Irreparable Rotator Cuff Tears

Literature Review

When a massive, irreparable defect in the rotator cuff tendons is identified at surgery, the surgeon has various treatment options to choose from. Local tissue transfer from the remaining intact rotator cuff, use of the upper portion of the subscapularis, incorporation of the intra-articular portion of the biceps tendon, supraspinatus advancement, deltoid muscle flap, synthetic materials, and tendon allograft have been proposed. Latissimus dorsi transfer has been described by Gerber and others, but there are questions about the morbidity of this procedure as well as the dynamic function of the graft. For patients in whom overhead work and stronger external rotation are vital, the relatively modest gains afforded by latissimus dorsi transfer can be of major importance. Subscapularis transfer and biceps incorporation are rarely performed. Synthetic grafts are currently a source of great interest, but little science is available to guide the orthopedic surgeon. Superior capsular reconstruction is gaining popularity, but more data are needed. Because irreparable tendon tears are almost always accompanied by profound muscle atrophy and fatty infiltration, it seems unlikely that synthetic tendon connected to non-viable muscle will function.

One of the most widely used open procedures was described by Rockwood, who débrided the edges of the necrotic tendon, thoroughly decompressed the subacromial space by performing an anterior and inferior acromioplasty, resected the coracoacromial ligament, and removed the subacromial bursa. The deltoid was meticulously repaired. Postoperatively, the patient was started on an immediate rehabilitation program. Rockwood obtained good results using this technique, with patients achieving pain relief and marked improvement in function. Our own experience was not as positive. The success rate was lower, and we found that after this procedure some patients experienced an improvement in pain, but a loss of strength.

Since these reports appeared, Nirschl has taught us to avoid acromioplasty in these patients. Preserving the coracoacromial arch helps keep the humeral head centered in the glenohumeral joint and prevents the disastrous complication of anterior superior humeral head subluxation.

Less has been written about the arthroscopic treatment of patients with irreparable tears. We have achieved good pain relief with arthroscopic treatment in a limited number of patients; reasonable pain relief has been documented in most patients at up to 5 years' follow-up. We emphasize thorough débridement and synovectomy, accompanied by the removal of any downward-protruding acromial or acromioclavicular joint spurs. Burkhart reported that among 25 patients with massive irreparable tears, 88% had good or excellent results after arthroscopic treatment; those results have not deteriorated with the passage of time. Many older individuals have relatively good active and passive motion; however, pain is their primary complaint. Arthroscopic débridement and biceps tenotomy can provide good pain relief with little morbidity. For individuals who need more motion or strength, reverse shoulder arthroplasty is a viable option.

Diagnosis

Physical examination usually demonstrates a normal or near-normal passive range of motion; however, there may be limits because of capsular contractures. The active range of motion is decreased. Supraspinatus and infraspinatus atrophy may be observed. Manual muscle testing demonstrates grade 3 or lower strength with external rotation and elevation. The patient's subscapularis function should be evaluated using either the belly-press test or the lift-off test with the arm internally rotated to the back.

Plain radiographs may show the humeral head centered in the glenoid, but superior migration may be present. Magnetic resonance imaging (MRI), which some surgeons do not use routinely in older patients, is often of great value in this clinical setting. The amount of tendon retraction is more clearly defined on MRI than on arthrography and, perhaps more importantly, the degree of atrophy and fatty degeneration or substitution in the rotator cuff muscles can be appreciated ( Fig. 14.2 ). If the patient's rotator cuff strength is grade 3 or less, and MRI demonstrates humeral head superior migration, retraction of the tendon to the glenoid rim, and severe muscular atrophy, the cuff defect is almost certainly irreparable.

The status of the subscapularis requires close attention. Patients with irreparable, retracted subscapularis tears can be treated with arthroscopic débridement. However, Burkhart has shown that patients with reparable subscapularis tears benefit from subscapularis repair even in the presence of superior humeral head migration ( Fig. 14.3 ).

Nonoperative Treatment

Nonoperative treatment consists of activity modification, nonsteroidal antiinflammatory medications, cortisone injections, and a physical therapy program designed to maintain or improve shoulder range of motion and to strengthen the deltoid, scapular rotators, biceps, and intact rotator cuff muscles.

We continue nonoperative treatment for at least 6 months. A surprising number of patients have reduced pain as the inflammation decreases, and they regain adequate function with muscle strengthening exercises. Stretching can often improve capsular contracture and further diminish pain.