Strategic Approach for Massive Rotator Cuff Tear: Arthroscopy vs. Arthroplasty
At ICJR’s Pan Pacific Orthopaedic Congress, Dr. Joo Han Oh reviewed the evidence for surgical techniques to manage massive rotator cuff tears. Below is the abstract of his presentation.
Joo Han Oh, MD, PhD
The author has no disclosures relevant to this article.
Massive rotator cuff tears, defined as a tear involving more than 2 cuff tendons or a tear of more than 5 cm, [1,2] are usually associated with functional loss and morbidity.
These tears were once considered irreparable via arthroscopic techniques. Recent advances in techniques and technology, however, now allow surgeons to attempt arthroscopic repair of massive rotator cuff tears.
Many publications have reported outcomes of arthroscopic surgical procedures for massive rotator cuff tears, including debridement,  partial repair, [4,5] interval slide, [6) margin convergence, [5,7) biceps augmentation,  patch graft using biologic material,  and tendon transfer.
However, even with better techniques and technology, outcomes of arthroscopic repair for massive tears remain less predictable due to high failure rates.  As a result, some authors believe arthroplasty should still be the primary option for managing a massive tear. Arthroplasty, they say, has satisfactory and predictable outcomes, despite few reports of long-term results. 
Selecting the appropriate treatment for massive rotator cuff tears is critical, and the surgeon needs to set strategies for dealing with these tears in many different situations. The following discussion provides insights into management strategies for arthroscopic and arthroplasty repair.
In many cases, complete primary repair of massive cuff tear may not be possible due to poor tissue quality and tendon retraction. Partial repair can be considered amenable treatment, which has yielded satisfactory outcomes comparable with complete repair of massive tears. 
A combination method can also be applied to repair of massive cuff tear. Kim et al  reported that arthroscopic partial repair and margin convergence showed satisfactory short-term outcomes in irreparable large to massive rotator cuff tears.
Massive, contracted rotator cuff tears are immobile and retracted both in the medial-to-lateral and in the anterior-to-posterior directions; they represent 10% of massive rotator cuff tears.  Interval slide is useful to mobilize and release in those cases.
Berdusco et al reported that functional scores and range of motion improved from the pre- to postoperative period after the interval slide. 
In arthroscopic repair of a rotator cuff tear, it is critical to achieve contact between tendon and bone. However, the tear may not be amenable to complete tendon to bone contact despite every effort to release contracted massive tear. In these cases, margin convergence can be useful.
Kim et al  reported that margin convergence shows significant improvement in functional scores but with a high re-tear rate of up to 47%. However, the re-tears tended to be smaller than the original tear size. No significant difference was observed in the short-term clinical results between the groups with or without a re-tear. 
It is hard to maintain appropriate tension in the repair of massive cuff tears, with undue tension causing structural failures. Arthroscopic biceps augmentation is effective in preventing these structural failures.
In a study by Cho et al,  patients with a massive rotator cuff tear who had biceps augmentation showed better results in forward flexion, external rotation, and internal rotation strength postoperatively than patients who did not have biceps augmentation.
With the advent of a new biologic scaffold, repair of massive rotator cuff tears using a patch graft is being widely utilized. Gupta et al  found that patients with a massive rotator cuff tear who received patch graft augmentation demonstrated significant improvement in pain, range of motion, and functional scores,
Reverse Total Shoulder Arthroplasty
In general, indications for reverse total shoulder arthroplasty (RTSA) in massive rotator cuff tears are irreparability or reparability with expected poor outcome.
Indications from Pill et al  include:
- Symptomatic rotator cuff tear arthropathy
- Multiple failed rotator cuff repair
- Static superior migration of humeral head
- Massive irreparable rotator tear
- Pseudoparalytic shoulder
- Advanced fatty degeneration over grade 3 according to the Goutallier classification 
Gerber et al  consider a massive rotator cuff tear to be “irreparable” if:
- The pseudoparalysis was chronic
- The acromiohumeral distance was <7 mm on a plain anteroposterior radiograph made with the shoulder in neutral rotation
- The fatty infiltration of the supraspinatus and infraspinatus muscles was greater than grade 2 according to the Goutallier classification 
Gerber et al  reported that reoperation rate was lower and final Constant score was higher in patients initially treated with RTSA than with a revision procedure.
Patients with pseudoparalysis of the shoulder with a preoperative active elevation less than 90° with or without arthritis, can expect to achieve good subjective results and functional outcome.  Frankle et al  also believe RTSA can be reliably applied to patients with pseudoparalysis from a massive rotator tear cuff tear in the absence of glenohumeral arthritis (Figure 1).
Figure 1. Algorithmic approach to massive rotator cuff tear. 
In case of glenohumeral arthritis, arthroplasty should be considered as the primary option (Figure 1). However, high complication rate and few reports of long-term survival should be taken into consideration before arthroplasty is performed. The most common complication of RTSA is scapular notching. [11,17] Other complications after RTSA include:
- Instability and dislocation
- Hematoma and infection
- Loosening and implant failure
- Glenoid loosening
- Scapular spine fracture
- Acromion fracture
- Neurologic complications
Eugene et al  reported a complication rate of up to 37% within 10 years after RTSA. Favard et al  found that the need for revision of RTSA was relatively low at 10 years (89% survivorship), with lower survivorship with lower Constant-Murley scores.
In view of the risk of complications, the surgeon should consider arthroscopic rotator cuff repair as the first line treatment rather than RTSA for massive rotator cuff tears.
Considerations for Managing Massive Rotator Cuff Tear
Various factors, including pseudoparalysis, fatty degeneration, age, and anatomic healing, have been reported to preoperatively predict reparability of a massive rotator cuff tear via arthroscopic techniques. It is imperative to assess these factors to determine if they are appropriate predictive criteria.
1. Does pseudoparalysis mean that the tear is irreparable or that it will have a negative effect on clinical outcome
Deficit in active range of motion is alleged to be a negative factors influencing rotator cuff repair. With the popularity of RTSA, there is a tendency toward performing RTSA in cases of non-arthritic, large-to-massive tears with pseudoparalysis. Studies, however, have noted that arthroscopic rotator cuff repair should be the first line treatment option for these tears despite the presence of pseudoparalysis. [20,21]
In a study by Oh et al,  no significant differences were found in healing rate and final functional scores between patients with and without pseudoparalysis of the shoulder who underwent arthroscopic rotator cuff repair. Following the procedure, 76% of patients with pseudoparalysis recovered function.
Denard et al  found that in primary repair of massive rotator cuff tear, pseudoparalysis was reversed in 90% of cases. Shorter duration of paralysis was associated with reversal of pseudoparalysis. 
2. Does higher fatty degeneration mean that the tear is irreparable or that it will have a negative effect on clinical outcomes? Reliability
In a study of computed tomography arthrography (CTA) analysis of fatty infiltration in 87 patients, the agreement of Goutallier classification had relatively low reliability: 0.61 for intra-observer and 0.40 for inter-observer reliability. 
Another study  of with magnetic resonance arthrography and CTA review in 75 cases also had low inter-observer reliability for the Goutallier grade in MRA (0.60-0.72) and CTA (0.43-0.60) and for the Fuchs grade in MRA (0.60-0.68) and CTA (0.43-0.60).
Caution in interpreting fatty degeneration data, therefore, is warranted.
Quantitative method: Measurements of Hounsfield Units
There is significant correlation between fatty degeneration grades and Hounsfield units (HU) measurement of all muscles pre- and postoperatively. In one study, reliability was higher in HU measurement. 
Using Photoshop software, quantitative measuring was reliable and correlated well with the pre-existing grade of fatty degeneration and the cuff tear size. In addition, there was a significant correlation between oblique sagittal images of MDCT and MRI using this method (Figure 2). 
Figure 2. Calculation of the occupation ratio by dividing the area of the supraspinatus muscle (A) by that of the supraspinatus fossa (B) using Photoshop on an oblique sagittal magnetic resonance image. 
Is fatty degeneration irreversible after repair?
Rotator cuff repair itself changed the fatty degeneration of the supraspinatus tendon and infraspinatus tendon on magnetic resonance imaging due to lateralization of muscle. This should be considered when assessing rotator cuff muscle changes postoperatively.  Supraspinatus muscle atrophy, as measured by occupation ratio, could be improved postoperatively in case of successful cuff repair (from 0.44 to 0.52; P<0.001). 
In a study that included 22 massive rotator cuff tears with fatty degeneration of grade 3 or 4, arthroscopic repair provided significant functional improvement in 86.4% of patients, who would have been classified as likely to fail by the Goutallier criteria. [14, 29]
3. Does age influence to outcome after repair?
One of the factors affecting tendon healing is age, with the healing rate found to be 87.8% in patients age 50 years or younger, 79.4% in patients age 51 to 60 years, and 65.4% in patients age 61 years and older.  Older age has also correlated with poorer healing rate on multivariate analysis. 
However, Charousset et al  noted that age itself is not associated with poor repair rates. Instead, the size of the tears affects the result.  In their study of 177 cases, univariate analysis, older age was related to poor postoperative Integrity and better Constant score anatomical healing. In multivariate study, however, age was not a determinant of anatomic or the functional outcome. 
Similarly, Oh et al  found in multivariate analysis of 339 small- to medium-sized tears (<3 cm), age was not a prognostic factor for the outcome (P=0.84). Greater amount of retraction (P = .027), higher fatty infiltration of the infraspinatus (P= .014), and lower bone mineral density (P = .001) were associated with cuff healing failure as independent prognostic factors (Figure 3). 
4. Is anatomic healing mandatory for a good clinical outcome?
In a study by Chung et al that included 108 cases,  multivariate analysis revealed functional scores significantly improved regardless of cuff healing. Anatomic healing is not mandatory for functional improvement of patients who undergo arthroscopic rotator cuff repair.
Paxton et al  also found that healing was not critical for a successful outcome after rotator cuff repair.
Even with pseudoparalysis, a higher grade of fatty degeneration, older age, and healing failure, the surgeon should consider arthroscopic rotator cuff repair as the first line treatment rather than RTSA in a massive rotator cuff tear in the absence of arthritis.
In cases in which arthritis is present with the massive rotator cuff tear, RTSA may be considered the primary option.
Joo Han Oh, MD, PhD, is from the Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea.
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