Management of the Irreparable Rotator Cuff Tear

Gregory L. Cvetanovich, MD; Brian R. Waterman, MD; Nikhil N. Verma, MD; Anthony A. Romeo, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(24):909-917. 

In This Article

Surgical Treatment Options

Reverse Total Shoulder Arthroplasty

If nonsurgical treatment fails, various surgical treatment options are considered. In patients with Hamada grade 3 or greater reflecting more intermediate- to advanced-stage rotator cuff arthropathy, those with anterosuperior escape or severe pseudoparalysis, or those older than age 65 years, the RSA is our preferred treatment option. Age is generally a relative contraindication and is adjusted based on individual patient assessment. Long-term outcomes of RSA for rotator cuff arthropathy in a generally older patient population have resulted in reliable pain relief and improved function.[6] Outcomes of RSA for irreparable rotator cuff tear without arthritis are promising in short- to mid-term follow-up, with most studies addressing patients older than 65 years with pseudoparalysis.[7,8] Hartzler et al[24] analyzed patients who underwent RSA for irreparable rotator cuff tear without arthritis at a minimum 2-year follow-up, finding that age <60 years, high preoperative function, and neurologic dysfunction were associated with poor outcomes. Boileau et al[8] found that the subgroup of patients with preoperative active elevation over 90° had loss of active elevation with 27% dissatisfaction rate. Ernstbrunner et al[25] recently reported a series of RSA for patients younger than age 60 years with a mean follow-up period of 11.7 years, finding subjective and functional improvement but with 39% complication rate and 9% failure rate. Therefore, we urge caution in applying RSA to younger patient populations with irreparable tears, minimal arthritis, and good preoperative function because they may not obtain their desired functional improvement and implant longevity remains a potential concern with higher activity levels and occupational demands.

Partial Repair

Traditionally, irreparable rotator cuff tears were treated with a combination of débridement, subacromial decompression, partial repair, and/or biceps tenotomy or tenodesis.[26] Partial repair is thought to work by restoring the force couple and the resultant cable system for force transmission. Tension free repair is important to achieve, and medialization by up to 10 mm for the supraspinatus may enhance the ability to achieve partial repair, although it changes shoulder biomechanics. Shon et al[27] found that partial repair resulted in initial improvement of symptoms, but functional outcome was variable and results deteriorated over time with 50% dissatisfaction at 2-year follow-up. Cuff et al[28] found that at 5 years after partial repair for patients who had intact preoperative active elevation averaging 168°, patients had improved American Shoulder and Elbow Surgeons (ASES) and simple shoulder test scores and reduction in pain, but that Hamada grade progressed in 36% and there was a 29% failure rate based on a composite end point of ASES <70, revision, or development of pseudoparalysis. Tuberoplasty has also been proposed as an option for irreparable rotator cuff tear without pseudoparalysis, with one study reporting mean 8-year outcomes in a series of 16 patients showing pain relief from visual analog scale (VAS) 6.9 to 2.3 and Constant score improvement from 27.2 to 59.2.[29] Although partial repair can improve pain and function by restoring the force couple, the authors generally opt for other options for an irreparable tear because the results of partial repair have tended to be less reliable in our experience.

Tendon Transfers

Tendon transfers have been described for restoring force couples in the shoulder with irreparable rotator cuff tear.[30] Latissimus dorsi transfer is generally used to replace the irreparable posterosuperior rotator cuff and has been shown to improve pain for patients with irreparable posterosuperior rotator cuff tears, although functional outcomes are more variable.[31,32] Inferior outcomes can be expected for patients with subscapularis dysfunction, severe teres minor fatty infiltration, revision procedures, and those with arthritic changes.[31,32] Furthermore, there may be glenohumeral arthritis progression in a third of patients.[33] Iannotti et al[34] performed an electromyography study showing that the latissimus tendon contracted in phase during active external rotation for 6/9 patients with a good clinical result and 0/5 patients with a poor clinical result.

Lower trapezius transfer has been more recently popularized for management of irreparable posterosuperior rotator cuff tear.[35] At average 47-month follow-up, Elhassan et al[35] found improved pain, functional scores, and range of motion, especially for patients with preoperative active elevation of >60°. Biomechanical evidence suggests that the lower trapezius transfer may be superior to latissimus transfer to restore joint reactive force and shoulder kinematics.[36] Further study will be necessary to define the role of lower trapezius transfer and relative merits of this transfer compared with latissimus dorsi transfer or other options for irreparable posterosuperior rotator cuff tears.

Pectoralis major transfer has been described to replace an irreparable anterosuperior tear involving the subscapularis, with multiple described techniques and literature mostly limited to retrospective case series with short-term follow-up. Moroder et al[37] reported that 27 patients with average 10-year follow-up had improved pain and internal rotation, with 77% satisfaction. Rotator cuff arthropathy progressed in 67% of patients, but only one patient underwent revision to RSA.[37] Latissimus dorsi transfer has also been described for the treatment of subscapularis insufficiency, although clinical outcomes data are lacking to date.[38]

Bridging Interpositional Graft

Bridging interpositional grafts have been described for irreparable rotator cuff tears, with results predominantly from small case series with short-term follow-up.[39] The graft is secured to the irreparable rotator cuff tendon and bridges the remaining cuff and the footprint on the humerus. Grafts used include autograft biceps tendon and fascia lata, allografts, xenografts, and synthetic materials. Structural healing has varied from 58% to 100%, and patients have had improved outcomes compared with preoperative.[39] Mori et al[40] reported a comparative study in which patients underwent either partial repair or partial repair with fascia lata autograft bridging interposition. They found that at 36-month follow-up, both groups had significant improvement compared with preoperative. The graft group achieved superior Constant and ASES scores, with no difference in UCLA scores compared with the partial repair group. The percentage of intact repairs was 79% for the graft group versus 58% for the partial repair group on postoperative imaging.[40]

Subacromial Spacer

An emerging strategy for management of irreparable rotator cuff tear has been the implantation of a degradable subacromial spacer that seeks to prevent humeral head elevation, thereby centering the humeral head in the glenoid and improving the ability of the deltoid to actively elevate the arm.[41] This device (InSpace; OrthoSpace, Israel) can be inserted arthroscopically into the subacromial space and inflated with saline before being sealed (Figure 3). The balloon is designed to degrade between 2 and 12 months postoperatively. It is currently the subject of an ongoing clinical trial in the United States. Senekovic et al[41] reported 5-year follow-up of a series of 20 patients with a mean age of 69 years who underwent this procedure without rotator cuff repair. The rate of follow-up for this study was poor with only 63%, with one patient undergoing RSA at 4 years, two patients dying of unrelated causes, and six patients otherwise lost to follow-up. They found that over 50% of subjects exceeded the minimal clinically significant improvement of >10 points on the Constant Score, with over 40% showing >25-point improvement. Deranlot et al[42] reported mean 32.8-month outcomes after spacer implantation in 37 patients with Hamada grade 1 or 2 rotator cuff tears and an average age of 69.8 years. They found improved forward elevation from 130° to 160°, external rotation from 30° to 45°, and Constant Score from 44.8° to 76.0°. One patient underwent revision for spacer migration, and Hamada progression was observed in 19% of patients.[42]

Figure 3.

Arthroscopic insertion of the subacromial balloon spacer (OrthoSpace) for massive irreparable rotator cuff tear. A, Diagnostic arthroscopy viewing from the mid-lateral portal showing massive irreparable rotator cuff tear. B, The deflated balloon spacer is inserted from the mid-lateral portal, and (C) saline is inserted to expand the balloon in subacromial space.

Superior Capsular Reconstruction

SCR has recently been proposed as a strategy for management of irreparable rotator cuff tears by reconstructing the superior capsule as a static restraint to prevent superior migration of the humeral head and maintain native glenohumeral station.[43] This technique involves anchors into the superior glenoid and greater tuberosity with an autograft fascia lata or acellular dermal allograft to recreate the superior capsule (Figure 4). Biomechanical data have shown promising results of SCR,[43] and the limited clinical outcomes available reveal potential to relieve pain and restore function for patients with irreparable rotator cuff tear and intermittently, pseudoparalysis.[44]

Figure 4.

SCR with acellular dermal allograft for massive irreparable rotator cuff tear. A, Diagnostic arthroscopy revealing massive rotator cuff tear retracted to the glenoid that was found to be irreparable. B, Anchors are inserted on the superior glenoid and greater tuberosity adjacent to the articular margin. C, Measurements are taken from the anchors, and the graft is cut to the appropriate size. D, The graft is secured with lateral row fixation and side-to-side repair of the graft to the residual posterior rotator cuff. E, Completed SCR is shown. SCR = superior capsular reconstruction

Mihata et al[44] reported the initial series of SCR with fascia lata autograft in 24 shoulders predominantly Hamada grade 1 and 2 (92.2%) at mean 34.1-month follow-up (range, 24 to 51). Four cases were revisions, and 20/24 cases (83.3%) were primary procedures. After SCR, patients had markedly improved forward elevation from 84° to 148°, external rotation from 26° to 40°, and American Shoulder and Elbow Surgeons score from 23.5 to 92.9, whereas the acromiohumeral distance reversed from 4.6 ± 2.2 mm preoperatively to 8.7 ± 2.6 mm postoperatively. Postoperative MRI showed that the SCR graft and rotator cuff tendon were intact in 20/24 shoulders (83.3%), with three cases of retear of the infraspinatus (12.5%) and one case of graft tear (4.2%). In a further larger series of 102 SCRs with fascia lata autograft, Mihata et al[45] found similar improvements of motion and functional scores, 95/102 (93%) with intact graft and tendon, return to previous work in 32/34 (94%), and return to recreational sports for 26/26 (100%).

Denard et al[46] recently published preliminary results of SCR with dermal allograft in 59 patients with minimum 1-year follow-up, finding improved forward flexion (130° to 158°), external rotation (36° to 45°), VAS pain (5.8 to 1.7), and ASES (43.6 to 77.5). They found that 45% (9/20) of grafts were completely healed on postoperative MRI, with graft failure occurring most commonly on the humeral side (7 cases), followed by intrasubstance (3 cases) and glenoid side (1 case). The success rate was 74.6% (46/59), but 11 patients (18.6%) went on to a revision procedure including seven RSAs. Future studies are needed to confirm the long-term viability and survivorship of this and determine whether the results of Mihata et al using a 4-ply thickness fascia lata autograft differ from results using a thinner 3- to 4-mm dermal allograft as is currently done in the United States.

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