Irreparable Massive Rotator Cuff Tear: How do I address

Despite advances in arthroscopic techniques and devices, symptomatic massive contracted rotator cuff tear is still a challenging to most shoulder surgeons. This rotator cuff tissue has all of the following characteristics; inelastic and friable tendon quality, adhesion and scarring to severely retracted tendon, muscle atrophy and fatty infiltration. All these factors preclude optimal repair without tension(1-3). In case of irreparable massive cuff tears, reverse total shoulder arthroplasty has emerged as an appropriate treatment modality for elderly, however the treatment options for younger patients vary from conservative care, simple debridement with biceps tenotomy/tenodesis, tuberoplasty, partial repair, tendon transfer, to biologic augmentation(1-7). Moreover, there is no clear guidance yet. Recently, reverse arthroplasty has extended its indication to irreparable massive tears without arthritis in relatively young patients. However, complication rate is relatively high and there is the issue of undetermined longevity(6). Particularly, there are not a few cases of internal rotation deficit postoperatively, which is related with personal hygiene(8). For that reason, many surgeons prefer to preserve the native joint as long as possible. Regardless of tear size or arthritis, we can often experience cases of relatively good function with tolerable pain in daily living activities. Levy et al reported satisfactory result after reconditioning of the deltoid to compensate for a deficient rotator cuff, however there is a debate of how long it will last. There are many other modalities of conservative treatment such as NSAID medication, corticosteroid injection, physical therapy, strengthening of remaining components of the rotator cuff or deltoid, which can be attempted initial period(8). If there is no effect for a long time, surgical options should be considered. Arthroscopic debridement is well suited for older patients with low physical demands and sometimes can be done in combination with tenotomy/tenodesis of long head of biceps(6, 9). Lesions of the long head of the biceps tendon is often associated with massive rotator cuff tear, and also not uncommonly responsible for shoulder pain and dysfunction due to its large network of sensory and sympathetic nerve fibers(9). Arthroscopic debridement has advantages of short operation time, uncomplicated rehabilitation and low risk of complication. On the other hand, it has only short-term benefit for clinical outcome, and do not improve strength of rotator cuff muscles, moreover cannot decelerate the progression of arthritic change(6). Though some researchers investigated that isolated arthroscopic biceps tenotomy/tenodesis improved symptoms in patients with massive irreparable rotator cuff tears(9), there is some debate for doing debridement or biceps tenotomy/tenodesis for its own sake. Arthroscopic tuberoplasty, trimming of the greater tuberosity of humerus provides better articulation in coracoacrmomial arch which is important passive stabilizer against anterior and superior humeral head subluxation(10, 11). Rhee et al(10) reported satisfactory result of arthroscopic tuberoplasty during the minimum follow-up (24 months). They concluded that arthroscopic tuberoplasty can be an option for diminishing pain and improving active forward flexion for irreparable massive rotator cuff tears. Recently, Park et al showed(11) 8-year follow up study, which supports previous results. It seems to be a good option for those who have significant pain despite of the possible active motion with irreparable massive rotator cuff tears. The conversion of the massive or irreparable rotator cuff tear to a functional rotator cuff tear by means of arthroscopic partial repair has produced satisfactory clinical outcomes by some. Even though the partial repair and margin convergence of the torn rotator cuff tear cannot cover the humeral head completely, the transverse force couple of the rotator cuff can be restored and play an important role as a stable fulcrum for the glenohumeral joint(1, 2). Recently, Kim et al. (1) compared the functional outcomes and structural integrity after arthroscopic partial versus complete repair of massive contracted rotator cuff tears. In their study, the complete repair was achieved by anterior and posterior interval slide and side to side repair of the interval slide edge (22 patients); the partial repair was achieved by anterior interval slide and margin convergence (19 patients) and the residual defect was about 11 mm at the time of surgery. At two-year followup, the functional outcomes were not different significantly between groups. Even though the preoperative tear sizes on magnetic resonance arthrography (MRA) images were not different significantly between groups, follow-up MRA identified a retear in 91% in complete repair group and the re-tear size of the complete repair group was significantly greater than that of the partial repair group. They concluded that the complete repair through aggressive release did not have better clinical and structural outcomes, compared with the partial repair without aggressive release for massive contracted rotator cuff tears. Kim et al(2). also reported satisfactory outcomes after arthroscopic partial repair with margin convergence (Fig. 1) for irreparable large to massive rotator cuff tears. Although there was a residual defect ranging from 5 mm to 32 mm (anterior to posterior width, mean 12 mm) at the time of surgery, and the mean acromiohumeral distance was decreased from 6.5 mm to 5.9 mm at the final follow-up, all shoulder scores improved significantly. Although the strength of the active forward flexion or abduction of the affected side significantly improved after surgery, it was not restored to the same level as the contralateral side. Although partial repair without aggressive release showed similar clinical result comparing to complete repair following it, radiologic outcome was better. Recently, in the case of supraspinatus and infraspinatus were completely absent, but subscapularis could be repaired, isolated subscapularis repair showed satisfactory results in patients with young age for arthroplasty. Kim et al(12) also reported Isolated repair of the subscapularis tendon in irreparable massive rotator cuff tears. They found satisfactory short-term outcomes and structural integrity in patients in their 50 s and 60 s without arthritis for average 3 year follow up. However, there was unsatisfactory result in the case of poor teres minor quality(12,13). The repair of anterior L-shaped tears is usually difficult because of the lack of anterior rotator cuff tendon to cover the footprint. The biceps tendon is usually exposed from the retracted anterolateral corner of the torn tendon and can be easily used to augment rotator cuff repair. Jeon et al(14) compared partial repair between complete repair due to biceps augmentation. And there was no difference in clinical outcomes and re-tear rate. They concluded only that partial tendon repair for reducing the footprint exposure without undue tension may be considered as one of the treatment options for large anterior L-shaped rotator cuff tears. Yoon(15) et al also tried biologic augmentation, they tried arthroscopic rotator cuff repair with bone marrow stimulation and patch augmentation in patients with massive rotator cuff tears. They found that concomitant bone marrow stimulation and patch augmentation significantly reduced retear and medial-row failure rates in the arthroscopic repair of massive rotator cuff tears Recently, another treatment option was introduced for irreparable rotator cuff tears. Mihata et al(4,5,16) reported that superior capsule reconstruction could restore superior stability of the glenohumeral joint in irreparable rotator cuff tears. According to their report, the reconstructed superior capsule restored superior stability better than did conventional patch graft, due to the suture anchor creating additional fixation at the superior glenoid in the superior capsule reconstruction. In a subsequent case-series clinical study, they reported satisfactory outcomes of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. In conclusion, if surgery was indicated due to severe intractable pain, one can choose arthroplasty rather than other surgical options in the case of preoperative pseudoparalysis, arthropathy, or failed repair for massive rotator cuff tear in elderly. On the other hand, if patients had good range of motion without osteoarthritis, one can choose preserving the native joint as possible; if partial repair can recreate robust force couple, repair with or without biologic augmentation. REFERENCE: 1. Kim SJ, Kim SH, Lee SK, Seo JW, Chun YM. Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity. J Bone Joint Surg Am. 2013;95(16):14828. 2. Kim SJ, Lee IS, Kim SH, Lee WY, Chun YM. Arthroscopic partial repair of irreparable large to massive rotator cuff tears. Arthroscopy. 2012;28(6):761-8. 3. Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;(267):45-56. 4. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40:2248-2255. 5. Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29:459-470. 6. Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C. 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.