Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

Abstract

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.

Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer

“…11,21,37 The development of cuff tear arthropathy is characterized by upward migration of the humeral head and progressive joint degeneration. 1,12,28,32,38 The radiographic examinations of our ILER patients revealed some progression of the cuff arthropathy after tendon transfer over time. Two patients with preoperative advanced cuff tear arthropathy (Hamada grade 3) required reoperation to perform an RSA (7 and 9 years after the tendon transfer, respectively) because of progressive glenohumeral joint degradation ( Fig.…”

“…The treatment of MIRCTs is still controversial and depends on the symptoms presented by the patient; conservative therapy, arthroscopic débridement with or without partial cuff repair, tendon transfers, and reverse shoulder arthroplasty (RSA) have all been proposed. 1,4,12,14,21,32,37 An RSA was not indicated in our patient because AFE was conserved (ie, the vertical muscle balance of the shoulder was maintained). 2,5 We hypothesized that a tendon transfer, which could re-establish the lost horizontal muscle balance of the shoulder, would result in improved AER and restore shoulder function.…”

Rotary Hood Massive Break Solutions? Massive Rotator Cuff Tear Solutions?

“…Goutallier's Staging is based on the results evidenced by CT and divides fat infiltration into 5 stages (Table 2) [5]. Fat infiltration gains importance when clinical studies find that it is associated with a worse prognosis and higher postoperative failure rates [5,15]. The degree of fatty infiltration of the supraspinatus and infraspinatus seems to be related to a worse prognosis [4,16,17].…”

“…When complete repair is not possible because of the extent of the rupture, the retraction or poor quality of the tissue, partial repair can also lead to improved pain and functional capabilities, achieving high satisfaction rates [9,15,42]. Duralde & Bair [2] studied 24 patients who underwent open partial repair, since complete repair was not possible.…”

Isolated Subscapularis Repair for Massive Rotator Cuff Tear

“…In these situations, other approaches have been advocated, with varying degrees of success. 1 These include physical therapy, 2 tuberoplasty, 3 partial rotator cuff repair, 4,5 palliative biceps tenotomy, 6 cuff debridement and subacromial smoothing, 7,8 muscle transfer, 9,10 cuff prosthesis, 11 and reverse shoulder arthroplasty. 12 Few studies have described this difficult problem.…”