EFORT course to focus on classification and appropriate care for massive rotator cuff tears

A 1-hour instructional course scheduled for June 4 at the 2010 EFORT Congress will cover anatomy/biomechanics, tear evaluation and classification, and treatment.

Selecting the best treatment for massive rotator cuff tears remains a critical issue for orthopaedic surgeons who treat upper extremity and shoulder problems. Fernando Marco Martinez, MD, PhD, is scheduled to deliver an instructional lecture on the topic of massive rotator cuff tears at the 2010 EFORT Congress.

The literature reports successful management of massive rotator cuff tears treated either nonoperatively, with debridement and decompression, or with partial repair. Even structurally failed repairs have been shown to have good clinical outcomes, according to Marco, who is chair of orthopaedics, Complutense University of Madrid.

Appropriate treatment

“It is only by reviewing pertinent information and matching it with personal experience that the surgeon can make appropriate treatment decisions,” Marco told Orthopaedics Today Europe.

Pectoralis major (pPM) subcoracoid transposition under the conjoined tendon (CT) for subscapularis ruptures. Images: Martinez FM

Marco plans to emphasize in his lecture the importance of careful patient and tear evaluation as a prerequisite for successful treatment. Patient-specific factors, such as medical comorbidities, should be considered regarding their capability to enhance shoulder dysfunction.

Imaging, surgical techniques

“Today, MRI has commonly taken the place of CT to evaluate in a reproducible manner atrophy and fatty infiltration of the cuff,” Marco wrote. He noted that such changes in the muscle’s appearance have been shown to correlate with poorer tendon healing, and poor healing has also correlated with worse outcomes.

Based on the outline of his lecture, Marco has allowed the most time for discussing the nuances of open and arthroscopic techniques used to treat these cuff tears, such as direct cuff repair, combining cuff repair and tissue substitution or augmentation, and cuff reconstructions that involve tendon transfers.

“Arthrodesis and arthroplasty should be considered end stage procedures, but while arthrodesis indications are receding, arthroplasty is in high tide,” particularly with the reported series of consistently good results obtained with the use of the reverse prosthesis, he wrote. – Susan M. Rapp

Reference:

• Marco Martinez F, Garcia-Fernandez C. Massive tears of the rotator cuff. To be presented at the 2010 EFORT Congress. June 2-5, 2010. Madrid.

• Fernando Marco Martinez, MD, can be reached at fermarco@hotmail.com or fmarco@med.ucm.es.

The definition of “massive” in the classification of extensive rotator cuff tears (RCTs) throughout the available literature is unclear. Anteroposterior dimension, the extent of mediolateral retraction, the number of tendons involved and the configuration of the tear are all qualities that have been used to define the class of tear.

Not all extensive tears of the rotator cuff are painful, and the majority of partial and small evolving tears are very painful. Pain is therefore not a helpful discriminator in choosing options for functional restoration in a cuff-deficient shoulder.

The clinical presentation is of a spectrum of weakness and unstable motion of the shoulder, complicated by stiffness and roughness — each feature presenting with specific pain. Instability of the shoulder occurs when the fibrous endoskeleton of the rotator cuff is ruptured or detached anterosuperiorly or posterosuperiorly, with eventual failure of the long head of biceps tendon (LHBT) by rupture or displacement. Weakness occurs when either the direct muscular attachments of the anterior and posterior cuff are detached (rare), or the muscular insertion into the fibrous endoskeleton is disrupted (musclotendinous rupture/avulsion), or the fibrous endoskeleton is detached. Stiffness, caused by synovial thickening and fibrosis, contracture of the ruptured capsule, and muscular degeneration and fibrosis presents, as with checkrein phenomena, with obligate opposite translations.

The clinical presentation can be expressed as the following equation:

[stiffness + weakness + failure of the fibrous endoskeleton] = unstable motion

Unstable motion can be compensated by the LHBT, and, in large diameter proximal humeri, the effect of the deltoid muscle. The male proximal humeral geometry with an intact LHBT thus favors function in extensive RCTs.

Motion of surfaces which should glide smoothly (the subacromio-delto-coracoid plane and the glenohumeral articular surface plane) is inhibited or limited by roughness of the surfaces, causing the clinical syndromes of impingement (internal, external, and articular surface).

The overall functional presentation can therefore be expressed as another equation:

[stiffness + weakness + failure of the fibrous endoskeleton + roughness] – [effect of LHBT + deltoid] = patient-specific dysfunction

Each component of the equation above can generate pain. Therefore, the diagnosis of each pain generator in extensive RCTs is fundamentally important in defining treatment goals and pathways.

Weakness can only be correctly assessed if stiffness is analyzed. If the excursion of a muscle-tendon unit is limited by a checkrein (contracture), it cannot generate an appropriate force. Similarly, articular surface roughness generates pain, which is inhibitory of muscle action.

Finally, the functional needs of the patient should be clearly understood. The presence of an extensive tear on an image alone is not an indication for intervention.

This form of analysis allows the clinician to separate the components of the clinical presentation, analyze the relationship between each of the components and define a patient-specific intervention. Intervention for stiffness (rehabilitation; and arthroscopic release of contractures), roughness (arthroscopic debridement; tuberoplasty; and acromioplasty), and other pain generators (synovectomy; acromioclavicular joint resection; and long head biceps tenoplasty, tenodesis, and tenotomy) can all transform a decompensating shoulder into one which compensates very well for the RCT. A deltoid-strengthening program, started once a functional, painless, smooth and passive range of motion has been re-established can deliver a “stable enough, strong enough” shoulder.

If weakness remains a function-limiting problem then intrinsic or extrinsic musculotendinous transfers (local rotator cuff flap or pectoralis major, latissimus dorsi and teres major flaps) are considered. If painful articular surface roughness persists, causing articular surface impingement, then replacement of the articular surfaces is indicated. If the shoulder is otherwise stable enough and strong enough then surface replacement arthroplasty is sufficient. If the shoulder is stable enough and strong enough but weak, then surface replacement arthroplasty with extrinsic musculotendinous flaps can be valuable. If the shoulder is neither strong enough nor stable enough then a reversed polarity or fixed-fulcrum arthroplasty can be considered. The better results of reversed polarity arthroplasty appear to be in patients who would have rehabilitated well if there had been less articular surface pain generation (i.e., the larger proximal humeral geometry, deltoid-sufficient condition).

Therefore, I use a mechanistic approach to the analysis of extensive RCTs rather than relying on size or the number of tendons affected. It is uncommon for the entire infraspinatus insertion to be avulsed or ruptured, yet such a lesion is often called a two-tendon lesion if combined with a supraspinatus rupture, and it is difficult to determine the region of transition from supraspinatus to infraspinatus on a magnetic resonance imaging or ultrasound scan.

Massive tears are generally defined as tears involving the subscapularis as well as the two posterosuperior tendons: in these cases the function of the LHBT is crucial to the stability and value of the shoulder. An intact, pain-free LHBT should, of course, be preserved in such cases and, if unstable, should be preserved and stabilized in the sulcus without strangulation.

Massive tears demand a comprehensive analysis of the components of equation the second equation above, combined with an appreciation of the relevant pain generators to deliver a diagnosis for treatment (see equation below). The condition of the shoulder will change over time, requiring adaptability of the program for treatment. Rehabilitation often restores a valuable shoulder, particularly if it is facilitated by early and specific adjunctive pain management (regional nerve blockade, medication, acupuncture, etc.) and should be pursued if possible before surgical management is contemplated.

The rotator cuff equation, describing a mechanistic approach to the analysis and management of RCTs is as follows:

Diagnosis = pain × {[stiffnessⁿ¹ + weaknessⁿ² + failure of the fibrous endo-skeletonⁿ³ + roughnessⁿ⁴] – [effect of LHBTⁿ⁵ + deltoidⁿ⁶]}

The factors ⁿ¹ through ⁿ⁶ in the equation above each have a different patient-specific weighting, which helps guide treatment.

“Massive” RCTs are tears characterized by painful persistent superior instability. It is suggested that the nomenclature “small, medium, large and massive” be replaced by a mechanistic description based on the “rotator cuff equation,” so that the patho-anatomy of extensive RCTs and consequent shoulder dysfunction can be appreciated more readily.

– Simon M Lambert
Consultant Orthopaedic Surgeon
The Problem Shoulder and Elbow Service
Royal National Orthopaedic Hospital NHS trust
Stanmore, UK