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    Don’t Overlook Partial Repair and Tuberoplasty for Massive Rotator Cuff Tears

    As this case of a 59-year-old patient with right shoulder weakness and pain illustrates, partial repair with tuberoplasty can restore function while relieving pain in patients younger than age 60, buying time until they are at a better age for reverse shoulder arthroplasty to manage a massive rotator cuff tear.

    Author

    Daniel E. Davis, MD, MS

    Background

    Rotator cuff pathology is one of the most common complaints seen by shoulder surgeons. Degenerative rotator cuff tears becoming more prevalent with increasing age: Nearly 50% for patients in their 50s and 60s, increasing by almost 10% with every decade of life. [1,2] Many patients with mild or low-grade tears are asymptomatic, complicating the diagnosis. In a large multicenter study, the MOON Group determined that approximately 75% of patients with a symptomatic tear become asymptomatic with a 6-week course of physical therapy. [3] Avoiding an operation is generally considered a success for many patients; however, there are times when early surgical management can prevent more advanced rotator cuff tears.

    A frequently discussed dilemma for shoulder surgeons is the patient who had developed a large, chronic, symptomatic rotator cuff tear in their 40s or 50s. Reverse total shoulder arthroplasty has become a reliable mainstay of treatment for patients in their 60s or older who have this diagnosis. [4] There is still hesitancy about performing reverse shoulder arthroplasty in younger patients, however, due to the concerns of longevity of the implant, as well as limited potential revision options. A number of alternatives to reverse shoulder arthroplasty have been developed for younger patients with chronic rotator cuff tears, including tendon transfers, graft augmentation, and superior capsular reconstruction.

    Partial rotator cuff repair with tuberoplasty has been reported as a successful alternative for treating these patients, as it can restore the function they desire. [5] This case report describes the presentation, examination, diagnosis, and surgical management of a 59-year-old male patient with a massive rotator cuff tear who was treated with partial repair and tuberoplasty.

    Case Presentation

    A 59-year-old, right hand-dominant male patient who works as an editor presented with a complaint of left shoulder weakness and pain. He had injured the shoulder in a fall while shoveling snow in January and was treated with a home exercise program for 6 weeks.

    He continued to have pain and weakness in the arm, but due to extenuating circumstances, he did not follow up for surgical consultation until 9 months after his fall. At presentation in the shoulder clinic, he reported significant weakness and mild pain. He had not had any cortisone injections.

    Physical Examination

    • Height: 6 feet, 0 inches; weight: 225 pounds; BMI: 30.5
    • Inspection: Normal contour and appearance of right shoulder; no ecchymosis or prior incisions
    • Palpation: No tenderness about the shoulder or the acromioclavicular joint
    • Range of motion: Passive forward elevation of 160°; active forward elevation of 30°; passive external rotation of 45° with no lag; internal rotation to mid-lumbar spine
    • Strength testing: Positive drop arm sign, cannot hold arm at the horizontal; 3/5 strength with resisted external rotation; positive abdominal compression test

    Imaging

    Plain Radiographs

    • Anteroposterior (AP) right shoulder: Superior migration of the humeral head with significantly decreased acromiohumeral interval; small inferior humeral head osteophyte (Figure 1a)
    • Axillary lateral right shoulder: Mild joint space narrowing; no subluxation of the joint (Figure 1b)

    Figures 1a-b. AP radiograph of the left shoulder (left) shows a superiorly migrated humeral head with mild osteoarthritic changes. Axillary lateral radiograph of the left shoulder (right) shows mild glenohumeral osteoarthritic changes.

    MRI

    • Massive rotator cuff tear involving the supraspinatus, infraspinatus, and possible upper border of subscapularis
    • Retraction of the supraspinatus and infraspinatus to the glenoid margin
    • Grade 3 fatty atrophy of the supraspinatus (Figure 2)

    Figure 2. T2 STIR imaging MRI of the left shoulder: Coronal view (top left) demonstrating a chronic supraspinatus tear with retraction to the glenoid margin. Axial view (top right) demonstrating possible partial upper border subscapularis tear. Sagittal view (bottom) demonstrating Grade III fatty atrophy of the supraspinatus and Grade II changes in the infraspinatus.

    Diagnosis

    • Massive, chronic rotator cuff tear with fatty atrophy of the supraspinatus

    Treatment

    The patient had progressed to the point where he had significant functional deficits with the left upper extremity. Although his pain was not severe, his weakness greatly affected his ability to perform normal activities of daily living. Surgical management options were discussed with him, including:

    • Partial repair with debridement and tuberoplasty
    • Superior capsular reconstruction
    • Tendon transfer
    • Reverse shoulder arthroplasty

    The option of a reverse shoulder arthroplasty was excluded due to the patient’s age and concern of longevity of the implant. The patient’s functional status – inability to raise his arm to horizontal and weakness with external rotation – caused us to also exclude superior capsular reconstruction. A trapezius tendon transfer was discussed; however, the patient was hesitant to undergo such a large operation.

    Therefore, we made the decision to move forward with an arthroscopic partial rotator cuff repair with debridement and tuberoplasty as needed.

    Procedure

    • The patient was positioned in a beach chair positioner sitting upright. The extremity was prepped and draped.
    • A standard posterior starting portal was created, and a diagnostic arthroscopy was performed. This showed a chronic, complete tear of the long head of the biceps tendon, degenerative changes in the joint with Grade III and Grade IV articular changes on the humeral head, a partial tear of the subscapularis with no full-thickness tear, and a full-thickness retracted tear of the supraspinatus extending into the infraspinatus (Figure 3).

     

    Figure 3. Diagnostic arthroscopic findings: Chronic tear of the long head of the biceps tendon (top left). Full-thickness tear of the supraspinatus visualized from the articular side (top right). Degenerative changes of the inferior portion of the humeral head (bottom left). Retracted tear of the supraspinatus visualized from the bursal side (bottom right).

    • An anterior portal was created, and a shaver was used to debride the retained stump of the biceps to the superior labrum.
    • The arthroscope was placed into the subacromial space and a lateral portal was created.
    • Releases were performed on the superior and inferior portions of the supraspinatus and the infraspinatus with an electrocautery wand.
    • Attempted mobilization of the tendons revealed that the supraspinatus was fibrotic and retracted to the glenoid margin as expected. Using a split between the supraspinatus and infraspinatus, the infraspinatus was mobilized back to the humeral head.
    • A triple-loaded corkscrew anchor was placed in the posterior medial aspect of the humeral head. One suture was passed in a horizontal mattress fashion through the infraspinatus and the other 2 sutures were passed in a simple fashion in between the horizontal mattress suture. The horizontal suture was tied first, followed by the simple sutures, which reduced the infraspinatus back to the posterior superior humeral head (Figure 4).

    Figure 4. Post-repair images show the repair of the supraspinatus back to the articular margin of the humerus. A horizontal mattress ripstop suture was placed, with 2 simple sutures between the mattress suture.

    • A burr was used to shave down the greater tuberosity to minimize impingement between the humerus and the acromion (Figure 5).
    • The patient was placed in an abduction sling with instructions to remain in the sling at all times except for showering and changing his clothes.

    Figure 5. View of the greater tuberosity after the tuberoplasty was performed to limit impingement of the greater tuberosity with the undersurface of the acromion.

    Postoperative Followup

    The patient was seen in the office 2 weeks after the procedure for suture removal and incision checks. He was instructed to remain in the sling at all times, except for showering and changing clothes, for an additional 4 weeks. He was instructed to remove the abduction pillow at 4 weeks postoperatively.

    At the 6-week office visit, the patient’s passive range of motion was noted to be 30° of external rotation and 120° of forward elevation. His pain was well controlled. He was given a prescription to begin 6 weeks of physical therapy, with instructions to advance with passive range of motion in all planes. The patient was allowed to discontinue the use of the sling but was instructed to avoid actively moving his elbow away from his side.

    The patient reported good progress with physical therapy when he returned for the 3-month postoperative visit. He denied having any pain. Passive range of motion was forward elevation to 160° and external rotation to 40°. Active range of motion revealed forward elevation to 100° and external rotation to 30°. The patient was prescribed an additional 6 weeks of physical therapy to continue with passive range of motion exercises and to begin active strengthening in all planes.

    At final follow-up 4½ months postoperatively, the patient had no pain and reported that he was able to do all activities he enjoyed doing. Active and passive range of motion with forward elevation was to 160° and external rotation was to 45°. The patient had some mild weakness, with Jobe’s testing at 4/5, but no pain and 4+/5 strength with resisted external rotation. He was transitioned to a home physical therapy program, with instructions on progressing back to normal activities.

    Discussion

    This case reviews a common, yet challenging, dilemma faced by many shoulder surgeons: How to manage a patient in their 50s or younger who has a large to massive rotator cuff tear with retraction and fatty atrophy. In this particular case, the patient was able to regain overhead motion with no pain, albeit in the short term. Although the chance of maintaining this outcome for a very long period of time is not high, the expectation was to achieve the reported outcome without adding a graft, changing the anatomy, or replacing the joint.

    The concept of recontouring the greater tuberosity was coined and described as a “tuberoplasty” in 2002 by Fenlin et al, [6] who discussed shaving and recontouring the greater tuberosity as the primary treatment for patients with massive, irreparable rotator cuff tears. It is important to note that the procedure was done without an acromioplasty and maintenance of the coracoacromial ligament and arch. Fenlin et al [6] reported 95% satisfactory outcome in 20 patients at follow-up of 27 months, with 68% of patients being completely pain free and 9 of 11 working patients returning to work.

    Partial repairs of massive rotator cuff tears have been widely described and reported. In a 2019 systematic review, Malahias et al [5] evaluated 11 studies with a total of 643 patients. Functional scores and strength testing were significantly improved when compared with preoperative values. Although the re-tear rate on postoperative imaging was found to be 48.9%, the reoperation rate was only 2.9%. [5]

    These outcomes demonstrate that a combination of treatment options can be expected to relieve pain and restore function at least for the short term. The re-tear rate of partial repairs is important to note and counsel patients on, as this treatment may provide only short-term benefit with strength and function, but perhaps longer relief of pain.

    Alternative treatment options, as mentioned above, include superior capsular reconstruction, tendon transfer, and reverse shoulder arthroplasty. Another option that has been used in Europe and is currently going through the Food and Drug Administration (FDA) approval process in the US is the balloon subacromial spacer.

    Superior capsular reconstruction was originally described by Mihata, who used a 7-mm-thick fascia lata autograft. [7] Use of a thinner dermal allograft has been described extensively as well, with mixed results. In a 2018 study, Denard et al [8] reported a graft healing rate of 45% and a success rate of 74.6% at 1 year. In a 2020 study, Burkhart et al [9] reported an 85% graft healing rate and an 81% success rate at 2 years. Although the 2-year follow-up results are promising, they are not much different than the results of a partial repair with a tuberoplasty. Plus, superior capsular reconstruction requires a graft; partial repair does not.

    Tendon transfers have also been reported for this population, with lower trapezius transfers gaining in popularity. [10] Although early results have been promising, the indications for this anatomy-altering procedure remain narrow, with patient selection being key to success. [11]

    Originally released in Europe, the subacromial balloon spacer is a bioabsorbable balloon that is inserted into the subacromial space to increase the acromiohumeral interval. The goal is to retrain the remaining or partially repaired rotator cuff tendons to keep the humeral head centered and regain overhead function. Again, results are preliminary, but with FDA approval on the horizon, use of a subacromial balloon spacer is sure to be an option in the armamentarium of shoulder surgeons. [12]

    Although concern has been expressed regarding its use in patients under age 60, reverse shoulder arthroplasty is starting to become a more common treatment for younger patients, with Ernstbrunner et al [13] reporting significant improvement at 10-year follow-up in patients with an average age of 57. Reverse shoulder arthroplasty should still be used with caution, and adequate patient counseling is necessary as revision rates in patients under age 60 have been reported to been nearly 5 times greater than those in patients over age 60. [14]

    Treatment for massive, irreparable rotator cuff tears in patients under age 60 is a constant topic of debate for shoulder surgeons. Although more options are being explored, including advanced techniques, implants, and replacements, the surgeon should not forget the sometimes simpler option of a partial repair with a tuberoplasty. Short-term functional improvements and pain control are achievable.

    Many times, the goal of patients with large to massive rotator cuff tears is to regain function until they are of more reasonable age for a reverse shoulder arthroplasty. Partial repair with a tuberoplasty can accomplish this goal without the use of grafts or a large number of anchors and without significantly altering the shoulder anatomy.

    Author Information

    Daniel E. Davis, MD, MS, is an orthopaedic surgeon with The Rothman Institute, Philadelphia, Pennsylvania, specializing in the treatment of shoulder and elbow conditions. He is also the Shoulder Section Editor for Rothman Institute Grand Rounds on ICJR.net.

    Disclosures: Dr. Davis has no disclosures relevant to this article.

    References

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