Irreparable rotator cuff tears are infrequent but well-defined lesions
consisting of massive rotator cuff tears that are not reparable by
conventional means. Rockwood and
others1-3
defined irreparable tears as those that, because of their size and retraction,
cannot be repaired primarily to their insertion onto the tuberosities despite
conventional techniques of mobilization and soft-tissue releases. Goutallier
et al. classified rotator cuff tears on the basis of the amount of muscle
atrophy and fatty infiltration of the affected rotator cuff muscles
demonstrated by computed tomographic
scans4. Often, these
tears are associated with concomitant arthritis of the glenohumeral joint,
making treatment options even more
complex5.
Patients with irreparable rotator cuff tears can present with a variety of
manifestations. They may have no symptoms or mild symptoms, or they may be
completely disabled and in severe pain. The true incidence of irreparable
rotator cuff tears is not known; however, anatomic studies on cadavera and
imaging studies of asymptomatic patients have demonstrated rotator cuff tears
in 30% to 50% of older patients, especially those older than seventy years of
age6-8.
Tempelhof et al. studied 411 asymptomatic individuals and found that 38% of
those older than the age of seventy had full-thickness rotator cuff
tears9. Rotator cuff
tears with an increased degree of fatty infiltration and muscle atrophy in
association with a high-riding humeral head to the acromion are at high risk
for irreparability. Goutallier et al. used computed tomography scans to
evaluate fatty infiltration, but magnetic resonance imaging is probably more
sensitive4.
Look for this and other related articles inInstructional
Course Lectures, Volume 56, which will be published by the American
Academy of Orthopaedic Surgeons in February 2007:• "Technical Pearls on How to Maximize Healing of the Rotator
Cuff," by Kenneth J. Accousti, MD, and Evan L. Flatow, MD
Look for this and other related articles inInstructional
Course Lectures, Volume 56, which will be published by the American
Academy of Orthopaedic Surgeons in February 2007:
• "Technical Pearls on How to Maximize Healing of the Rotator
Cuff," by Kenneth J. Accousti, MD, and Evan L. Flatow, MD
Massive irreparable rotator cuff tears occur in two physiologically
distinct patient groups, but they can present in all age and activity groups.
Most often, these tears occur in physiologically older, lower-demand patients
(older than seventy years of age and usually female) who have been
asymptomatic until minor trauma created symptoms. The second group consists of
physiologically younger, more active patients, often in the sixth decade of
life, who present with dramatic symptoms of pain and disability after an acute
event or with a history of rotator cuff surgery or of chronic rotator cuff
injury.
In addition to different clinical presentations, irreparable rotator cuff
tears also occur in two distinct anatomic patterns. Complete tears of the
supraspinatus, infraspinatus, and teres minor tendons are posterosuperior
failures and are more common. Complete tears of the supraspinatus and
subscapularis tendons, sometimes with damage or disruption of the long head of
the biceps tendon, are anterosuperior failures. Both anatomic patterns often
result in severe disability and poor function. Loss of the coracoacromial arch
combined with anterosuperior instability may lead to escape of the humeral
head, a potentially devastating clinical situation.
Clinical Findings
The presenting history, chief symptom, and results of physical examination
of a patient with an irreparable rotator cuff tear can be a confusing picture.
Patients can have variable amounts of pain, unpredictable deficits in both the
active and the passive range of motion, and inconsistent levels of disability.
The physical examination reveals atrophy of the scapular muscles in patients
who have had longstanding lesions. In more severe cases, crepitus and
hemarthrosis may also be evident. Patients can have varying degrees of
weakness and loss of motion, ranging from little or no deficit to a complete
loss of active motion.
Patients with posterosuperior disruption of the rotator cuff often have
decreased abduction, forward flexion, and active external rotation, giving
rise to two classic physical findings. One is a positive external rotation lag
sign, which is the inability to externally rotate the arm against resistance
or to hold the arm in external rotation against resistance. With complete loss
of external rotation power, the patient may have the second classic finding: a
positive hornblower's sign (Fig.
1). The hornblower's sign has been shown to have 100% sensitivity
and 93% specificity with regard to indicating irreparable tears of the teres
minor12.
Patients who have an anterosuperior failure often have decreased abduction
and forward flexion. They can have increased passive external rotation as well
as positive belly-press and lift-off signs. The lift-off sign was described by
Gerber and
Krushell13. The
patient places the dorsum of the hand against the lumbar spine. If he or she
can lift the hand off the back, the subscapularis is functioning. When the
patient cannot internally rotate the shoulder enough to place the hand behind
the back, a belly-press test can be used. A belly-press test is considered to
be positive (also indicating loss of subscapularis function) when the patient
cannot keep the wrist straight and the elbow away from the side when he or she
presses the palm against the abdomen. Patients with complete loss of rotator
cuff function may only be able to shrug the shoulder.
Radiographic Findings
Imaging studies including plain radiographs, computed tomography scans, and
magnetic resonance imaging scans can help to guide both the diagnosis and the
treatment of irreparable rotator cuff tears. The position of the humeral head,
evidence of degenerative arthritis of the glenohumeral joint, and disorders of
the acromioclavicular joint are seen on plain radiographs. Computed tomography
scans have been used to assess rotator cuff muscle atrophy and fatty
infiltration. Goutallier et
al.4 classified the
quantity of fatty infiltration as 0 (no fat within the muscle), 1 (minimal
fatty infiltration), 2 (more muscle than fat), 3 (fat content equal to muscle
content), or 4 (more fat than muscle). Magnetic resonance imaging is the most
effective modality used to assess the involved shoulder, and it has replaced
computed tomography scanning as the imaging modality of choice for the
assessment of rotator cuff lesions. Magnetic resonance imaging can demonstrate
rotator cuff tears with 100% sensitivity and can be used to estimate the width
of a tear (with up to 77% accuracy) and retraction (within 5 mm) 63% of the
time14. More
importantly, magnetic resonance imaging can be used to assess fatty
infiltration more effectively, as described above
(Fig. 2).
The amount of fatty infiltration of the rotator cuff muscles is directly
related to the likelihood of a retear and to the functional
outcome15,16.
When the muscle has Type-3 or 4 fatty infiltration, it is of poor quality and
will not improve after surgical repair. The extent of fatty infiltration of
the rotator cuff muscles has proven to be a valuable preoperative guide for
assessment of the potential reparability of a massive rotator cuff
tear15,16.
Treatment of symptomatic irreparable rotator cuff tears is extremely
challenging because, at present, there are no perfect solutions to this
complex and sometimes disabling problem. Treatment depends on the presenting
symptoms (pain and/or disability), age, and functional level. Other issues
such as medical comorbidities, the presence of an intact coracoacromial arch,
and possible concomitant glenohumeral arthritis are also factors that must be
considered in the treatment plan. The treatment options range from
conservative (nonoperative) to surgical intervention. Surgical options include
débridement with or without partial rotator cuff repair, tendon
transfer, muscle tendon slide procedures, the use of rotator cuff allografts
and synthetic grafts, arthrodesis, and shoulder arthroplasty, including the
use of reverse ball prostheses.
No one treatment is best for all irreparable rotator cuff tears. The
surgeon needs to select the type of procedure that will provide the best
outcome as dictated by the specific patient's needs. Unfortunately, there have
been no evidence-based, prospective, matchedpatient studies comparing the
different nonoperative and surgical options, to our knowledge.
Nonoperative Management
Many chronic irreparable rotator cuff tears can be treated successfully
without surgery. A nonoperative approach to relieve pain and create
"biomechanically compensated" function by muscle substitution with
use of the remaining rotator cuff, deltoid, and periscapular muscles is often
the best method of initial treatment.
Nonoperative treatment includes nonsteroidal anti-inflammatory medications,
steroid injections, and local therapeutic modalities to relieve pain. Early
restoration of the passive range of motion and activity modification are
imperative initially. Once pain relief has been obtained and the range of
motion has been restored, specific strengthening exercises for the remaining
rotator cuff, deltoid, and scapular muscles can be started in order to
recreate a stabile fulcrum for deltoid function. Strengthening exercises for
the internal and external rotators of the shoulder should include resistive
exercises below chest level initially. Deltoid strengthening exercises begin
with the patient supine and are then progressed to antigravity positions such
as sitting and standing. It may take more than three months for conservative
treatment to be successful.
There have been few specific reports on the outcomes of conservative
treatment of irreparable tears. In one study, on the nonoperative management
of fifty-three patients, Bokor et
al.17 found that
thirty-nine patients had no to slight pain at the time of follow-up. The
success rate correlated directly with the duration of symptoms prior to
treatment. Patients with symptoms for less than three months did better than
those who had had symptoms for longer than six months. The final result was
usually evident after six months of nonoperative management.
Surgical Management
The surgical management of irreparable rotator cuff tears includes a number
of procedures of varying degrees of complexity. These procedures include
subacromial débridement and acromioplasty with or without partial
repairs, tendon transfers, and the use of conventional or reverse prostheses.
The choice of procedure depends on the patient's age, activity level, joint
stability, and concomitant arthritic changes.
Subacromial Débridement, Partial Repair, Cuff
Débridement,and Biceps Tenotomy: Open and Arthroscopic
In some cases, subacromial decompression and rotator cuff
débridement alone may relieve symptoms in patients with a massive
irreparable tear of the rotator
cuff1,18-23.
Subacromial débridement is indicated in healthy, lower-demand patients
whose primary symptom is pain. The best results are in patients who have
active elevation and control of the descent of the shoulder as well as
glenohumeral stability. Patients in whom a subacromial injection relieves
symptoms and improves function are good candidates for this procedure.
These procedures have been carried out both arthroscopically and through
open techniques. An arthroscopic débridement has the advantage of not
violating the deltoid insertion. The procedures can include all or any of the
following: limited, nondestabilizing acromioplasty (smoothing the acromion
without release of the coracoacromial ligament); bursectomy;
débridement of the rotator cuff edge; and release of a damaged long
head of the biceps tendon. A tuberoplasty of the greater tuberosity and
acromioclavicular joint resection may also be indicated depending on the
presenting symptoms.
Burkhart et
al.24 described the
advantage of a partial repair of the posterior and anterior portions of the
tear without transposition or transfer in selected patients. They described a
"suspension bridge model" whereby continuity between the anterior
and posterior tendons resulted in a fibrous frame reconstruction close to the
equator of the humeral head, creating a force to stabilize the humeral head
against the glenoid and enabling the deltoid to raise the
arm11. Burkhart et
al. reported that thirteen of fourteen patients had pain relief and
improvement of function after such a partial repair. According to the UCLA
Shoulder Rating Scale, which assigns a maximum of 10 points for pain, 10
points for function, and 5 points each for the range of motion, strength of
forward flexion, and overall patient
satisfaction25, the
mean score improved from 9.8 to 27.6 points.
Reports of the clinical experience with débridement have been
anecdotal and retrospective. In 1995, Rockwood et
al.1 reported
decreased pain and improved function in forty-four of fifty-three shoulders at
an average of six and a half years after open acromioplasty, decompression,
and rotator cuff débridement. Gartsman reported that twenty-six of
thirty-three patients had decreased pain and an improved range of motion but
decreased strength at an average of five years after an open
repair18. In a
study by Ellman et al., arthroscopic débridement resulted in pain
relief in nineteen of twenty-two shoulders with an irreparable tear but there
was no significant increase in strength or the range of
motion19. Burkhart
described good pain relief and function in ten of eleven patients who had
undergone arthroscopic débridement alone for treatment of a
biomechanically stable irreparable rotator cuff
tear26. In later
reviews, however, Zvijac et
al.22 and Kempf et
al.23 noted
substantial deterioration in pain relief, strength, and functional outcome in
short periods of time after arthroscopic débridement procedures.
Walch et al.27
reported relief of pain in seventy-four of eighty-seven patients who had
undergone a tenotomy of the long head of the biceps tendon for the treatment
of an irreparable rotator cuff tear, but there was no effect on the range of
motion or strength. One-third of these patients also had an arthroscopic
acromioplasty, which clouded the true results of the tenotomy.
Fenlin et al.28
described tuberoplasty in twenty patients, nineteen of whom had a successful
result. They carried out the procedure through open surgery, but it could be
done arthroscopically, and it included shaving and reshaping of the overhang
on the greater tuberosity to create a recontoured subacromial space that would
articulate smoothly with the undersurface of the acromion.
From this review of the literature, certain principles emerge.
Débridement is best carried out in elderly low-demand patients with
irreparable rotator cuff tear for which other muscles have compensated. There
are no real differences between the results of open and arthroscopic
procedures; however, arthroscopic techniques are less invasive and do not
violate the deltoid insertion. Loss of the coracoacromial arch is associated
with severe
failures29;
therefore, decompression should include flattening and shaping of the acromion
as opposed to a true release of the coracoacromial ligament in this patient
population. Débridement does not consistently improve function in
patients with pain and poor function. In such cases, other surgical
reconstructive options should be considered, especially in younger, more
active patients.
Rotator Cuff Reconstructive Procedures: Tendon Transfers and Graft
Procedures
The approaches used to reconstruct irreparable massive rotator cuff tears
include transfers of the existing rotator cuff tendons, tendon transfers from
other periscapular muscles, and repair of tissue with grafts or synthetic
substitutions. In the past, the upper third of the subscapularis tendon was
transferred to repair a residual anterosuperior defect in the rotator
cuff30.
Unfortunately, transfer of the subscapularis tendon risks loss of power of
internal rotation and creation of a possible internal rotation contracture.
For this reason, the procedure is no longer advocated.
Tendon transfers from other periscapular muscle groups are useful in young,
active patients with an irreparable rotator cuff tear and profound functional
weakness as the primary symptom. These patients must have good deltoid
function. The tendons that have most commonly been transferred include the
latissimus dorsi for posterosuperior rotator cuff
tears3,31,32
and the pectoralis major for irreparable anterosuperior
tears33-35.
In 1992,
Gerber31 reported
the early results of latissimus dorsi transfer for treatment of massive
rotator cuff tears. The latissimus dorsi muscle is used to restore external
rotation and head depression forces that were lost as a result of the massive
tear. Gerber found good-to-excellent results in thirteen of sixteen patients,
and the results were stable for more than ten years. He noted that the results
were better when the subscapularis tendon was intact
(Fig. 3).
Miniaci and
MacLeod36 reported
satisfactory results in fourteen of seventeen patients who had undergone a
latissimus dorsi transfer after a failure of a previous surgical repair of a
massive rotator cuff tear. In their series, primary latissimus transfer was
rarely indicated for irreparable massive rotator cuff tears, and they
recommended primary repair, débridement, or partial repair as the
initial surgical procedure.
Iannotti et
al.37 described
improvements with regard to pain relief and function in nine of fourteen
patients who had been treated with a latissimus dorsi transfer. All patients
had active electromyographic activity within the transferred latissimus dorsi
with adduction of the arm or with resisted isometric external rotation with
the arm at the side. No patient had electromyographic activity of the transfer
with active forward elevation, and no patient had electromyographic activity
with external rotation in more than one plane of motion. Twelve of the
fourteen patients had a clear demonstration of the tendon transfer on magnetic
resonance imaging studies. This study supports the concept of a tenodesis
effect with some active functional role of the latissimus transfer.
Subcoracoid pectoralis major transfer has been reported at a number of
centers33-35.
In each series, the upper portion of the pectoralis major was passed under the
conjoined tendon and sutured to the lesser tuberosity
(Fig. 4). Resch et
al.33 reported on a
series of twelve patients, six of whom had a negative belly-press test
postoperatively; all four patients with preoperative instability had
resolution of that symptom. Overall, the improvement was good to excellent in
eight of the twelve patients. Wirth and
Rockwood35 reported
satisfactory results in ten of thirteen patients who had undergone a
pectoralis major transfer.
Warner and
Gerber38 reported
the use of a split pectoralis major tendon transfer or split pectoralis
major-teres major transfer in complicated cases of unstable anterosuperior
rotator cuff deficiency. Twenty patients underwent these procedures, and in
eleven of them the split pectoralis tendon transfer alone was used. All
patients in the series were evaluated with the system described by Constant
and Murley39, which
consists of individual scores for pain (15 points), activity (20 points),
active mobility (40 points), and strength (25 points). The mean improvement in
the Constant score was from 42 to 61 points, with the nine patients treated
with a combination of a split pectoralis major and teres major transfer having
a mean improvement from 34 to 55 points. These results were in patients who
had complicated disorders with limited functional goals. Tests for
subscapularis insufficiency remained positive after the surgery for all
patients.
Aldridge et
al.40 reported the
use of a pectoralis major and latissimus dorsi tendon transfer to treat
massive cuff defects in eleven patients with minimal pain and a limited range
of motion and function. On the average, active elevation increased from
42° to 86°; active external rotation, from 0° to 13°; strength
in elevation, from 2.3 to 3.1 lb (1.0 to 1.4 kg); and strength in external
rotation, from 2.1. to 2.7 lb (0.95 to 1.2 kg). Four patients reported feeling
no better, two had slight improvement, and five had substantial
improvement.
Tendon transfers are complex surgical procedures that require a long period
of rehabilitation. They are not indicated for older, more debilitated patients
since the amount of muscle reeducation determines, to some degree, the amount
of success. For this reason, patients who are not willing to undergo extensive
long rehabilitation programs should not undergo these procedures.
Tissue substitution with synthetic materials and with autogenous and
allograft tissue implants has been attempted, but there are limited published
data on these procedures. Neviaser et
al.41 reported good
to excellent results in fourteen of sixteen patients treated with a
freeze-dried allograft for a massive, but probably not irreparable, tear.
Synthetic allograft patches have been utilized to augment rotator cuff
repairs. Unfortunately, these tendon substitutes can create foreign body
reactions leading to rejection and then cannot replace the atrophic or
weakened rotator cuff muscle. These muscles must function if functional
improvement is to be expected.
Glenohumeral Arthrodesis
Glenohumeral arthrodesis is usually used when the deltoid and rotator cuff
muscles are not functional. Arthrodesis is the best treatment for some
high-demand patients disabled by a irreparable cuff tear who require a strong,
stable shoulder girdle for function. Patient treated with a glenohumeral
arthrodesis can expect a strong shoulder girdle but limited rotation. As with
any arthrodesis, nonunion as well as postoperative limitations of motion and
function are substantial concerns following a glenohumeral arthrodesis.
Conventional and Reverse Arthroplasty
An arthroplasty may be the best treatment for some patients with an
irreparable rotator cuff tear and concomitant arthritis or anterosuperior
instability. Patients with an irreparable rotator cuff tear and glenohumeral
arthritis but a competent coracoacromial arch have had successful results
following hemiarthroplasty with or without an extended-coverage humeral head
component42-44
(Fig. 5). These patients can
expect pain relief with a reasonable return of function. Field et
al.44 reported on
the use of hemiarthroplasty for the treatment of cuff tear arthropathy and an
irreparable rotator cuff tear in sixteen patients. Twelve patients had a good
to excellent return of function and pain relief, but the procedure was
unsuccessful in four patients. All patients with an unsuccessful result had
had a previous acromioplasty and an unstable shoulder. Hemiarthroplasty should
not be done in patients who have had previous surgery, including
acromioplasty, or in those with anterosuperior shoulder instability.
Arntz et al.45
reported on twenty-three patients with disabling pain associated with an
irreparable rotator cuff tear. Twelve patients were treated with a
hemiarthroplasty and eleven patients, with an arthrodesis. The authors
concluded that hemiarthroplasty was the better method for managing complex
irreparable tears of the rotator cuff in shoulders in which the articular
surface had been destroyed but only when the deltoid was functional. In their
series, arthrodesis was better for patients who had both an irreparable
rotator cuff tear and irreparable deficiencies of the deltoid muscle.
In a study by Williams and
Rockwood43,
twenty-one shoulders underwent a hemiarthroplasty for cuff tear arthropathy.
At the time of follow-up, eighteen of the twenty-one had mild or no pain and
three had moderate pain. All patients had improved function and were satisfied
with the result.
Hemiarthroplasty is not indicated for patients who have an irreparable tear
with anterosuperior instability and glenohumeral arthritis. For such patients
and those with pseudoparalysis of the shoulder, a reverse ball prosthesis is
now recommended. This is a new prosthesis, and long-term results are not yet
known. Initially described by Grammont and
Baulot46, the
reverse ball prosthesis is based on a biomechanical design in which the center
of rotation is located within the glenoid component, medializing the center of
rotation and increasing the deltoid lever arm. The sheer force of the deltoid
is converted into a compressive force, increasing the deltoid advantage
(Figs. 6-A and 6-B). The
reverse ball prosthesis has been utilized extensively in Europe. It has
recently been approved for use in the United States for patients with rotator
cuff tear arthropathy.
Reports from Europe have indicated that the reverse ball prosthesis
provides better results than hemiarthroplasty in patients with an irreparable
rotator cuff tear. Improvements in pain relief, anterior elevation, and
function have been substantial in some mid-term follow-up
studies47-50;
however, these procedures are not without complications. Long-term glenoid
loosening remains a concern, and increased rates of hematoma, infection, and
instability have been
reported50-52.
Chronic irreparable rotator cuff tears can cause substantial shoulder pain
and disability. As a result of the complex pathology in shoulders with
irreparable rotator cuff tears, there are many different clinical scenarios
and many available treatment options (Fig.
7). For this reason, careful patient evaluation and treatment
selection are critical to ensure a good result. Many chronic irreparable
rotator cuff tears can be treated nonoperatively, especially when the shoulder
has reasonably good function. The goals of surgical reconstruction must be
considered in terms of the patient's individual needs, medical condition, and
functional abilities.
Débridement and partial repair can be considered for some patients,
whereas reconstruction of the rotator cuff is most useful in young active
patients for whom functional restoration is important. Latissimus dorsi muscle
transfer is the preferred treatment for active disabled patients with a
posterosuperior irreparable cuff defect and good deltoid function.
Anterosuperior irreparable defects can be treated with pectoralis and teres
major tendon transfers but with less predictable results. A hemiarthroplasty
can be considered for patients with severe disability, arthritis, and
glenohumeral stability; however, in patients with unstable glenohumeral
arthritis, the reverse ball prosthesis will provide more predictable pain
relief and return of function, at least in the short term.