Wide armamentarium still needed to treat massive cuff tears

Treatment methods for massive cuff tears must maximize footprint coverage, optimize biologic environment.

Rotator cuff tears are a common shoulder injury. Massive tears, which are defined as more than 5 cm in diameter or tears that involve two or more tendons, occur in about 10% to 20% of cases. Massive cuff tears usually present among older patients due to degenerated shoulder tendons and muscles, sources told Orthopedics Today.

“Patients are living longer and we know that as they get older the incidence of rotator cuff tears is higher and higher, such that by age 80 to 89 [years]the incidence of rotator cuff tears, including massive tears, probably exceeds 50% of the population,” Samer S. Hasan, MD, PhD, orthopedic surgeon at Mercy Health – Cincinnati Sports Medicine and Orthopedic Center and chief of surgery at Jewish Hospital in Cincinnati, told Orthopedics Today.

Older patients tend to have lower demands for recovery compared with younger patients, such that they may be better able to compensate for a massive cuff tear, especially if it is a chronic tear. Although massive rotator cuff tears are relatively rare in younger patients, these are mostly due to trauma and the tears may be more symptomatic and especially challenging to treat if not repaired early, according to Hasan.

Source: Massachussetts General Hospital

In this Cover Story, shoulder surgeons discuss surgical and nonsurgical techniques — new, as well as proven — for the treatment of reparable and irreparable massive rotator cuff tears.

The pulley and the motor

When treating massive cuff tears, it is important to understand the patient’s likelihood for healing, according to Jon J. P. Warner, MD, chief of the shoulder service and professor of orthopedic surgery at Massachusetts General Hospital and Harvard Medical School. Massive cuff tears with good quality muscle and tendon “are straight-forward technical exercises that many surgeons now do extremely well arthroscopically, and the expectation of the patient is an excellent outcome,” he said.

In an irreparable tear, Warner noted, “the tendon is retracted to such a degree that it simply cannot be brought back to where it should attach.”

“I like to tell patients ... the rotator cuff tendon is like the pulley and the muscle attached to the tendon is like the motor,” he told Orthopedics Today. “When the pulley fails, and the motor keeps going, it burns out, and that is exactly what happens.”

Traditional surgical treatment

A study by Robert Thorsness, MD, and Anthony A. Romeo, MD, stated the goal of current surgical treatment methods is to maximize footprint coverage and optimize the biologic healing environment.

For an acute massive cuff tear, a primary repair may prove to be a beneficial treatment because the muscles and tendons are not scarred down and can be mobilized, and the tissue quality and muscle volumes are good, John E. Kuhn, MD, Kenneth D. Schermerhorn professor of orthopedics and director of Vanderbilt Sports Medicine at Vanderbilt Medical Center, said.

However, research has already shown not all patients can reach the best outcomes after a primary repair. In those cases, partial rotator cuff repair has shown to yield pain relief, as well as slightly improved functional outcomes, Mark A. Frankle, MD, professor of orthopedic surgery at University of South Florida, noted.

“The idea of doing a partial repair of a massive cuff tear is if you get some of it to heal that might help reduce their pain,” Frankle said.

Reverse shoulder replacement

Beside looking at the likelihood that healing will occur, orthopedists also need to consider the patient’s age and other comorbidities. Older patients or patients with arthritis may benefit from undergoing reverse shoulder replacement (RSR), according to Warner. This procedure allows surgeons to change the mechanics of the shoulder when the rotator cuff is deficient or torn, he said.

Frankle said published series have demonstrated predictable improvement in comfort and function among patients with massive rotator cuff tears who have minimal osteoarthritis and clinical pseudoparalysis and are treated with RSR. These patients could maintain their function at a minimum of 10 years of follow-up, he noted.

However, Stephen S. Burkhart, MD, of the San Antonio Orthopedic Group, believes RSR is being over-used in patients who do not have arthritis.

“In general, if I have an active patient with no arthritis but a massive rotator cuff tear, I am going to look at doing a repair or doing a superior capsular reconstruction with a dermal allograft,” Burkhart, an Orthopedics Today Editorial Board Member, said.

Superior capsular reconstruction, which was introduced by Teruhisa Mihata, MD, PhD, and colleagues of Japan, is a procedure for irreparable tears that has recently gained in popularity, according to Hasan.

“Superior capsular reconstruction ... is a concept where you take dermal allograft tissue or part of the patient’s tensor fascia lata of the leg (Mihata technique), and you reconstruct the superior capsule to stabilize the shoulder when the superior part of the rotator cuff (supraspinatus, infraspinatus) is torn and irreparable,” Warner said.

Elhassan noted superior capsular reconstruction is popular among orthopedic surgeons because it is an arthroscopic technique that has been shown to yield good results.

Burkhart, who has performed 132 superior capsular reconstructions to date, has found a low reoperation rate, with only two of his patients requiring a second surgery. Among 60 patients who reached at least 1-year postoperative, he noted there was an increase in forward flexion from 137° preoperatively to 165° postoperatively and scores on the American Shoulder and Elbow Surgeon and Single Assessment Numerical Evaluation scales improved, respectively, from 49.2 to 87.9 points and from 38.2 to 85.7 points. Burkhart said VAS pain scores decreased from 4.86 preoperatively to 0.70 postoperatively.

In terms of healing of grafts after superior capsular reconstruction among 40 patients who had 1-year postop MRI results, there was full healing in 82.5%; partial healing in 10%; and no healing in 7.5%, Burkhart said.

“My general impression of [superior capsular reconstruction] SCR with dermal allograft is it more reliably restores function (strength and motion) than the other procedures (primarily tendon transfer and reverse total shoulder replacement) advocated by some surgeons,” Burkhart said. “It is particularly appealing because it is a joint-preserving procedure with a low rate of complications.”

Hasan cautions that superior capsular reconstruction has a long recovery process and requires patients to undergo slow and disciplined rehabilitation, which may not be the best option for every patient.

“I think it remains to be seen, the effectiveness and appropriate utilization of superior capsular reconstruction,” Warner said. “That will be emerging over the next several years and we will see literature that will come out explaining its value or lack thereof, and that would be of great interest.”

Tendon transfer

A lower trapezius tendon transfer or a latissimus tendon transfer, a technique developed by Bassem T. Elhassan, MD, have been shown to yield promising results in young, active patients with an irreparable massive cuff tear and minimal OA.

“If you get a patient who has massive rotator cuff tear, let’s say posterior superior [tear], and they do not have much arthritis, ... 80% to 90% of patients had significant improvement of pain, range of motion and strength,” Elhassan, professor of orthopedic surgery at Mayo Clinic, told Orthopedics Today.

Orthopedic shoulder surgeons are generally uncomfortable performing tendon transfer because “it is more demanding and because it cannot be done arthroscopically,” Elhassan said, noting these techniques benefit both patients and surgeons since they can be done arthroscopically assisted.

“Our technique that treats both the anterior rotator cuff and posterior rotator cuff can be done arthroscopically assisted, which means the hesitation about doing tendon transfer because of prior experience in the past ... has been changed now,” he said.

Biodegradable balloon technology

The InSpace biodegradable balloon (OrthoSpace) is a device that is approved for use in Europe to treat a massive cuff tear. Under investigation for use in the United States through a large, FDA investigational device exemption study, at the time Orthopedics Today went to press there were 14 studies published worldwide on the InSpace biodegradable balloon, according to PubMed.

The InSpace balloon is inserted intraoperatively between the humeral head and acromion and is then filled with saline, according to Kuhn.

“It repositions the joint and then the patient goes through physical therapy, builds up the muscles and the kinematic patterns to compensate. Then when the balloon dissolves the patients seem to do fairly well,” Kuhn told Orthopedics Today.

Hasan, who is a site investigator in the FDA-mandated InSpace investigation, believes the study will “be a quantum leap forward” because of the inclusion of a partial repair control group and the high number of practices and patients involved in the endeavor.

“I am excited about it, but now I am not going to be able to offer it to my patients until it gets FDA approved, which may take 3 years or longer,” Hasan, an Orthopedics Today Editorial Board Member, said.

Pitfalls in surgery

Despite the high rates of improvement associated with treatment of massive rotator cuff tears, complications after surgery can occur. Several sources identified failure to heal as one of the most common complications of arthroscopic repair.

“Failure to heal and stiffness are probably two of the most common complications we see with our arthroscopic technique,” Hasan said. “Then, with the reverse shoulder replacement, there are issues related to the implant durability, the implant dislocating, the scapula fracturing or breaking from fatigue or increased loading.”

Identifying the right tear pattern is one way to avoid failure after surgery, according to Burkhart.

“If you do not get the tear pattern right, which is the same as the normal tendon anatomy, then you are going to have kind of a mismatch in the tension of your repair and it is going to fail,” he said.

Burkhart noted that a re-tear — although less common now than it once was — is a complication that patients who have anatomic and physiologic deficiencies may experience.

“[Re-tear is] less common than it used to be ... because we have better techniques and we are going more slowly with our rehab than we used to,” Burkhart said. “It used to be that well over 50% of massive cuff tears would re-rupture or re-tear, but now that is down to around 15% if you look at a more recent series.”

Treatment via physical therapy

One way to avoid the pitfalls of surgery is to involve some nonoperative treatments. Published research has shown this can be effective in more than 80% of patients with chronic, massive rotator cuff tears who experience pain and weakness in the shoulder without trauma, Warner noted.

“You offer [patients] the opportunity for therapy, explain to them it is a lower risk proposition and many of them function well ... with their rotator cuff tear because they are older, and just the therapy changes the [shoulder] mechanics and they feel better,” Warner said.

Physical therapy is mostly used to strengthen the deltoid and remaining intact rotator cuff. It may be beneficial for patients with a large or chronic rotator cuff tear who do not need an immediate surgical intervention, according to Hasan. Progressive inclined, deltoid strengthening, which is also known as the Reading United Kingdom program, is a popular physical therapy program and it has been effective in most patients, he noted.

“What that program involves is strengthening the deltoid beginning by having the patient actively elevate the arm while laying on their back, so gravity is not working against them, and as their arm elevation improves they can gradually incline the head of the bed,” Hasan said.

Caution with physical therapy

Sometimes physical therapy may not be appropriate for all patients. For example, patients with pseudoparalysis who cannot initiate elevation may not be able to participate in a physical therapy program in lieu of surgery, Hasan said.

Patients with OA may also not fare well with rehabilitation, Kuhn noted.

“If it is mild osteoarthritis, I think rehabilitation has a chance to be successful,” Kuhn said. “If the osteoarthritis is fairly severe, I would be less optimistic the rehabilitation would work.”

Regardless of the patient, it is important the physical therapy not be started too soon after surgery, Warner noted, as it may negatively affect the healing process.

When doing physical therapy, patients should see a physical therapist who understands how the rotator cuff works and works with the orthopedic surgeon, Warner added.

“More and more we understand that integrated practice units, meaning groups that work together to benefit the patient, have better success,” he said. “A therapist that can work with surgeons understanding the principles of healing and following the guidelines of what they want are essential to avoiding pitfalls [and] problems during the recovery period.”

There is a lack of benchmarks for physical therapy in this case, but Warner noted patients should generally be finished with physical therapy within 4 months of the date of surgery. Not overutilizing physical therapy will reduce the risk of affecting the healing process, as well as reduce the overall cost of care.

“With a rotator cuff repair, if you look at the 1-year cost of care from the time of surgery to 1 year later inclusive of therapy, physical therapy accounts for 74% of all costs after the surgery,” Warner said. “Proper utilization of physical therapy is essential to having a cost-effective approach to care.”

Advice for orthopedists

Overall, orthopedic surgeons should implement an organized approach when treating massive cuff tears, which sources said can be learned from courses and hands-on experience.

“[Massive cuff tears] are difficult cases with a lot of steps and so [surgeons] need to be thinking about what the order of steps is going to be. They need to think about how they are going to optimize each step and I think they need to understand that the majority of these tears can be repaired. It should be a priority of [theirs] to learn the steps to do that, if possible, by practicing on cadavers, attending courses where they can learn how to do it and get some hands-on experience,” Burkhart said.

Orthopedists should also have an armamentarium of tools at their disposal that includes nonoperative and operative treatments, rehabilitation strategies and an understanding of the patient’s goals.

“I think the way to approach it is you have to have all of those tools in your toolbox and be able to use every one and then sit down with the patient, figure out what their expectations are, what their goals are and then try to achieve them with the best approach that would match what they are trying to get out of the treatment,” Kuhn said.

This includes having a “firm foundation in evidence-based medicine” to find and apply the best practices, according to Warner.

“We need to be able to advise our patients based on three factors: number one, the evidence available in the clinical literature; number two, the best scientific evidence that suggests something might work; and number three, what would we do if it were us or our family,” Warner said. “If you approach it from that point of view, then you will match the right treatment with the right patient and understand that the diagnosis of massive rotator cuff tear is not diagnosis, it is a family of conditions.” – by Casey Tingle

• References:
• Cuff DJ, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.17.00175.
• Hartzler RU, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2015.04.015.
• Muleiri P, et al. J Bone Joint Surg Am. 2010;doi:10.2106/JBJS.I.00912.
• Rotator cuff tears: Surgical treatment options. Available at: https://orthoinfo.aaos.org/en/treatment/rotator-cuff-tears-surgical-treatment-options. Accessed Feb. 6, 2018.
• Thorsness R, et al. Orthopedics. 2016;doi:10.3928/01477447-20160503-07.

• For more information:
• Stephen S. Burkhart, MD, can be reached at 400 Concord Plaza Dr., San Antonio, TX 78216; email: ssburkhart@msn.com.
• Bassem T. Elhassan, MD, can be reached at 1216 2nd St., SW, Rochester, MN 55902; email: elhassan.bassem@mayo.edu.
• Mark A. Frankle, MD, can be reached at 13020 Telecom Pkwy. N., Tampa, FL 33637; email: mfrankle@floridaortho.com.
• Samer S. Hasan, MD, PhD, can be reached at 10663 Montgomery Rd., Cincinnati, OH 45242; email: s1663h@yahoo.com.
• John E. Kuhn, MD, can be reached at 3200 MCE South Tower, 1215 21st Ave. South, Nashville, TN 37232; email: j.kuhn@vanderbilt.edu.
• Jon J.P. Warner, MD, can be reached at 55 Fruit St., Yawkey Center for Outpatient Care, Suite 3G, Boston, MA 02114; email: jwarner@mgh.harvard.edu.

Disclosures: Burkhart reports he is a consultant for and receives inventor’s royalties from Arthrex. Frankle reports he receives royalties from and is a consultant for DJO Global on shoulder implants, including reverse total shoulder arthroplasty; and he has received royalties from Zimmer Biomet; and is a consultant for the company on its BioWick biological anchor for rotator cuff repairs. Hasan reports he receives research support from OrthoSpace and is a consultant for and receives royalties from DJO Global. Warner reports he is a design surgeon for a reverse shoulder implant and receives royalties from Wright Medical. Elhassan and Kuhn report no relevant financial disclosures.