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Massive Rotator Cuff Tears

These tears usually exceed 4 to 5 cm in dimension, but can be deceiving. Clearly a tear retracted in a lateral to medial direction of 5 cm presents as a very challenging repair whereas a tear extending 5 cm in an anterior to posterior direction without significant retraction is a much easier surgical problem to solve.

In general, massive tears refer to those chronic, retracted tears that are usually accompanied by fatty infiltration, muscle belly atrophy as well as thinning and scarring of the torn end of the rotator cuff. The approach to these massive, retracted tears can be difficult, and requires that the clinician gather as much information as possible before embarking on a therapeutic course.

These patients often present with pain as their overwhelming symptom, and on examination can exhibit significant motion restriction. Not uncommonly, if motion is restored with a well-supervised physical therapy program, the pain can be significantly reduced. If functioning force couples are in effect, restoration of motion may be all that is required to attain a satisfactory result without surgery.

For those with significant strength deficits, the prospect of a repair has to be considered. Certainly concomitant fatty infiltration and muscle atrophy are poor prognostic factors, and patients must be counseled accordingly. Achieving re-attachment of the rotator cuff may not result in significant functional improvement if the rotator cuff is significantly diseased in advance of surgery.

Simple debridement and acromial “contouring” have been described as salvage-type procedures that may palliate some of the pain; however, the risk of violating the coracoacromial arch and of losing anterior-superior head containment must be carefully considered before embarking on a debridement-only approach.

Clearly, if such an approach is selected, minimizing bone resection is of utmost importance. If the rotator cuff cannot keep the humeral head centered, the coracoacromial arch becomes a fulcrum for shoulder elevation. If the arch is violated and an aggressive bone resection is performed, the humeral head can erode through what remains of the acromion.

The technical principles guiding the repair of massive rotator cuff tears remain consistent with the techniques previously described. As the tear patterns become more complex, additional surgical maneuvers become applicable such as the double-interval slide described by Burkhart and Lo.

When a complete repair of a massive tear is not technically feasible, consideration of a partial repair must be entertained. Restoring balanced force couples in a massive tear may provide enough stability for a functional outcome.

A discussion of post-operative rotator cuff integrity and its effect on the final outcome is relevant. Utilizing ultrasound, Harryman et al.It reported on a 65% incidence of intact rotator cuffs post-operatively. In his study, the results were directly correlated with the integrity of the final repair, namely pain relief and strength were better in those with an intact cuff.

Galatz et al. It reported on the outcome of large and massive rotator cuffs repaired arthroscopically. Seventeen of 18 tears recurred as documented by post-operative ultrasound. Although at 12 months following surgery, the results were impressive from a pain relief and functional perspective, at 2 years and greater follow-up, two-thirds of the patients exhibited deterioration in both categories. Klepps et al.

It described an experience with post-operative MR evaluation of open cuff repairs and noted that 74% had an intact cuff post-operatively if the initial tear was smaller while those with larger tears had an intact cuff in 62% of the cases. In this study, the end result was not affected by the integrity of the repair, and furthermore, improved strength, as well as pain relief, was noted in those who exhibited a recurrent tear based on post-operative imaging. Jost reported similar findings with their patient population in which an intact cuff did not correlate with better results.

Perhaps the partial repair concept may be the best explanation. Burkhart et al. It has proposed a unified rationale for the treatment of rotator cuff tears, including partial repairs based on maintaining functional force couples. An arthroscopic approach to partial repairs in large and massive tears has also been reported as an alternative to tissue transfer.

A proponent of partial repair of otherwise massive, irreparable tears of the rotator cuff, Burkhart has argued that maintaining force couples is of greater concern than closing the defect. Although the repair is not water tight, and although a defect may be present post-operatively as judged by MR or ultrasound, the restoration of balanced force couples keeps the humeral head well-centered thereby allowing the extrinsic musculature to function efficiently.

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