Irreparable Tears: The Role for Debridement or Partial Rotator Cuff Repair☆
Introduction
DeOrio and Cofield1 classified massive rotator cuff tears (RCT) as tears that are greater than 5 cm in size in either the anterior-posterior or medial-lateral dimension, whereas Gerber defined massive tears as those involving complete tears of at least 2 tendons.2 Regardless of classification, massive tears can present a management challenge, but multiple treatment options are available based upon a number of factors including both patient and tear characteristics. Nonoperative management includes activity modification, physical therapy to strengthen the deltoid and periscapular muscles, and oral anti-inflammatories or corticosteroid injections. Surgical options include debridement, biceps tenotomy or tenodesis, partial rotator cuff repair, rotator cuff repair with patch augmentation, tendon transfers, and reverse total shoulder arthroplasty.
What constitutes a partial repair varies between studies, but a plausible definition would be that a partial rotator cuff repair is any surgical management that successfully reduces the gap created by the RCT but does not completely reduce the rotator cuff to the footprint, leaving a residual gap between some portion of the rotator cuff and the humeral head.3
Burkhart originally proposed the concept of a functional rotator cuff repair, which involves repair of the margins of the tear to restore the force couples and “suspension bridge” system of force transmission in the shoulder.4, 5 The subscapularis and infraspinatus muscles represent the axial force couple, providing joint stability by a compressive joint reaction force in the axial plane. Likewise, the supraspinatus and the deltoid act as a force couple, in which the humeral head is compressed into the glenoid during abduction.6 Specific movements of the shoulder can be adversely affected by massive tears. Posterosuperior tears involving the infraspinatus or teres minor lead to weakness in active external rotation and an increase in passive internal rotation. Conversely, tears involving the subscapularis lead to weakness in active internal rotation and increased passive external rotation.7 In addition, subscapularis function appears critical to prevent anterior-superior humeral head migration, a factor in the development of pseudoparalysis.
Massive rotator cuff tears produce abnormal kinematics, such that in order to achieve shoulder abduction, greater forces are required by the deltoid and the remaining intact rotator cuff.8 The progression of a rotator cuff tear to disrupt the axial force couple leads to superior subluxation of the humeral head. Tear propagation will occur, particularly if the remaining tendon is of poor quality, with the increasing force that is required to move the arm.7
Section snippets
Rotator Cuff Debridement
The simplest surgical option to manage a massive, irreparable rotator cuff tear is a debridement. Classically, this has been reserved for the elderly low demand patient with good glenohumeral mobility but persistent pain despite conservative measures. It is well recognized that pain generators in the setting of rotator cuff disease include the biceps, subacromial bursitis, and joint synovitis. Debridement of the joint may include biceps tenotomy or tenodesis, subacromial bursectomy with limited
Partial Rotator Cuff Repair
The main concept of a partial rotator cuff repair is to restore the force couple of the shoulder, allowing stabilization of the humeral hear during arm elevation to restore the deltoid force couple. A complete anatomical repair of massive rotator cuff tears is not always surgically possible as a result of poor tissue quality, tendon loss, severe retraction, or increased tension of the repair.14 In these situations, restoration of the anterior and posterior force couples may restore humeral head
Surgical Technique
The patient is placed in the beach-chair position. Regional supraclavicular regional blockage and general endotracheal anesthesia are provided by the anesthesia team. After preparation and draping, a standard posterior viewing portal is established off the posterolateral corner of the acromion. A working portal is then established in the anterosuperior rotator interval by use of an outside-in technique. Diagnostic arthroscopy is performed, in which evaluation of the rotator cuff can often occur
Conclusions
Complete anatomical repair of massive rotator cuff tears is not always surgically possible because of poor tissue quality, tendon loss, severe retraction, or increased tension of the repair. Debridement of the rotator cuff or partial rotator cuff repair offer viable options for patients with goals of pain relief and improvement in range of motion. The optimal patients are those with pain, in the setting of maintained arm elevation, recalcitrant to conservative care. Although partial repair
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Cited by (1)
Arthroscopic Partial Rotator Cuff Repair for an Irreparable Tear
2018, Operative Techniques in OrthopaedicsCitation Excerpt :In fact, this concept is rarely discussed, as the classic description of partial repair is still often utilized and only mandates anterior and posterior cuff reattachment. Furthermore, studies that look at the outcomes following partial repair have disparate definitions of what is considered a partial repair, with some following the described Burkhart technique and some attempting to cover as much of the native footprint as possible.6 Subsequently, there appear to be few studies that determine which fixation construct (ie, single-row or double-row configurations) for partial repair should be used to optimize structural tendon-bone healing.
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No grant support.
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N.A.F. and her immediate family, and any research foundations with which they are affiliated, have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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N.N.V. receives research support from Arthrex, Arthrosurface, DJ Orthopaedics, Ossur, Smith & Nephew, Athletico, ConMedLinvatec, Miomed, and Mitek; has stock/stock options in Cymedica, Minivasive, and Omeros; is a paid consultant for Minivasive, Orthospace, and Smith & Nephew; and receives royalties from SLACK Inc, Smith & Nephew, and Vindico Medical-Orthopedics Hyperguide.