Partial Rotator Cuff Tear Repair in Massive Rotator Cuff Tears Repair

Massive rotator cuff tears challenge the concept of complete repair because of tissue
retraction and inelasticity, bursal scarring, muscle atrophy, and fatty degeneration. These
patients have the worst prognosis of all of those presenting with rotator cuff tears in terms of
restoration of strength and function. Massive rotator cuff tears were defined by Cofield as having
a diameter greater than or equal to 5 cm and involving at least 2 of the 4 musculotendinous units.
The rotator cuff was involved in the dominant extremity in 76% of cases.1

Burkhart et al have described kinematic patterns in shoulders with massive rotator cuff
tears to explain how a patient with a large rotator cuff tear can still couple the forces of the
deltoid and remaining rotator cuff muscles to forward elevate the arm effectively. They describe
these tears as anatomically deficient but biomechanically intact. They challenged the concept
that a complete rotator cuff repair was required for restoration of adequate function and pain
relief after rotator cuff surgery and promoted this technique for massive irreparable rotator cuff
tears.1

Little is known about the progression of retear rate over time of surgically repaired
rotator cuffs. Retears after surgery are relatively common, reportedly occurring at a rate of 15%-
92%, and are clinically significant because they are associated with less satisfactory clinical
outcomes and may lead to additional operations. They are consequently an important topic of
consideration for orthopedic surgeons.3

Retears after arthroscopic rotator cuff repair have been shown to be associated with larger
preoperative tear size, increased age of the patient, and higher degree of fatty infiltration of the
rotator cuff muscles. The retear rate is also dependent on time, but the timing of retears remains
unclear. Understanding when retears occur will allow more informed postsurgical expectations
and guidelines for progression of physical activity. This is particularly applicable to medium,
large, and massive tears, as those that are classified as small tend to heal relatively frequently.
Knowledge of rotator cuff retear rates at given time points is also beneficial to those who
evaluate clinical trials, which often report a retear rate of a particular cohort at a single time after
surgery.3

Those who have researched this topic have generally reported a steady increase in rotator
cuff retears during the first few months after surgery, followed by a decline in the incidence of
additional retears. Iannotti et al serially imaged patients at 2, 6, 12, 16, 26, 39, and 52 weeks
after surgery and found that 18 of 19 (94.7%) retears in patients with rotator cuff tears measuring
1-4 cm occurred within 26 weeks of surgery. Miller et al reported similar findings after repair of
large rotator cuff tears and imaging at multiple time points up to 2 years postoperatively. Of note,
retear in the context of this study is defined by the presence of a full-thickness discontinuity on
postoperative 3-dimensional imaging. This term is used to refer to those tears that either failed to
heal after surgery or healed and retore after repair.3
 For massive tears, the retear set are clustered around the time between 10 and 15 months.
Based on the data available, it appears that the retear rate for cuff repairs involving massive tears
can vary substantially and may still be increasing at 10-15 months.3

Large rotator cuff tears may not be amenable to complete primary repair. The less
retracted edges of the tear near the anterior and posterior margins are usually reparable, but the
central portion of the tear with the greatest retraction may be irreparable.2

Burkhart has introduced the concept of the "functional rotator cuff tear". This is a tear
that is anatomically deficient yet biomechanically intact. Patients with functional rotator cuff
tears have normal function despite unrepaired holes in the rotator cuff. This concept has provided
a bio mechanical rationale for debriding rather than repairing selected rotator cuff tears. This
idea is further supported by recent investigations, that confirmed normal function and good
clinical results in patients who had residual rotator cuff defects after repair.2

The purpose of the Burkhart et al study is to introduce the concept and rationale of partial
rotator cuff repair as a reasonable treatment alternative in the irreparable tear, converting the tear
to a functional rotator cuff tear that is biomechanically intact. This is accomplished through
partial repair of the cuff by restoring the shoulder's force couples and its cable system of force
transmission.2

When the tears were found to be irreparable, the margins were repaired anatomically to
as great an extent as possible, and a defect in the cuff was left where the retracted margins could
not be anatomically repaired.2

A commonly used technique to cover a massive rotator cuff defect is tendon

transposition. In this procedure, all or a part of an intact subscapu laris or infraspinatus tendon is
transferred superiorly to cover the hole in the cuff. However, the mechanics of the shoulder are
unfavorably altered by this transfer. Ordinarily, the centroid (line of action) of the subscapularis
passes inferior to the center of rotation of the humeral head. In this position, the subscapularis
forms an important coronal plane force couple with the deltoid. By transferring this muscle
superiorly to cover the defect in the cuff, the centroid of the transferred portion of subscapularis
passes superior to the center of rotation. In this position, the moment produced by the
subscapularis is in the same direction as the moment created by the deltoid, and the force couple
is destroyed. This destruction of the coronal plane force couple, which is responsible for
maintaining a stable fulcrum of motion for the shoulder, can contribute to superior migration of
the humerus.2

Preoperative assessment done by clinical examination and magnetic resonance imaging.

Belly press test and Gerber’s liftoff sign were positive, diagnostic of subscapularis weakness.
Jobe’s test was positive for supraspinatus tear. General anesthesia with regional interscalene
block is preferred.4

The patient is placed in the beach chair position with an assistant to hold the arm in the
desired position. Glenohumeral diagnostic arthroscopy is performed using standard posterior
portal using 30_ scope, and the arthroscope is shifted to the subacromial region. Subacromial
decompression, acromioplasty, and bursectomy are performed to improve visualization. The
accessory anterior portal is established in the rotator interval region after localization with a
spinal needle by an inside-out technique. The needle is then replaced with a 7-mm threaded
arthroscopic shoulder cannula. A 70_ arthroscope is used for subscapularis repair. The
subscapularis tear is identified, and the edges of the tear are freshened. Biceps tenotomy is done
with radiofrequency. Reduction of the tear is checked with a grasper. The rotator interval is
cleared. Mobilization of the subscapularis is done by triple release. Clearing of rotator interval,
release of medial glenohumeral ligament and capsule, and subcoracoid release are performed.
Suture loops are passed through the subscapularis muscle using Truepass to give traction. The
footprint is identified and prepared by microfracture. One triple-loaded and one double-loaded
anchor suture are inserted to form the medial row. Suture loops are replaced one by one by the
anchor sutures, and the suture bridge technique is performed. Arm is rotated externally, and the
surface is prepared for lateral row. Knotless anchors are inserted on the lesser tuberosity to form
the lateral row after adequate tensioning. Supraspinatus tear is examined again. It appears to
reduce better after subscapularis repair. Supraspinatus tear is reduced with an apex knot and
repaired by a tensionless double-row suture bridge technique in a similar manner. After repair,
the arm is internally and externally rotated to confirm stability of the repair. The postoperative
protocol consists of abduction sling immobilization with slight internal rotation for 6 weeks.4

Patients are limited to early pendulum shoulder exercises. Passive range of motion is
performed only under the supervision of a physical therapist for the first 6 weeks, with no
external rotation past 45_. At 6 weeks postoperatively, active assisted range of motion is initiated
with a gradual progression to full range of motion. Strengthening exercises begin 12 weeks after
the surgery. Other activities and return to sports are permitted after 6 months.4

According to Xavier et al, the overall results were excellent in 11 patients (46%), good in
5 (21%), fair in 7 (29%), and poor in 1 (4%). Therefore, 67% of patients had either excellent or
good results after partial repair of massive rotator cuff tears. Subjectively, 92% (23/24) were
satisfied with the results of surgery. Overall function in activities of daily living improved
significantly after surgery. Improvement in 4 of the more strenuous activities of daily living is
depicted in. Remarkably, 14 patients (58%) regained the ability to lift a 10-lb weight overhead.1

Results were graded according to the various tear patterns. There were no statistical
differences between groups in terms of preoperative and postoperative changes with respect to
pain, shoulder index, or acromiohumeral distance. There was no correlation between outcome
and sex, age, or length of symptoms preoperatively.1

No arthrosis was noted on postoperative radiographs. There were no deep infections, no

nerve injuries, and no instances of deltoid detachment postoperatively. Two patients did require
revision surgery in this series. One patient had an excellent result until a second injury occurred
at a construction site 3 years after repair. He fell off of a ladder, sustaining a retear of the rotator
cuff. At revision surgery, no significant rerepair was possible, and this patient’s final outcome
after the second surgery is poor. A second patient had a large acromioclavicular joint cyst
develop that was excised 2 years after rotator cuff repair. His overall rating was fair.1
 Burkhart et al in their study using UCLA scores improved from a preoperative average of
9.8 to a postoperative average of 27.6. There were two excellent, six good, five fair, and one
poor results. It should be noted that even those with fair results were significantly improved in
terms of pain and function. Bear in mind that the preoperative UCLA scores were extremely
poor. All but one patient (the poor result) expressed satisfaction with the procedure.2

Their study shows that partial repair of massive irreparable rotator cuff tears can produce
significant functional gains. The 14 patients in this study who underwent partial repair of
massive cuff tears gained an average of 90.8 ° forward elevation and an average of 2.3 grades in
flexion strength (0-to-5- point scale). Flexion strength presumably improved because of the
improved function of the rotator cuff, with restoration of a stable glenohumeral fulcrum for the
deltoid to work against.2

Massive rotator cuff tears are rare in reported series, but even the majority of these tears
can be repaired primarily to bone. When complete repair is possible, the results of surgery are
good even with large and massive tears, with greater than 90% pain relief and greater than 85%
restoration of satisfactory function. When tendon tissue quality is so poor that direct bone-to-
tendon repair is not possible, a variety of techniques have been recommended. The relative
indications for debridement versus partial repair versus tendon transfers have not been well
delineated in the literature. Arthroscopic debridement and open debridement of irreparable
rotator cuff tears have been shown to provide good pain relief. Restoration of strength, however,
has been inferior to series in which complete or partial repair has been performed. Deterioration
of results has also been reported with this technique, which appears best suited for relatively
inactive and elderly patients. Warner states that it is appropriate to consider tendon transfer for
patients with a painful rotator cuff tear associated with poor function and in whom there is a low
probability that primary reconstruction will be successful. These tend to be younger patients with
higher demands on their shoulders.1

The goal was to convert them to functional cuff tears by restoring the force couples, even
if could not completely cover the hole. A functional rotator cuff tear must satisfy five
biomechanical criteria :
1. Force couples must be intact in the coronal and transverse planes.
2. A stable-fulcrum kinematic pattern must exist.
3. The shoulder's "suspension bridge" must be intact.
4. The tear must occur through a minimal surface area.
5. The tear must possess edge stability.

The goal of surgical repair was to satisfy these biomechanical criteria to the extent that
created a functional cuff tear. In high-demand patients with irreparable cuff tears, one should
consider partial repair of the posterior or anterior cuff to restore the force couples, even though
the superior cuff is generally too retracted to repair. This requires that the surgeon leave a hole in
the top of the cuff.2

The concept involves identification of those patients that have an imbalance between the
subscapularis anteriorly and the infraspinatus-teres minor complex posteriorly. Physical
examination will detect the muscle deficits. A patient with torn external rotators will have little if
any strength with resisted external rotation. A patient with a torn subscapularis will have a
positive lift-off test with inability to lift the maximally internally rotated forearm off the lower
lumbar area. With the aid of these two tests (resisted external rotation and the lift-off test),
surgeon can choose the ideal patients for repair and restoration of the transverse plane force
couple. Such patients would have an inability to function overhead. They would also exhibit one
of the following physical findings on examination: (a) positive lift off but strong external
rotators; or (b) negative (intact) lift-off but weak external rotators.2

Asymptomatic rotator cuff tears are a common finding in older patients. Burkhart et al
describe a functional rotator cuff tear as one typically involving the supraspinatus tendon and one
half of the infraspinatus tendon. As long as the rotator cuff tear does not extend inferior to the
equator of the humeral head, the cuff can often maintain the humeral head centrally located in
the glenoid and allow rotation by the deltoid. In the only comparable reported series to this one,
Burkhart et al demonstrated an improvement of 90.8° of active forward elevation, from 59.6° to
150.4°, after partial repair of massive rotator cuff tears.1

Multiple clinical studies in which both open and arthroscopic techniques of rotator cuff
repair were used have documented little effect on results from partial or complete cuff failure
postoperatively. These studies demonstrate a growing body of literature emphasizing the
importance of stable fulcrum kinematics and force coupling around the shoulder as the most
important factor predicting outcome in the rotator cuff. The concept of closing the hole is less
important in the treatment of rotator cuff tears than that of reestablishment of stable fulcrum
kinematics. The closure of nonfunctional tendon tissue around the humeral head may serve
temporarily as a watertight seal but in no way maintains the humeral head centered in the glenoid
or allows improvement in either strength or function after repair.1

The definition of a massive rotator cuff tear remains controversial, with some authors
stating that 3 tendons must be involved. Tear size and reparability, however, are not always
related because of variability in tissue retraction and muscle atrophy. All of the tears were
irreparable by use of standard techniques, regardless of whether 2 or 3 tendons were involved.1

In all of these cases an attempt to obtain a complete repair was made with a tedious and
careful mobilization of cuff tissue to a point as lateral as possible. A tension-free repair was
obtained with the arm at the side in all cases, and the residual defect was left based on the
anatomy of that particular tear.1

The results of Deepak et al study suggest a difference in retear rate over time between
tears of different sizes. This is consistent with the many studies that have found that retear rate of
rotator cuff repairs is dependent on the size of the original tear. Based on the results of this study,
it appears that retear rates for medium and large tears are generally increasing steadily until
about 10-15 months postoperatively, after which they may approach an upper limit at a slower
rate. However, more data on retear rates between 15 and 30 months would allow a better
assessment of this trend.3

It is difficult to draw conclusions about the progression of the retear rate for massive tears
because the majority of data points are clustered within a small time interval between 10 and 15
months. However, it does appear that the retear rate is still increasing at least up until this time
point. For large tears, there was a progressive increase in retear rate over time, and it appeared to
be increasing until at least about 12 months postoperatively. For medium tears, the retear rate
increased steadily up to about 12 months.3

One important conclusion to be drawn is that a residual defect in the rotator cuff is not
necessarily painful. Much of the previous literature regarding treatment of rotator cuff tears has
revolved around covering the hole, as if the hole in the cuff were the source of pain and
dysfunction. A recent comparison of arthroscopic debridement versus open rotator cuff repair
demonstrated equal relief of pain by either debridement or repair, although overall function was
somewhat better with repair.2

The results are clearly superior to those of simple debridement of the rotator cuff, with
excellent pain relief and significant improvement in strength and overhead function. These
patients had an inferior result to that in the series reported by Bigliani et al and Rokito et al, who
both reported on complete repairs of massive rotator cuff tears.1

Partial repair of massive rotator cuff tears represents a reasonable alternative in the
treatment of these challenging patients.1