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Surgeons Challenged By Massive Rotator Cuff Tears

Large tears of the shoulder rotator cuff are determined by size (more than an inch wide) or by how many tendons are affected (two or more of the four tendons that make up the rotator cuff). Treatment isn't just a simple surgery to patch everything together. Large or massive tears (as the surgeons call them) often don't heal well. Poor tendon healing, repeated tears, and tears that simply get bigger over time can be obstacles surgeons (and patients) face.

Some tears can't be repaired. Others require extensive surgery to debride (clean up) any frayed edges and remove tissue damaged beyond repair. A tendon transfer may be needed. No matter what decision is made, there are various techniques to choose from when performing the procedure. The bottom line is to restore the shoulder to as near normal as possible and have the repair hold up over time.

To help surgeons reach this goal, the authors of this update review ways to do rotator cuff repairs, what to expect in terms of results with each type of repair, and ways to assist tendon healing. First of all they point out that when rotator cuff tears occur without trauma, there are usually degenerative changes already present. That means healing is going to be affected. The tissue is stiffer with scarring (fibrosis) and loss of good blood supply at the cellular level. The tissue is of such poor quality that surgical repair may be impossible.

For patients who are medically unable to have surgery and for those who don't want surgery, physical therapy has been shown effective as a nonoperative approach to treatment. The therapist shows the patient ways to move that will reduce the stress and pressure on shoulder structures. At the same time, an exercise program is used to strengthen the muscles that still work normally in order to restore as much normal shoulder function as possible. Steroid injections may be used to help with pain control and improve motion during therapy.

For patients whose rotator cuff can be repaired, the surgeon must consider how the rest of the shoulder joint and soft tissues compensate for the loss of tendon integrity. Shifts occur in the shoulder structures that can affect shoulder stability and strength. Other factors such as age, tear size, smoking, diabetes, and the use of antiinflammatories must be considered because any of these can affect the final results or outcomes of surgery.

Much has been written about how shoulder surgeries should be performed. Is the minimally invasive arthroscopic technique better than the open incision approach? There are pros and cons to both but it's starting to look like arthroscopic technique has improved enough that the results are neck and neck between the two operative methods. The final proof of which one is better may come when long-term results (10 to 20 years later) can be reported. Until then, surgeons continue to look for ways to improve repairs with different suture techniques, suture materials, and combinations of these techniques. The authors provide descriptions and drawings of different stitches that can be used including a tensionless technique called interval slides.

A new area of focus in tendon healing is called biologic augmentation. Instead of using tendon transfers, various agents (biologics) are being tried to help bridge the gap between the torn and retracted tendon and bone where the tendon should be attached. Collagen (building material for soft tissues) from animals such as pigs and a portion of the small intestine are two experimental implants being investigated. Growth factors have been tried but without much success. They do stimulate tissue to develop but it's often just poor-quality scar tissue and not real (strong) tendon tissue.

Maybe one of the most useful aspects of this article is the treatment algorithm (decision pathway) provided by the surgeons who wrote the article. When the surgeon is working with a patient who has a massive rotator cuff tear, the algorithm starts with conservative (nonoperative) care and then branches according to whether the patient has a rotator cuff tear that can be repaired or one that is irreparable. On the repair side, the next step is to decide whether the procedure should be done arthroscopically or with an open incision. Of course, then the next step is to determine what surgical technique is best for that patient.

For massive rotator cuff tears that can't be repaired, surgery may still be an option. Instead of trying to repair and reattach the tendon, the area may be cleaned up as best as possible with a partial repair. Or a tendon transfer may be able to salvage the situation. Experimental techniques described may someday become a mainstream part of repair and/or salvage of massive cuff tears so they are listed off to the side at the bottom of the chart.

When it's all said and done, the surgeon must still evaluate each patient on and individual basis. The location, size, and condition of the tear guide treatment. The surgeon may not have all the information needed about these factors until during the operation when they can take a look and see what's really going on. Then all other variables come into play such as patient goals, age, health, and condition of other shoulder structures.

There isn't much a surgeon can do right now about tired, worn out tendons that rupture. Until science delivers safe, effective, and reliable biologic augmentation, surgeons do the best they can with what they have to work with. And as it turns out, that is often enough to give patients a stable, workable shoulder with reduced pain and improved function.

References: Shane J. Nho, MD, MS, et al. Biomechanical and Biologic Augmentation for the Treatment of Massive Rotator Cuff Tears. In The American Journal of Sports Medicine. March 2010. Vol. 38. No. 3. Pp. 619-629.

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