Arthroscopic Management of Massive

Retracted Rotator Cuff Tears

 

 

                           Clinical Professor Orthopaedics

University of Florida

                             Department of Orthopaedics

                           Address correspondence to:

                          

                                    Edward S. Bittar, M.D., Ph.D.

                                    5200 Babcock St. N.E.

                                    Palm Bay, FL. 32905

Abstract:

Objective of Study:   Evaluation of the role and effectiveness of arthroscopy in the management of massive retracted rotator cuff tears (RCT).

Materials and Methods:   Seventy-four patients, ranging in age from 54 to 82 years, with massive (15 cm² or greater), retracted RCT underwent out-patient arthroscopic debridement, subacromial decompression and mobilization of the rotator cuff.  The superior, anterior and posterior capsular recess was arthroscopically released to allow mobilization and anatomic reduction of the free rim of the avulsed rotator cuff.  The RCT was then repaired with the arm in neutral using a mini-arthrotomy approach.  Post-operatively, the RCT repair was protected with six weeks of full, passive range of motion.  Active range of motion was initiated after six weeks, followed by progressive resistive exercises.

Results:   Sixty-one patients (83%) recovered active, functional and pain-free shoulder range of motion post-operatively after four months of aggressive rehabilitation.  Thirteen patients (17%) complained of persistent pain post-operatively.  Six of the thirteen patients with persistent pain underwent imaging confirming re-tear of the repaired RCT.  Nineteen patients required up to eighteen months of supervised post-operative strengthening before restoring normal torque strength and function to their involved shoulders.  Patients were followed clinically for at least three years and up to eight years.  Results did not diminish with time.

Conclusion:   Arthroscopically-assisted repair of massive (15 cm² or greater) retracted RCT provides substantial advantages over open repairs.  The glenohumeral joint can be evaluated and debrided arthroscopically prior to treatment of rotator cuff pathology.  The character of the RCT can be evaluated and the torn tissue fully mobilized prior to performing an arthrotomy or a bony decompression of the acromial arch.  Extensile arthrotomies are obviated completely.  Arthroscopic mobilization and reduction confirms that the RCT can be reduced and repaired anatomically prior to altering shoulder mechanics with an arthroscopic bony subacromial decompression and Mumford procedure.  Only the final RCT repair requires the use of a mini-arthrotomy approach.  Mobilization and repair of a massive, retracted RCT can be performed with arthroscopic assistance with substantially reduced morbidity and with good or excellent results in 82% of patients.  Extensile arthrotomy for exposure is eliminated and post-operative recovery is markedly enhanced.  Shoulders with an irreparable RCT can be debrided arthroscopically while providing a measure of pain relief to patients with minimal morbidity.

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Introduction

         Massive, retracted tears of the rotator cuff are difficult to manage. They usually occur in older individuals with compromised tissues that are not easily  mobilized and repaired.  Visualization of a massive tear, which involves more than one tendon and is usually retracted to the level of the glenoid rim, is a challenge when performed through an arthrotomy, even when extensile exposures are utilized.   Exposure can require the release of the deltoid origin with associated morbidity and with potential failure of the reattachment of the deltoid.    Once exposed, the torn rotator cuff tissue may not have sufficient length to be adequately mobilized and reduced anatomically. Once mobilized and reduced, the bony and soft tissues may not be robust enough for repair.    Once repaired, the damaged and weakened tissues may not withstand rigorous therapy and can tear once again.  

            Fortunately, the management of massive, retracted rotator cuff tears (RCT) continues to evolve as techniques for treatment improve.   Management options are varied and include non-surgical management (1), open debridement with decompression (2), arthroscopic debridement alone (3),  arthroscopic debridement with decompression (4), partial repair of the torn cuff (5), open repair (6), mini-open repair (7-13), arthroscopic repair (14-17), and options that combine management techniques.   For the past decade, tears of the rotator cuff have been managed more aggressively with arthroscopic surgery.   Debridement with repair is reported to yield results that are superior to debridement alone (18-19).   Mini-open and arthroscopic repairs of small and medium size tears have the advantage of decreased morbidity compared with open techniques (20).   The arthroscopic management of massive tears, however, remains controversial.

 

            It is argued that the arthroscopically-assisted management of RCT is a demanding technique that is dependant upon individual skill and can therefore be potentially less precise.            However, repair strategies that employ arthroscopy for visualization, management of gleno-humeral joint pathology, mobilization of the retracted tendons, and subacromial debridement and decompression obviate the need for extensile exposures in the surgical treatment of massive RCT, and minimize morbidity.   Additionally, massive, retracted tears of the rotator cuff are often very difficult to visualize, mobilize and repair in spite of an extensile exposure.   From that perspective,  a mini-open repair of a massive tear combined with arthroscopic assistance, or when technically feasible, an arthroscopic repair of a massive tear has substantial merit.

 

            This study was undertaken to assess the relative effectiveness of arthroscopic management of massive retracted tears of the rotator cuff.   Arthroscopy allows the torn tissue to be visualized, probed and mobilized to assess the extent of

 

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its damage and repairablity.   It obviates the need for an extensile arthrotomy and creates much less morbidity.   It is predictable that patients who have undergone arthroscopic management of their tears will have a less protracted post operative course and will have a more rapid return of full function and return of routine activities of  daily living.

Materials and Methods:

 

            Seventy-four patients ranging in age from fifty-four to eighty-two years and             with an average age of seventy-two years presented with massive, retracted tears of the rotator cuff.   The tears were all visualized preoperatively with MRI and noted to be chronic, massive tears that were retracted to the level the glenoid rim.   All but  eight of the patients had a history of chronic shoulder problems that had been treated  with multiple injections for pain through the years, while most had failed a strengthening exercise program, some patients were in such extreme pain, that they rejected all attempts at non-surgical management.   All patients underwent an arthroscpic examination and debridement of the glenohumeral joint prior to addressing the tear of the rotator cuff.   The subacromial compartment was cleared of adhesions, torn bursal tissue and reactive synovitis.   The exposed retracted cuff was then released from surrounding soft tissues on its superior and inferior sides and the superior capsular recess was debrided.   The cuff remnant was mobilized by lysing adhesions at the anterior, superior and posterior capsular recess with an arthroscopic scissors and motorized shaver until the free edge of the cuff could be lifted as unit with a grasping tool and translocated as a unit toward its attachment site on the greater tuberosity.   The reduction was performed with the shoulder in neutral.   On six occasions, patients were excluded from the study if the free edge of the cuff could not be mobilized enough to be reduced with the arm held in neutral or if the tissue quality was too poor to support a repair and a simple debridement was accomplished.    After it was confirmed that the cuff could be mobilized and reduced anatomically, a subacromial decompression was performed which included an acromioplasty and resection of the coraco-acromial ligament.  It was important to confirm that an anatomic repair could be performed with only a moderate amount of tension at  most with the arm held in neutral, before modifying the subacromial arch.   A decompression was not performed unless the cuff could be repaired, to avoid changing the mechanical advantage that the arch provided in patients that required the arch as a fulcrum for abduction.    The free edge of the cuff was then reattached to the greater tuberosity using bioabsorbable anchors with #2 braided nonabsorbable suture material.   To accomplish the repair, a miniarthrotomy was performed just lateral to the lateral edge of the lateral acromion.    The incision was just large enough (approximately 3 cm in length ) to allow a self-retaining retractor to be introduced into a split between deltoid muscle fibers.   The optimal position for the deltoid-splitting incision was selected with arthroscopic guidance using an 18 gauge spinal needle introduced through the skin and into the subacromial space.   The entire rotator cuff could be easily visualized through the “window” in the deltoid as the arm was fully internally and externally rotated.    The repair was facilitated if a monofilament suture which was introduced with a suture-punch into the free edge of the cuff was used to hold the cuff reduced.   The surgery was performed with the patients in a lateral decubitus position and under general anesthesia.

 

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An interscalene regional block was used for postoperative analgesia.   Postoperatively, patients were protected with a sling until sensation and function returned.    Passive, full range of motion exercises were begun on the first postoperative day and continued  for six weeks to protect the repair of the rotator cuff.   Active exercises were initiated after six weeks, and progressive resistive exercises were begun as tolerated, usually within two weeks after active exercises were begun.  

Results:

 

            Seventy–four patients with an average age of 67 years (range 54 to 82 years) underwent repair of a massive, retracted tear of the rotator cuff .    Using a modified UCLA shoulder rating scale, 28 (38%) of the 61 patients had an excellent result, while 33 (45%) of the patients had a good result.   Seven of the patients (9%) had a fair result and 6 (8%) of the patients had a  poor result. 

            Sixty-one of the seventy-four patients (83%) recovered active, functional and pain-free range of motion postoperatively after four months of aggressive, supervised rehabilitation.    Nineteen patients required up to eighteen months of supervised postoperative strengthening before restoring normal torque strength and function to the involved shoulder.  

            Thirteen patients (17%) complained of persistent pain postoperatively and underwent  a repeat postoperative MRI to assess the status of the repair.   Six of the thirteen with persistent pain had MRI imaging that confirmed  a re-tear of the repaired  cuff.  

            Patients were followed postoperatively for a minimum of three years and for up to eight years.    Results did not diminish with time.

           

Discussion:

 

            Massive, retracted tears of the rotator cuff represent a management challenge to the orthopaedic surgeon.   The chronically torn tissue is commonly  retracted and scarred to the rim of the glenoid.     The retracted edge of the cuff, as a consequence, is not easily visualized or accessible.   Most surgical approaches, including  those that employ extensile exposures, fail to visualize the retracted cuff with ease.    Additionally,  increased exposure usually requires greater dissection and substantially increased morbidity.  

            Arthroscopically-assisted repairs obviate the need for extensive dissection and  provide remarkable visualization of the  torn rotator cuff tissues.   Arthroscopic visualization of the joint and the torn rotator cuff also provide the surgeon with a means of evaluating the joint pathology and the extent and character of the tear of the rotator cuff prior to considering an arthrotomy.   Indeed, in some situations where a repair is not considered feasible,  surgical management can be abandoned with substantial reduction in the morbidity of an arthrotomy.

            This study was undertaken to retrospectively evaluate the relative value of arthroscopically–assisted repairs of massive tears of the rotator cuff.    In many cases the torn tissue has been chronically torn and retracted and is poor quality and compromised by poor vascularity.     Additionally, massive tears occur  in an elderly population with poor quality bone stock which further compromises suture repair and suture-anchor fixation.     Arthroscopic evaluation of the tear and the surrounding tissues allows the surgeon to make strategic decisions concerning the amount and character of the surgery to be performed or whether a reconstruction should be undertaken or abandoned.      Mobilization, reduction and fixation  of the torn cuff are substantially facilitated  with arthroscopic assistance.     Visualization and surgical manipulation of the tear are profoundly improved and facilitated.  

            The majority of patients (83%) appear to have been substantially improved with arthroscopically-assisted debridement, mobilization, and capture of the free edge of the rotator cuff to allow a miniarthrotomy repair to be performed.   Patients with massively torn rotator cuffs have extremely compromised function because of pain and altered shoulder mechanics.    An arthroscopically-assisted miniarthrotomy repair effectively restores function and  eliminates most of the pain in most cases.    Predictably, the use of a miniarthrotomy with a deltoid splitting approach causes much less postoperative pain and dysfunction than an extensile exposure.    Similarly, arthroscopic assistance allows the surgeon to use a much smaller  miniarthrotomy with a concomitant decrease in morbidity.    Over the past three years, we have been performing massive rotator cuff repairs arthroscopically with the predictable observation that morbidity is diminished even further.

           

The present study confirms that massive, retracted tears of the rotator cuff can effectively be treated with arthroscopic assistance with substantial reduction in morbidity.   The tears can be more accurately visualized, mobilized and reduced.   Most recent work suggests that  arthroscopic repairs will improve the post operative course of patients that undergo repair of  massive  tears.

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BIBLIOGRAPHY

 

 

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BIBLIOGRAPHY (cont.)

 

 

 

18.  Montgomery TJ, Yerger B, Savoie FH III.  Management of Rotator Cuff Tears:  A Comparison of Arthroscopic Debridement and Surgical Repair.  J Shoulder Elbow Surg.  1994;3:70-78.

19.  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.  July 1999;81(7):991-997.

20.  Iannotti JP.  Full-Thickness Rotator Cuff Tears:  Factors Affecting Surgical Outcome.  J Am Acad Orthop Surg.  1994;2:87-95.