Repair of Massive Rotator Cuff Tears
Abstract & commentary
Synopsis: Although attempted repair is recommended, the prognosis should be guarded because of a moderate re-tear rate, muscle atrophy, and fatty degeneration.
Source: Gerber C, et al. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-515.
Gerber and colleagues have described the results of a prospective study of attempted repair in 29 massive rotator cuff tears. This involved the complete detachment of at least two tendons and, in many times, three. The repair was carried out with the arm in slight abduction. Significant soft-tissue dissection was necessary in order to replace the tendons back to their natural osseous bed. Soft tissue was removed and a transosseous tunnel was used. A specific suturing technique, which was referred to as a modified Mason-Allen stitch, was done with a number three braided polyester suture. In order to protect the sutures from cutting through the bone, a titanium plate was used with seven holes to tie the sutures over. The patients were protected in an abduction splint to take tension off the repair when the supraspinatus was involved.
Gerber et al described in detail the preoperative MRI findings as well as the postoperative findings trying to correlate the degree of muscle atrophy seen on the preoperative MRI with their postoperative findings. The patients were followed for a minimum of two years.
Patients’ postoperative Constant score improved an average of 36%, which signified increased motion as well as increased strength, diminution of pain, and an increase in performance of daily activities. Seventeen of 29 patients had a structurally successful repair and an excellent clinical outcome. They noted that muscle atrophy could not be reversed except in the case of a successfully repaired supraspinatus musculotendinous unit. In the remainder of cases, fatty degeneration increased in all muscles on postoperative MRIs. They had a moderate re-tear rate (10 of 29), but in general, little if any change in the muscular atrophy and fatty degeneration. They did note the re-tears occurred more often in patients who had a shorter interval between the onset of their symptoms and the operative procedure. Patients with re-tears still generally had some improvement of the shoulder but not as substantial as those with a successful repair.
Comment by JAMES P. TASTO, MD
Massive rotator cuff tears continue to be a difficult problem in our ever-aging population. There are multiple techniques, which involve suture anchors, transosseous tunnels, bioabsorbable and titanium plates, and a variety of side-to-side techniques, as well as partial repair techniques.1,2 It is important for the clinician preoperatively to assess these tears so that the patient can better understand the rather extensive rehabilitation that is necessary, as well as the guarded outcome for most of these tears. The value of an MRI in these circumstances certainly can be appreciated from an academic standpoint to validate results. It can also be of excellent prognostic value if one sees significant fatty degeneration in one, two, or three of the musculotendinous units of the rotator cuff. The injury can be documented as well as the prognosis altered. There are many surgeons who feel that the presence of significant fatty degeneration in the musculotendinous unit is a relative contraindication to repair.3 Gerber et al felt that attempted repair in all of these cases was definitely warranted, but the results need to be guarded. There still exists significant controversy as to executing a repair after extensive capsular dissection and then immobilizing the patient in an abduction splint. This can, at times, be followed by the patient re-tearing his or her repair because of a foreshortened construct.
Early recognition of rotator cuff tears, as well as early intervention before significant chronic fatty degeneration takes place physiologically is imperative.
References
1. Burkhart SS, et al. Partial repair of irreparable rotator cuff tears. Arthroscopy 1994;10:363-370.
2. Gerber C, et al. Experimental rotator cuff repair. A preliminary study. J Bone Joint Surg Am 1999;81: 1281-1290.
3. Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative débridement and subacromial decompression. J Bone Joint Surg Am 1997;79: 715-721.
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