We have yet to determine how best to deal with massive cuff tears. For me, three of the major determinants in decision-making are:
- The age of the patient
- The presence of degenerative change in the gleno-humeral joint
- Whether the shoulder is functional, which essentially means whether the patient can lift the arm above shoulder level
Procedures such as latissimus dorsi transfer and reverse prosthesis are major undertakings. In my practice, I usually recommend arthroscopic surgery prior to considering these options. Good results have been reported with arthroscopic decompression without repair for rotator cuff tears - although most comparative studies suggest better results if the cuff is repaired.
I will almost always attempt at least a partial repair. The best indication for this is a painful but functional shoulder with minimal degenerative change. The diagnostic component of the procedure assists with future decision-making. I am particularly interested in the presence of arthritic change and whether the subscapularis tendon is intact, as these are determinants of outcome for latissimus transfer and reverse arthroplasty.
My decompression is limited. I remove obvious acromial spurs and preserve the coraco-acromial ligament as much as possible. Preservation of the sub-acromial arch will minimize the risk of antero-superior escape if an arthroplasty is later performed. I resect the lateral end of the clavicle if that joint is arthritic , as it is usually a pain generator.
My management of the biceps tendon is traditional. If there is a partial tear greater than 50% through the tendon, I perform a tenotomy or tenodesis. There is interesting recent literature concerning the beneficial effect of biceps tenotomy in this group, with some advocating it as a routine part of the procedure. My opinion is that an intact biceps may assist healing of the cuff repair by functioning as a humeral head depressor.
The cuff repair itself is done based on the teaching of Stephen Burkhart and is usually a partial repair with margin convergence, although I will use releases and tendon to bone repair if possible. The goal is to restore the posterior and anterior cuff above the equator of the humeral head. Burkhart found that the results were as good for massive as for smaller tears. I cannot verify this finding, but I have certainly seen some surprisingly good results in terms of pain relief and improved function.
The potential for improvement is significant and the downside risk of an arthroscopic procedure is relatively small. If the patient does not have a good result, then the information gained from the arthroscopy will guide future treatment. If I find an intact subscapularis in a younger patient, then a latissimus dorsi transfer may be the best option. An older patient with significant arthritic change would be a candidate for a reverse prosthesis.
- Burkhart S., Danacen S.M., Pearce C.E. Arthroscopic rotator cuff repair: analysis of results by tear size and by repair technique - margin convergence versus direct tendon-to-bone repair. Arthroscopy. 2001; 17: 905-912
- Boileau P., Baque F., Valerio L., et al. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007; 89:747--757.
- Kempf J., Mole D., Walch G., et al. A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthroscopy. 1999; 15:56--66.
Reprinted with permission from the Spring 2009 issue of COA Bulletin