Advances in rotator cuff repair

Issue: December 2004

ByGary M. Gartsman, MD

Rotator cuff tears are one of the most common shoulder injuries, representing a significant source of pain and disability. Recent advances in the diagnosis and nonoperative and operative treatment options allow for arthroscopic repair of the torn rotator cuff.

Diagnosis

Gary M. Gartsman, MD,
is clinical professor, Department of Orthopedics, University of Texas Health Science Center, and is in private practice at the Texas Orthopedics Hospital in Houston, Texas.

Diagnosing rotator cuff injuries requires a thorough patient history and physical examination. Magnetic resonance imaging (MRI) and arthrograms may be necessary to confirm the diagnosis and to identify other underlying problems, such as acromioclavicular joint arthritis, glenohumeral joint arthritis or labrum tears. Although orthopedic surgeons prefer using MRI as a diagnostic tool, a new advance in the diagnosis of rotator cuff injury is the ultrasound. The affordability and technological improvements of ultrasound machines have made this a desirable diagnostic modality

Nonoperative treatment

Rehabilitation and medication are forms of nonoperative treatment for patients with rotator cuff tendon complications. Advances in the management of patient outcomes, such as new scoring systems, have led to success for nonoperative treatment measures. Surgeons are now able to quantitate the effect of treatment with instruments that are self-assessed by patients that do not apply a significant burden to the patient or the physician.

Operative treatment

For patients who are candidates for rotator cuff repair, three options exist: open repair, mini-open repair or arthroscopically assisted repair. Although each of these options is effective, surgeons choose one option based on their preference and the extent of the complication.

A spectrum of abnormalities occurs in conjunction with rotator cuff injuries. The biceps tendon or labrum can become frayed or torn. The acromioclavicular joint may become damaged or arthritic. For patients with tendonitis or partial thickness rotator cuff injuries, surgery is performed with an arthroscope. Also, acromioplasty may be performed.

Reports of open and arthroscopic treatment for full thickness rotator cuff tears and repair without acromioplasty are found in the literature. In short-term studies, acromioplasty does not affect patient outcomes.^1-4 If similar results are reported in long-term studies and found in wider applications, then there is the potential for impact on rotator cuff surgery, as this will cause surgeons to re-examine their understanding of the underlying pathophysiology.

For patients with full thickness tears of the rotator cuff, the tear can be repaired arthroscopically. The bone is prepared for the tendon to be reattached, and metal anchors (stainless steel suture anchors) are placed in the bone that contains sutures. These sutures are weaved through the tendon, and the tendon is mobilized back to its bony attachment. Metal anchors are deep in the bone and do not need to be removed. If the tear is large or chronic, then the arthroscopic technique is effective but some surgeons prefer an open incision procedure. The incision is placed in the area of the rotator cuff on the side of the shoulder, and the repair is performed with suture anchors and bone tunnels.

The type of sutures used in rotator cuff repair is debated. Various studies appear in the literature concerning the construct of the sutures: Is the rotator cuff best repaired with simple sutures, mattress sutures or another type of suture configuration? These questions led to the central debate of how well surgeons should fix rotator cuffs and how they know when the rotator cuffs are fixed appropriately.

Recently, attention has been given to the type of fixation of the rotator cuff. Surgeons have been moving from traditional bone tunnels to anchor-tied materials. The question of tacks is also debated. The ease of anchor and tack insertion and repair security must be balanced against their increased cost. Other advances in rotator cuff surgery include rotator cuff tendon repair. Surgeons question the use of lateral and medial fixation. This has been the focus of basic science laboratory studies in which researchers are working to improve the footprint of the rotator cuff tendon as it heals. Whether this idea will enter the clinical application and what types of materials to use to repair the rotator cuff in a single or double row are yet to be determined. Generally, the use of autograft as a grafting material is not favored by surgeons for larger rotator cuff tendon tears. Surgeons are interested in tendon transfers for treatment, which are indicated for active patients who require overhead strength and have a massive irreparable tear.

Rotator Cuff Tear

Douglas W. Jackson, MD: The incidence of rotator cuff tears in patients who are 65 years of age and older is high. What is the diagnostic accuracy of a physical examination in predicting arthroscopy findings in patients with suspected rotator cuff tear?

Gary M. Gartsman, MD: The incidence of rotator cuff tears in patients is age-related. Most series study patients with an average age of 60 — a large percentage of patients are over 65. The incidence of full thickness tears in the contralateral shoulder is 33%. If a surgeon prefers managing a patient nonoperatively, then this number demonstrates that the presence of a rotator cuff tear is not necessarily an indication for operative intervention. Other options should be considered before resorting to arthroscopic surgery.

Drew V. Miller, MD: For patients who have arthroplasties and have metallic artifacts, what is the learning curve for surgeons using an ultrasound and how does a surgeon implement the learning curve?

Gartsman: Learning to use the ultrasound is a challenge because formal courses are not available. Most ultrasounds are performed by radiologists. Perhaps the best way to learn is to find an orthopedic surgeon who uses ultrasound on a regular basis.

Postoperative rehabilitation

Current rehabilitation techniques include passive motion, continuous passive motion, active motion and strengthening. Outcome studies are becoming more precise, demonstrating that patients note improvement after surgery. Instruments that are self-assessed by patients allow a surgeon and therapist to document the effect of various rehabilitation protocols.

Discussion

To assess the benefits of advances in rotator cuff repair and to determine what will be seen in the future, several questions must be addressed. A basic principle that must be understood is the source of pain. What causes pain in patients with rotator cuff tears? Patients have multiple sources of pain and, in the future, treatment will be more precise and surgeons will identify the specific source of pain in a patient. What is the value of an MRI? An MRI costs $1,200 and reimbursement for surgery is $1,800, making the total expenditure $3,000. Consider a situation in which the insurance company offers $2,500 to care for this patient. How many MRIs should a surgeon order and why?

When assessing surgical management, is it necessary to arthroscope the glenohumeral joint? How do surgeons determine what lesions are significant? How are biceps lesions managed? What is the appropriate treatment for particular individuals — stabilization, no treatment, tenotomy or tenodesis? Is a bursectomy necessary? Acromioplasty will continue to be defined as to its proper indications. The debridement of the edge of the rotator cuff tendon, in terms of searching for vascularity or structural strength, has not yet been decided. Another fundamental issue is how surgeons make decisions on what is repairable. Currently, the determination is subjective according to the surgeon. Surgeons must address the issues of fixation relating to the tendon in the rotator cuff footprint, the double-row or single-row controversy and the bone tunnel method. Are these techniques acceptable? Are surgeons going to return to performing some form of these techniques in the future? If fixation is appropriate, then perhaps suture construct is an inappropriate model. An advance that surgeons will see is the determination of the type of point fixation technique that can be applicable to rotator cuff tendons. Surgeons will see a resolution in the controversy of the type of anchor and anchor material. There is a natural tendency to use a radiolucent or a biodegradable material, but evidence that surgeons are proceeding in an appropriate direction does not exist. New sutures that have tensile strength, new material handling properties and absorbability are going to change how rotator cuff repair is performed. Augmentation patches represent an advance occurring in the past few years. Some evidence exists that this is helpful in an experimental and clinical model. Will augmentation patches become more popular or cost prohibitive?

Future

In the future, surgeons will see further improvements in rotator cuff repair. The diagnosis of rotator cuff repair will be based more on ultrasound testing, rather than MRI. This change will be driven primarily by the cost to the patient, to the health insurance carrier and, increasingly, to the surgeon and his or her institution. Nonoperative management will become more precise as surgeons are more able to define the exact source of pain in patients and deal with the pain appropriately. Intra-articular surgery, particularly as it relates to the biceps tendon, will become defined as the question about which patients respond best to certain treatments is clarified.

New and different methods of rotator cuff repair will emerge. Currently, techniques are physical (eg, tacked sutures). However, surgeons will see the advent of biologic materials and the type of glues that precisely adhere the tendon to its bed. Postoperative treatment will become more standardized as the efficacy of various types of postoperative treatment and medication are analyzed. Most importantly, surgeons will better evaluate the efficacy of surgery from a patient’s point of view by asking more specific and detailed questions.

References

Gartsman GM, Brinker MR, Khan M, Karahan M. Self-assessment of general health status in patients with five common shoulder conditions. J Bone Joint Surg Am. 1998;7:228-237.
Gartsman GM, Brinker MR, Khan M, Karahan M. Early effectiveness of arthroscopic repair for patients with full-thickness tears of the rotator cuff. J Bone Joint Surg Am. 1998;1:33-40.
Gartsman GM, O'Connor D. Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: A prospective, randomized study of one-year outcomes. J Bone Joint Surg Am. 2004;13:424-426.
Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br. 1994;76:371-380.