Evidence Based Medicine:

Massive Tears of the Rotator

Cuff

Presented by Dr. 邱致皓

Outline

• Definition

• Nonoperative Treatment

• Operative Treatment

Definition

• Diameter of >5 cm

- Cofield, J Bone Joint Surg Am. 2001

• Complete detachment of two or more tendons

-Zumstein, J Bone Joint Surg Am. 2008

• Anteroposterior x Mediolateral of the tear in scope

-Tauro, Arthroscopy. 2006

Massive rotator cuff tear

• Difficult repair

- Tendon

- Muscle

- Joint

• Higher recurrence rate smaller tears- J Shoulder Elbow Surg. 2007

- J Shoulder Elbow Surg. 2008

- Clin Orthop Relat Res

- JBJS Am. 2003

- JBJS Am. 1991

To do or not to do?

Nonoperative Treatment

• Stable GH abduction without excessive superior humeral

head translation

• Higher forces in the deltoid and the remaining rotator cuff

- Hansen, JBJS Am. 2008

- Levy, J Shoulder Elbow Surg. 2008

- Zingg, JBJS Am, 2007

Repairable?

• Signs of irreparability:

- Superior migration of the humeral head

- Narrow acromiohumeral interval: <7mm

- Fatty infiltration >50% -

Rokito JBJS Am. 1999

- OKU 8

Fatty Infiltration

Fatty Infiltration

• Fatty infiltration on MRI: correlated with

a. Shoulder biomechanics

b. Shoulder function

c. Poor tendon-tissue quality

Debridement and Subacromial

Decompression

• Arthroscopic debridement: for elderly, low-demand patients with pain but good ROM and intact GH joint force couple

- Burkhart, CORR 1991

• Open vs Arthroscopic subacromial decompression and debridement

a. Open decompression + resection of CA ligament: poor

- Augereau Rev Chir Orthop Reparatrice 1988

b. Open decompression and debridement: ↓pain, ↑ funciton, ↓strength

- Gartsman, JBJS Am, 1997

c. Arthroscopic debridement: modest improvement in the overall Constant score

- Kempf, Arthroscopy. 1999

Biceps Tenotomy ?

• Controversial

• Tenotomy: particularly effective for

massive tears

- OKU 8

Biceps Tenotomy ?

Partial Repair

• Restoration of stable

fulcrum of the GH joint

> complete closure

- Duralde, J Shoulder Elbow Surg.2005

Complete Repair

• Retear rate > small tear

• Tear configuration and tissue quality

• Single row vs. Double row

a. Double-row repair: increased tendon-

bone contact area than single row

b. Double-row configurations: overtension

Double row vs. Single row

• ASES and Constant scores following double-row repairs were significantly improved compared with those after single-row repairs of tears of >3 cm

- Park, Am J Sports Med. 2008;36:1310-6

• Single- and double-row techniques provide comparable clinical outcome at 2 years

• Double-row technique: mechanically superior but do not translate into superior clinical performance

- Franceschi, Am J Sports Med. 2007

• Dermis-Based Patches

a. Bond: 94% satisfactory

b. Burkhead: UCLA score 926

c. Badhe: Constant score 4162

• Small Intestinal Submucosa Patches:

poor

Repair with Scaffolds or Tissue

Augmentation

- Bond, Arthroscopy. 2008

- Burkhead, Arthroplasty. 2007

- Badhe, J Shoulder Elbow Surg. 2008

Tendon Transfers

• Ideal candidate:

a. No glenohumeral arthritis

b. Impaired function related to weakness

and loss of external rotation

• Latissimus Dorsi Transfer

• Pectoralis Major Transfer

Latissimus Dorsi Transfer

Warner, Complex and revision problems in shoulder

surgery. Philadelphia: Lippincott-Raven; 1997. p

195-6

Latissimus Dorsi Transfer

• Miniaci and MacLeod: 82% satisfaction

• Warner and Parsons:

- 73% satisfaction

- 27% rerupture and worse outcomes

• Iannotti:

- 64% satisfaction

- Poor prognostic factor: female, poor pre-OP

function, generalized muscular weakness-Warner, J Shoulder Elbow Surg. 2001

- Miniaci, JBJS Am. 1999

- Iannotti, JBJS Am. 2006

Pectoralis Major Transfer

• Wirth and Rockwood: 77% satisfaction

• Resch: 75% satisfaction

• Jost:

- 80% satisfaction

- Better in isolated subscapularis tendon tear

• Elhassan: poor in after failed shoulder replacement

Resch, JBJS Am, 2000

Hemiarthroplasty

• Contraindication: static anterosuperior

escape of humeral head

• Mixed outcome

Hemiarthroplasty• Zuckerman:

- UCLA score: 11 22 points

- 87%: satisfaction

- Forward flexion improved only 17 degree

- External rotation improved only 14 degree

• Sanchez-Sotelo:

- Pain score: 4.2 2.2

- 27%: moderate pain at rest

- 21%: anterosuperior instability

- Successful rate: 67%

• Field:

- 63%: satisfaction

- 38%: unsuccessful outcome

- 19%: anterosuperior instability

-Sanchez-Sotelo JBJS Am. 2001

- Zuckerman, J Shoulder Elbow Surg. 2000

- Field, J Shoulder Elbow Surg. 1997

Reverse Shoulder

Arthroplasty

• Described in 1993

• Rotation center: scapular

neck

• Increase lever arm of

Deltoid

• Medializtion of humerus

OKU 9

Reverse Shoulder Arthroplasty

• Guery:

- Constant score: 23 66 points

- Active elevation: 73 to 138 degree

- Survival rate: 91% 75% 30% (5, 7, 8 years)

- 3 years: Early loosening

- 6 years: Functional score ↓• Werner:

- Constant score: 29 64 points

- Complication rate: 50%

- Revision: 33%

• Frankle: Complication rate: 17%, revision rate: 13%

- Guery JBJS Am, 2006

- Werner JBJS Am. 2005

- Frankle JBJS Am. 2005

OKU on massive tear

• Latissimus dorsi transfer improves painful shoulder with loss of function in irreparable rotator cuff tear

• Poor result:

a. Female patient with generalized muscle weakness

b. Pre-OP shoulder function poor

- OKU 9

Conclusion

• Nonoperative treatment: asymptomatic patients

with satisfactory function

• Arthroscopic debridement and partial repair:

older, low-demand patients

• Repair: younger, symptomatic patients

• Double row of sutures: biomechanically better

Conclusion

• Tendon transfers: High-demand patients

• Hemiarthroplasty: preserved active elevation

• Reverse shoulder prothesis: advanced cuff tear

arthropathy , painful pseudoparalysis