Common Questions Regarding Treatment of a Large Rotator Cuff Tear

[mtomaino]

I recently answered a number of questions from a 53 yo patient who emailed me.He has a large cuff tear--sustained in November. He has weakness and some pain, but pretty good function. He is from out of state and is contemplating a repair because he wants to ensure that he does not miss the opportunity for repair.

Of note, his MRI reveals some atrophy of the supra- and infraspinatus muscles, which can lessen the success of tendon to bone healing even after a technically successful repair. And, there is slight superior elevation, which implies that the humeral head is starting to migrate due to loss of the depressor function of the cuff.

I thought my responses to his questions would be worthwhile to post since these are common questions. Further, my answers may serve as a springboard for others to comment and/or posttheir own questions.

See the next thread for these questions and my responses.

[mtomaino]

His questions to me, followed by my responses:

a) have you had significant experience with tears that are this large ?

YES!!
See this link: http://www.rearmyourself.com/article/arthroscopic-repair-of-massive-rotator-cuff-tears

b) were their any unsuccessful outcomes in (a) and why ?

YES—re-tears can occur due to poor compliance (use of a sling with no motion for 6 weeks) or due to poor tissue quality. But in younger pts I have had good success.

c) what is likelihood that this tear is getting worse presently - pain / other ?

Increasing pain is the best litmus test for this: see this link:
http://www.rearmyourself.com/question/If%20my-rotator%20cuff%20is-torn,%20but%20I%20do%20not%20want-surgery,%20what%20are%20the%20downsides

d) am I ok with keeping the shoulder very active as discussed above as long as I don’t put stress on the supra and infra ? Is supra and infra ROM ok even with light resistance ?

YES to both---

e) how critical is it that I get this completed sooner with respect to tissue quality and overall repairability, etc ?

No way to know for sure---but sooner is better than delayed to prevent further atrophy and retraction.

f) Are there instances where you start a "arthroscopic surgery" and then do a "open" because of complications or initial size of tear ?

No—never had to in the last 8 years!!

g) is their a “worst case scenario” that you would do if the existing tendon quality is poor ? Would you take a tendon from elsewhere to support the structure ? It seems to me that until anyone puts a scope inside the joint any definitive answer is very subject - true ? ...obviously I would prefer a "arthro" vs. a "open".

If the tear in not fixable, at your age, with your function, I would probably not advise an open surgery---certainly not right away. If you started to lose function you might be a candidate for a latissimus transfer. See this link:
http://www.rearmyourself.com/article/latissimus-dorsi-tendon-transfer-for-irreparable-rotator-cuff-tears

However, once you hit your mid sixties, were function to decline, and pain to increase, I would lean more towards a reverse shoulder. No question that the 1st step is an arthroscopic procedure.

h) how many of your surgeries have lead to "open" procedures ? how traumatic is a open procedure on the deltoid ? Also I read that the subscapularis is to some degree compromised ? My subscap is excellent given physical testing.

Again—I would not perform any open surgery—it is never needed.

i) do you use any innovative inputs to aid in healing such as - blood spinning or patches in the compromised areas effected ?

I do not---These “biologic” interventions have “theoretical” merit, but there is no true evidence in the literature to support; as a result, insurance precludes trying them.

[mtomaino]

1. regarding the scope …. Is this something you would do as a exploratory procedure and then proceed only if the tendons were re-attachable ?

The scope is done 1st and at the same procedure I repair the tendons. If repair is not possible we clean debris up and possibly release and tenodese the biceps tendon—which can help with pain relief

2. is this a procedure that can wait 2-3 months for seasons change ? ….tough dealing with the after-affects during winter !

Yes---but 3 months may result in further muscle change---in other words, absent the normal strain on the muscles from an attached tendon unit, atrophy can progress and muscle stiffness may prevent the tendon from reaching the bone to allow repair.

3. what would the cost be if you just did a scope and no procedure ?

Much less---but there would be no reason not to fix the tendons if repair is possible!

4 with respect to atrophy are you referring to the tendon and its condition / quality OR the notes on the MRI indicating mild / moderate atrophy in the supra and infra muscle bellies, respectively ? I suspect the former.

Atrophy refers to the muscle, not the tendon. Think of the muscle as the “motor”—thus, if there is atrophy, even if the repair heals, you may have less gas in the motor.

5. if there is tendon atrophy would you do a latimus dorsi transplant to compensate ?

The latissimus transfer is performed in the event that your tears are not fixable and when you begin to lose the ability to raise your arm overhead as effectively.

[mtomaino]

Matt –

i appreciate the guidance and very helpful responses. Yesterday to my total surprise a spot opened up in Canada for next Wednesday so I took it . I originally was told sometime late May / 2011 would be the earliest which lead me to explore US alternatives. Quite frankly I am most impressed by the US medical system versus our system which is quite a lot more guarded given they don’t need to compete. Again I wish to extend my appreciation to you for your insightful answers to my questions. I will most certainly refer your name to my athletic and other professional colleagues . I will let you know how I am progressing and hopefully you can learn from my situation.