Massive Cuff Tear Repair - You Mean We Don’t Need a Graft?

By Wesley M. Nottage, M.D.

The definition of a massive tear varies between authors, but the general criteria for a massive rotator cuff is based on either the number of tendons involved (two or three), a direct measurement greater than 5 cm(1,11) or a combination of these criteria.(3,8,9)

The treatment options include: nonoperative treatment with injections and physical therapy; bursal debridement and biceps tenotomy or tenodesis; a partial cuff repair; a complete rotator cuff repair, a complete rotator cuff repair with augmentation; tendon transfers; a superior capsular reconstruction; a subacromial balloon; or a reverse shoulder arthroplasty.

The clinical presentation is important. The ability to go overhead (with pain, or better after a bursal anesthetic) despite the tear suggests an arthroscopic partial or complete repair may do well. The morbidity of the treatment options and the surgeon experience significantly play a role in the selected treatment option. Remember that most of these tears are usually acute on chronic, and the patients were functioning without enough problems to seek help prior to the latest symptoms that bring them to you for treatment. One goal of treatment can be considered to return the patient to their status prior to the last event that brought them to you for care.

"Massive" and "irreparable" are two different concepts. Despite a preoperative MR imaging and exam suggesting a massive tear, the literature reports in this group 50-80% of these tears are completely repairable. A complete repair of the massive rotator cuff is associated with good results and improvement in functional scores over nontreatment, a partial repair or debridement. However, a complete rotator cuff repair requiring aggressive soft-tissue releases is not superior to a partial repair. Double-row and transosseous repairs result in lower retear rates than single-row techniques. The clinical judgment as to how far to go to get a repair plays a major role in the outcomes.

Eliminating excessive rotator cuff tension is the key principle to respect when attempting a complete repair. Utilization of the principles of margin convergence; multiple-double or triple-loaded anchors to decrease the load per suture; and the use of transosseous-equivalent techniques when possible will favor a durable repair. Certainly, after starting, a number of complete repairs will end up as partial repairs, which, although not as good as a complete repair, can still offer significant pain relief.

There are several systemic reviews of the complete repairs of massive rotator cuff tears.

"Arthroscopic Repair for Chronic Massive Rotator Cuff Tears: A Systematic Review" by Patrick Henry, M.D., David Wasserstein, M.D., Sam Park, M.D., Tim Dwyer, M.B.B.S., Jaskarndip Chahal, M.D., Gerard Slobogean, M.D. and Emil Schemitsch, M.D., reviewed 18 papers that met the eligibility criteria; they involved 954 patients with a mean age of 63 (range 37 to 87), and 48% of whom were female. There were five prospective and 13 retrospective study designs. The overall study quality was poor according to the Modified Coleman Methodology Score. Of the 954 repairs, 81% were complete repairs and 19% were partial repairs. The follow-up range was between 33 and 52 months, and the mean duration between symptom onset and surgery was 24 months. Single-row repairs were performed in 56% of patients, and double-row repairs were performed in 44%. A pooled analysis demonstrated an improvement in visual analog scale from 5.9 to 1.7, active flexion range of motion from 125 to 169 and the Constant-Murley Score from 49 to 74. The pooled retear rate was 79%. Conclusions: Arthroscopic repair of chronic massive rotator cuff tears is associated with complete repair in most cases and consistently improves pain, range of motion and functional outcome scores; however, the retear rate is high.

"The Complete Repair of Massive RCT Study Group" by Rodney J. Stanley, M.D., Matthew D. Williams, M.D. and Wesley M. Nottage, M.D. performed a systemic review which found similar data. Studies with minimum two-year clinical follow-up that described the criteria used for diagnosing a massive or irreparable rotator cuff tear and provided validated patient-reported outcomes and range of motion data were included.

Eleven studies encompassed 857 patients with massive rotator cuff tears who underwent 867 repairs. Follow-up of the patients averaged 43.6 months (24–118 months.) Multiple outcomes scoring systems were used, but the Constant Score was most common. The Constant Score increased from an average 45.6 preoperatively to 80.08 postoperatively.(1,2,4,8,10,11) The ASES Score was used in three studies and improved from 45.15 to 87.13 following repair.(6,9,10) UCLA scores also improved postoperatively and rose from 15.75 to 30.5 after repair.(6,7,10) All other metrics used saw improvements, including VAS, SPADI, SST and the SSV.(2-6,9,11)

Survival of the rotator cuff repair construct was evaluated using MRI, CT or ultrasound. The average retear percentage was 55.25% (29% to 91%).(1,4-5,7-11) One study compared the retear rates of differing repair constructs, where single-row repairs failed 29% of the time while double-row repairs failed 17% of the time.

Zumstein(4) reported that open repair of massive rotator cuff tears yielded satisfactory results at a mean.9.9 years postoperatively, suggesting the results are durable once established. This long-term study of open repair reported results at 3.1 years and 9.9 years follow-up and noted sustained results after three years. The retear rate at 9.9 years was 57%, compared to 37% at 3.1 years. The relative Constant Score, which had significantly increased from 51% preoperatively to 83% (range 38% to 100%) at 3.1 years, averaged 85% (range 22% to 100%) at 9.9 years.

Based on the 11 studies and data presented, a Journal of Bone and Joint Surgery (JBJS) Grade-C Recommendation supports complete arthroscopic repair for the management of massive rotator cuff tears. The grade is based on conflicting or poor-quality evidence not allowing a recommendation for or against the intervention. Complete repair of the rotator cuff is associated with good results and improvement in functional scores over partial repair or debridement. However, complete rotator cuff repair requiring aggressive soft-tissue release is not superior to partial repair. Double-row and transosseus repairs result in lower retear rates than single-row techniques. Open repair results demonstrated consistently good results 9.9 years after the initial repair.

Compare these results with the recent publication by Burkhart, Pranckun and Hartzler, (Arthroscopy 36:2, 2020, pp 373-380) reporting on superior capsular reconstruction in 41 patients, at a mean of 34 months, providing an arthroscopic dermal allograft for an irreparable posterior superior rotator cuff tear, noting 85% graft healing, two revisions and six failures to reach the minimally important improvement in the ASES Score, producing 19% unsatisfactory outcomes and 81% satisfactory outcomes. ASES Score improved from 52 to 90 at one-year and from 89-92 at final follow-up. All secondary clinical outcomes improved from preoperative to final evaluation.

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