- Email: [email protected]
Massive rotator cuff tears: The result of partial rotator cuff repair
Massive rotator cuff tears: The result of partial rotator cuff repair Xavier A. Duralde, MD,a and Brant Bair, MD,b Atlanta, GA, Santa Fe, NM
Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P ⬍ .001). Active elevation improved from 114° to 154°, and no patient lost strength after surgery. The ability to raise the arm to at least 135° improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears. (J Shoulder Elbow Surg 2005;14:121-127.)
M assive rotator cuff tears challenge the concept of
complete repair because of tissue retraction and inelasticity, bursal scarring, muscle atrophy, and fatty degeneration.2,4,6,9 These patients have the worst prognosis of all of those presenting with rotator cuff tears in terms of restoration of strength and function.1,4,6,9 Although most rotator cuff tears can be repaired primarily to bone1,6,16 and even the majority of massive rotator cuff tears can be completely repaired,1,6,16 a significant proportion of massive tears defy traditional techniques for complete repair to bone. A variety of treatment recommendations have been made in the literature for these irreparable tears of the rotator cuff including debridement,11,13 muscle advancement,4 tendon transfers,1,10 and grafting with either synthetic, allograft, or xenograft16 materials. Burkhart et al2 have described kinematic patterns in shoulders with massive rotator cuff tears to explain From Peachtree Orthopaedic Clinica and Santa Fe Orthopaedics.b Reprint requests: Xavier A. Duralde, MD, Peachtree Orthopaedic Clinic, 2045 Peachtree Rd, Suite 700, Atlanta, GA 30309. (E-mail: [email protected]). Copyright © 2005 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2005/$30.00 doi:10.1016/j.jse.2004.06.015
how a patient with a large rotator cuff tear can still couple the forces of the deltoid and remaining rotator cuff muscles to forward elevate the arm effectively. They describe these tears as anatomically deficient but biomechanically intact. They challenged the concept that a complete rotator cuff repair was required for restoration of adequate function and pain relief after rotator cuff surgery and promoted this technique for massive irreparable rotator cuff tears. The purpose of this study is to review the results of 25 such cases, performed by 1 surgeon, in whom a complete repair was not possible in those with massive rotator cuff tears. MATERIALS AND METHODS Sixty-eight patients underwent 70 open repairs for massive rotator cuff tears between October 1994 and February 2001. Massive rotator cuff tears were defined by Cofield4 as having a diameter greater than or equal to 5 cm and involving at least 2 of the 4 musculotendinous units. In 25 of 70 repairs (36%) the rotator cuff could not be completely repaired. These 25 patients are the focus of this retrospective study. One male patient died 6 months after surgery from unrelated problems. Therefore, there are follow-up data in only 24 patients for a mean of 43 months (range, 24-72 months). There were 5 women and 20 men, with a mean age of 61 years (range, 38-76 years). The rotator cuff was involved in the dominant extremity in 76% of cases. One patient (patient 7) had had a previous rotator cuff repair performed on the affected shoulder that had failed. Patients were assessed by use of the American Shoulder and Elbow Surgeons (ASES) scale, including evaluation of subjective pain, functional assessment, range of motion, and strength testing. The patients filled out subjective questionnaires both preoperatively and postoperatively. The mean duration of symptoms before surgery was 17 months (range, 1-81 months). Of the patients, 76% (19/25) complained of night pain, and 72% described their pain as greater than 5 on a 10-point scale. Preoperative active forward elevation averaged 114° (range, 0°-180°) and active external rotation averaged 44° (range, 0°-90°). Passive forward elevation averaged 156°. No patient had preoperative stiffness. Four patients (sixteen percent) were unable to hold the arm actively at 0° of external rotation with the arm at the side, indicating a positive lag sign. Of the patients, 72% (18/25) had a positive impingement sign, and 5 (25%) had ruptured the long head of the biceps. The acromioclavicular joint was
121
122
Duralde and Bair
tender in 32% of patients (8/25). Strength was tested manually and graded by use of a standard 5-point scale. All testing was done by the operating surgeon. Only 2 patients (8%) had normal preoperative forward elevation and external rotation strength. Varying degrees of weakness were noted in the remaining 92% of patients (range, 0-4). Patients were asked to describe their function preoperatively including 10 questions from the ASES questionnaire regarding activities of daily living. Preoperatively, only 4 of 25 patients (16%) were able to use the affected arm for any overhead function but with moderate difficulty in all cases. Radiographic evaluation of the affected shoulder revealed a high-riding humeral head (acromiohumeral distance ⬍6 mm) in 14 patients (56%).6 There was no evidence of cuff tear arthropathy in any of these patients. Of the patients, 16 underwent magnetic resonance imaging (MRI) preoperatively, whereas 3 had an arthrogram, and in 6 patients no preoperative imaging study beyond radiographs was performed. All 16 MRI scans revealed a massive rotator cuff tear involving at least the supraspinatus and infraspinatus tendons with severe retraction. Significant muscle atrophy was noted in 11 cases. Muscle tissue, however, was visible in the supraspinatus and infraspinatus fossae on all of these patients. In the 6 patients who did not undergo advanced imaging studies, clinical signs such as a drop-arm sign, severe atrophy, and a high-riding humeral head on radiographs were suggestive of a massive tear.
Operative technique and pathology All operations were performed by the same surgeon between 1994 and 2001 using a combination of general anesthesia and interscalene block. The surgical technique was modified from that of Bigliani et al,1 which has been described previously. Several important distinctions require mention. The deltoid origin was released by electrocautery from the anterior acromion, allowing the deltoid split to be carried down the anterolateral raphe and giving greater access to the posterior aspect of the rotator cuff. This tendon was repaired back to the acromion through drill holes at the end of surgery by use of nonabsorbable polyester sutures. The coracoacromial ligament was incorporated into the deltoid repair whenever possible to help create a buttress against anterosuperior instability. In no case was the subscapularis tendon transferred. Modified Mason-Allen sutures were used when tissue quality was poor. Otherwise, simple sutures were used. The rotator cuff was repaired to bone through bone tunnels by use of No. 1 polyester sutures. An attempt at complete repair was made in all cases. The cuff was repaired with the arm at the side to avoid tension on the repair. No reinforcement of the tendons by use of xenograft, allograft, or synthetic material was performed. A defect was left according to the anatomy of the tear. In 12 of 25 patients (48%), a formal distal clavicle resection was performed, and in the remaining 13 patients, a modified acromioclavicular joint arthroplasty was performed by resecting the prominent inferior border of the acromioclavicular joint to eliminate impingement from this structure. In 6 of 25 patients (24%), a spontaneous rupture of the long head of the biceps tendon was found. A biceps tenodesis was performed in 14 of 25 patients, and 5
J Shoulder Elbow Surg March/April 2005
Figure 1 Appearance of rotator cuff after partial repair. The long head of the biceps (LHB) is visible through the defect in the supraspinatus tendon. The infraspinatus tendon (IST), humeral head (HH), and greater tuberosity (GT) are marked.
patients had a normal appearing biceps that was not disturbed. The size of the remaining defect after partial repair measured along the greater tuberosity ranged from 5 mm to 3 cm (mean, 1.7 cm). Of 25 defects, 19 were posterosuperior, 3 involved only the supraspinatus, and the remaining 3 were at the junction of the supraspinatus and subscapularis (Figure 1). The massive rotator cuff tears were categorized into 1 of 4 groups based on operative findings. Group I included 7 patients (28%) who had tears involving the supraspinatus, infraspinatus, and teres minor. In group II there were 13 patients (52%) who had tears involving the supraspinatus and infraspinatus. In group III there were 4 patients (16%) who had a tear involving the supraspinatus, infraspinatus, and subscapularis. Finally, in group IV there was 1 patient (4%) who had a tear involving the supraspinatus and subscapularis. The patient who died belonged to group I. Rehabilitation was performed per the protocol of Bigliani et al1 with passive exercises for 6 weeks followed by active assisted exercises. Resistive exercises were introduced at 3 months. No abduction pillows were used. At the final follow-up visit, patients were asked to fill out a subjective ASES questionnaire regarding their ability to perform 10 activities of daily living and to assess their pain and medication requirements.12 Range of motion and strength were assessed by the surgeon. Repeat radiographs were performed to measure the acromiohumeral distance and to assess for signs of arthropathy. No follow-up MRI studies were performed. Outcomes were rated by use of the criteria of Bigliani et al1 for assessment of patients after massive rotator cuff repair. Outcomes were placed into 1 of 4 categories: excellent, good, fair, and poor. Patients with an excellent result were essentially pain-free and had maintained within 10° of normal active motion in all planes. Those with an excellent result had resumed unrestricted activity. Patients with a good result had occasional weather-related ache, had active forward elevation greater than 140°, and had greater than 30° of external rotation. They exhibited some
J Shoulder Elbow Surg Volume 14, Number 2
Figure 2 Overall results.
limitation of strenuous overhead activity because of decreased strength. Patients with a fair result had intermittent episodes of pain requiring analgesics, could actively forward elevate between 90° and 140°, and could actively externally rotate between 0° and 30°. Those in whom these criteria were not met had a poor result. The ASES shoulder index was also calculated for all patients. Paired t tests were used to compare the changes in shoulder index, pain, and acromiohumeral distance before and after surgery. To test whether these changes were significantly different between groups I, II, and III, a 1-way analysis of variance was used, followed by Bonferroni post hoc comparisons. Because group IV contained only 1 subject, this group was excluded from analysis of variance. Statistical significance was declared at the .05 level.
RESULTS The overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%) (Figure 2). Therefore, 67% of patients had either excellent or good results after partial repair of massive rotator cuff tears. Subjectively, 92% (22/24) were satisfied with the results of surgery. Significant pain relief was realized after surgery, with preoperative pain averaging 5.8 (SD, 2.3) and postoperative pain averaging 1.7 (SD, 2.2) (P ⬍ .001). However, there were no significant differences in pain relief between groups I, II, and III. Postoperatively, 14 patients (58%) rated their pain as less than 2, whereas an additional 7 (29%) rated their pain as less than 5. Only 3 patients continued to have night pain postoperatively compared with 17 patients preoperatively. A significant change in the shoulder index was realized after surgery, with preoperative shoulder index averaging 41.0 (SD, 19.9; range, 15-90) and postoperative shoulder index averaging 80.1 (SD, 23.0; range, 20-100) (P ⬍ .001). However, there were no significant differences in the shoulder index between groups I, II, and III (Figure 3). Mean active forward elevation improved from 114° preoperatively to 154° (⫹40°) postoperatively (range, 90°-180°). No patient lost forward elevation. Active external rotation improved from 44° preoper-
Duralde and Bair
123
Figure 3 Shoulder index preoperatively (Preop) versus postoperatively (Postop).
atively to 54° (⫹10°) postoperatively (range, 30°80°). Preoperatively, only 13 patients (54%) could forward elevate their arms to 135° or greater, whereas postoperatively, 21 patients (88%) could forward elevate actively to 135° or greater (Table 1). Overall function in activities of daily living improved significantly after surgery. Improvement in 4 of the more strenuous activities of daily living is depicted in Figure 4. Remarkably, 14 patients (58%) regained the ability to lift a 10-lb weight overhead. Forward elevation strength increased by at least 1 grade in 63% of patients postoperatively, and in no patient was strength lost after surgery. Forward elevation strength increased from a mean of 3.6 preoperatively (range, 0-5) to 4.5 postoperatively (range, 4-5), an increase of 0.9. External rotation strength increased from a mean of 3.5 preoperatively (range, 0-5) to 4.5 postoperatively (range, 4-5), an increase of 1.0. The 4 patients with a positive lag sign preoperatively demonstrated significant improvement in external rotational strength to 4, 4, 4, and 5, respectively. Results were graded according to the various tear patterns (I-IV) as previously described. As noted earlier, there were no statistical differences between groups I, II, and III in terms of preoperative and postoperative changes with respect to pain, shoulder index, or acromiohumeral distance. The 1 poor result in this series was the sole patient in group IV. There was no correlation between outcome and sex, age, or length of symptoms preoperatively. No arthrosis was noted on postoperative radiographs. There was no significant change in acromiohumeral distance, which averaged 5.4 mm preoperatively (SD, 3.5 mm; range, 0-12 mm), nor were there any significant differences in the change in acromiohumeral distance between groups I, II, and III. In addition, there was no association between final result (overall rating scale) and postoperative acromiohumeral distance (Figure 5). There were no deep infections, no nerve injuries, and no instances of deltoid detachment postopera-
124 Duralde and Bair
Table I Results
Group
Patient No.
Age (y)
Sex
Length of symptoms (mo)
I I I I I I I II II II II II II II II II II II II II III III III III IV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
67 56 60 67 68 56 38 58 50 71 76 69 54 72 46 68 59 67 74 63 74 43 73 60 52
M M F M M M M M M F M F M M M F M M M M F M M M M
3 5 11 40 1 6 7 9 2 10 2 11 81 8 16 15 24 4 3 10 57 1 12 60 5
Preoperative Pain 8 8 2 8 2 4 8 8 8 6 6 6 6 8 8 8 8 4 6 4 6 6 4 8 0
Preoperative function*
Preoperative external rotation strength
Preoperative forward elevation strength
Active elevation (°)
Active external rotation (°)
Preopecative SI
5 7 15 13 6 19 11 16 10 0 3 22 17 9 6 3 8 20 11 25 15 13 11 11 24
0 3 4 4 0 4 4 4 3 4 0 4 4 5 5 0 4 4 4 4 5 4 4 5 5
0 3 4 4 0 4 4 4 3 4 0 4 4 5 4 4 3 4 4 4 4 4 4 4 5
0 180 180 100 0 110 145 160 30 90 0 100 135 45 100 160 30 170 135 150 170 170 180 100 180
0 10 60 60 0 45 20 30 45 20 0 20 45 50 45 0 20 60 30 60 70 60 60 45 90
18.3 21.6 65 31.7 50 61.7 28.3 36.7 26.7 20 25 56.7 48.3 25 20 15 23.3 63.3 38.3 71.7 45 41.7 48.3 28.3 90
J Shoulder Elbow Surg March/April 2005
SI, ASES Shoulder Index (range, 0 –100); I, Suprasinatus, infraspinatus, and teres minor; II, supraspinatus and infraspinatus; III, subscapularis, supraspinatus, and infraspinatus; IV, supraspinatus and subscapularis; F, fair, E, excellent; N/A, not applicable; G, good; P, poor. *Function was based on ASES score (range, 0 –30).
J Shoulder Elbow Surg Volume 14, Number 2
Table I Continued
Postoperative function*
4 0 0 0 0 2 2 0 4 2 4 0 0 6 2 0 0 0 0 0 4 0 0 6 6
21 30 30 N/A 28 28 28 23 19 22 22 30 30 7 19 19 30 24 28 30 19 27 19 15 0
4 5 5 4 5 4 4 5 5 4 4 5 5 4 4 5 5 5 4 5 5 5 4 4 5
Postoperative forward elevation strength
Active elevation (°)
Active external rotation (°)
Postoperative SI
Overall rating
4 5 5 4 5 4 5 5 5 4 4 5 5 5 4 4 5 5 4 5 5 5 4 4 5
110 180 180 135 170 90 180 180 180 135 135 180 180 100 150 180 180 170 135 170 160 170 180 160 125
30 50 70 60 50 50 30 45 60 45 50 45 60 45 50 60 60 60 40 70 60 60 60 60 80
65 100 100 N/A 96.7 86.7 86.7 88.3 61.7 76.7 66.7 100 100 31.7 71.7 81.7 100 90 96.7 100 61.7 95 81.7 45 20
F E E N/A E F E E G F F E E F G E E E F E G G G F P
Duralde and Bair
Postoperative pain
Postoperative external rotation strength
125
126
Duralde and Bair
Figure 4 Selected activities of daily living preoperatively (Preop) versus postoperatively (Postop). #, Pounds.
Figure 5 Relationship of acromiohumeral (AH) distance postoperatively (post-op) to final result of note.
tively. Two patients did require revision surgery in this series. One patient had an excellent result until a second injury occurred at a construction site 3 years after repair. He fell off of a ladder, sustaining a retear of the rotator cuff. At revision surgery, no significant rerepair was possible, and this patient’s final outcome after the second surgery is poor. A second patient had a large acromioclavicular joint cyst develop that was excised 2 years after rotator cuff repair. His overall rating was fair. DISCUSSION Massive rotator cuff tears are rare in reported series,6,9,13 but even the majority of these tears can be repaired primarily to bone.1,4,6,9,14 When complete repair is possible, the results of surgery are good even with large and massive tears, with greater than 90% pain relief and greater than 85% restoration of satisfactory function.1,14 When tendon tissue quality
J Shoulder Elbow Surg March/April 2005
is so poor that direct bone-to-tendon repair is not possible, a variety of techniques have been recommended. The relative indications for debridement versus partial repair versus tendon transfers have not been well delineated in the literature. Arthroscopic debridement and open debridement of irreparable rotator cuff tears have been shown to provide good pain relief.11,13 Restoration of strength, however, has been inferior to series in which complete or partial repair has been performed.2,9,11 Deterioration of results has also been reported with this technique,11 which appears best suited for relatively inactive and elderly patients. Warner16 states that it is appropriate to consider tendon transfer for patients with a painful rotator cuff tear associated with poor function and in whom there is a low probability that primary reconstruction will be successful. These tend to be younger patients with higher demands on their shoulders. Local tendon transfer involving the superior portion of the subscapularis has been reported in the literature with some success,3 but these results have not been uniformly reproducible. Although satisfactory pain relief has been achieved, subscapularis transfer can adversely affect active elevation of the shoulder and should be used with caution in patients who have full functional elevation preoperatively.3,10 Gerber and Hersche5 evaluated the results of latissimus dorsi transfer in the treatment of 16 irreparable, massive rotator cuff tears, reporting good or excellent results in 13 of 16. Active forward elevation in these patients improved from 83° preoperatively to 135° postoperatively. Asymptomatic rotator cuff tears are a common finding in older patients.15 Burkhart et al2 describe a functional rotator cuff tear as one typically involving the supraspinatus tendon and one half of the infraspinatus tendon. As long as the rotator cuff tear does not extend inferior to the equator of the humeral head, the cuff can often maintain the humeral head centrally located in the glenoid and allow rotation by the deltoid. In the only comparable reported series to this one, Burkhart et al2 demonstrated an improvement of 90.8° of active forward elevation, from 59.6° to 150.4°, after partial repair of massive rotator cuff tears. Residual defects were comparable to this study. The majority of the tear patterns in that series were posterosuperior, as in our study. Although the report describes techniques similar to those used in our series, 5 separate surgeons were involved in compiling the data for 14 patients, introducing an element of variability in these patients’ care. Multiple clinical studies in which both open and arthroscopic techniques of rotator cuff repair were used have documented little effect on results from partial or complete cuff failure postoperatively.7-9 These studies demonstrate a growing body of litera-
Duralde and Bair
J Shoulder Elbow Surg Volume 14, Number 2
ture emphasizing the importance of stable fulcrum kinematics and force coupling around the shoulder as the most important factor predicting outcome in the rotator cuff. The concept of closing the hole is less important in the treatment of rotator cuff tears than that of reestablishment of stable fulcrum kinematics.2 The closure of nonfunctional tendon tissue around the humeral head may serve temporarily as a watertight seal but in no way maintains the humeral head centered in the glenoid or allows improvement in either strength or function after repair. The definition of a massive rotator cuff tear remains controversial, with some authors stating that 3 tendons must be involved.5 Tear size and reparability, however, are not always related because of variability in tissue retraction and muscle atrophy. All of the tears in this series were irreparable by use of standard techniques, regardless of whether 2 or 3 tendons were involved. This patient cohort exemplifies the challenge of treatment of irreparable tears despite the variation in the tear pattern seen. In all of these cases an attempt to obtain a complete repair was made with a tedious and careful mobilization of cuff tissue to a point as lateral as possible. A tension-free repair was obtained with the arm at the side in all cases, and the residual defect was left based on the anatomy of that particular tear. This study has several definite weaknesses. It is a retrospective study, and strength testing was relatively subjective, relying on resistive testing by the operating surgeon. Surgical technique was identical in all cases, however, and our grading system depended heavily on objective data such as active range of motion and functional improvement. Because this series did not use tendon transfers or tendon augmentation with graft material, we believe it serves as a basis of comparison for those more extensive procedures in the treatment of massive, irreparable rotator cuff tears. The results are clearly superior to those of simple debridement of the rotator cuff, with excellent pain relief and significant improvement in strength and overhead function. These patients had an inferior result to that in the series reported by Bigliani et al1 and Rokito et al,14 who both reported on complete repairs of massive rotator cuff tears. Our patient group had more advanced pathol-
127
ogy with a poorer-quality tendon and muscle tissue. Our results are not significantly different from those reported by Gerber5 for latissimus dorsi transfer. No patient lost active elevation, as has been reported with transfers of the subscapularis.10 Partial repair of massive rotator cuff tears represents a reasonable alternative in the treatment of these challenging patients. REFERENCES
1. Bigliani LU, Cordasco FA, McIlveen SJ. Operative repair of massive rotator cuff tears: long-term results. J Shoulder Elbow Surg 1992;1:120-30. 2. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy 1994;10:363-70. 3. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982;154:66772. 4. Cofield RH. Current concepts review: rotator cuff disease of the shoulder. J Bone Joint Surg Am 1985;67:974-9. 5. Gerber C, Hersche O. Tendon transfers for the treatment of irreparable rotator cuff defects. Orthop Clin North Am 1997;28: 195-203. 6. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-15. 7. Harryman DT, Mack LA, Wang KY, et al. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982-9. 8. Jost B, Pfirrmann C, Gerber C, Switzerland Z. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 2000;82:304-14. 9. Iannotti JP. Full-thickness rotator cuff tears: factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95. 10. Karas SE, Giachello TL. Subscapularis transfer for reconstruction of massive tears of the rotator cuff. J Bone Joint Surg Am 1996; 78:239-45. 11. Mellio AS, Savoie FH, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am 1997;28: 117-24. 12. Richards RR, An K, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994; 3:347-52. 13. Rockwood CA Jr, Williams GR Jr, Burkhead WZ. Debridement of degenerative irreparable lesions of the rotator cuff. J Bone Joint Surg Am 1995;77:857-66. 14. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am 1999;81:991-7. 15. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5. 16. Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect 2001;50:63-71.
Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P ⬍ .001). Active elevation improved from 114° to 154°, and no patient lost strength after surgery. The ability to raise the arm to at least 135° improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears. (J Shoulder Elbow Surg 2005;14:121-127.)
M assive rotator cuff tears challenge the concept of
complete repair because of tissue retraction and inelasticity, bursal scarring, muscle atrophy, and fatty degeneration.2,4,6,9 These patients have the worst prognosis of all of those presenting with rotator cuff tears in terms of restoration of strength and function.1,4,6,9 Although most rotator cuff tears can be repaired primarily to bone1,6,16 and even the majority of massive rotator cuff tears can be completely repaired,1,6,16 a significant proportion of massive tears defy traditional techniques for complete repair to bone. A variety of treatment recommendations have been made in the literature for these irreparable tears of the rotator cuff including debridement,11,13 muscle advancement,4 tendon transfers,1,10 and grafting with either synthetic, allograft, or xenograft16 materials. Burkhart et al2 have described kinematic patterns in shoulders with massive rotator cuff tears to explain From Peachtree Orthopaedic Clinica and Santa Fe Orthopaedics.b Reprint requests: Xavier A. Duralde, MD, Peachtree Orthopaedic Clinic, 2045 Peachtree Rd, Suite 700, Atlanta, GA 30309. (E-mail: [email protected]). Copyright © 2005 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2005/$30.00 doi:10.1016/j.jse.2004.06.015
how a patient with a large rotator cuff tear can still couple the forces of the deltoid and remaining rotator cuff muscles to forward elevate the arm effectively. They describe these tears as anatomically deficient but biomechanically intact. They challenged the concept that a complete rotator cuff repair was required for restoration of adequate function and pain relief after rotator cuff surgery and promoted this technique for massive irreparable rotator cuff tears. The purpose of this study is to review the results of 25 such cases, performed by 1 surgeon, in whom a complete repair was not possible in those with massive rotator cuff tears. MATERIALS AND METHODS Sixty-eight patients underwent 70 open repairs for massive rotator cuff tears between October 1994 and February 2001. Massive rotator cuff tears were defined by Cofield4 as having a diameter greater than or equal to 5 cm and involving at least 2 of the 4 musculotendinous units. In 25 of 70 repairs (36%) the rotator cuff could not be completely repaired. These 25 patients are the focus of this retrospective study. One male patient died 6 months after surgery from unrelated problems. Therefore, there are follow-up data in only 24 patients for a mean of 43 months (range, 24-72 months). There were 5 women and 20 men, with a mean age of 61 years (range, 38-76 years). The rotator cuff was involved in the dominant extremity in 76% of cases. One patient (patient 7) had had a previous rotator cuff repair performed on the affected shoulder that had failed. Patients were assessed by use of the American Shoulder and Elbow Surgeons (ASES) scale, including evaluation of subjective pain, functional assessment, range of motion, and strength testing. The patients filled out subjective questionnaires both preoperatively and postoperatively. The mean duration of symptoms before surgery was 17 months (range, 1-81 months). Of the patients, 76% (19/25) complained of night pain, and 72% described their pain as greater than 5 on a 10-point scale. Preoperative active forward elevation averaged 114° (range, 0°-180°) and active external rotation averaged 44° (range, 0°-90°). Passive forward elevation averaged 156°. No patient had preoperative stiffness. Four patients (sixteen percent) were unable to hold the arm actively at 0° of external rotation with the arm at the side, indicating a positive lag sign. Of the patients, 72% (18/25) had a positive impingement sign, and 5 (25%) had ruptured the long head of the biceps. The acromioclavicular joint was
121
122
Duralde and Bair
tender in 32% of patients (8/25). Strength was tested manually and graded by use of a standard 5-point scale. All testing was done by the operating surgeon. Only 2 patients (8%) had normal preoperative forward elevation and external rotation strength. Varying degrees of weakness were noted in the remaining 92% of patients (range, 0-4). Patients were asked to describe their function preoperatively including 10 questions from the ASES questionnaire regarding activities of daily living. Preoperatively, only 4 of 25 patients (16%) were able to use the affected arm for any overhead function but with moderate difficulty in all cases. Radiographic evaluation of the affected shoulder revealed a high-riding humeral head (acromiohumeral distance ⬍6 mm) in 14 patients (56%).6 There was no evidence of cuff tear arthropathy in any of these patients. Of the patients, 16 underwent magnetic resonance imaging (MRI) preoperatively, whereas 3 had an arthrogram, and in 6 patients no preoperative imaging study beyond radiographs was performed. All 16 MRI scans revealed a massive rotator cuff tear involving at least the supraspinatus and infraspinatus tendons with severe retraction. Significant muscle atrophy was noted in 11 cases. Muscle tissue, however, was visible in the supraspinatus and infraspinatus fossae on all of these patients. In the 6 patients who did not undergo advanced imaging studies, clinical signs such as a drop-arm sign, severe atrophy, and a high-riding humeral head on radiographs were suggestive of a massive tear.
Operative technique and pathology All operations were performed by the same surgeon between 1994 and 2001 using a combination of general anesthesia and interscalene block. The surgical technique was modified from that of Bigliani et al,1 which has been described previously. Several important distinctions require mention. The deltoid origin was released by electrocautery from the anterior acromion, allowing the deltoid split to be carried down the anterolateral raphe and giving greater access to the posterior aspect of the rotator cuff. This tendon was repaired back to the acromion through drill holes at the end of surgery by use of nonabsorbable polyester sutures. The coracoacromial ligament was incorporated into the deltoid repair whenever possible to help create a buttress against anterosuperior instability. In no case was the subscapularis tendon transferred. Modified Mason-Allen sutures were used when tissue quality was poor. Otherwise, simple sutures were used. The rotator cuff was repaired to bone through bone tunnels by use of No. 1 polyester sutures. An attempt at complete repair was made in all cases. The cuff was repaired with the arm at the side to avoid tension on the repair. No reinforcement of the tendons by use of xenograft, allograft, or synthetic material was performed. A defect was left according to the anatomy of the tear. In 12 of 25 patients (48%), a formal distal clavicle resection was performed, and in the remaining 13 patients, a modified acromioclavicular joint arthroplasty was performed by resecting the prominent inferior border of the acromioclavicular joint to eliminate impingement from this structure. In 6 of 25 patients (24%), a spontaneous rupture of the long head of the biceps tendon was found. A biceps tenodesis was performed in 14 of 25 patients, and 5
J Shoulder Elbow Surg March/April 2005
Figure 1 Appearance of rotator cuff after partial repair. The long head of the biceps (LHB) is visible through the defect in the supraspinatus tendon. The infraspinatus tendon (IST), humeral head (HH), and greater tuberosity (GT) are marked.
patients had a normal appearing biceps that was not disturbed. The size of the remaining defect after partial repair measured along the greater tuberosity ranged from 5 mm to 3 cm (mean, 1.7 cm). Of 25 defects, 19 were posterosuperior, 3 involved only the supraspinatus, and the remaining 3 were at the junction of the supraspinatus and subscapularis (Figure 1). The massive rotator cuff tears were categorized into 1 of 4 groups based on operative findings. Group I included 7 patients (28%) who had tears involving the supraspinatus, infraspinatus, and teres minor. In group II there were 13 patients (52%) who had tears involving the supraspinatus and infraspinatus. In group III there were 4 patients (16%) who had a tear involving the supraspinatus, infraspinatus, and subscapularis. Finally, in group IV there was 1 patient (4%) who had a tear involving the supraspinatus and subscapularis. The patient who died belonged to group I. Rehabilitation was performed per the protocol of Bigliani et al1 with passive exercises for 6 weeks followed by active assisted exercises. Resistive exercises were introduced at 3 months. No abduction pillows were used. At the final follow-up visit, patients were asked to fill out a subjective ASES questionnaire regarding their ability to perform 10 activities of daily living and to assess their pain and medication requirements.12 Range of motion and strength were assessed by the surgeon. Repeat radiographs were performed to measure the acromiohumeral distance and to assess for signs of arthropathy. No follow-up MRI studies were performed. Outcomes were rated by use of the criteria of Bigliani et al1 for assessment of patients after massive rotator cuff repair. Outcomes were placed into 1 of 4 categories: excellent, good, fair, and poor. Patients with an excellent result were essentially pain-free and had maintained within 10° of normal active motion in all planes. Those with an excellent result had resumed unrestricted activity. Patients with a good result had occasional weather-related ache, had active forward elevation greater than 140°, and had greater than 30° of external rotation. They exhibited some
J Shoulder Elbow Surg Volume 14, Number 2
Figure 2 Overall results.
limitation of strenuous overhead activity because of decreased strength. Patients with a fair result had intermittent episodes of pain requiring analgesics, could actively forward elevate between 90° and 140°, and could actively externally rotate between 0° and 30°. Those in whom these criteria were not met had a poor result. The ASES shoulder index was also calculated for all patients. Paired t tests were used to compare the changes in shoulder index, pain, and acromiohumeral distance before and after surgery. To test whether these changes were significantly different between groups I, II, and III, a 1-way analysis of variance was used, followed by Bonferroni post hoc comparisons. Because group IV contained only 1 subject, this group was excluded from analysis of variance. Statistical significance was declared at the .05 level.
RESULTS The overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%) (Figure 2). Therefore, 67% of patients had either excellent or good results after partial repair of massive rotator cuff tears. Subjectively, 92% (22/24) were satisfied with the results of surgery. Significant pain relief was realized after surgery, with preoperative pain averaging 5.8 (SD, 2.3) and postoperative pain averaging 1.7 (SD, 2.2) (P ⬍ .001). However, there were no significant differences in pain relief between groups I, II, and III. Postoperatively, 14 patients (58%) rated their pain as less than 2, whereas an additional 7 (29%) rated their pain as less than 5. Only 3 patients continued to have night pain postoperatively compared with 17 patients preoperatively. A significant change in the shoulder index was realized after surgery, with preoperative shoulder index averaging 41.0 (SD, 19.9; range, 15-90) and postoperative shoulder index averaging 80.1 (SD, 23.0; range, 20-100) (P ⬍ .001). However, there were no significant differences in the shoulder index between groups I, II, and III (Figure 3). Mean active forward elevation improved from 114° preoperatively to 154° (⫹40°) postoperatively (range, 90°-180°). No patient lost forward elevation. Active external rotation improved from 44° preoper-
Duralde and Bair
123
Figure 3 Shoulder index preoperatively (Preop) versus postoperatively (Postop).
atively to 54° (⫹10°) postoperatively (range, 30°80°). Preoperatively, only 13 patients (54%) could forward elevate their arms to 135° or greater, whereas postoperatively, 21 patients (88%) could forward elevate actively to 135° or greater (Table 1). Overall function in activities of daily living improved significantly after surgery. Improvement in 4 of the more strenuous activities of daily living is depicted in Figure 4. Remarkably, 14 patients (58%) regained the ability to lift a 10-lb weight overhead. Forward elevation strength increased by at least 1 grade in 63% of patients postoperatively, and in no patient was strength lost after surgery. Forward elevation strength increased from a mean of 3.6 preoperatively (range, 0-5) to 4.5 postoperatively (range, 4-5), an increase of 0.9. External rotation strength increased from a mean of 3.5 preoperatively (range, 0-5) to 4.5 postoperatively (range, 4-5), an increase of 1.0. The 4 patients with a positive lag sign preoperatively demonstrated significant improvement in external rotational strength to 4, 4, 4, and 5, respectively. Results were graded according to the various tear patterns (I-IV) as previously described. As noted earlier, there were no statistical differences between groups I, II, and III in terms of preoperative and postoperative changes with respect to pain, shoulder index, or acromiohumeral distance. The 1 poor result in this series was the sole patient in group IV. There was no correlation between outcome and sex, age, or length of symptoms preoperatively. No arthrosis was noted on postoperative radiographs. There was no significant change in acromiohumeral distance, which averaged 5.4 mm preoperatively (SD, 3.5 mm; range, 0-12 mm), nor were there any significant differences in the change in acromiohumeral distance between groups I, II, and III. In addition, there was no association between final result (overall rating scale) and postoperative acromiohumeral distance (Figure 5). There were no deep infections, no nerve injuries, and no instances of deltoid detachment postopera-
124 Duralde and Bair
Table I Results
Group
Patient No.
Age (y)
Sex
Length of symptoms (mo)
I I I I I I I II II II II II II II II II II II II II III III III III IV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
67 56 60 67 68 56 38 58 50 71 76 69 54 72 46 68 59 67 74 63 74 43 73 60 52
M M F M M M M M M F M F M M M F M M M M F M M M M
3 5 11 40 1 6 7 9 2 10 2 11 81 8 16 15 24 4 3 10 57 1 12 60 5
Preoperative Pain 8 8 2 8 2 4 8 8 8 6 6 6 6 8 8 8 8 4 6 4 6 6 4 8 0
Preoperative function*
Preoperative external rotation strength
Preoperative forward elevation strength
Active elevation (°)
Active external rotation (°)
Preopecative SI
5 7 15 13 6 19 11 16 10 0 3 22 17 9 6 3 8 20 11 25 15 13 11 11 24
0 3 4 4 0 4 4 4 3 4 0 4 4 5 5 0 4 4 4 4 5 4 4 5 5
0 3 4 4 0 4 4 4 3 4 0 4 4 5 4 4 3 4 4 4 4 4 4 4 5
0 180 180 100 0 110 145 160 30 90 0 100 135 45 100 160 30 170 135 150 170 170 180 100 180
0 10 60 60 0 45 20 30 45 20 0 20 45 50 45 0 20 60 30 60 70 60 60 45 90
18.3 21.6 65 31.7 50 61.7 28.3 36.7 26.7 20 25 56.7 48.3 25 20 15 23.3 63.3 38.3 71.7 45 41.7 48.3 28.3 90
J Shoulder Elbow Surg March/April 2005
SI, ASES Shoulder Index (range, 0 –100); I, Suprasinatus, infraspinatus, and teres minor; II, supraspinatus and infraspinatus; III, subscapularis, supraspinatus, and infraspinatus; IV, supraspinatus and subscapularis; F, fair, E, excellent; N/A, not applicable; G, good; P, poor. *Function was based on ASES score (range, 0 –30).
J Shoulder Elbow Surg Volume 14, Number 2
Table I Continued
Postoperative function*
4 0 0 0 0 2 2 0 4 2 4 0 0 6 2 0 0 0 0 0 4 0 0 6 6
21 30 30 N/A 28 28 28 23 19 22 22 30 30 7 19 19 30 24 28 30 19 27 19 15 0
4 5 5 4 5 4 4 5 5 4 4 5 5 4 4 5 5 5 4 5 5 5 4 4 5
Postoperative forward elevation strength
Active elevation (°)
Active external rotation (°)
Postoperative SI
Overall rating
4 5 5 4 5 4 5 5 5 4 4 5 5 5 4 4 5 5 4 5 5 5 4 4 5
110 180 180 135 170 90 180 180 180 135 135 180 180 100 150 180 180 170 135 170 160 170 180 160 125
30 50 70 60 50 50 30 45 60 45 50 45 60 45 50 60 60 60 40 70 60 60 60 60 80
65 100 100 N/A 96.7 86.7 86.7 88.3 61.7 76.7 66.7 100 100 31.7 71.7 81.7 100 90 96.7 100 61.7 95 81.7 45 20
F E E N/A E F E E G F F E E F G E E E F E G G G F P
Duralde and Bair
Postoperative pain
Postoperative external rotation strength
125
126
Duralde and Bair
Figure 4 Selected activities of daily living preoperatively (Preop) versus postoperatively (Postop). #, Pounds.
Figure 5 Relationship of acromiohumeral (AH) distance postoperatively (post-op) to final result of note.
tively. Two patients did require revision surgery in this series. One patient had an excellent result until a second injury occurred at a construction site 3 years after repair. He fell off of a ladder, sustaining a retear of the rotator cuff. At revision surgery, no significant rerepair was possible, and this patient’s final outcome after the second surgery is poor. A second patient had a large acromioclavicular joint cyst develop that was excised 2 years after rotator cuff repair. His overall rating was fair. DISCUSSION Massive rotator cuff tears are rare in reported series,6,9,13 but even the majority of these tears can be repaired primarily to bone.1,4,6,9,14 When complete repair is possible, the results of surgery are good even with large and massive tears, with greater than 90% pain relief and greater than 85% restoration of satisfactory function.1,14 When tendon tissue quality
J Shoulder Elbow Surg March/April 2005
is so poor that direct bone-to-tendon repair is not possible, a variety of techniques have been recommended. The relative indications for debridement versus partial repair versus tendon transfers have not been well delineated in the literature. Arthroscopic debridement and open debridement of irreparable rotator cuff tears have been shown to provide good pain relief.11,13 Restoration of strength, however, has been inferior to series in which complete or partial repair has been performed.2,9,11 Deterioration of results has also been reported with this technique,11 which appears best suited for relatively inactive and elderly patients. Warner16 states that it is appropriate to consider tendon transfer for patients with a painful rotator cuff tear associated with poor function and in whom there is a low probability that primary reconstruction will be successful. These tend to be younger patients with higher demands on their shoulders. Local tendon transfer involving the superior portion of the subscapularis has been reported in the literature with some success,3 but these results have not been uniformly reproducible. Although satisfactory pain relief has been achieved, subscapularis transfer can adversely affect active elevation of the shoulder and should be used with caution in patients who have full functional elevation preoperatively.3,10 Gerber and Hersche5 evaluated the results of latissimus dorsi transfer in the treatment of 16 irreparable, massive rotator cuff tears, reporting good or excellent results in 13 of 16. Active forward elevation in these patients improved from 83° preoperatively to 135° postoperatively. Asymptomatic rotator cuff tears are a common finding in older patients.15 Burkhart et al2 describe a functional rotator cuff tear as one typically involving the supraspinatus tendon and one half of the infraspinatus tendon. As long as the rotator cuff tear does not extend inferior to the equator of the humeral head, the cuff can often maintain the humeral head centrally located in the glenoid and allow rotation by the deltoid. In the only comparable reported series to this one, Burkhart et al2 demonstrated an improvement of 90.8° of active forward elevation, from 59.6° to 150.4°, after partial repair of massive rotator cuff tears. Residual defects were comparable to this study. The majority of the tear patterns in that series were posterosuperior, as in our study. Although the report describes techniques similar to those used in our series, 5 separate surgeons were involved in compiling the data for 14 patients, introducing an element of variability in these patients’ care. Multiple clinical studies in which both open and arthroscopic techniques of rotator cuff repair were used have documented little effect on results from partial or complete cuff failure postoperatively.7-9 These studies demonstrate a growing body of litera-
Duralde and Bair
J Shoulder Elbow Surg Volume 14, Number 2
ture emphasizing the importance of stable fulcrum kinematics and force coupling around the shoulder as the most important factor predicting outcome in the rotator cuff. The concept of closing the hole is less important in the treatment of rotator cuff tears than that of reestablishment of stable fulcrum kinematics.2 The closure of nonfunctional tendon tissue around the humeral head may serve temporarily as a watertight seal but in no way maintains the humeral head centered in the glenoid or allows improvement in either strength or function after repair. The definition of a massive rotator cuff tear remains controversial, with some authors stating that 3 tendons must be involved.5 Tear size and reparability, however, are not always related because of variability in tissue retraction and muscle atrophy. All of the tears in this series were irreparable by use of standard techniques, regardless of whether 2 or 3 tendons were involved. This patient cohort exemplifies the challenge of treatment of irreparable tears despite the variation in the tear pattern seen. In all of these cases an attempt to obtain a complete repair was made with a tedious and careful mobilization of cuff tissue to a point as lateral as possible. A tension-free repair was obtained with the arm at the side in all cases, and the residual defect was left based on the anatomy of that particular tear. This study has several definite weaknesses. It is a retrospective study, and strength testing was relatively subjective, relying on resistive testing by the operating surgeon. Surgical technique was identical in all cases, however, and our grading system depended heavily on objective data such as active range of motion and functional improvement. Because this series did not use tendon transfers or tendon augmentation with graft material, we believe it serves as a basis of comparison for those more extensive procedures in the treatment of massive, irreparable rotator cuff tears. The results are clearly superior to those of simple debridement of the rotator cuff, with excellent pain relief and significant improvement in strength and overhead function. These patients had an inferior result to that in the series reported by Bigliani et al1 and Rokito et al,14 who both reported on complete repairs of massive rotator cuff tears. Our patient group had more advanced pathol-
127
ogy with a poorer-quality tendon and muscle tissue. Our results are not significantly different from those reported by Gerber5 for latissimus dorsi transfer. No patient lost active elevation, as has been reported with transfers of the subscapularis.10 Partial repair of massive rotator cuff tears represents a reasonable alternative in the treatment of these challenging patients. REFERENCES
1. Bigliani LU, Cordasco FA, McIlveen SJ. Operative repair of massive rotator cuff tears: long-term results. J Shoulder Elbow Surg 1992;1:120-30. 2. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy 1994;10:363-70. 3. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982;154:66772. 4. Cofield RH. Current concepts review: rotator cuff disease of the shoulder. J Bone Joint Surg Am 1985;67:974-9. 5. Gerber C, Hersche O. Tendon transfers for the treatment of irreparable rotator cuff defects. Orthop Clin North Am 1997;28: 195-203. 6. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-15. 7. Harryman DT, Mack LA, Wang KY, et al. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982-9. 8. Jost B, Pfirrmann C, Gerber C, Switzerland Z. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 2000;82:304-14. 9. Iannotti JP. Full-thickness rotator cuff tears: factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95. 10. Karas SE, Giachello TL. Subscapularis transfer for reconstruction of massive tears of the rotator cuff. J Bone Joint Surg Am 1996; 78:239-45. 11. Mellio AS, Savoie FH, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am 1997;28: 117-24. 12. Richards RR, An K, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994; 3:347-52. 13. Rockwood CA Jr, Williams GR Jr, Burkhead WZ. Debridement of degenerative irreparable lesions of the rotator cuff. J Bone Joint Surg Am 1995;77:857-66. 14. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am 1999;81:991-7. 15. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5. 16. Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect 2001;50:63-71.