Another Option for Irreparable Rotator Cuff Tears

“I’m worried that my rotator cuff may not be repairable: Do I need a shoulder replacement or can it be fixed?”

For people whose rotator cuff problems do not respond to physical therapy, injections or other nonsurgical solutions, the usual answer to the question above was “shoulder replacement.” But we now have promising data on a new way to reconstruct the rotator cuff that preserves good parts of the joint, rather than replacing the entire joint.

The rotator cuff is a set of muscles that attach to the humerus (upper arm bone) and help with shoulder function, including elevation of the arm. A rotator cuff tear can cause pain and weakness in the shoulder. Tears can occur from repetitive rubbing (impingement), degeneration of the tendon or from trauma such as falls or dislocation.

Treatment is dictated by the symptoms and the nature of the tear. Often surgery is not necessary, since many individuals respond well to physical therapy and conservative treatments when the tear is small. Injections with either cortisone or newer biologic injections, such as platelet rich plasma (PRP) or stem cell therapy, can also be effective for small tears. However, sometimes these less invasive treatments fail and surgery is needed.

Surgical repair involves reattaching the rotator cuff tendons back to the bone (humerus). A smaller tear may only need a debridement procedure that smooths and trims the tear. After a period of healing and rehabilitation, most people respond very well and make a good recovery after surgery.

In some cases, the rotator cuff does not heal well or can be re-injured and tear. Patients may continue to have pain or inability to elevate their arm satisfactorily. Re-tear rates are higher when the initial repair is attempted on very large tears, particularly if the tear was chronic.

As we age, the healing response is not as robust, and re-tear rates are higher. Furthermore, trauma after a successfully repaired cuff can result in a re-tear that is then much more challenging to repair. Factors that can result in failure of surgical repair include:

• The patient being older than 65
• Poor quality of the tissue or tendon
• The tear was very large
• Patient does not comply with restrictions post-surgery or rehabilitation.

Are we entering a new era of rotator cuff reconstruction?

Historically irreparable rotator cuff tears were managed with a shoulder replacement (reverse total shoulder) that recreated the fulcrum of the motion of the shoulder joint. However, despite satisfactory outcomes these procedures have their own subset of complications and limitations. One major downside in a person who does not have severe arthritis, is that an otherwise normal joint is replaced because of dysfunction of the muscles. Until recently, there were very few other options for someone with an irreparable rotator cuff tear.

A new technique involving rotator cuff reconstruction (superior capsular reconstruction) with replacement tissue became a viable option instead of replacing the entire shoulder. Recently, data out of Japan showed good outcomes at 5-year follow-up appointments on patients who had undergone superior capsular reconstruction.

This new data has provided optimism for patients with dysfunction of their shoulder due to an irreparable rotator cuff. A superior capsular reconstruction involves placing a tissue graft (either harvested from the patient or from a donor) to replace the function of the rotator cuff.

This can be done arthroscopically, which is a minimally invasive surgery sometimes called keyhole surgery. Arthroscopy is specifically designed for examining the inside of a joint using a thin tube with a camera, an arthroscope. The surgeon can repair the rotator cuff using instruments inserted through the arthroscope.

The potential benefit is that the entire shoulder is not replaced, hopefully preserving the joint while regaining improved function after a period of healing and rehabilitation. The patient usually will have the shoulder immobilized for about 6 weeks in an abduction pillow. This is similar to a sling and keeps the shoulder in an elevated position and prevents it from moving in toward the body, promoting healing.

Passive therapy begins at about week 4 after surgery, with a therapist moving the shoulder to regain full range of motion. After 12 weeks the patient usually can begin doing strengthening exercises.

Not long after superior capsular reconstruction, patients generally report a considerable reduction in pain. They also return to reliable functionality in about three months.