Surgeons navigate options for massive rotator cuff tears
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Defined as a tear greater than 5 cm in the anterior-posterior dimension or a complete tear of two or more rotator cuff tendons, a massive rotator cuff tear can be caused by traumatic injuries or degeneration of the tendons.
“I would say it is more common to see [massive rotator cuff tears] in an older population; however, you can see them in any age group,” Frank A. Petrigliano, MD, chief of the USC Epstein Family Center for Sports Medicine at Keck Medicine of the University of Southern California, told Healio/Orthopedics Today. “In younger patients, you can see a large or massive tear after trauma and, in older patients, it is typically a tear that has been neglected either because it was asymptomatic for a long time and the patient did not realize that they had it, or they had pain and never sought treatment for it.”
Source: Jessica Sebastian
Published research has shown that the repair of massive rotator cuff tears can be complicated by structural failure and poor outcomes and it has been found to have high retear rates. With several management options available for massive rotator cuff tears, orthopedic surgeons should have a good understanding of the indications, pathomechanics and clinical outcomes of the various treatment modalities.
“A lot of the time, patients, despite the fact that they have a similar looking MRI, can have vastly different symptoms and that can make [treatment] tricky because it is more based on your physical examination, your history, as opposed to the imaging,” Lawrence V. Gulotta, MD, chief of the shoulder and elbow division of the Sports Medicine Institute at Hospital for Special Surgery, said. “So there may be a little bit more subjective evidence that you need to go on as opposed to the radiology objective evidence you can go on.”
Factors for treatment
Of the various factors that surgeons need to consider when deciding which treatment method to use, age is a major one, according to Joseph A. Abboud, MD, professor of orthopedic surgery in the shoulder and elbow division at Rothman Orthopaedic Institute at Thomas Jefferson University Hospital.
“If you are [younger than] 60 [years], it bodes better for you as far as healing response, but [older than] 60 [years], the state of the muscle belly on the MRI, meaning if the muscle belly is robust and does not show signs of atrophy, that usually bodes well for somebody who is going to have good excursion of the tendon and potentially good elasticity and recovery of muscle tendon function,” Abboud, who is an Orthopedics Today Editorial Board Member, said.
In addition, comorbidities, such as diabetes, hypercholesterolemia, malnutrition, smoking, heart disease and bone density, as well as retraction of the tendon, also play a role in treatment, he said.
Sources who spoke with Healio/Orthopedics Today noted that injury onset and patient activity level, social support, goals and expectations can also help guide treatment decisions and options.
“The treatment choice depends a lot on the age of the patient, the onset and what their goals are,” Peter J. Millett, MD, MSc, of The Steadman Clinic, told Healio/Orthopedics Today. “If it is an atraumatic onset and the patient is lower demand, then I think nonsurgical treatment would be reasonable.”
Nonoperative treatment
Research published by the Multicenter Orthopaedic Outcomes Network shoulder group showed that physical therapy may relieve pain and reduce the need for surgery in patients with rotator cuff tears, according to Julie Y. Bishop, MD, professor of orthopedics and chief of the division of shoulder surgery at The Ohio State University Wexner Medical Center.
“The results of treating large tears nonoperatively, if it is a degenerative tear and someone’s function is intact, then we would always start with therapy because there are not easy solutions for those massive irreparable tears and there is evidence that physical therapy can help people live with those tears and avoid surgery,” Bishop told Healio/Orthopedics Today.
Gulotta said cortisone injections, in addition to physical therapy, may provide relief of pain in patients with a chronic, degenerative massive rotator cuff tear that has been aggravated.
“If you give [these patients] a cortisone injection, give it about a week for the cortisone to kick in and then put them in physical therapy, eight times out of 10 we are able to get patients back to their baseline, which is having a shoulder that might ache here or there, but, overall, they can do everything they want to do,” Gulotta said.
Reparable vs. irreparable tears
However, sources said patients with massive rotator cuff tears caused by high- or low-energy trauma have better results with surgery.
“If you can get to [a traumatic tear] quickly, the muscle has not atrophied, the tendon has not lost its elasticity, so even if it is massive, it can be a straightforward repair,” Bishop said.
However, patients who have had a shoulder condition for several years, who have profound weakness on physical examination, particularly weakness with external rotation, who have anterosuperior escape, an elevated humeral head on X-ray and fatty infiltration of the rotator cuff on MRI are likely to have an irreparable rotator cuff tear, according to Gulotta.
“The frustrating thing can be, once you get into the situation in which the rotator cuff is technically irreparable, where we are no longer able to anatomically restore the rotator cuff and get it to heal, then the surgeries can be somewhat unpredictable and few of the surgical options result in a 100% perfectly normal shoulder,” Gulotta told Healio/Orthopedics Today.
Operative treatment
Among the surgical options for either reparable or irreparable massive rotator cuff tears, arthroscopic debridement involves removal of any inflamed tissue and scar tissue from the shoulder, according to Petrigliano. He said surgeons may also address any additional pain generators in the shoulder during debridement, such as the biceps tendon or acromioclavicular joint.
“This is the ‘clean out’ of the shoulder and the functional improvement from that type of surgery is modest, but it can be effective in improving pain in a certain select patient population,” Petrigliano said.
Bishop said another surgical option is a partial repair, where the surgeon addresses all of the same areas as are addressed during an arthroscopic debridement in addition to repairing part of the tendon.
“I think the results [of a partial repair] are similar to debridement, maybe a little better. But, again, we have kept looking for more options because the outcomes were not as good as we would like them,” Bishop said.
A variety of grafts can also be used to patch a large hole in the rotator cuff, either by bridging the repair or augmenting the repair, according to Petrigliano.
“These are generally for patients who have reasonable rotator cuff muscle quality and maybe it is a one- or two-tendon tear that can be bridged,” Petrigliano said. “The results from this are functionally better than a debridement and partial repair, but probably not as good as primary rotator cuff repair.”
Superior capsular reconstruction
Superior capsular reconstruction (SCR) became another option for treatment of massive rotator cuff tears in the early 2010s after it was popularized in Japan by Teruhisa Mihata, MD, PhD, Petrigliano said. The SCR procedure, as originally described by Mihata, is performed by placing a fascia lata autograft between the glenoid and the humeral bone to act as a bumper or trampoline between the humeral head and the acromion, he said.
“In the right population, the results from [SCR] are fairly good with reasonable improvements in patient-reported outcomes and pain relief and improvement in function, as well,” Petrigliano said. “However, you need to have an intact or reparable subscapularis tendon, an intact posterior rotator cuff and a functional deltoid to do the surgery.”
He said SCR can be expensive because, in the United States, it is performed using allograft tissue and seven suture anchors and can yield a lengthy OR time. There is also controversy around whether SCR can improve pseudoparalysis of the shoulder, Petrigliano said.
“Pseudoparalysis is basically an inability to lift the arm because of a rotator cuff tear. Some studies suggest that [SCR] can reverse pseudoparalysis and some suggest that it does not reverse pseudoparalysis and so extensive patient counseling and proper patient selection are necessary for that surgery to be successful,” he said.
Subacromial balloon spacer
Another new treatment modality for massive rotator cuff tears is the subacromial balloon spacer (InSpace, Stryker), which was approved by the FDA in August 2021. Made of a material similar to Vicryl suture (Ethicon), Abboud said the subacromial balloon spacer is inflated with saline when implanted and resorbs during 3 to 12 months postoperatively.
The subacromial balloon spacer “expands the subacromial space, essentially what is called the acromiohumeral interval. It is changing the tension on the remaining cuff muscles and subscapularis, teres minor, latissimus, pectoralis and deltoid. It is changing the center of rotation, so it is re-educating the shoulder to create a chronic compensated tear pattern that you see in a fair number of patients,” Abboud told Healio/Orthopedics Today.
The subacromial balloon spacer is indicated for patients older than 65 years who have minimal arthritis of the ball-and-socket joint, an intact subscapularis, who have 90° forward elevation of the arm, a functional deltoid and who have not had a cortisone injection within 1 month, according to Abboud. As far as results, he said he has seen a reasonably significant improvement in VAS scores, American Shoulder and Elbow Surgeon scores, forward flexion and abduction.
“I would say 75% of patients who go through the procedure are happy they had it done and see sustained benefits,” Abboud said. “I have been following my patients carefully at this point since the release of the device and I am going into year 2 of follow-up of a lot of these patients, but I have several patients now from the initial FDA [Investigational Device Exemption] IDE that was started in 2015 that are 5 to 7 years out and still seeing the benefit.”
He said he has not seen any reactive changes in the joint, any progression of arthritis, any significant progression of muscle atrophy and any significant or undue adhesions in the subacromial space in patients who need to undergo revision.
“[The subacromial balloon spacer] is a fairly simple technology. It translates to being able to likely be used in the hands of surgeons who have good arthroscopic skills, but who may not be [among] the best arthroscopists,” Abboud said. “Ideally, you are able to implant something in your patient that helps them and that, over time, dissolves so there is no debris burden left in the patient’s shoulder.”
Complex procedures
Although it is a complex procedure, tendon transfer may be a good treatment option depending on the patient’s deficit, according to Petrigliano.
For a tendon transfer, Petrigliano said surgeons take “muscle and tendon units that are intact from either the trapezius or the latissimus and use them to reconstruct the posterosuperior rotator cuff.” Used to improve elevation and external rotation, tendon transfer can be performed in patients with severe external rotation deficit due as a result of their rotator cuff tear, he said.
“[Tendon transfers] are technically complex and require extensive neuromuscular rehabilitation and they should be performed by people who have training in that specific intervention,” Petrigliano said. “The results are promising if we look at the existing data for both, but, again, have specific patient indications, including a functional subscapularis, a functional deltoid and ability to participate in an extensive neuromuscular rehabilitation program.”
Bishop said reverse total shoulder arthroplasty is the “most definitive option for the irreparable rotator cuff tear.” Although reverse TSA is not recommended for young patients with irreparable rotator cuff tears, she said it can provide good outcomes in older patients who have the beginning of arthritis and a high-riding humeral head.
“The outcomes [of reverse shoulder arthroplasty] are good, and it was created for people with an irreparable cuff tear and arthritis in an arm that does not work,” Bishop said. “But if you have perfect function and you have a reverse, you might lose a little bit of your function.”
Regenerative techniques in the future
In addition to the treatment options currently available for massive rotator cuff tears, more research is needed on regenerative techniques that take rotator cuff muscles and tendons deemed irreparable and make these amenable to repair, Gulotta said.
“There is probably some work to be done in terms of combination of patches with biologic augmentation, whether it be stem cells or other growth factors, that are going to be able to stimulate healing,” he said.
Similar to screening tools used to identify genetic risk factors for cancer, Abboud said future research regarding this condition should help develop assessment tools to predict which patients are at risk for developing rotator cuff tears. He also said development of a simple serum or synovial test that identifies inflammatory markers may be helpful in predicting patients who have or are at risk for a rotator cuff tear.
Also of value would be “more refined algorithms to help us predict who is likely to benefit and heal a repair vs. who may go through a repair and have a recurrent tear, and I think there are certain macrophage markers that can help look at that,” Abboud said.
Consider patient, injury factors
Millett said outcomes research is also important to further identify which patients will benefit from which treatments. He said research presented at the American Orthopaedic Society for Sports Medicine Specialty Day Meeting held during the American Academy of Orthopaedic Surgeons Annual Meeting this year showed that careful patient selection and proper technique can yield good outcomes with repair in older patients with massive rotator cuff tears, a finding that contradicts historical data.
“Historically, there was a thought that patients older than age 70 [years] would do poorly with repairs, so you should just go to a reverse shoulder arthroplasty,” Millett, who is an Orthopedics Today Editorial Board Member, said. “Well, our data suggested that it is more about the physiology and what the quality of the remaining tendons are and, if you can repair them, they tended to do well.”
Although the Neer Circle of the ASES published a consensus statement on the treatment of massive rotator cuff tears that yielded good consensus regarding treatment of older patients with massive rotator cuff tears, Millett said consensus is still lacking when it comes to younger patients in many of the surgical scenarios.
When diagnosing a rotator cuff tear, he said surgeons should also take their time and consider all the factors that influence decision-making, including age, activity levels, the patient’s goals, general health and well-being, as well as tear pattern, quality of the remaining muscle and the status of the rest of the joint.
“Consider all those factors and then figure out what is going to be the most predictable option in your hands,” Millett said. “There are a lot of different options that are out there. Try and match the option that will give the best outcome to that individual patient.”
- References:
- Dey Hazra RO, et al. Paper 17. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting. March 7-11, 2023; Las Vegas.
- Kucirek NK, et al. Curr Rev Musculoskelet Med. 2021;doi:10.1007/s12178-021-09714-7.
- Mancuso F, et al. Acta Biomed. 2021;doi:10.23750/abm.v92iS3.11766.
- Mihata T, et al. Am J Sports Med. 2012;doi:10.1177/0363546512456195.
- St. Pierre P, et al. J Shoulder Elbow Surg. 2021;doi:10.1016/j.jse.2021.05.012.
- Verma N, et al. J Bone Joint Surg Am. 2022;doi:10.2106/JBJS.21.00667.
- For more information:
- Joseph A. Abboud, MD, of the Rothman Orthopaedic Institute, can be reached at joseph.abboud@rothmanortho.com.
- Julie Y. Bishop, MD, of The Ohio State University Wexner Medical Center, can be reached at julie.bishop@osumc.edu.
- Lawrence V. Gulotta, MD, of Hospital for Special Surgery, can be reached at carnevalen@hss.edu.
- Peter J. Millett, MD, MSc, of The Steadman Clinic, can be reached at drmillett@thesteadmanclinic.com.
- Frank A. Petrigliano, MD, of Keck Medicine of the University of Southern California, can be reached at frank.petrigliano@med.usc.edu. Website: www.drpetrigliano.com.
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