Arthroscopic
Repair of Massive Rotator Cuff Tears: Outcome and Analysis of Factors
Associated with Healing Failure or Poor Postoperative Function
Repair of Massive Rotator Cuff Tears: Outcome and Analysis of Factors
Associated with Healing Failure or Poor Postoperative Function
Chung SW, Kim
JY, Kim MH, Kim SH, Oh JH.Am J Sports Med. 2013 Apr 30.
[Epub ahead of print]
JY, Kim MH, Kim SH, Oh JH.Am J Sports Med. 2013 Apr 30.
[Epub ahead of print]
Take
Home Message: Following repair of massive rotator cuff tears, pre-operative
fatty infiltration of the infraspinatus and post-operative reduced
acromiohumeral distance negatively affects healing and functional outcomes,
respectively. Each of these factors should be considered when determining
prognosis and prescribing treatment strategies.
Home Message: Following repair of massive rotator cuff tears, pre-operative
fatty infiltration of the infraspinatus and post-operative reduced
acromiohumeral distance negatively affects healing and functional outcomes,
respectively. Each of these factors should be considered when determining
prognosis and prescribing treatment strategies.
Massive rotator cuff
tears are a common cause of shoulder pain and dysfunction. Unfortunately, surgical repair of massive
cuff tears is often unsuccessful (failure rate up to 94%). Interestingly, many patients are able to
achieve functional improvement even with an unhealed cuff after repair. However, the factors which affect function
after massive cuff tear, particularly after failed repair, are unclear. Therefore, the purpose of this study was to
evaluate outcomes after repair of massive cuff tears, to identify prognostic
factors that affect cuff healing, and ultimately to determine the factors
influencing functional outcome in failed rotator cuff healing. The authors included a total of 108 patients
with an average age of 64 years and evaluated functional outcomes
pre-operatively and a minimum of 1 year post-operatively. They also assessed cuff
integrity post-operatively and numerous key factors that can affect the outcome
of arthroscopic repair: age, sex, symptom duration, preoperative pain intensity,
comorbidities, hand dominance, bone and tissue quality (bone mineral density and
fatty infiltration [FI]), preoperative stiffness and pseudoparalysis, tear size
and location, acromiohumeral distance (AHD), repair technique, and concomitant
surgical procedures (distal clavicle resection and biceps procedures). The authors evaluated differences according
to cuff healing and functional outcome. Almost
40% of patients had anatomic failure of the repair while functional status
improved regardless of cuff healing.
Many factors associated with failure of cuff healing; however, pre-operative
FI of the infraspinatus was a key determinant of healing failure. Additionally, among patients with failed cuff
healing, only reduced post-operative AHD was related to poor functional outcome
while no preoperative factors were identified.
tears are a common cause of shoulder pain and dysfunction. Unfortunately, surgical repair of massive
cuff tears is often unsuccessful (failure rate up to 94%). Interestingly, many patients are able to
achieve functional improvement even with an unhealed cuff after repair. However, the factors which affect function
after massive cuff tear, particularly after failed repair, are unclear. Therefore, the purpose of this study was to
evaluate outcomes after repair of massive cuff tears, to identify prognostic
factors that affect cuff healing, and ultimately to determine the factors
influencing functional outcome in failed rotator cuff healing. The authors included a total of 108 patients
with an average age of 64 years and evaluated functional outcomes
pre-operatively and a minimum of 1 year post-operatively. They also assessed cuff
integrity post-operatively and numerous key factors that can affect the outcome
of arthroscopic repair: age, sex, symptom duration, preoperative pain intensity,
comorbidities, hand dominance, bone and tissue quality (bone mineral density and
fatty infiltration [FI]), preoperative stiffness and pseudoparalysis, tear size
and location, acromiohumeral distance (AHD), repair technique, and concomitant
surgical procedures (distal clavicle resection and biceps procedures). The authors evaluated differences according
to cuff healing and functional outcome. Almost
40% of patients had anatomic failure of the repair while functional status
improved regardless of cuff healing.
Many factors associated with failure of cuff healing; however, pre-operative
FI of the infraspinatus was a key determinant of healing failure. Additionally, among patients with failed cuff
healing, only reduced post-operative AHD was related to poor functional outcome
while no preoperative factors were identified.
This study identified the
single most influential factor that negatively affected cuff healing (higher
FI) and another for functional outcome (reduced postoperative AHD). Failed rotator cuff healing has previously
been attributed to poor tissue quality (high FI). Despite various combinations
of involved tendons, FI of the infraspinatus was the most influential predictor
of failed cuff healing. The infraspinatus
plays an important role in providing compression of the humeral head on the
glenoid through the anterior-posterior “force couple” provided by the
subscapularis anteriorly and infraspinatus posteriorly. FI of the infraspinatus may disrupt this “force
couple”, alter glenohumeral joint mechanics, and ultimately impair healing in
the remaining repaired tendons. Additionally,
functional outcomes after repair have previously been related to AHD; however,
controversy still exists regarding its effect. Findings from this study suggest that
post-operative AHD may be an indicator of rotator cuff function. Monitoring of
AHD during the post-operative period may help determine patient prognosis and
assist in development of treatment strategies.
Specifically, clinicians may want to address reduced AHD via
non-operative interventions such as physical therapy to improve functional
outcomes following massive cuff repair.
single most influential factor that negatively affected cuff healing (higher
FI) and another for functional outcome (reduced postoperative AHD). Failed rotator cuff healing has previously
been attributed to poor tissue quality (high FI). Despite various combinations
of involved tendons, FI of the infraspinatus was the most influential predictor
of failed cuff healing. The infraspinatus
plays an important role in providing compression of the humeral head on the
glenoid through the anterior-posterior “force couple” provided by the
subscapularis anteriorly and infraspinatus posteriorly. FI of the infraspinatus may disrupt this “force
couple”, alter glenohumeral joint mechanics, and ultimately impair healing in
the remaining repaired tendons. Additionally,
functional outcomes after repair have previously been related to AHD; however,
controversy still exists regarding its effect. Findings from this study suggest that
post-operative AHD may be an indicator of rotator cuff function. Monitoring of
AHD during the post-operative period may help determine patient prognosis and
assist in development of treatment strategies.
Specifically, clinicians may want to address reduced AHD via
non-operative interventions such as physical therapy to improve functional
outcomes following massive cuff repair.
Questions for
Discussion: How do you think the results of this study will affect clinical practice? Should reduction of the AHD in patients with
massive cuff tears be the goal of post-operative rehabilitation?
Discussion: How do you think the results of this study will affect clinical practice? Should reduction of the AHD in patients with
massive cuff tears be the goal of post-operative rehabilitation?
Written by: Katie
Reuther
Reuther
Reviewed by: Jeffrey Driban
Related Posts:
Chung SW, Kim JY, Kim MH, Kim SH, & Oh JH (2013). Arthroscopic Repair of Massive Rotator Cuff Tears: Outcome and Analysis of Factors Associated With Healing Failure or Poor Postoperative Function. The American Journal of Sports Medicine PMID: 23631883
Katie nice post! Your last question is interesting but something that I don't think we are clear on. First without an ultrasound we cant measure this in the clinic. Second I don't think we know how to increase AHD through therapeutic exercises. I think trying to train the rotator cuff to function dynamically to center the humeral is key and as you point out if the infraspinatus doesn't heal then we lost the anterior-posterior force couple. However we also dont know if that anterior-posterior force couple prevents superior migration of the humeral head. There are also other factors that may decrease the AHD like glenoid inclination. Some have described the subscap as a humeral head depressor so should we be targeting that muscle in our rehab. These are questions that I know cant be answered I just wanted to raise them to get people thinking and show that there is still a lot of work to be done! Thanks for the post.