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Massive, Irreparable Tears of the Rotator Cuff. Results of Operative Débridement and Subacromial Decompression*

GARY M. GARTSMAN, M.D., HOUSTON, TEXAS

Investigation performed at The Methodist Hospital, Houston

	Abstract

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Thirty-three consecutive patients in whom an irreparable tear of the rotator cuff had been treated with operative débridement and subacromial decompression were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily living, range of motion, strength, and satisfaction. The assessments were performed with the Shoulder Score Index of the American Shoulder and Elbow Surgeons and the scoring systems of the University of California at Los Angeles and Constant and Murley. At the time of follow-up, twenty-six patients thought that the condition of the shoulder was improved; three, that it was unchanged; and four, that it was worse after the operation. There was a significant decrease in pain (p = 0.001) and significant increases in the range of motion (p = 0.038) and the ability to perform activities of daily living (p = 0.016). However, these improvements were inferior to those in reported series in which torn rotator cuffs had been repaired. Strength with elevation was decreased after the operations in the present series (p = 0.0007).

	Introduction

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A number of treatment options are available to the surgeon when a massive, irreparable defect of the tendons of the rotator cuff is found at the time of an operation. These methods include local tissue transfer from the remaining intact portion of the rotator cuff, with use of the superior portion of the subscapularis¹⁰ or incorporation of the intra-articular portion of the biceps tendon²¹; advancement of the supraspinatus^12,18; or use of a deltoid muscle flap³, synthetic materials²⁹, or a tendon allograft²⁶. Gerber¹⁶ recently described his approach to irreparable defects with transfer of the latissimus dorsi. One of the most widely used options, described by Rockwood et al.³¹, includes débridement of the edges of the necrotic tendon, thorough decompression of the subacromial space with an anterior and inferior acromioplasty, resection of the coracoacromial ligament, removal of the subacromial bursa, and meticulous repair of the deltoid. A postoperative rehabilitation program is started immediately. Rockwood et al. reported good results with use of this technique, with relief of pain and marked improvement in function. Good results have also been reported with arthroscopic decompression and débridement^6,14.

A prospective study was done to evaluate the effectiveness of open decompression and débridement of the shoulder to treat massive, irreparable tears of the rotator cuff.

	Materials and Methods

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Four hundred and sixty-seven repairs of the rotator cuff were performed at The Methodist Hospital, Houston, Texas, from 1984 to 1991. All of the operations were done by me or under my direct supervision. The inclusion criteria for this study were a massive (at least five-centimeter-long) tear involving two, three, or four tendons of the rotator cuff that could not be closed without excessive tension after lysis of intra-articular and extra-articular adhesions, release of the coracohumeral ligament and rotator interval, and incision of the superior and posterior aspects of the capsule. Patients who had a massive tear of the rotator cuff that was reparable, who had had a partial tendon repair (medialization), or who had had a previous operation on the rotator cuff were excluded.

Forty-two tears (9 per cent) were determined to be irreparable at the time of the operation. Six patients were excluded as they had had a previous procedure involving the rotator cuff (five repairs and one débridement). Of the remaining thirty-six patients, one patient died from unrelated causes and two others were lost to follow-up; this left a study group of thirty men and three women. The average age was sixty-two years (range, forty-two to seventy-seven years). Twenty-five dominant upper extremities were involved. The average duration of the symptoms was seventeen months (range, six to ninety-six months). All patients had pain at night and with exertion of the upper extremity. Thirteen patients were involved in a Workers' Compensation claim, seven were receiving Medicare, and thirteen had private insurance. In order to allow the results of this study to be compared with those of others, the patients were evaluated with the Shoulder Score Index of the American Shoulder and Elbow Surgeons³⁰ and the shoulder-rating systems of the University of California at Los Angeles^7,13 and Constant and Murley¹¹.

Preoperative Evaluation
Patient satisfaction: No patient was satisfied with the condition of the shoulder.

Pain: The average pain score was 7.9 points on the visual analog scale of 0 to 10 points, 2.1 points according to the system of the University of California at Los Angeles, and 3.2 points according to the system of Constant and Murley¹¹.

Range of motion: I measured active elevation and abduction as well as passive elevation, external rotation, and behind-the-back internal rotation (Table I). Twenty-eight patients could not actively abduct the shoulder more than 90 degrees (range of abduction, 20 to 90 degrees), and the average range of active elevation for these patients was 83 degrees (range, 45 to 130 degrees).

Function: The patients recorded their ability to perform ten common activities of daily living according to the Shoulder Score Index of the American Shoulder and Elbow Surgeons³⁰ (Table I). They also rated the function of the shoulder according to the scoring systems of the University of California at Los Angeles^7,13 (Table II) and Constant and Murley¹¹ (Table III).

Radiographic changes: An analysis of the preoperative radiographs was performed according to the method described by Gerber¹⁶. Osteoarthrosis of the glenohumeral joint was considered mild if there was an osteophyte on the inferior aspect of the humeral head or the glenoid that was less than three millimeters long, moderate if it was three to five millimeters long with irregularity of the joint line and subchondral sclerosis, and severe if either the osteophyte was more than five millimeters long or there was increased irregularity of the joint. Four patients had mild arthrotic changes, but no cartilage abnormalities of either the humeral head or the glenoid were found at the time of the operation. No shoulder had moderate or severe arthrotic changes. No patient who had radiographic changes consistent with rotator cuff arthropathy²⁴ was included in this study. Superior migration of the humeral head was also evaluated radiographically. I found, as did Gerber, that measurements of the interval between the humeral head and the acromion were unreliable. The distance measured varied markedly according to the position of the patient, the rotation of the arm, and the angle of the x-ray beam. The shape of the acromion on the supraspinatus outlet radiograph^4,23 was type I (flat) in four patients, type II (curved) in twenty-two, and type III (hooked) in seven. Osteoarthrosis of the acromioclavicular joint (narrowing of the joint space and sclerosis) was noted in ten patients (five of whom had resection of the acromioclavicular joint at the time of the operation), and osteophytes were noted in the inferior aspect of the joint in nine patients who did not have arthrotic changes. Routine postoperative radiographs were not made.

Imaging studies: Twenty-eight patients had imaging studies made before the operation and five did not. Fifteen patients had a positive magnetic resonance image and thirteen had a positive arthrogram. There were no false-negative magnetic resonance images or arthrograms. No patient had both a magnetic resonance image and an arthrogram made. The fifteen magnetic resonance imaging studies were evaluated. All patients had retraction of the supraspinatus and infraspinatus tendons to the level of the glenoid, and all demonstrated severe atrophy and fatty infiltration of the muscles. The subscapularis and teres minor muscles were judged to be normal.

Operative indications: The indications for the operation included pain that interfered with work and activities of daily living or pain at night, or both, that was unresponsive to a non-operative treatment program consisting of modification of activity; non-steroidal anti-inflammatory medications (thirty-one patients); injections of cortisone (twenty-two patients received one to five injections; average, 2.2 injections); or a program of physical therapy that was designed to maintain or improve the range of motion of the shoulder and strengthen the deltoid, scapular rotators, biceps, and intact rotator cuff muscles³¹. All of the patients rated the pain as severe (7 to 10 points) on the visual analog scale. The indications for resection of the acromioclavicular joint (five patients) were pain localized to that joint, pain on direct palpation of that joint, and pain in the joint that was relieved by local injection of an anesthetic. Sixteen patients had an injection into the acromioclavicular joint, and nine of them had a positive result (the pain in the joint was relieved). No asymptomatic acromioclavicular joint was resected in order to improve operative exposure. The undersurface of the acromioclavicular joint was beveled in patients who had radiographic evidence of osteophytes in the inferior aspect of the joint without pain.

Operative Technique
The operative procedure consisted of an acromioplasty and resection of the coracoacromial ligament in all thirty-three patients. The patient was placed in the semi-sitting position, and an incision was made along the lateral border of the acromion. The interval between the anterior and middle thirds of the deltoid was identified. The deltoid attachment to the anterior aspect of the acromion was dissected subperiosteally and detached. No abnormalities of the deltoid muscle were noted other than a qualitative impression of atrophy, which was rated as none in thirteen shoulders, mild in fifteen, and moderate in five. The portion of the acromion that extends anterior to the anterior border of the acromioclavicular joint was resected. The coracoacromial ligament was excised along with the anterior acromial fragment. An inferior acromioplasty was then performed. The goal of the inferior acromioplasty was to convert the shape of the acromion^4,23 to type I. As the sizes of the patients and the thicknesses of the bone differed, the amount of bone that needed to be removed to accomplish this goal varied.

Five patients had resection of the acromioclavicular joint, with the usual amount of the resection from the lateral aspect of the clavicle measuring fifteen millimeters. Thirteen patients had beveling of the undersurface of the acromioclavicular joint. A complete bursectomy was performed. The biceps tendon was normal in three shoulders, absent in twelve, frayed but intact in fourteen, and hypertrophied in four. One biceps tendon repair and one biceps tenodesis were performed. The indications for the repair were a partial tear of more than 50 per cent of the tendon and sufficient quality of the non-damaged part of the biceps to allow repair. The tenodesis was performed because the quality of the tendon was inadequate. A prominent greater tuberosity was noted in seven shoulders and was excised to prevent impingement during elevation of the upper extremity. Operative techniques that were used to dissect the tendons free included division of the coracohumeral ligament, rotator interval release⁵, lysis of extra-articular adhesions, and capsular release for intra-articular adhesions. Care was taken during dissection of the tendon to avoid injury to the suprascapular nerve. The minor defects in the superior portions of the teres minor and subscapularis were repaired. If the tendons were so scarred that I could not dissect them free or if there was loss of tendon substance such that the defect was irreparable, the tendons were debrided to eliminate irregularities in the edges and to remove any source of soft-tissue compression between the humeral head and the acromion when the upper extremity was elevated. The portion of the deltoid that was detached during the exposure was reattached anatomically with number-1 non-absorbable braided sutures through the acromion. Three to six sutures were used in the repair, depending on the amount of deltoid that had been detached. No wound-drainage tubes were used. The open technique was used in all patients. No patient was evaluated arthroscopically.

Operative Findings
A massive defect of five centimeters or more that involved the supraspinatus and infraspinatus tendons was noted in all but one patient, who had tears of the supraspinatus and subscapularis tendons, neither of which was reparable. The subscapularis tendon was torn in eight shoulders (three had a partial tear of the superior portion and five had a complete tear), and the teres minor was partially torn along its superior margin in four. The three partial tears of the subscapularis were repaired anatomically. Two of the complete tears of the subscapularis were repaired, but the remaining three were irreparable. Two of the tears that included the teres minor were partially reparable; the remaining defect in the supraspinatus and infraspinatus tendons could not be closed without excessive tension with the upper extremity at the side. The residual tendon defects involved the supraspinatus and infraspinatus in twenty-eight shoulders; the supraspinatus, infraspinatus, and subscapularis in two; the supraspinatus, infraspinatus, and teres minor in two; and the supraspinatus and subscapularis in one. No tendon transfers of the subscapularis or teres minor in a superior direction were employed.

Postoperative Treatment
Postoperatively, the upper extremity was placed in a sling and passive range-of-motion exercises in elevation and external rotation were started the afternoon of the operation. In order to allow healing of the deltoid, an active range of motion was delayed for three weeks after the operation. Passive and active range-of-motion exercises were continued until maximum movement was achieved. Strengthening of the remaining muscles was started as soon as pain-free resistance was noted on physical examination, generally six weeks after the operation. Strengthening consisted of concentric and eccentric strengthening with use of surgical tubing, and it concentrated on the remaining intact portions of the rotator cuff, the three parts of the deltoid, the scapular rotators, and the biceps³¹.

The patients were evaluated two weeks, six weeks, three months, six months, nine months, and one year after the operation and yearly thereafter. All thirty-three patients were followed for at least two years. The patients obtained maximum improvement at one year. With the small number of patients available for study, I could detect no significant changes in any of the factors analyzed at the two-year evaluation or afterward. The average duration of follow-up was 63.2 months (range, forty-eight to 117 months).

Statistical Evaluation
The paired or dependent t test was used to analyze the differences between the preoperative and postoperative ranges of motion. The other data were analyzed with use of the sign test. This test is used with ordinal data when the distinction to be made involves an increase or decrease in a rating measure from one observation to a second observation.

	Results

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Patient satisfaction: Twenty-six patients thought that the condition of the shoulder was improved after the operation; three, that it was unchanged; and four, that it was worse. The four patients who thought that the condition was worse did not differ from the rest of the series with regard to demographics or operative findings. None of the four patients (or any other patient in the study) sustained dehiscence of the deltoid. Twenty patients (61 per cent) responded yes to the question "Are you satisfied with the condition of your shoulder?", and thirteen responded no. All of the patients who had an excellent or good result and eleven who had a fair result, according to the scoring system of the University of California at Los Angeles, were satisfied.

Pain: Pain was significantly decreased (p = 0.001; sign test) (Table I).

Range of motion: The passive range of elevation and external rotation did not improve noticeably. Passive behind-the-back internal rotation improved three vertebral levels, which was significant (p = 0.0038, paired t test). Active elevation (p = 0.0041, paired t test) and abduction (p = 0.0022, paired t test) also improved significantly (Table I).

Strength: The strength of internal and external rotation did not improve noticeably. The strength of resisted elevation decreased significantly from 3.3 points preoperatively to 2.7 points at the most recent follow-up examination (p = 0.0007, sign test) (Table I).

Function: All of the scores for activities of daily living improved significantly (p = 0.016, sign test) except for toileting, which did not change (Table I).

Rating of the result: There was a significant decrease in pain and a significant improvement in the ability to perform activities of daily living, active forward elevation, and patient satisfaction (p < 0.0008, sign test) (Table II). Strength at the most recent examination was decreased compared with preoperatively. I described the postoperative function of the shoulder as excellent (a total score of 34 or 35 points), good (28 to 33 points), fair (21 to 27 points), or poor (0 to 20 points), according to the method described by Burkhart⁶. There was a modest general improvement between the preoperative and postoperative ratings: the preoperative rating was poor for all thirty-three patients, whereas the postoperative rating was excellent for one patient, good for eight, fair for eighteen, and poor for six. The total score according to the system of Constant and Murley¹¹ improved significantly (p < 0.0001) (Table III). The results obtained with the three scoring systems were consistent with one another (Table IV).

	Discussion

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Few reports in the literature have specifically addressed irreparable tears of the rotator cuff^{1,2,5-7,10,20,25,26}. The supraspinatus advancement described by Debeyre et al.¹² has recently been questioned, as anatomical studies have demonstrated a limited ability to advance the supraspinatus without endangering its neurovascular supply³². The value of local tissue transfer of the superior portion of the subscapularis¹⁰ also has been questioned, as the benefit of coverage of the humeral head may be outweighed by the potential loss of anterior glenohumeral stability⁸ or decreased function of the subscapularis as a depressor of the humeral head during abduction³¹. Neviaser et al.²⁶ reported good results with the use of a tendon allograft. Gerber¹⁶ reported promising results with transfer of the latissimus dorsi to treat irreparable tears of the rotator cuff. He described excellent relief of pain and restoration of approximately 80 per cent of normal function of the shoulder (80 of 100 points according to the system of Constant and Murley¹¹) and believed that, in individuals who have an irreparable tear of the cuff and for whom strength and overhead function are critical, the results of transfer of the latissimus dorsi are superior to that of débridement and decompression.

Rockwood et al.³¹ reported a rate of good or excellent results of 83 per cent (forty-four of fifty-three patients) over-all with tendon débridement and decompression. Those authors noted that the postoperative range of motion was improved and all patients had marked improvement in the ability to perform routine activities of daily living; they concluded that the results compared favorably with those of similar studies in which both an acromioplasty and a repair of the rotator cuff were performed.

However, others have not reported such good results. Harryman et al.¹⁹ found that the integrity of the tendon repair (as determined on follow-up ultrasonography) was the factor most significantly (p < 0.0001) associated with a good functional result after repair of the rotator cuff. While Apoil and Augereau^1,3 once debrided massive tears, that approach was abandoned when arthropathy and superior subluxation of the humeral head developed in more than 25 per cent (eleven) of their forty-three patients who were followed for more than ten years. Montgomery et al.²², in a prospective, consecutive study, reported a satisfactory result in 78 per cent (thirty-nine) of fifty patients after open repair but in only 39 per cent (fifteen) of thirty-eight patients after arthroscopic débridement without repair. Ogilvie-Harris and Demazière²⁸ evaluated the results after arthroscopic subacromial decompression and débridement and compared them with those after operative repair and acromioplasty. While both procedures resulted in improvement and similar patient satisfaction, relief of pain, and active forward elevation, the scores for function and strength and the over-all score were better after the repairs.

Although reports comparing the results of débridement with those of repair clearly show a general trend, it must be emphasized that the patient groups represented in the studies are not matched. While each type of procedure is performed for a complete tear of the rotator cuff, the results of studies that include massive, irreparable tears cannot be strictly compared with those of studies of operative repair, as patients who have a massive, irreparable tear are generally older, may have superior subluxation of the humeral head or a tear of the biceps tendon, and most likely have remaining muscle and tendon that is of poorer quality because of substantial pre-existing dysfunction of the shoulder.

It may be more accurate to compare the present report on decompression and débridement for massive, irreparable tears of the rotator cuff with the report on operative repair of massive tears of the rotator cuff by Bigliani et al.⁵. Those authors reported a satisfactory result in 85 per cent (fifty-two) of sixty-one patients, satisfactory relief of pain in 92 per cent (fifty-six), and average gains of 76 and 30 degrees in forward elevation and external rotation, respectively.

The results of the present study do not compare favorably with those of the study by Bigliani et al.⁵ or those of other studies in which patients were evaluated after repair of a wider spectrum of tears of the rotator cuff. Ellman et al.¹³ noted that 84 per cent (forty-two) of their fifty patients had a good or excellent result and 16 per cent (eight) had a fair or poor result, according to the scoring system of the University of California at Los Angeles. According to the same system, 27 per cent (nine) of the thirty-three patients in the present study had a good or excellent result and 73 per cent (twenty-four) had a fair or poor result. Twenty-six patients (79 per cent) believed that the shoulder was improved, but they were not always satisfied with the outcome. Only twenty patients (61 per cent) were satisfied with the condition of the shoulder. According to the Shoulder Score Index of the American Shoulder and Elbow Surgeons and the scoring systems of the University of California at Los Angeles and Constant and Murley¹¹ the over-all results were only 55, 59, and 66 per cent of normal, respectively (Table IV).

Nonetheless, a number of the patients in the present study did quite well after the operative procedure. There was a decrease in pain and an increase in passive internal rotation as well as active elevation and abduction after operative débridement and subacromial decompression. The ability to comb hair, reach a high shelf, lift ten pounds (4.5 kilograms) overhead, work, and participate in sports activities was improved in the postoperative period, despite the fact that resisted strength-testing showed a small but significant decrease in strength of elevation (p = 0.0007). It is possible that this decrease was due to resection of the coracoacromial ligament as advocated by Rockwood et al.³¹. Nirschl²⁷ and Flatow¹⁵ reported the importance of preservation of the coracoacromial ligament in patients who have an irreparable tear. They suggested that resection of the coracoacromial ligament leads to loss of superior containment of the humeral head, to superior migration, and to decreased function. It appears most likely that, from the patient's point of view, the functional improvement is more important than any measured deficit in strength.

It is clear that the subjective impression of pain relief was the most important factor, as all patients who had an excellent or good result as well as all those who were satisfied with the condition of the shoulder had no or little pain. The patients who had more than slight pain had a fair or poor result and were not satisfied with the condition of the shoulder. However, the preoperative factors that would allow prediction of which patients will have satisfactory pain relief after operative decompression and débridement are not clear.

When the end result was evaluated in terms of superior migration of the humeral head on preoperative radiographs, this factor was not found to have a significant association with pain relief. However, all of the patients who had severe superior migration had a poor result with regard to range of motion, function, strength, and satisfaction. With the small number of patients available for study, I could detect no significant difference in terms of pain relief or over-all score between the patients who had had mild arthrotic changes evident on preoperative radiographs and those who had not had evidence of arthrotic changes.

The factors that are more likely to result in a satisfactory range of motion and overhead function are intact subscapularis and teres minor tendons with an absence of muscular atrophy, as determined on magnetic resonance images; no or only slight superior migration of the humeral head; good function of the deltoid; and an intact biceps tendon. I agree with Gerber and Krushell¹⁷ that the subscapularis is critical to function in patients who have irreparable tears of the supraspinatus and infraspinatus. Three patients in this study had an irreparable tear of the subscapularis and two had an irreparable tear of the teres minor tendon. These five patients had decreased active motion and pain relief compared with the group as a whole. It appears that an intact or reparable subscapularis or teres minor, or both, is necessary but is not a sufficient criterion with which to predict a satisfactory result. This finding also supports the work of Burkhart et al.^6,8 regarding the importance of anterior and posterior stability of the shoulder joint in individuals who have a massive tear of the rotator cuff. An absent biceps tendon does not necessarily result in a poor outcome. Of the twelve patients who had an absent biceps tendon in the present study, one had an excellent result and three had a good result.

The factors associated with an unsatisfactory result were an irreparable tear of the subscapularis or teres minor, or both; muscular atrophy of these two muscles, as determined on preoperative magnetic resonance images; and moderate-to-severe superior migration of the humeral head. Because of the exclusion criteria in this report, none of the patients had had a previous operation on the shoulder that could have impaired the function of the deltoid and no patient had any other lesion that impaired such function. However, it seems reasonable that a well functioning deltoid will improve function of the shoulder and that a dysfunctional deltoid, such as that seen after a previous operation or a neurological injury, will impair function of the shoulder.

In conclusion, this study documented a decrease in pain and an improvement in the range of motion and the ability to perform activities of daily living after open operative débridement and decompression of irreparable tears of the rotator cuff; however, strength of elevation was decreased. Furthermore, according to the Shoulder Score Index of the American Shoulder and Elbow Surgeons and the scoring systems of the University of California at Los Angeles and Constant and Murley¹¹, the results of operative débridement and subacromial decompression are clearly inferior to those of operative decompression and repair of a torn rotator cuff^9,13,19,20.

NOTE: The author thanks Jeffrey A. Russell, M.S., A.T.C., Director of Research, The Joe W. King Research Institute, Texas Orthopedic Hospital, for his help with the statistical analysis.

	Footnotes

 

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Fondren Orthopedic Group, Texas Orthopedic Hospital, 7401 South Main Street, Houston, Texas 77030. E-mail address for Dr. Gartsman: gary@fondren.com.

	References

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