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Evidence Based Medicine:
Massive Tears of the Rotator
Cuff
Presented by Dr. 邱致皓
Outline
• Definition
• Nonoperative Treatment
• Operative Treatment
Definition
• Diameter of >5 cm
- Cofield, J Bone Joint Surg Am. 2001
• Complete detachment of two or more tendons
-Zumstein, J Bone Joint Surg Am. 2008
• Anteroposterior x Mediolateral of the tear in scope
-Tauro, Arthroscopy. 2006
Massive rotator cuff tear
• Difficult repair
- Tendon
- Muscle
- Joint
• Higher recurrence rate smaller tears- J Shoulder Elbow Surg. 2007
- J Shoulder Elbow Surg. 2008
- Clin Orthop Relat Res
- JBJS Am. 2003
- JBJS Am. 1991
To do or not to do?
Nonoperative Treatment
• Stable GH abduction without excessive superior humeral
head translation
• Higher forces in the deltoid and the remaining rotator cuff
- Hansen, JBJS Am. 2008
- Levy, J Shoulder Elbow Surg. 2008
- Zingg, JBJS Am, 2007
Repairable?
• Signs of irreparability:
- Superior migration of the humeral head
- Narrow acromiohumeral interval: <7mm
- Fatty infiltration >50% -
Rokito JBJS Am. 1999
- OKU 8
Fatty Infiltration
Fatty Infiltration
• Fatty infiltration on MRI: correlated with
a. Shoulder biomechanics
b. Shoulder function
c. Poor tendon-tissue quality
Debridement and Subacromial
Decompression
• Arthroscopic debridement: for elderly, low-demand patients with pain but good ROM and intact GH joint force couple
- Burkhart, CORR 1991
• Open vs Arthroscopic subacromial decompression and debridement
a. Open decompression + resection of CA ligament: poor
- Augereau Rev Chir Orthop Reparatrice 1988
b. Open decompression and debridement: ↓pain, ↑ funciton, ↓strength
- Gartsman, JBJS Am, 1997
c. Arthroscopic debridement: modest improvement in the overall Constant score
- Kempf, Arthroscopy. 1999
Biceps Tenotomy ?
• Controversial
• Tenotomy: particularly effective for
massive tears
- OKU 8
Biceps Tenotomy ?
Partial Repair
• Restoration of stable
fulcrum of the GH joint
> complete closure
- Duralde, J Shoulder Elbow Surg.2005
Complete Repair
• Retear rate > small tear
• Tear configuration and tissue quality
• Single row vs. Double row
a. Double-row repair: increased tendon-
bone contact area than single row
b. Double-row configurations: overtension
Double row vs. Single row
• ASES and Constant scores following double-row repairs were significantly improved compared with those after single-row repairs of tears of >3 cm
- Park, Am J Sports Med. 2008;36:1310-6
• Single- and double-row techniques provide comparable clinical outcome at 2 years
• Double-row technique: mechanically superior but do not translate into superior clinical performance
- Franceschi, Am J Sports Med. 2007
• Dermis-Based Patches
a. Bond: 94% satisfactory
b. Burkhead: UCLA score 926
c. Badhe: Constant score 4162
• Small Intestinal Submucosa Patches:
poor
Repair with Scaffolds or Tissue
Augmentation
- Bond, Arthroscopy. 2008
- Burkhead, Arthroplasty. 2007
- Badhe, J Shoulder Elbow Surg. 2008
Tendon Transfers
• Ideal candidate:
a. No glenohumeral arthritis
b. Impaired function related to weakness
and loss of external rotation
• Latissimus Dorsi Transfer
• Pectoralis Major Transfer
Latissimus Dorsi Transfer
Warner, Complex and revision problems in shoulder
surgery. Philadelphia: Lippincott-Raven; 1997. p
195-6
Latissimus Dorsi Transfer
• Miniaci and MacLeod: 82% satisfaction
• Warner and Parsons:
- 73% satisfaction
- 27% rerupture and worse outcomes
• Iannotti:
- 64% satisfaction
- Poor prognostic factor: female, poor pre-OP
function, generalized muscular weakness-Warner, J Shoulder Elbow Surg. 2001
- Miniaci, JBJS Am. 1999
- Iannotti, JBJS Am. 2006
Pectoralis Major Transfer
• Wirth and Rockwood: 77% satisfaction
• Resch: 75% satisfaction
• Jost:
- 80% satisfaction
- Better in isolated subscapularis tendon tear
• Elhassan: poor in after failed shoulder replacement
Resch, JBJS Am, 2000
Hemiarthroplasty
• Contraindication: static anterosuperior
escape of humeral head
• Mixed outcome
Hemiarthroplasty• Zuckerman:
- UCLA score: 11 22 points
- 87%: satisfaction
- Forward flexion improved only 17 degree
- External rotation improved only 14 degree
• Sanchez-Sotelo:
- Pain score: 4.2 2.2
- 27%: moderate pain at rest
- 21%: anterosuperior instability
- Successful rate: 67%
• Field:
- 63%: satisfaction
- 38%: unsuccessful outcome
- 19%: anterosuperior instability
-Sanchez-Sotelo JBJS Am. 2001
- Zuckerman, J Shoulder Elbow Surg. 2000
- Field, J Shoulder Elbow Surg. 1997
Reverse Shoulder
Arthroplasty
• Described in 1993
• Rotation center: scapular
neck
• Increase lever arm of
Deltoid
• Medializtion of humerus
OKU 9
Reverse Shoulder Arthroplasty
• Guery:
- Constant score: 23 66 points
- Active elevation: 73 to 138 degree
- Survival rate: 91% 75% 30% (5, 7, 8 years)
- 3 years: Early loosening
- 6 years: Functional score ↓• Werner:
- Constant score: 29 64 points
- Complication rate: 50%
- Revision: 33%
• Frankle: Complication rate: 17%, revision rate: 13%
- Guery JBJS Am, 2006
- Werner JBJS Am. 2005
- Frankle JBJS Am. 2005
OKU on massive tear
• Latissimus dorsi transfer improves painful shoulder with loss of function in irreparable rotator cuff tear
• Poor result:
a. Female patient with generalized muscle weakness
b. Pre-OP shoulder function poor
- OKU 9
Conclusion
• Nonoperative treatment: asymptomatic patients
with satisfactory function
• Arthroscopic debridement and partial repair:
older, low-demand patients
• Repair: younger, symptomatic patients
• Double row of sutures: biomechanically better
Conclusion
• Tendon transfers: High-demand patients
• Hemiarthroplasty: preserved active elevation
• Reverse shoulder prothesis: advanced cuff tear
arthropathy , painful pseudoparalysis