrees. Strength improved an average of 2.3 grades on a 0-to-5-point scale. The average score on the UCLA Shoulder Rating Scale improved from a preoperative value of 9.8 to a postoperative value of 27.6. All but one patient was very satisfied

Some authors have used biological and prosthetic grafts to repair large cuff defects. Neviaser, (Neviaser, 1971) Bush, (Bush, 1975) and McLaughlin and Asherman (McLaughlin and Asherman, 1951) employed grafts from the long head tendon of the biceps to patch cuff defects. Ting and coworkers (Ting, Jobe, 1987) found that the electromyographic activity and size of the long head tendon of the biceps is significantly greater in patients with cuff tears compared with the uninjured shoulder. Their study suggests that the long head of the biceps may be a greater contributor to abduction and flexion in the shoulder with cuff tear than in the normal shoulder and that sacrificing the intracapsular portion of the tendon for grafting material may not be advisable. Heikel (Heikel, 1968) used fascia lata to close cuff defects, and both Heikel and Bateman described the use of the coracoacromial ligament. Freeze-dried rotator cuff has been used by Neviaser and coworkers (Neviaser, Neviaser, 1978) In this report, sixteen patients with massive tears had cadaver grafts, producing decrease in nocturnal pain in all sixteen. The change in shoulder function and strength was not reported. Post (Post, 1985) reported on preliminary results in five patients in whom a carbon fiber prosthesis was used to manage massive cuff deficiencies. Three had excellent to good results and two failed, one because of possible infection. The author states that these results are no better than with conventional repairs. Finally, synthetic cuff prostheses have been used by Ozaki and colleagues (Ozaki, Fujimoto, 1984) and Post. (Post, 1985) The former found that of 168 shoulders with cuff tears (almost all of which were "chronic" and "massive"), twenty-five could not be repaired by standard surgical techniques. Their defects were typically 6 * 5 cm. These patients had cuff reconstruction with Teflon fabric, Teflon felt, or Marlex mesh. This procedure was followed by a structured postoperative program, including the use of an abduction orthosis to keep the arm elevated in the plane of the scapula for two to three months and continued rehabilitation for three to six months. At an average of 2.1 years follow-up, 23 of 25 patients gained 120 to 160 degrees of abduction (the other 2 having had axillary nerve injury). Whereas twenty had reported continual or intolerable pain preoperatively, pain was absent in twenty-three patients at follow-up. The authors found that results were better with the thicker felt and now recommend the use of 3- to 5-mm-thick Teflon felt in their patients with massive defects.

Some authors recommend postoperative immobilization in an abduction splint, (Bakalim and Pasila, 1975, Bateman, 1963, Debeyre, Patte, 1965, Heikel, 1968) while others advise against this. (McLaughlin, 1963, Nixon and DiStefano, 1975)

Results of treatment

Neer and coworkers (Neer, Flatow, 1988) reported the results of 233 primary cuff repairs with an average follow-up of 4.6 years. Results were excellent (essentially normal), in 77 per cent, satisfactory in 14 per cent, and unsatisfactory in 9 per cent. The unsatisfactory ratings were usually due to lack of strength rather than pain and usually occurred in patients with long-standing, neglected tears. Hawkins and coworkers found that 86 per cent of their patients had relief of pain after repair. (Hawkins, Misamore, 1985) Recovery of strength was more common in patients with smaller tears. (Hawkins, Misamore, 1985) In other series pain relief was reported in 58 per cent, (Peterson, 1982) 60 per cent, (Heikel, 1968) 66 per cent, (Debeyre, Patte, 1965) 74 per cent, (Godsil and Linscheid, 1970) and 85 per cent. (Samilson and Binder, 1975)

Gore and associates (Gore, Murray, 1986) reviewed the results from 63 primary cuff repairs with an average of 5.5 years' follow-up. The shoulders without a traumatic onset were repaired an average of 32 months after the onset of symptoms, whereas those with a traumatic onset were repaired an average of 6 months after the traumatic episode. The surgical approach and technique varied somewhat but usually consisted of acromioplasty and tendon repair to bone or to adjacent tendon. Six shoulders had biceps tendon grafts. Most shoulders were immobilized at the side for four to six weeks, but twelve had immobilization in abduction. Subjective improvement was seen in 95 per cent of shoulders with repaired cuffs. Flexion averaged 126 degrees actively and 147 degrees passively. Most patients had marked relief of pain and minimal or no problems with activities of daily living. Patients with tears less than 2.5 cm long had better results than those with larger tears. The superior results with repair of smaller tears is consistent with the observations of Godsil and Linscheid (Godsil and Linscheid, 1970) and Post and coworkers. (Post, Silver, 1983) Watson (Watson, 1985) found that results were worse in patients with larger cuff defects, with multiple preoperative steroid injections, and with preoperative weakness of the deltoid. Ellman and colleagues (Ellman, Hanker, 1986) reported a 3.5-year follow-up of 50 patients having rotator cuff repair. Techniques of repair included tendon-to-tendon suture, reimplantation into bone, grafts, and tendon flaps. Comfort and function were usually improved by these procedures. Their report provides additional support for timely repair: patients with symptoms of longer standing had larger tears and more difficult repairs. Shoulders with Grade 3 or less strength of abduction before surgery had poorer results; those with an acromiohumeral interval of 7 mm or less also had poorer results. Arthrography was not consistently accurate in estimating the size of the tear.

Hawkins found that acromioplasty and cuff repair relieved the patients' pain and restored the ability to sleep on the affected side in most patients. Seventy-eight per cent were able to use the arm above shoulder level after surgery, whereas only sixteen per cent were able to do so before surgery. Hawkins and coworkers (Hawkins, Misamore, 1985) found that the results of cuff repair were worse in patients on Workmen's Compensation. Only two out of fourteen patients unable to work because of cuff tears could return to work after surgery, whereas eight of nine patients not on Workmen's Compensation did return to work after operation. Other series of cuff repairs include those of Codman, (Codman, 1934b) Moseley, (Moseley, 1952) Neviaser, (Neviaser, 1971) Wolfgang, (Wolfgang, 1978) Bakalim and Pasila, (Bakalim and Pasila, 1975) Bassett and Cofield, (Bassett and Cofield, 1983) Earnshaw and coworkers, (Earnshaw, Desjardins, 1982) Packer and associates, (Packer, Calvert, 1983) Post and colleagues, (Post, Silver, 1983) Samilson and Binder, (Samilson and Binder, 1975) and Weiner and Macnab. (Weiner and Macnab, 1970a) Cofield (Cofield, 1985) averaged the results of many reports in the literature and found that pain relief occurred in 87 per cent (range 71 to 100 per cent), and patient satisfaction averaged 77 per cent (range 72 to 82 per cent). The reader is encouraged to compare and contrast these results with those following non operative treatment which was described earlier in this chapter.

Some reports focus on the results of acute repairs. Bakalim and Pasila reviewed their series of 55 patients with arthrographically verified rupture of the cuff tendons treated surgically. (Bakalim and Pasila, 1975) Whereas only half of the workers were able to return to their previous work, all workers operated upon within one month of a traumatic rupture of the cuff were able to return to their jobs. Bassett and Cofield (Bassett and Cofield, 1983) presented a series of 37 patients having surgical repair within three months of cuff rupture. At an average follow-up of seven years, active abduction averaged 168 degrees for those having repair within 3 weeks and 129 degrees for those having repair within 6 to 12 weeks after injury. Patients with small tears averaged 148 degrees and those with large tears averaged 133 degrees of elevation. The authors concluded that surgical repair must be considered within 3 weeks of injury to obtain maximal return of shoulder function.

The importance of continued postoperative exercises is emphasized by the data of Walker and associates, (Walker, Couch, 1987) who measured the isokinetic strength of the shoulder after cuff repair. They found a significant increase in strength between 6 and 12 months after surgery. One year after operation, abduction was 80 per cent of normal and external rotation was 90 per cent of normal. Brems (Brems, 1987 Jan) found that the strength of external rotation after cuff repair averaged 20 per cent at three months, 38 per cent at six months, 57 per cent at nine months, and 71 per cent at one year.

Rokito et al (Rokito, Zuckerman, 1996) followed at 3 month intervals the isokinetic strength of 42 patients having repair of full thickness defects. The torques for the operated shoulder (as a percent of the opposite uninvolved shoulder) are shown in table 3).

Table 3

Recovery of strength correlated primarily with the size of the tear: for small and medium sized tears, the recovery of strength was almost complete during the first year. For large and massive tears, recovery was slower and less consistent. The authors concluded that at least a year is required to regain strength after a cuff repair.

Kirschenbaum et al (Kirschenbaum, Coyle, 1993) came up with very similar results in their evaluation of 25 shoulders tested isokinetically with a pain-relieving subacromial lidocaine injection before and after cuff repair (see table 4).

Table 4

The analysis of the results of cuff repair is hampered by lack of a uniform approach to the description of

1. the shoulder's preoperative functional status,
2. the magnitude and location of the cuff defect,
3. the quality of the tissue available for repair,
4. the anatomical integrity at followup, and
5. the post operative functional status.

The need for correlation of anatomical and functional outcomes is demonstrated by the surprisingly good results obtained with debridement for irreparable cuff tears. Neer, (Neer, 1972) Rockwood, (Rockwood, 1983 and 1987) and others have reported that in certain cases when the cuff cannot be repaired, comfort and function may be improved by debridement of the shreds of residual cuff and subacromial smoothing followed by muscle strengthening and range-of-motion exercises. The realization that patients may have good function and comfort in the presence of major cuff defects makes the definition of "success" after a cuff repair challenging.

Interestingly, there have been few follow-up studies of the relationship of cuff integrity to the quality of the result after cuff surgery. Lundberg (Lundberg, 1982) followed 21 cuff repairs with arthrography and found leakage in 7. The results in the leaking cuffs were not as good as in those with sealed cuffs. Calvert and associates (Calvert, Packer, 1986) performed double-contrast arthrograms in 20 patients at an average of 30 months after operative repair of a torn cuff. In 17 of 20 shoulders the contrast leaked into the bursa, indicating a cuff defect. These defects were estimated to be small in 8, medium in 8, and large in 2. However, 17 patients had complete relief of pain, 15 had a full range of shoulder elevation, and 10 felt that they had regained full function. The authors suggest that a complete closure of the cuff is not essential for a good functional result and that arthrography may not be helpful in the investigation of failure of repair.

Ultrasonography appears to offer a greater potential for evaluating postoperative cuff integrity. Mack and coworkers (Mack, Nuberg, 1987) investigated the accuracy of ultrasonography in this regard. In a group of symptomatic postoperative shoulders that were subsequently reoperated, ultrasonography accurately diagnosed recurrent cuff tears in 25 of 25 cases and correctly confirmed cuff integrity in 10 of 11. Using expert ultrasonography Harryman (Harryman, Mack, 1991) correlated the integrity of the cuff with functional status following 105 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). The numbers of patients in each age decade were as follows: 30-39:l, 40-49:16, 50-59:31, 60-69:42, 70-79:14, and 80-89:1. 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.

The status of the cuff at surgery and at follow-up was characterizedin terms of the integrity of the different tendons: Type O was a cuff of normally full thickness, Type 1A was thinning or a partial-thickness defect of the supraspinatus tendon, Type 1B was a full-thickness defect of the supraspinatus, Type 2 wasa full thickness two-tendon defect involving the supraspinatus and the infraspinatus, and Type 3 was a full-thickness defect involving three tendons: the supraspinatus, infraspinatus, and subscapularis.

The results are summarized in table 5.

Table 5

Integrity of Cuff Repairs at Follow-up

(Reproduced with permission from Matsen FA III et al: Practical Evaluation and Management of the Shoulder. W.B. Saunders Company, Philadelphia, PA, 1994.)

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 (no full thickness defect) 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.

Patients were generally satisfied with the results of surgery, even when expert sonography showed that the cuff was no longer intact (see table 6).

Table 6
Influence of Size of Cuff Defect at Follow-up on Active Range, Comfort
and Satisfaction at Follow-up

Active Range of Motion at Follow-up

(Reproduced with permission from Matsen FA III et al: Practical Evaluation and Management of the Shoulder. W.B. Saunders Company, Philadelphia, PA, 1994.)

Follow-up

Shoulders with intact repairs (no full thickness defect) at follow-up had the greatest range of active flexion (129±20 degrees) as compared to those with large recurrent defects (71±41 degrees) (see figure 53).Shoulders with intact repairs 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 54).

Although the chances of having an intact repair at followup was less for those with large tears, patients with intact repairs of large tears had just as good function as did those with intact repairs of small tears. Similarly there was an overall greater incidence of recurrent defects in shoulders with repeat repairs, yet, shoulders with intact cuffs after repeat repairs functioned as well as did those with intact primary repairs.

From this study it can be concluded that

1. the integrity of the rotator cuff at follow-up (and not the size of the tear at the time of repair) is a major determinant of the functional outcome of surgical repair,
2. that the chances of the repair of a large tear remaining intact, however, are not as good as those for a small tear, and
3. that older patients tended to have larger tears and to have a higher incidence of recurrent defects (see table 7).

Table 7

Influence of Size of Cuff Tear Repaired at Surgery
on Active Range of Motion at Follow-up

(Reproduced with permission from Matsen FA III et al: Practical Evaluation and Management of the Shoulder. W.B. Saunders Company, Philadelphia, PA, 1994.)

In a very comparable study, Gazielly et al (Gazielly, Gleyze, 1994, Gazielly, Gleyze, 1995a, Gazielly, Gleyze, 1995b) examined the anatomic condition by ultrasonography and the function of the rotator cuff at four years following surgical repair in a series of 100 full thickness rotator cuff tears. The series comprised 98 patients, (62 men and 36 women) whose average age was 56 years. 69 tears were less than 2 cm in size (39 cases) or between 2 to 4 cm (3 cases) of the supra-spinatus, 22 tears of the supra- and infraspinatus measuring between 2 to 4 cm, and 9 massive tears. All 98 patients were operated on by the same surgeon using the same repair technique. Ultrasonography revealed intact cuffs in 65 per cent, thinned cuffs in 11 per cent and recurrent full thickness tears in 24 percent of cases. The risk of recurrent tear increased with the extent of the tear to be repaired (57 percent), in older patient (25 percent) and with a higher level of post-surgical occupational use (18 percent). At follow-up, they noted a close correlation between the anatomic condition of the cuff by ultrasound and Constant's functional score.

Similar results have been reported by Cammerer et al (Cammerer, Habermeyer, 1992) and Bellumore et al. (Bellumore, Mansat, 1994)

Wulker et al (Wulker, Melzer, 1991) followed 97 of 116 shoulders operated on for rotator cuff lesions after an average follow-up time of 37 months. Seventy percent had a good or excellent clinical result, however ultrasonographic examination revealed that only 37 had a normal rotator cuff, 31 had thinning and/or hyperdensity, and 29 had a complete rupture of the cuff. The authors concluded that rotator cuff tears should be closed only if this can be achieved without undue tension and without extensive tissue mobilization or coverage otherwise they recommended that the lesion should be debrided and left open, and only an anterior acromioplasty should be performed.

Taken together these studies provide strong evidence that following cuff repair surgery, a high percentage of patients have a satisfactory clinical result in spite of recurrence of the cuff defect. Several conclusions are evident:

1. one cannot infer integrity of the repaired cuff from a "good" or "excellent" clinical result,
2. factors other than cuff integrity must contribute to the quality of the clinical result from rotator cuff surgery, and
3. if we are to learn more about the value of cuff repair, analysis of cuff integrity and change in functional status must become essential elements in outcome studies of cuff repair surgery.

Arthroscopically assisted repair

Some authors have reported short term follow-up of arthroscopic assisted rotator cuff repair. (Levy, Urie, 1990, Palette, Warner, 1993) These authors suggest that required components of the repair include an adequate smoothing of the undersurface of the acromion and the AC joint; arthroscopic (or open) resection of the distal clavicle in the presence of significant AC joint arthrosis; mobilization of the entire rotator cuff with release of adhesions and scar tissue; and repair of strong tendon to a properly placed, well-prepared, bleeding bone trough.

The rotator cuff repair is often performed through a lateral deltoid muscle splitting incision. The deltoid is not detached from the acromion. The deltoid muscle is split with blunt dissection with careful attention to the axillary nerve, which crosses on the deep surface of the deltoid as close as 5 cm to the lateral edge of the acromion. A bony trough is developed in the greater tuberosity. Reapposition of the torn cuff edge to the greater tuberosity is accomplished with nonabsorbable sutures passed through drill holes and tied over bone.

Alternative methods for arthroscopically assisted cuff repair include the percutaneous insertion of absorbable tacks and metallic staples. Use of fixation implants of this type carries the potential for loss of fixation, particularly in patients with soft cancellous bone. Loss of fixation can result in failure of tendon repair as well as mechanical irritation caused by displacement of these devices in the subacromial space.

Palette et al reported success in the arthroscopic management of small tears. (Palette, Warner, 1993) Levy et al (Levy, Urie, 1990) in 1990 reported on 25 patients with full thickness rotator cuff tears treated with an arthroscopically assisted rotator cuff repair. After performing an arthroscopic acromioplasty, the rotator cuff was identified, debrided, mobilized with arthroscopically placed sutures and then repaired to a bony trough through a limited deltoid splitting approach. The patients, average age 57.7 years (range 21-74 years) were evaluated at an average of 18 months (range of 12-27 months). Based on the UCLA shoulder rating scale, 80 percent of the patients were rated as excellent or good, with reported significant improvements in pain, function, motion, and strength. Ninety-six per cent of the patients were satisfied with their result. Of the 15 large tears (3-5 cm), four were excellent, 6 were good (67% satisfactory), four were fair, and one was poor (33% unsatisfactory). Of the patients with small (< 1 cm) or moderate (1-3 cm) size tears, 100% received a satisfactory rating.

Warren et al (Warren, Altchek, 1991) reported good or excellent results in 13 of their 17 patients who underwent arthroscopic acromioplasty and arthroscopic-assisted rotator cuff repair who were followed for a minimum of two years with an average follow-up of 25 months. Tear size was small in 4, moderate in 5, large in 6, and massive in 2. The rotator cuff was repaired into a prepared bony trough using arthroscopically placed sutures through a limited deltoid splitting incision and in some cases, using percutaneous fixation with a cannulated tack. Eight of nine tennis-players and all the golfers returned to their previous sports.

Paulos and Kody (Paulos and Kody, 1994), in 1994, reported their results of 18 consecutive patients who underwent arthroscopic acromioplasty and rotator cuff repair through a 4 cm deltoid-splitting approach with an average follow-up of 46 months (range 36-72 months); mean age 47.2 years (range 26-74 years). Sixteen repairs were tendon-to-bone; two repairs were tendon-to-tendon. Sixteen patients (88%) scored good to excellent on the UCLA shoulder rating scale with significant improvement in pain and function scores. Two patients had poor results; both had workers compensation cases pending. One patient with a poor result had 2 complications: superficial infection and failure of repair that required reoperation. 17 of the 18 patients (94%) were satisfied with their result.

In 1994, Liu (Liu, 1994), reported on 44 patients (average age 58 years, range 35-76) with full thickness rotator cuff tears at an average of 4.2 years (range 2.5 - 6.1 years) after arthroscopic assisted rotator cuff repair. Eighty-five percent of the patients were discharged from the hospital immediately after the operation. The results were rated as good or satisfactory in 84% (37/44) (8/8 in those with small tears (less than 1 cm), 15/17 with moderate tears (1 to 3 cm), 12/15 with large tears (3 to 5 cm) and 2/5 with massive tears (greater than 5 cm). Eighty-eight percent of the patients were satisfied with the result and 64% of the athletes returned to their previous sport. The size of the tear seemed to be a determining factor in the functional outcome: the small and moderate tears did better than large and massive tears. The patients satisfaction, however, did not seem to relate to the size of the tear repair; those with small, moderate and large tears were equally satisfied.

In 1995, Baker and Liu (Baker and Liu, 1995) compared the results of open and arthroscopically assisted rotator cuff repair in 36 patients with a minimum follow-up of 2 years. The open repair group (average age 60 years) comprised 20 shoulders with an average follow-up of 3.3 years; the arthroscopic assisted repair group (average age 59 years) comprised 17 shoulders with an average follow-up of 3.2 years. Overall the open repair group had 88 percent good-to-excellent results and 88 percent patient satisfaction; the arthroscopically assisted repair group had 85 percent good-to-excellent and 92 percent patient satisfaction (based on the UCLA rating scale). The functional outcome with regard to shoulder flexion, strength of abduction and the size of the rotator cuff tear repaired did not differ significantly between the two treatment groups. In general, however, small and moderate sized tears (< 3 cm) demonstrated earlier return to full function after arthroscopically assisted rotator cuff repair; this group was hospitalized 1.2 days less, and returned to previous activities an average of 1 month earlier. In the patients with large tears, 2 out of 4 patients (50%) in the arthroscopically assisted repair group and 4 of 5 (80%) in the open repair group had good-to-excellent results. In general, the authors found arthroscopically assisted rotator cuff repair to be as effective as open repair in the treatment of small and moderated sized tears (<3 cm); whereas large tears did better after open repair.

These studies suggest that arthroscopic acromioplasty combined with arthroscopically-assisted rotator cuff repair can provide acceptable clinical results in the management of small full thickness rotator cuff tears in the presence of excellent quality tissue with minimal tissue retraction and scarring. These results, however, are not directly comparable with the results of traditional open surgery because studies involving open techniques include larger numbers of older patients, many of whom have large chronic tears requiring extensive soft-tissue mobilization. The long term clinical results and the integrity of the cuff after these arthroscopically-assisted repairs have yet to be determined.

Open operative treatment when repair is not possible

While it used to be said by some that "the term irreparable cuff reflects more on the surgeon than the patient," the fact is that some rotator cuff tears may be impossible to repair. Rockwood et al (Rockwood, 1983 and 1987, Rockwood, Williams, 1995) reported on their experience using a modified Neer acromioplasty and debridement of massive irreparable lesions involving the supraspinatus and infraspinatus tendons in 53 shoulders (average age 60). At an average of 6.5 years followup the comfort, function and satisfaction were satisfactory in 83%. Good prognostic findings were an intact biceps, an intact anterior deltoid and no previous shoulder surgery. Active forward flexion improved from 105 to 140 degrees. These results indicate that subacromial smoothness and vigorous post surgical rehabilitation can substantially improve comfort and function, even when large cuff defects are irreparable.

In a small series Hawkins et al (Hawkins, Misamore, 1985) reported only 50 percent satisfactory results with open subacromial decompression alone in patients with massive full thickness rotator cuff tears.

Bakalim and Pasila (Bakalim and Pasila, 1975) found that acromial excision alone gave relief of night pain in certain cases.

Arthroscopic operative treatment when repair is not possible

Several authors have reported acceptable clinical results with full thickness cuff defects when arthroscopic acromioplasty and debridement was performed without rotator cuff repair, especially for the sedentary, low demand patients whose main complaint is pain. (Ellman, 1988, Esch, Ozerkis, 1988, Gartsman, 1990, Hawkins, Saddamis, 1992, Speer, Lohnes, 1991, van Holsbeeck, DeRycke, 1992)

In one of the earliest studies, Wiley (Wiley, 1985), in 1985, reported on 20 patients with full thickness rotator cuff tears who underwent arthroscopic, rotator cuff debridement and shoulder manipulation without acromioplasty. Within 24 months, sixteen patients had pain relief (5 complete, 11 partial), twelve had increased range of motion, and 11 were able to return to work. He concluded that arthroscopic treatment was useful in treating older patients with chronic shoulder pain associated with full thickness rotator cuff tears.

Ellman (Ellman, 1987) in 1987, presented 10 patients with full thickness tears of the rotator cuff treated with arthroscopic acromioplasty and rotator cuff debridement. Based on the UCLA shoulder rating scale, 80% were rated satisfactory (8 good) and 20% unsatisfactory (2 poor). It was noted that none of the eight satisfactory results achieved an excellent objective rating.

Esch et al (Esch, Ozerkis, 1988), in 1988, presented their results according to the degree of rotator cuff tendon failure. Their patients with complete tears were divided into groups of tears less than 1 cm in size, tears greater than 1 cm in size, and massive tears. The patients were treated with an arthroscopic acromioplasty, coracoacromial ligament resection, and debridement of acromioclavicular spurs. All patients were followed for a minimum of 1 year. Four patients with tears less than 1 cm in size had a satisfactory result and an excellent rating. Of the 16 patients with tears greater than 1 cm in size, 14 were satisfied and objectively 13 had a good or excellent result (based on the UCLA shoulder rating scale). There were three fair objective ratings and no poor ratings. Of the 6 patients with massive tears, 5 were satisfied but only 3 had a satisfactory score. Thus, patients with complete rotator cuff tears had an overall patient satisfaction rate of 88% and an objective satisfactory rating of 77%. Esch subsequently concluded that results are related to tear size. Patients with small full thickness tears may achieve excellent results with arthroscopic acromioplasty and cuff debridement. Of the patients with large tears, only 4 of the 13 obtained an excellent objective result.

Gartsman (Gartsman, 1990), as part of a larger series, reported on 25 patients with full thickness rotator cuff tears treated with arthroscopic acromioplasty, resection of the coracoacromial ligament and subacromial bursa, removal of osteophytes, and a minimal debridement of the rotator cuff defect. The tears were divided into four groups based on size of the tear; small tears of less than 1 cm (3 total), tears between 1 cm and 3 cm (13 total), tears between 3 cm and 5 cm (6 total) and 3 massive tears which were greater than 5 cm. At an average of 31 months, there were 14 satisfactory and 11 unsatisfactory results. Seven of these patients were subsequently treated with open rotator cuff repair, six of which had a satisfactory result. Notably, there was no correlation between the final result and the patient's age, sex, hand dominance, or the location of the tear. Only rotator cuff tear size correlated with outcome - 13 of 16 patients with a tear less than 3 cm in size had a satisfactory result while only 1 of 9 patients with a larger tear (over 3 cm) did well.

Montgomery et al (Montgomery, Yerger, 1992) reported on 87 patients with 89 full thickness rotator cuff tears who failed to respond to conservative treatment. Fifty patients (Group I) were treated with open rotator cuff repair and Neer acromioplasty. Thirty-eight patients (Group II) were managed by arthroscopic debridement, acromioplasty, and abrasion of the greater tuberosity. With similar size rotator cuff tears represented in each group at 1 year follow-up, the authors found no statistically significant difference between the two groups. However, on re-evaluation at 2 years post-surgery, the open surgical repair group (I) was statistically much better than the arthroscopic debridement group (II)with regard to pain and function. Four of the 38 patients in the arthroscopic debridement group developed rotator cuff tear arthropathy which was thought to occur secondary to the instability and abnormal movement of the humeral head on the glenoid.

In 1991, Levy et al (Levy, Gardner, 1991) reported on 25 patients with full thickness tears of the rotator cuff treated with arthroscopic acromioplasty and rotator cuff tendon debridement alone. There was significant improvement in pain, function, motion, and strength. 84% of the cases were rated as excellent or good (and 88% of the patients were satisfied with the procedure). Although all tear sizes were improved significantly, small tears fared better than larger tears.

In a follow-up series (Zvijac, Levy, 1994), Zvijac, Levy and Lemak reevaluated all 25 patients from the original study group with full thickness rotator cuff tears who underwent arthroscopic acromioplasty. At mean follow-up of 45.8 months, 68% of the patients were rated as excellent or good, representing a significant decrease from the initial report of 84% satisfactory result at a mean follow-up of 24.6 months. The authors found a significant decrease in rating with regard to pain and function. Ratings for motion and strength did not change significantly with time. Large and massive rotator cuff tears fared worse over time when compared to small and moderate size tears. These finding led the authors to abandon support for the use of arthroscopic acromioplasty and rotator cuff debridement alone in the treatment of repairable full thickness rotator cuff tears.

In 1993, Ellman et al (Ellman, Kay, 1993) reported their follow-up results of 40 full thickness rotator cuff tears treated by arthroscopic acromioplasty and debridement in a selected group of patients. The patients were divided into 3 groups based on the size of their tear. Small (0-2 cm) tears (N=10) in older patients not involved in strenuous activities were rated satisfactory in 90% of cases. Patients with larger (2-4 cm) repairable tears (N=8) did poorly (50% satisfactory results). Arthroscopic treatment in patients with massive irreparable tears (N=22) did not improve range of motion or restore strength, but did result in significant pain relief and 86% were satisfied with the results on a "limited-goals basis". Ellman and his co-authors concluded that for patients with medium-size tears, pain relief from arthroscopic acromioplasty alone is inadequate, and the "procedure probably should not be offered". In carefully selected patients described as "relatively older and very sedentary", however, with small rotator cuff tears (0-2 cm), arthroscopic acromioplasty can have a useful role. Ellman emphasized that even for these patients, and certainly for the majority of patients, repairable rotator cuff tears are best treated with open surgical repair.

In a series of 80 consecutive arthroscopic acromioplasties in 76 patients with stage II and III impingement syndrome, Paulos et al (Paulos and Franklin, 1990) identified seven patients with full thickness rotator cuff tears. Three of these patients, all with small (1 cm) tears remained symptomatic and required reoperation for open repair of the rotator cuff tear.

In 1993, Oglivie-Harris et al (Ogilvie-Harris and Demaziere, 1993), in a prospective cohort study, compared the results of arthroscopic acromioplasty and rotator cuff debridement (22 patients) and open repair and acromioplasty (23 patients) as treatment for tears of the rotator cuff 1 to 4 cm in size. Follow-up varied from 2 to 5 years. The two treatment groups showed no significant differences in age, size of tear, preoperative pain, function, range of active forward flexion, and strength of forward flexion. At follow-up, both groups had similar pain relief and range of active forward flexion. The open repair group scored significantly better for function, strength, and overall score, however, patient satisfaction was similar in both groups. These authors found no significant difference in the final result in relation to the age of the patient or the size of the rotator cuff tears. On the basis of their results, the authors consider use of arthroscopic acromioplasty and debridement for patients with demands whose main complaints are pain and loss of range of movement. For patients, however, who needs good function and strength, arthroscopic debridement and acromioplasty are not sufficient, and open repair and acromioplasty is advised.

Olsewski and Depew (Olsewski and Depew, 1994) in 1994 reported on their results of arthroscopic acromioplasty and rotator cuff debridement performed on 61 consecutive patients with a minimum of 2 year follow-up (mean 27.7 months). In this study 13 full thickness rotator cuff tears were identified. Of the 13 full-thickness tears treated, 10 were rated satisfactory (77%) and 3 unsatisfactory (33%). Of the 10 satisfactory results, eight were in patients who were either retired or worked at sedentary jobs that did not demand above shoulder activities and strength and whose principal preoperative complaint was pain. All 10 of these patients had relief of their pain. The 3 unsatisfactory results were all in active patients with demands on strength and overhead activity.

Burkhart (Burkhart, 1991) described 10 patients with massive (irreparable/ greater than 5 cm) complete rotator cuff tears involving primarily the supraspinatus treated with arthroscopic acromioplasty with debridement of redundant nonfunctional rotator cuff tissue. All patients except one had normal active motion and strength preoperatively and all had a roentgenographically normal acromiohumeral distance and an anterior-inferior acromial osteophyte. The procedure was offered to a subset of older patients, with activity limiting pain, who were preoperatively found to have a full range of active shoulder motion and normal strength of external rotation. Arthroscopic debridement and decompression was accompanied by pain relief without loss of motion or strength in all 10 patients. The follow-up period ranged from eight to 33 months (mean 17.6 months). Patients ranged from 53 to 77 years of age (average 65 years). There were 7 excellent and 3 good results. All patients were satisfied with their results.

Cost effectiveness of treatment of full thickness cuff tears

Rotator cuff disease is one of the commonest afflictions of the shoulder. Many health care dollars are spent on its evaluation and management. It is apparent that a large number of variables affect the effectiveness of treatment of cuff lesions. The cost of various treatment methods varies substantially as well. To initiate a practical investigative method by which the cost effectiveness might be compared among treatment methods, the authors conducted a preliminary study of 67 unmatched patients presenting for treatment of documented, symptomatic full thickness tears. Based on our clinical assessment and the desires of the patient, one of three treatment methods was selected for each patient: nonoperative management, subacromial smoothing without repair and surgical repair. The number of patients, average age, gender, and length of follow-up for the patients in each of the three groups is given in table 8.

Table 8

Data on 67 Patients Treated for Documented Full Thickness Tears of the Rotator Cuff

SST and SF-36

All patients completed Simple Shoulder Tests and SF-36 questionnaires preoperatively and at follow-up. The effectiveness of treatment was measured in terms of the postoperative-preoperative change in the number of "yes" responses on the Simple Shoulder Test and the postoperative - preoperative change in the SF 36 comfort score. This analysis indicated that the greatest improvement was found in the group having surgical repair (see solid bars in figure 55). The change in SST and SF 36 comfort score results for each patient were then divided by the total hospital, office and physician charges for the treatment to yield the average change/$1000 charge. In this analysis, nonoperative treatment was associated with the greatest change per unit charge (see hollow bars in figure 55).

While no conclusions should be drawn from these preliminary results, it is hoped that further studies of this type will help determine the cost-effectiveness of different treatment methods.

Authors' preferred method of treatment for surgical management of full thickness rotator cuff tears

The goal of rotator cuff surgery is to improve comfort and function of the shoulder. Surgery is considered

1. in the patient with a significant acute cuff tear and
2. in the patient with a chronic cuff defect associated with significant symptoms which have been refractory to a 3 month course of nonoperative management.

In the situation of an acute cuff tear in a previously normal shoulder, the quality and quantity of tendon for repair should be excellent. Repair should be carried out promptly before tissue loss, retraction, and atrophy occur. 

For tears older than six months, surgical repair is not an emergency: there is time to explore nonoperative management, including a general shoulder stretching and strengthening program. This nonoperative program may be the treatment of choice in patients with chronic weakness who are not candidates for surgery or for those in whom achieving a durable repair seems unlikely (see table 2).

This regime has been described earlier in this chapter as the "Jackin's program"; it emphasizes stretching and strengthening the muscle groups which provide elevation and rotation of the shoulder. Surgical exploration is considered for patients with functionally significant symptoms from longer-standing tears refractory to nonoperative management, provided that their expectations are realistic. While a successful cuff repair may increase the strength of the shoulder, patients with repairs of chronic tears are advised against returning to heavy lifting, pushing, pulling, or overhead work after surgery for fear of re rupturing the abnormal tendon tissue. Thus, we initiate vocational rehabilitation as soon as the diagnosis is made, indicating that, in spite of optimal treatment, there is asubstantial risk of retearing if the cuff is again subjected to major loads. It is important to remind both the patient and the employer that a cuff tear usually occurs through abnormal cuff tendon. Repairing the tear does not restore the quality of the tendon tissue; thus the repaired cuff remains permanently vulnerable to sudden or large loads.

Critical determinants of a durable repair are the quality of the tendon and muscle and the amount of cuff tendon tissue that has been lost. The strength of the cuff tendon diminishes with age and disuse; as a result, the chances of a durable cuff repair also decrease in older and less active shoulders. This is particularly the case if the cuff defect has been long-standing.

Table 2 lists some of the factors that contribute to a durable repair, as well as those which predispose to failure. None of the factors in this table requires special imaging of the rotator cuff; all are discernible from the history, physical examination, and plain radiographs. While none of these factors is a contraindication to surgery, each works to some degree against the chances of a durable repair. The choice of treatment of shoulder weakness caused by cuff failure is determined by the functional needs of the patient and the likeliness of a durable surgical repair. Patients with low functional requirements and a substantial number of the "discouraging" factors from table 2 are given a nonoperative program to help optimize the strength and coordination of the muscles about the shoulder that remain intact. At the opposite extreme, patients with major functional demands and mostly "encouraging" factors are presented with the option of an attempt at surgical repair, and informed that the success of this repair will be determined primarily by the quality of the tendon and muscle and the amount of tissue lost.

We recall that cuff repair is a shoulder tightening operation: in a sense it is a capsulorrhaphy. Thus it is not a treatment for the shoulder whose primary functional limitation is caused by tightness, even if a cuff defect is also present. If the shoulder demonstrates stiffness, a shoulder mobilization program is instituted before consideration of surgery.

About the surgery

For surgery, the patient is positioned in a semi-sitting (beach chair) position. Both the anterior and posterior aspects of the chest and the arm are prepared to allow access to the back of the shoulder and full motion of the arm. Surgery begins with an inspection of the cuff through a "deltoid on" acromioplasty approach (see figure 56). This incision offers excellent exposure and the opportunity for a cosmetic closure. Great care is taken to preserve the tendon fibers of the deltoid origin to permit a strong repair. The deltoid has an important tendon of origin between its anterior and middle thirds. Arising from the anterior lateral corner of the acromion, this tendon is not only the guide to exposure of the cuff, but is also the key to reattachment of the deltoid origin at the conclusion of the surgery. This tendon is split longitudinally for 2 cm distal to the acromion in line with its fibers, taking care to leave some of the tendon on each side of the split. The split is continued up over the acromion and into the trapezius insertion. Although it is usually unnecessary for inspection of the cuff, additional exposure can be achieved by sharply dissecting the deltoid origin off the acromion for one centimeter on either side of this split so that the strong bony attachment fibers remain with the muscle. These fibers provide a strong "handle" on the muscle, so a solid repair can be achieved at the conclusion of the procedure.Splitting the parietal layer of the bursa on the deep aspect of the deltoid provides a view of the rotator cuff. Later closure of the split is facilitated if at this point in the procedure a suture is placed on each side of the split fixing the incised bursal layer to the deltoid. 

Before a "reflex" acromioplasty is performed, this window is used to inspect the cuff and determine its reparability without furthercompromising the deltoid or the coracoacromial arch. Hypertrophic bursa and scar tissue are resected to allow a good view of the cuff tendon involvement, tendon quality and tendon tissue loss. Cuff tendon involvement is conveniently characterized using the system introduced by Harryman et al (Harryman, Mack, 1991) which is based on the number of tendons torn. In Type 1, only one tendon (almost always the supraspinatus) is torn. In Type 2, two tendons (usually the supraspinatus and infraspinatus) are torn. In Type 3, the supraspinatus, infraspinatus and subscapularis are torn. Type 1 is broken down into Type 1A-a partial thickness-tear, and Type 1B-the full thickness tear confined to a single tendon. The quality of the cuff tissue is judged in terms of its ability to hold a strong pull applied to a suture passed through its edge. Finally, it is critical to note the amount of tissue that has been lost. The extent of tissue loss and the ability of the remaining tissue to hold suture are the major determinants of cuff reparability.

Standard anteroinferior acromioplasty

If inspection of the cuff at surgery reveals good quality tissue in sufficient quantity and quality for a robust repir, a standard anteroinferior acromioplasty may be performed if necessary to improve exposure and to protect the repair from abrasion. A flexible osteotome is directed so that the anterior undersurface of the acromion is resected in the same plane as the posterior acromion (see figure 57). Rough spots are smoothed with a motorized bur.

The goal of repair is a strong fixation of the tendon to the humerus under normal tension with the arm at the side. The desired attachment site is at the sulcus near the base of the tuberosity. This goal is facilitated by using three stages of sequential release. These releases are required because the cuff is usually retracted and because tissue is lost in chronic cuff disease. Unless these releases are carried out, increased tension in the repaired tendon will predispose to tightness of the glenohumeral joint and will additionally challenge the repair site. (Zuckerman, Leblanc, 1991) The humeral head is rotated to present successively the margins of the cuff defect through the incision, rather than enlarging the exposure to show the entire lesion at one time. The deep surface of the cuff is searched for retracted laminations. All layers of the cuff are assembled and tagged with sutures. By applying traction to these sutures, the cuff is mobilized sequentially as necessary to allow the torn tendon edge to reach the desired insertion at the base of the tuberosity. First, the humeroscapular motion interface (see figures 58 and 59) is freed between the cuff and the deltoid, acromion, coracoacromial ligaments, coracoid, and coracoid muscles. Next, the coracohumeral ligament/rotator interval capsule (see figure 60) is sectioned around the coracoid process to eliminate any restriction to the excursion of the cuff tendons and to minimize tension on the repair during passive movement (see figure 61). This release of the coracohumeral ligament and rotator interval capsule also contributes to the comfort and ease of motion after the surgical repair by minimizing the capsular tightening effect of cuff repair. (Zuckerman, Leblanc, 1991) At this point the ease with which the cuff margins can be approximated to their anatomic insertion at the base of the tuberosity is evaluated. If good tissue cannot reach the sulcus, the third release is carried out. This release divides the capsule from the glenoid just outside the glenoid labrum (see figure 52), which allows the capsule and tendon of the cuff to be drawn further laterally toward the desired tuberosity insertion without restricting range of motion.

After the necessary releases have been completed, a judgment is made concerning the site at which the cuff can be implanted into the bone without undue tension while the arm is at the side. Ideally, the site of implantation will be in the sulcus at the base of the tuberosity. In large cuff defects, a somewhat more medial insertion site may be necessary. Often, when a medial insertion site is required for a large cuff defect, the new insertion lies in an area where the articular cartilage has been damaged by abrasion against the undersurface of the acromion.

The repair is accomplished as a tongue in groove, with the cuff tendon drawn into a trough near the tuberosity, providing a smooth upper surface to glide beneath the acromion (see figure 62). This groove provides the additional advantage that if some slippage occurs in the suture fixation of the cuff to bone, contact between these two structures is not lost. Nonabsorbable sutures woven through the tendon margin are passed through drill holes in the distal tuberosity so that the knots will not catch beneath the acromion (see figure 63). The knots are tied over the tuberosities so that they will lie out of the subacromial space. If the bone of the tuberosities is osteopenic, the sutures can be passed through bone more distally, even down to the junction of the metaphysis and diaphysis. If there is a longitudinal component to the tear, it is repaired side-to-side with the knots buried out of the humeroscapular motion interface. The repair is checked throughout a range of motion to 140 degrees of elevation and 40 degrees of external rotation to assure that it is strong, that it is not under excessive tension, and that it will permit smooth subacromial motion. If additional subacromial smoothing is required to allow smooth passage of the repaired tendon, it is performed at this time.

After a careful and robust deltoid repair using nonabsorbable sutures (see figure 64) and cosmetic skin closure, the patient is returned to the recovery room with the affected arm in continuous passive motion (see figure 65). Immediate postoperative motion is valuable because there is a tendency for scarring between the raw undersurface of the acromion and the upper aspect of the rotator cuff or proximal humerus. Immediate postoperative continuous passive motion is facilitated if the surgery is performed under a brachial plexus block, which lasts up to 18 hours after surgery. Continuous passive motion is continued for up to 48 hours after surgery but does not appear to be necessary after that. The patient is expected to perform passive exercises in flexion and external rotation. Before dischargefrom the medical center, the patient should be able to attain comfortably 140 degrees of passive flexion and 40 degrees of passive external rotation. A progress chart mounted on the patient's wall helps to document progress toward these discharge goals (see figure 66).

Postdischarge management must consider the magnitude of the tear and the strength of the repair. It is unlikely that the repair will have substantial strength until at least three months after surgery. (Frank, 1996) As is the case with repairs of the anterior cruciate ligament, major cuff repairs may require six to twelve months to regain useful strength. Thus, in the first several postoperative months, the emphasis is placed on maintaining passive motion and avoiding loading of the repair. Posterior capsular stretching is not started until three months after surgery. Gentle progressive strengthening of the repaired cuff muscles is also started at three months. Work and sports are not resumed until the shoulder is comfortable, flexible and strong.

When cuff repair cannot be achieved

If the initial inspection of the cuff reveals major tissue loss and residual tendon of poor quality and if it becomes evident that a robust repair cannot be performed, the coracoacromial arch is preserved. When primary stability from an intact cuff cannot be restored, it is important to avoid a "reflex" acromioplasty. Sacrifice of the coracoacromial arch jeopardizes the secondary stabilization required in cuff deficiency. Without this secondary restraint, the shoulder is prone to anterosuperior "escape" of the humeral head when superiorly directed loads are applied to the humerus. Therefore, when a strong rotator cuff repair cannot be performed because of limited quantity and quality of the residual cuff tissue, we preserve the coracoacromial arch and assure the smoothness of its undersurface to allow unimpeded passage of the humeral head and residual cuff beneath. Any debris, scar, useless fronds of cuff or thickened bursa in the subacromial area is excised. It is important to also assure smoothness of the upper surface of the uncovered proximal humerus, particularly if the tuberosities are prominent or irregular.

A strong repair of the deltoid is accomplished using a side-to-side repair of the surgical split in the deltoid tendon and a secure reattachment to the acromion using drill holes in the bone as necessary (see figure 64). The full thickness of the deltoid, including the deltoid side of the bursa, is incorporated in the sutures to be certain that it does not impede smooth motion in the humeroscapular motion interface.

A subcuticular skin closure reinforced with paper tapes provides optimal cosmesis. The patient is returned to the recovery room with the arm in continuous passive motion to minimize the tendency to form adhesions in the humeroscapular motion interface (see figure 66).

The patient is taught passive mobilization of the shoulder to 140 degrees of elevation (see figures 67 and 68) and 40 degrees of external rotation (see figure 69) as well as stretching of the posterior capsule (see figures 70 and 71) and is discharged from the medical center when these goals are achieved. Active use of the shoulder with the arm at the side is instituted immediately. Sling immobilization is unnecessary. Strengthening of the deltoid and residual cuff muscles is started six weeks after surgery. An ideal exercise for optimizing the strength of active elevation is the progressive supine press (see figure 72). In this exercise small increments are used to train the remaining muscles to optimal advantage. Note that the scapular muscles are also put to work in these exercises (see figures 73 and 74). This program is easy for the patient to learn and to carry out alone.

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