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Rotator Cuff Tears

The earliest published description of a rotator cuff tear was by cuff tears do not heal spontaneously, and may progress with
Alexander Munro in 1788, when he described a hole with ragged time.5,8,9 This is thought to be due to poor vascularisation
edges in the capsular ligament of the humerus.1 Since this within the rotator cuff as well as the intra-articular environment
description there has been little agreement amongst orthopaedic which can inhibit healing.10-12 A number of patients will develop
surgeons regarding the exact indications for surgical repair of a an irreparable rotator cuff tear due to progression of the tear
torn rotator cuff.2 This review describes the epidemiology and and tendon retraction, and some patients will go on to develop
management of degenerative rotator cuff tears. secondary degenerative changes of the glenohumeral joint
termed rotator cuff arthropathy (Fig. 1 and Fig. 2).13
Epidemiology
The prevalence of rotator cuff disease increases with age, with 4% Management The management of a rotator cuff tear is
of asymptomatic patients aged < 40 years and 54% of patients multifaceted. Conservative management includes analgesia
aged 60 years, having partial or complete tears of the rotator and anti-inflammatory medications, physical therapy, activity
cuff on a MRI scan.3 Ultrasound scanning has demonstrated modification and subacromial injections of local anaesthetic
that 13% of the population in the fifth decade, 20% in the sixth and/or steroid. Operative interventions include arthroscopic
decade and 31% in the seventh decade of life have a rotator debridement of the tear or repair of the torn rotator cuff, with
cuff tear.4 Yamaguchi et al5 demonstrated that more than half of or without subacromial decompression. Most reports in the
asymptomatic rotator cuff tears become symptomatic within 3 literature are procedure oriented, consisting of retrospective
years and progressed in size during this time period. single surgeon series with limited numbers of patients. A
Cochrane review performed in 200414 analysed interventions
The Natural History of a Rotator Cuff Tear for rotator cuff tears and concluded that there is little evidence
Neer6 originally described three stages of rotator cuff disease.6 to support or refute the efficacy of commonly used treatment
Stage I occurring in patients < 25 years with oedema and methods.
hemorrhage of the tendon and bursa. Stage II involves tendinitis A suggested approach to management of a rotator cuff tear
and fibrosis of the rotator cuff in patients aged between 25 and The aim in managing a rotator cuff tear is to reduce pain and
40 years of age. Stage III involves tearing of the rotator cuff, either improve function. The evidence for conservative management of
partial or full-thickness, and occurs in patients > 40 years of age. a rotator cuff tear dictates an initial period between six weeks
Whether the pathological changes observed in the rotator cuff and three months of non-operative treatment unless there is
is secondary to intrinsic tendon degeneration and/or extrinsic evidence of an acute tear in a younger patient.15-17 Prolonged
mechanical impingement is a matter of debate. Yamanaka and conservative management in symptomatic patients can have
Matsumoto7 demonstrated that 10% of partial-thickness tears negative consequences. These include increase in tear size, tear
heal and 10% become smaller, but 53% of tears will propagate retraction, increased difficulty of repair18,19 and muscle atrophy
and 28% progress to full-thickness tears. Full-thickness rotator with fatty infiltration, all of which can result in a diminished

Fig. 1. Rotator cuff arthropathy secondary to rotator cuff disease. Fig. 2. U-shaped tear in the rotator cuff

2012 British Editorial Society of Bone and Joint Surgery 1


2 N.D. CLEMNENT, J.M. MCBIRNIE

outcome.19-22 excluded and unsatisfactory results occurred in 14 of 33 (42%)


Despite limited evidence, physiotherapy is the mainstay with 12 patients eventually undergoing surgery. Patients with an
of conservative management of rotator cuff tears. An ultra- insurance claim were less likely to be satisfied.
sound or MRI scan may be obtained for patients with persistent
symptoms that have not improved after two to three months Operative Management
of conservative management. There is no good evidence for Repair of a torn rotator cuff has been shown to give predictable
or against steroid injection in the management of rotator cuff pain relief and functional improvement, with good overall patient
tears, although empirically these do seem to have a positive satisfaction.25 The results of open, mini-open and arthroscopic
effect in some patients. Multiple injections should be avoided rotator cuff repair have all generally been favourable, but
however, especially if there is a diagnosed rotator cuff tear that approximately 38% of patients suffer a post-operative
is potentially repairable. complication.26 Re-rupture rates of 13%27 to 68%28 have been
Initial radiological assessment includes an anteroposterior, reported after rotator cuff repair, however patients suffering a re-
scapulolateral, and axillary view. If a rotator cuff tear is suspected rupture still have significant improvement in pain and function.29
based on clinical assessment, an ultra-sound or MRI scan can The re-rupture rate, as assessed by MRI is 20% to 39%30-32 and
be obtained. An ultrasound scan offers dynamic assessment of in larger tears the rate at 2 years is nearly double this (41% to
the rotator cuff with less expense, relative to a MRI scan, but it 94%).33-35 Patients with an intact repair have significantly better
is operator dependent. A MRI scan can also evaluate tear size outcomes.31,34 The outcome of revision surgery for symptomatic
and retraction, but in addition the rotator cuff muscles can be failed primary repairs is inferior to successful primary repair,
assessed for fatty atrophy which predicts outcome after repair. with only 69% of patients being satisfied.36 Despite the risk
of complications and tendon re-rupture, rotator cuff repair
Conservative Management predictably reduces pain and improves strength and function in
Symptomatic rotator cuff tears treated conservatively can give a symptomatic patients.37
baseline to which the outcome after surgical intervention can be There is great debate throughout the literature as to whether
compared. Bartolozzi, Andreychik and Ahmad15 in a study of 136 arthroscopic rotator cuff repair is superior to that performed
patients managed conservatively with symptomatic rotator cuff through a mini-open approach. A recent systematic review by
disease identified that full-thickness tears > 1cm2, symptoms Lindley and Jones38 found no statistically significant difference
persisting more than 1 year, and functional impairment in postoperative outcome or incidence of re-ruptures of those
and weakness were associated with a worse outcome. They rotator cuff tendons repaired arthroscopically versus using the
recommended that surgery be considered in these patients mini-open repair technique. There was, however, decreased
with those risk factors. Itoi and Tabata17 reported 62 cuff tears post-operative pain in the short-term for patients who underwent
in 54 patients that were treated conservatively and found that arthroscopic repair. In addition to the surgical approach for
72% of patients had good or excellent results at an average repair, the technique of cuff repair is also contested. Options for
of 3.4 years. This however was a selected cohort of patients this include a single row, double row, or suture bridge repair (Fig.
presenting with mild pain and minimal functional deficit. Bokor 3). Trappey and Gartsman39 performed a systematic review of the
et al16 reported that 74% of patients with confirmed rotator literature to answer this question. They identified four randomised
cuff tears managed conservatively had minimal or no pain at control trials, all of which demonstrated no difference in the
seven years and 86% were satisfied with their result. In this clinical outcome between single or double row repairs. The most
study, patients who failed conservative treatment and went on recent study, by Gartsman et al40, demonstrated a significant
to have surgery were excluded, which introduces an obvious difference in the re-rupture rate when comparing a single
selection bias. Samilson and Binder23 report the largest series row repair (20% re-rupture) with a double row suture bridge
of conservatively managed full-thickness rotator cuff tears (n = technique (7% re-rupture) (Fig. 3c). They did not assess clinical
292), demonstrating that 72% of shoulders had more than 150 outcome and this improved re-rupture rate may translate into a
of abduction after treatment but 40% were rated as having a superior patient outcome. Trappey and Gartsman40 suggest that
fair or poor outcome. Hawkins and Dunlop24 reported a smaller more sophisticated outcome analyses may be needed to confirm
series of 33 patients managed conservatively. No patients were the superiority of double row repairs.

Fig. 3a. Diagram showing a single row repair on Fig. 3b. Diagram showing a double row repair Fig. 3c. Diagram showing a double row bridging
the lateral aspect of the foot print securing the rotator cuff tendon into the foot repair securing the rotator cuff tendon into the
print foot print.

THE JOURNAL OF BONE AND JOINT SURGERY


ROTATOR CUFF TEARS 3

Conclusion 17. Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop
Most of the guiding principles used for decision-making in 1992;275:165-73.
treating rotator cuff disease are based on limited evidence and 18. Prasad N, Odumala A, Elias F, Jenkins T. Outcome of open rotator cuff repair: an
minimal science. Factors that seem to be important include analysis of risk factors. Acta Orthop Belg 2005;71:662-6.
duration of symptoms, weakness, size of the tear, and muscle 19. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff: end-result study of factors
atrophy. If surgery is performed, either by a mini-open or influencing reconstruction. J Bone Joint Surg [Am] 1986;68-A:1136-44.
arthroscopic technique, a double row bridging repair seems to 20. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van DS. Influence of cuff muscle
be biomechanically stronger, provided this can be performed in fatty degeneration on anatomic and functional outcomes after simple suture of full-
a tension-free environment. At this point in time however, there thickness tears. J Shoulder Elbow Surg 2003;12:550-4.
is no clinical evidence to support double row repair over single 21. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty infiltration of
row repair. disrupted rotator cuff muscles. Rev Rhum Engl Ed 1995;62:415-22.
22. Thomazeau H, Rolland Y, Lucas C, Duval JM, Langlais F. Atrophy of the
N.D. Clemnent MRCS ED supraspinatus belly: assessment by MRI in 55 patients with rotator cuff pathology. Acta
J.M. McBirnie FRCS Ed (Tr & Orth) Orthop Scand 1996;67:264-8.
Department of Orthopaedics and Trauma 23. Samilson RL, Binder WF. Symptomatic full thickness tears of rotator cuff: an
The Royal Infirmary of Edinburgh analysis of 292 shoulders in 276 patients. Orthop Clin North Am 1975;6:449-66.
Little France 24. Hawkins RH, Dunlop R Nonoperative treatment of rotator cuff tears. Clin Orthop
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25. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a
E-mail: Julie.McBirnie@luhtscot.nhs.uk systematic review. Clin Orthop 2007;455:52-63.
26. Mansat P, Cofield RH, Kersten TE, Rowland CM. Complications of rotator cuff
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