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CURRENT CONCEPTS
Second Thoughts on the Necessity to Repair Small or Medium Size Tears of Rotator Cuff–A Clinical Perspective
Nahum Rosenberg, MD
Shoulder Service, Rambam – Human Health Campus, Haifa, ISRAEL
Suhail Karkabi, MD
Shoulder Service, Rambam – Human Health Campus, Haifa, ISRAEL
In young, healthy individuals, the rotator cuff tendons are exposed to high tensile forces without failing or losing their structural integrity. With age, these tendons are weakened by degeneration, loose their tensile strength, and may tear. Additionally, the cuff tendons might degenerate with excessive repetitive mechanical strain. Partial- and full-thickness tears result and, when the tear is large enough, proximal migration of the humeral head might occur causing a secondary subacromial impingement.
Due to increasing use of arthroscopy in the treatment of shoulder disorders, tears of the rotator cuff have been thoroughly documented and described. The management of rotator cuff tears has subsequently been defined according to tear size, patient age and activity level, and tear etiology.
Operative treatment is usually directed at sub- acromial decompression and rotator cuff repair. However, there is evidence that shows that this combined approach is not always necessary. A correlation has been shown between the success of subacromial decompression and the size of the rotator cuff tear. In this report, patients with small tears demonstrated 90% good functional results, while only 50% of good results were achieved when tears were larger than 2 cm. Similarly, another report demonstrated 50% good results after arthroscopic debridement without repairing the cuff tear. In contrast, in a study on the comparison between
arthroscopic decompression without cuff repair and open repair of the torn rotator cuff, patients who were treated with arthroscopic decompression alone had less satisfactory results than those who had repair. In that report, 78% of patients who had repair of the cuff with subacromial decompression had satisfactory functional outcome in comparison to 61% in patients treated with arthroscopic subacromial decompression alone.
We showed that in 96% of 160 elderly patients with small or moderate tears of the supraspinatus who were treated by subacromial decompression without repairing the cuff achieved a satisfactory postoperative functional outcome. Another analysis of 210 elderly, less active, low-demand patients over 60 years of age treated by arthroscopic acromioplasty alone showed that decompression, without cuff repair, is an effective method of treatment for their shoulder pain and limitation of function.
The postoperative management of the patients after acromioplasty alone is less demanding because there is no need to immobilize the shoulder to protect the repaired cuff. This allows immediate mobilization and earlier return of function, which is a great advantage for the elderly patient. We believe that for certain patients over 60 years of age, pain relief and sufficient shoulder function can be achieved by subacromial decompression alone, providing there is clear evidence of a supraspinatus and infraspinatus tear less than 3 cm. This clinical approach reduces the peri-operative risks and facilitates the rehabilitation in such patients.
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32 ISAKOS NEWSLETTER 2015: Volume II