Non-arthroplasty Management of Irreparable Rotator Cuff Tears
By: Shariff K. Bishai, D.O., M.S., FAANA; Joseph A. Abboud, M.D. and Guy R.S. Ball, D.O.
Rotator cuff tears are the most common form of shoulder disability in the United States.1 Current iData research places the number of rotator cuff related surgeries at well over 400,000 each year. However, there are a wide variety of rotator cuff tears. A rotator cuff tear can range from partial thickness, including partial articular-sided supraspinatus tendon avulsion (PASTA) and partial-thickness articular surface intratendinous tear (PAINT), to full-thickness (small, greater than 1 cm, medium 1-3 cm, large 3-5 cm, massive, less than 5 cm) and even irreparable. Within the spectrum of disease also exists a spectrum of treatment. Most people are familiar with initial conservative management consisting of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy plus or minus injections.
If conservative options fail to provide relief, there are also many surgical options available. For most people with rotator cuff disease, a traditional single or double-row repair with scheduled formal physical therapy works well with a success rate exceeding 90% for many small tears. However, as tears grow larger the success rate falls to below 10% in large and massive tears.2 As we move to the far end of the spectrum, we begin to see higher failure rates when the traditional surgical approaches are employed. If we look at the work of Gerber et al., we see that fatty infiltration and tendon retraction are significant predictors of outcome. Less than 15 mm of tendon length was correlated with a 92% failure rate, whereas greater than 15 mm tendon length reduced overall failure rate to below 25%.3 Thanks to the work of Chalmers et al., we even have an algorithm-based application that can predict success and possibility of recurrent tear. Several studies have evaluated age as a risk factor and have been able to show that younger people are significantly more likely to heal.4,5 We also now know that smoking, hyperlipidemia, vitamin D deficiency and osteoporosis all negatively impact rotator cuff healing.6 We now have the information to know who is more likely to do well and who is likely to do poorly with traditional rotator cuff repair surgery. The only question left to answer is: What do we do for the patients we know are going to fail traditional repair?
One of the emerging areas of interest in rotator cuff repair is augmenting the repair with biologics. Over the last several years, platelet-rich plasma (PRP) and stem cell augmentation have become increasingly popular. A rotator cuff tear Level 1 2021 randomized clinical trial published in Arthroscopy: The Journal of Arthroscopic and Related Surgery outlines the potential benefits, and superiority to corticosteroids, of PRP for partial-thickness rotator cuff tears.7 The enthusiasm that exists around biologic technologies is largely due to their success in vitro. However, when some of the biologics are brought into the operating room, the results remain less than significant. A 2018 Journal of Bone and Joint Surgery analysis neatly lays out the current guidelines in respect to PRP and stem cells.8 At this time, there is little evidence to support widespread use of PRP or stem cell therapy; however, the recommendations may change as more studies emerge.
Large, massive and irreparable rotator cuff tears provide a special challenge to Orthopaedic Surgeons. Part of the challenge is providing optimal surgery to your patient, considering the patient’s short- and long-term functional requirements. In select populations, massive rotator cuff tears can be treated with debridement of the cuff tear, tenotomy of the torn tendon and physical therapy. This method has been shown to be a good pain improver but does little to improve overall strength or motion.9 Another option is to perform a partial repair with margin convergence. This option can balance forces across the shoulder and attempt to maintain humeral head depression. This method has not been shown to improve function; even worse, this method can have retear rates as high as 52%.10
One technique that is gaining popularity when repairing large and massive cuff tears is the use of bioinductive and bioabsorbable-wicking implants. Bioinductive implants are reconstituted bovine collagen and function to create a scaffold for new rotator cuff tendon to grow to. The graft itself is not mechanical but has shown promise in overall healing rates and short- to long-term follow-up. In 2019, Savoie and O’Brien examined large and massive tears augmented with bioinductive collagen patch and found a 96% healing rate, with new tendon formation visible on ultrasound or MRI.11 This study also found bioinductive patches to be safe with no adverse events attributed to the patch. On the other hand, bioabsorbable patches work by holding growth factors between the tendon’s undersurface and the greater tuberosity. This method is almost always combined with a marrow vent technique. A previous issue with the bioabsorbable and bioinductive products was their lack of mechanical or structural support. The BioBraceTM implant (BIOREZ, New Haven, Connecticut) has worked to solve this problem. It is a novel collagen-PLLA biocomposite soft tissue scaffold composed of a Type 1 bovine collagen sponge and PLLA microfilaments. This design allows for a highly porous implant with added strength of repair. The implant can hold 300% of its own weight in fluid. This promotes rapid influx of marrow cells, leading to an overall stronger repair. Preliminary work by Walsh et al. has shown that there is infiltration of the graft by host fibroblast at six weeks and there is dense regularly oriented connective tissue that contributes to the overall thickness of healing tendon. There is maturation and remodeling of the fibrovascular connective tissue at 12 weeks.
One of the hottest topics in shoulder surgery over the last decade has been superior capsular reconstruction (SCR) and the role it plays in irreparable rotator cuff repair. It was initially difficult to recreate the success Mihata and his colleagues had with their original SCR data. One of the speculative reasons for the early discrepancy between outcomes in the United States and Japan is the difference between graft type and thickness. Mihata originally used tensor fascia lata autografts roughly 8 mm thick while proprietary SCR kits in the United States use dermal allografts of only 3 mm thick.12, 13 Despite using a graft of nearly half the initial thickness, SCR has shown improvement in the visual analogue scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score and active forward flexion at two-year follow-up.13 However, graft thickness has been shown to be important. Mihata demonstrated that a graft thickness of greater than 4 mm was able to reduce subacromial contact pressure but did not improve superior humeral head migration. Further, a graft thickness of less than 8 mm attached at 15-45 degrees of abduction not only reduced subacromial contact pressure but also reversed superior humeral head migration.14 Over the same time period that SCR has become so popular, we have built a better understanding of the shoulder mechanics that lead to pain and disability when the humeral head is no longer centered in the glenoid. As rotator cuff tears grow, the humeral head migrates superiorly. Higher levels of superior humeral head migration have been linked to a decrease in forward flexion as well as external rotation leading to pseudoparesis that is often seen with massive and irreparable rotator cuff tears.15 The goal of procedures such as SCR is to allow the humeral head to be recentered in the glenohumeral joint, therefore creating favorable kinematics for shoulder motion. With that said, SCR does have its limitations. As glenohumeral arthritis worsens, SCR does not predictably alleviate pain. SCR is indicated in patients with massive and/or irreparable rotator cuff tears, Hamada Grade 1 or 2 changes and an intact or repairable subscapularis tendon. SCR is contraindicated in patients with massive and/or irreparable rotator cuff tear with associated moderate to severe rotator cuff arthropathy, Hamada Grade 3 or higher and an irreparable subscapularis tear.12
Another emerging technique when treating irreparable rotator cuff tears is the biodegradable subacromial balloon spacer. It is a technique that was first described in Europe in 2012, but only recently has been approved by the Food and Drug Administration (FDA) for use in the United States. InSpace (Stryker, Caesarea, Israel) is a subacromial spacer made of copolymer poly-L-lactide-co-ɛ-caprolactone. It is placed between the humeral head and acromion and aids in humeral head depression. The product dissolves over 12 months. The subacromial spacer can be combined with a rotator cuff repair or performed as a stand-alone procedure for massive and irreparable tears. The only true contraindication to the procedure is allergy to the components of the balloon spacer, or active infection.23 Chevalier et al. demonstrated through biomechanical work that the balloon spacer reduces peak pressures across the glenohumeral joint as well as increases distribution of load within the subacromial space.24 There is some concern about placing a subacromial balloon in patients with deficient subscapularis musculature as it may result in significant anterior translation of the humeral head.23 This may also mean that caution should be used if a concomitant subscapularis repair is going to be performed alongside a balloon spacer. Early clinical data on the subacromial balloon spacer out of Europe showed improvement in pain as early as one week postoperatively and improvement in strength at 18 months follow-up.23 Although it is described that the spacer dissolves over 12 months, there are reports of spacers dissolving as early as three-six months. This does not appear to have an impact on clinical improvement.23 With the recent FDA approval, indications may become clearer; however, at this point in time, best outcomes are likely to appear in patients with forward flexion to at least 90 degrees, an intact or repairable subscapularis and at least partial infraspinatus.23
Tendon transfers have been around for decades to circumvent deficient muscle groups. Although tendon transfers can be combined with arthroplasty to improve range of motion in rotator cuff arthropathy, that is not the focus of this discussion. In the shoulder, posterior cuff tears result in losing external rotation strength. A technique that was initially used to overcome this was the L’Episcopo, or modified L'Episcopo. The original L’Episcopo technique was described for use in obstetric palsies. The teres major and latissimus dorsi are transferred to the footprint of the posterior rotator cuff and thereby restore external rotation.16 In recent years, Orthopaedic Surgeons have moved away from combined transfers of the latissimus and teres major and moved toward the isolated latissimus dorsi transfer. Isolated latissimus transfers produce better active abduction and flexion as well as protect against progression of cuff tear arthropathy versus combined transfers.17 In the absence of glenohumeral arthritis, patients with massive and irreparable rotator cuff tears who also have an intact subscapularis, latissimus dorsi transfers can be a very effective surgery.
When we step back and take a deeper look at optimizing tendon transfers, we realize that transferring the latissimus dorsi from the front to the back of the shoulder creates an out-of-phase transfer. Simply stated, it asks an internal rotator to become an external rotator, simply by changing its insertion site. This obviously can, and has, been done successfully for many years. It nevertheless begs the question: Can we perform a transfer in the shoulder that follows more of the principles of tendon transfer? Ideally, we need a muscle that is expendable, has similar tension and excursion, uses a similar line of pull and attempts to replace only one function of the recipient muscle.18,19 We can come close to accomplishing all these principles with a lower trapezius transfer (LTT). The lower trapezius muscle closely resembles the infraspinatus’ normal line of pull and is naturally active during the shoulder’s external rotation; when transferred, only the external rotation is affected. One significant advantage is the ability to perform the procedure using arthroscopic assistance. This allows for the ability to partially repair the rotator cuff that can then be augmented with lower trapezius transfer.
The technique of arthroscopic-assisted lower trapezius transfer has been described by Elhassan.19,20 The procedure is indicated for patients that have an intact or reparable subscapularis and a well-functioning deltoid; however, the patient should not have a rotator cuff arthropathy. Lower trapezius transfer can restore force couples across the shoulder and centralize the humeral head within the glenoid, with force production then falling to the deltoid muscle.19 When we look at the results of the LTT we see improvement in pain, subjective shoulder value (SSV) and Disabilities of the Arm, Shoulder and Hand (DASH) scores as well as range of motion (ROM).21 In 2016, Elhassan demonstrated preoperative forward flexion of the shoulder greater than 60 degrees was a positive indicator for improved ROM. However, shoulder external rotation improved regardless of preoperative ROM.21 If we compare LTT to latissimus dorsi tendon transfer, we see that LTT is superior at restoring native glenohumeral kinematics as well as joint reaction forces.22
The term “irreparable rotator cuff” was originally named for its representation of a tear that could not be fixed reliably with current surgical strategies. The topics discussed in this review shed light on how we are redefining the term “irreparable.” This review is not all inclusive of the options that exist to tackle complex rotator cuff pathology, but it hopes to highlight some of the current literature and techniques that can be used.
- Wani, Z., Abdulla, M., Habeebullah, A., Kalogriantis, S. “Rotator Cuff Tears: Review of Epidemiology, Clinical Assessment and Operative Treatment.” Journal of Trauma and Acute Care Surgery. 2016;18(3):190-204.
- Abtahi, A.M., Granger, E.K., Tashjian, R.Z. “Factors Affecting Healing After Arthroscopic Rotator Cuff Repair.” World Journal of Orthopedics. 2015;6(2):211-220.
- Meyer, D.C., Wieser, K., Farshad, M., Gerber, C. “Retraction of Supraspinatus Muscle and Tendon as Predictors of Success of Rotator Cuff Repair.” The American Journal of Sports Medicine.
- Tashjian, R.Z., Hollins, A.M., Kim, H.M., et al. “Factors Affecting Healing Rates After Arthroscopic Double-Row Rotator Cuff Repair.” American Journal of Sports Medicine. 2010;38(12):2435-2442.
- Cho, N.S., Lee, B.G., Rhee, Y.G. “Arthroscopic Rotator Cuff Repair Using a Suture Bridge Technique: Is the Repair Integrity Actually Maintained?” American Journal of Sports Medicine. 2011;39(10):2108-2116.
- O'Donnell, E.A., Fu, M.C., White, A.E., et al. “The Effect of Patient Characteristics and Comorbidities on the Rate of Revision Rotator Cuff Repair.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2020;36(9):2380-2388.
- Kwong, C.A., Woodmass, J.M., Gusnowski, E.M., et al. “Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2021;37(2):510-517.
- Smith, K.M., Le, A.D.K., Costouros, J.G., Dragoo, J.L. “Biologics for Rotator Cuff Repair: A Critical Analysis Review.” JBJS Reviews. 2018;6(10):e8.
- Kim, J.R., Cho, Y.S., Ryu, K.J., Kim, J.H. “Clinical and Radiographic Outcomes After Arthroscopic Repair of Massive Rotator Cuff Tears Using a Suture Bridge Technique: Assessment of Repair Integrity on Magnetic Resonance Imaging.” American Journal of Sports Medicine. 2012;40(4):786-793.
- Berth, A., Neumann, W., Awiszus, F., Pap, G. “Massive Rotator Cuff Tears: Functional Outcome After Debridement or Arthroscopic Partial Repair.” Journal of Orthopaedics and Traumatology. 2010;11(1):13-20.
- Thon, S.G., O'Malley II, L., O'Brien, M.J., Savoie III, F.H. “Evaluation of Healing Rates and Safety With a Bioinductive Collagen Patch for Large and Massive Rotator Cuff Tears: Two-Year Safety and Clinical Outcomes.” American Journal of Sports Medicine. 2019;47(8):1901-1908.
- Ishihara, Y., Mihata, T., Tamboli, M., et al. “Role of the Superior Shoulder Capsule in Passive Stability of the Glenohumeral Joint.” Journal of Shoulder and Elbow Surgery. 2014;23(5):642-648.
- Pashuck, T.D., Hirahara, A.M., Cook, J.L., Cook, C.R., Andersen, W.J., Smith, M.J. “Superior Capsular Reconstruction Using Dermal Allograft Is a Safe and Effective Treatment for Massive Irreparable Rotator Cuff Tears: Two-Year Clinical Outcomes.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2021;37(2):489-496.e1.
- Mihata, T., McGarry, M.H., Kahn, T., Goldberg, I., Neo, M., Lee, T.Q. “Biomechanical Effect of Thickness and Tension of Fascia Lata Graft on Glenohumeral Stability for Superior Capsule Reconstruction in Irreparable Supraspinatus Tears.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2016;32(3):418-426.
- Sahara, W., Yamazaki, T., Inui, T., Konda, S. “Three-Dimensional Kinematic Features in Large and Massive Rotator Cuff Tears With Pseudoparesis.” Journal of Shoulder and Elbow Surgery. 2021;30(4):720-728.
- Gerhardt, C., Lehmann, L., Lichtenberg, S., Magosch, P., Habermeyer, P. “Modified L'Episcopo Tendon Transfers for Irreparable Rotator Cuff Tears: Five-Year Follow-Up.” Clinical Orthopaedics and Related Research. 2010;468(6):1572-1577.
- Lichtenberg, S., Magosch, P., Habermeyer, P. “Are There Advantages of the Combined Latissimus Dorsi Transfer According to L'Episcopo Compared to the Isolated Latissimus Dorsi Transfer According to Herzberg After a Mean Follow-Up of Six Years? A Matched-Pair Analysis.” Journal of Shoulder and Elbow Surgery. 2012;21(11):1499-1507.
- Brand, P.W., Beach, R.B., Thompson, D.E. “Relative Tension and Potential Excursion of Muscles in the Forearm and Hand.” Journal of Hand Surgery – American Volume. 1981;6(3):209-219.
- Wagner, E.R., Elhassan, B.T. “Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer.” Current Reviews in Musculoskeletal Medicine. 2020;13(5):592-604.
- Ghoraishian, M., Stone, M.A., Elhassan, B., Abboud, J.A., Namdari, S. “Techniques for Lower Trapezius Tendon Transfer for the Management of Irreparable Posterosuperior Rotator Cuff Tears.” Journal of Orthopaedics. 2020;22:331-335.
- Elhassan, B.T., Wagner, E.R., Werthel, J.D. “Outcome of Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tear.” Journal of Shoulder and Elbow Surgery. 2016;25(8):1346-1353.
- Omid, R., Heckmann, N., Wang, L., McGarry, M.H., Vangsness Jr., C.T., Lee, T.Q. Biomechanical Comparison Between the Trapezius Transfer and Latissimus Transfer for Irreparable Posterosuperior Rotator Cuff Tears.” Journal of Shoulder and Elbow Surgery. 2015;24(10):1635-1643.
- Wright, M.A., Abboud, J.A., Murthi, A.M. “Subacromial Balloon Spacer Implantation. Current Reviews in Musculoskeletal Medicine. 2020;13(5):584-591.
- Chevalier, Y., Pietschmann, M.F., Thorwächter, C., et al. “Biodegradable Spacer Reduces the Subacromial Pressure: A Biomechanical Cadaver Study.” Clinical Biomechanics (Bristol, Avon). 2018;52:41-48.