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Best Way to Repair Massive Rotator Cuff Tear

Orthopedic surgeons from around the world continue to look for ways to improve results of surgery for rotator cuff tears (RCTs) of the shoulder. Of special interest are the results of surgery for massive RCT tears.

The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The rotator cuff connects the humerus to the scapula. The rotator cuff helps raise and rotate the arm.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

This article addresses the question of what surgical treatment works best: complete repair, partial repair, or just debridement. Debridement refers to a surgical procedure in which the surgeon cleans the area of debris and torn fragments. The rotator cuff is then left to heal on its own. There are pros and cons to each technique. Sometimes working backwards is the most accurate way to know which way to go.

And that's what they did in this study. The surgeons reviewed the cases of 72 patients who all had massive (complete rupture) of the rotator cuff. They were divided into three separate treatment groups based on the type of surgery (complete repair, partial repair, debridement).

The type of procedure was decided during surgery when the surgeon could see the location and severity of the lesion (tear). Partial-thickness tears and full-thickness tears can often be repaired if the damage isn't too much. But massive, full-thickness tears may be too much to allow for any kind of repair. That's when debridement is done instead.

The results (joint motion, function) from this study were obtained by measuring and comparing outcomes before and after surgery. The good news is that everyone in all three groups improved. They had less pain after surgery, more motion, and could use the arm more.

A closer look at the data showed that the patients in the complete repair group had the best results. They seemed to gain more active (patient-controlled) shoulder motion afterwards. And more motion translated into better daily function.
Taking a look at the results for partial repair versus debridement, there was no difference between those two groups.

The results of this study are important when considering treatment of a complete rupture of the rotator cuff. Other studies have shown that tears can be so massive that surgery won't help. Re-rupture after rotator cuff repair is fairly common. No one wants to go through major surgery and a long rehab program only to retear the cuff.

Knowing that a complete repair yields the best results helps guide the surgeon when selecting the right course of action for each patient. It is still true that the best results occur with repair of small or moderate tears of the rotator cuff. The size of the tear really does predict the final outcome.

The larger tears tend to fill in with fat and scar tissue making surgical repair more difficult. The tendon can retract (pull away) so far that it cannot be restored to its correct anatomical insertion. Poor quality of the torn rotator cuff is another factor the surgeon considers when deciding what type of surgery to perform.

It should be noted that there was no control group in this study. In other words, they did not compare results with patients with massive rotator cuff tear who did not have surgery. Future studies may need to include this group to get a complete picture of results between these three types of surgery and conservative care.

The authors did recommend complete repair of massive rotator cuff tears. But they also said that the differences between results for the three groups (though measurable) were not large enough to be statistically significant.

When choosing between repair and debridement, there was a general trend for better results after debridement. It is a less invasive and less expensive procedure with fewer complications. Patients can have the surgery as an out-patient, they still get pain relief, and the rehab period is much shorter. For older adults, that's a recipe for success in getting back motion and function.

References: Alexander Berth, MD, et al. Chronic Rotator Cuff Tears: Debridement Versus Complete Versus Partial Repair. In Journal of Orthopedics. 2011. Vol. 8. No. 3. Pp. e10.

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