Orthopedics

Review Article 

The Role of Partial Rotator Cuff Repairs in Patients With Massive Irreparable Tears Without Arthritis

Katie Thomas, MD; Joseph K. Kendal, MD, MSc; Yohei Ono, MD, PhD; Ian K. Y. Lo, MD, FRCSC; Aaron J. Bois, MD, MSc, FRCSC

Abstract

In patients with chronic massive rotator cuff tears, complete repair is often not achievable or the repair is performed under significant tension with risk of early failure. The goal of a partial rotator cuff repair is to decrease pain, restore force couples, and improve range of motion of the shoulder. A systematic review was performed to assess active range of motion (ie, forward elevation, external rotation), pain, and patient-reported outcome scores after partial repair of massive rotator cuff tears. Significant improvements in forward elevation, visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, and Constant scores were observed, and perioperative complication rates were minimal. Partial rotator cuff repairs remain a viable treatment option in this patient population. [Orthopedics. 2020; 43(1):e1–e7.]

Abstract

In patients with chronic massive rotator cuff tears, complete repair is often not achievable or the repair is performed under significant tension with risk of early failure. The goal of a partial rotator cuff repair is to decrease pain, restore force couples, and improve range of motion of the shoulder. A systematic review was performed to assess active range of motion (ie, forward elevation, external rotation), pain, and patient-reported outcome scores after partial repair of massive rotator cuff tears. Significant improvements in forward elevation, visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, and Constant scores were observed, and perioperative complication rates were minimal. Partial rotator cuff repairs remain a viable treatment option in this patient population. [Orthopedics. 2020; 43(1):e1–e7.]

Massive rotator cuff tears (MRCTs) remain a significant source of shoulder pain and disability. A MRCT is defined as a tear size greater than or equal to 5 cm, a complete tear of at least 2 tendons, or both.1,2 An irreparable tear is defined as a tear that is unable to be repaired to its anatomical position on the bony footprint. In patients with chronic degenerative tears, surgical repair may be complicated by biologic factors such as tendon retraction, muscle atrophy, and fatty infiltration. Collectively, these factors create a challenge in completely relieving shoulder pain and restoring adequate function following surgical repair.3–6

In patients for whom a complete repair is not achievable, a partial repair (PR) can be performed and may lead to favorable results even in cases in which full anatomic restoration is not possible. One theoretical explanation is that a PR may restore the balance between the coronal and sagittal plane force couples of the shoulder.4,7 A PR can be used in relatively higher-demand patients without degeneration of the glenohumeral joint (GHJ) to restore the force couples and preserve the joint, converting a nonfunctional rotator cuff tear into a biomechanically functional tear (Figure 1).8 However, concern remains regarding the overall healing response following a PR, and whether clinical results would persist in the absence of tendon healing. The ability of a PR to stabilize the GHJ fulcrum in true instances of pseudoparalysis and anterior-superior escape, often seen clinically in cases of chronic MRCTs, is also unclear. A treatment alternative in this clinical scenario is a reverse shoulder arthroplasty (RSA), which may help alleviate pain and improve function but has also been associated with a complication rate of up to 20%.9 To correctly identify appropriate patients who may benefit from a PR, it is imperative that clinical outcomes and complications are well understood.

Transverse plane force couple is disrupted due to massive tear involving the posterior rotator cuff: infraspinatus, and teres minor (A). Alternative pattern of disruption of transverse plane force couple due to massive tear involving the anterior rotator cuff: subscapularis (B). [Reprinted from Arthroscopy, 10(4), Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A, Partial repair of irreparable rotator cuff tears, 363–370, 1994, with permission from Elsevier.]

Figure 1:

Transverse plane force couple is disrupted due to massive tear involving the posterior rotator cuff: infraspinatus, and teres minor (A). Alternative pattern of disruption of transverse plane force couple due to massive tear involving the anterior rotator cuff: subscapularis (B). [Reprinted from Arthroscopy, 10(4), Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A, Partial repair of irreparable rotator cuff tears, 363–370, 1994, with permission from Elsevier.]

The purpose of this systematic review was to summarize the reported outcomes and complications following a PR in patients with irreparable MRCTs to further clarify indications for this intervention. The authors hypothesized that pain, American Shoulder and Elbow Surgeons (ASES) scores, and Constant scores would improve following a PR. They also hypothesized that active forward elevation (FE) and external rotation (ER) would be variably affected, depending on the proportion of anterosuperior and posterosuperior tears included in the study population, respectively. They further hypothesized that perioperative complication rates would be minimal, in keeping with an acceptable risk based on the published literature for general arthroscopic procedures in the shoulder.10

Materials and Methods

Search Strategy

A systematic review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.11 The literature search was performed using Medline and Embase databases. The last date of the literature search was December 8, 2018. The search terms used included the following: “massive rotator cuff tear*” OR “irreparable rotator cuff tear*”; “rotator cuff” AND “partial repair.” Inclusion criteria were as follows: level I to IV evidence written in English; MRCTs were clearly defined as 5 cm or greater or a complete tear of 2 or more tendons; the repair was specified as partial; and at least 1 of the primary outcomes of interest (FE, ER, and pain scores) was reported. For the purposes of this study, a tear was considered irreparable if it could not be repaired anatomically to the rotator cuff footprint. Studies were excluded if data included patients with GHJ arthritis (Hamada-Fakuda grade >3)12; repairs with graft augmentation; or PRs that were part of a tendon transfer procedure. Animal and cadaveric studies were also excluded.

The following data were extracted from each study: patient age, sex, dominant arm involvement, mean follow-up, complications, and pre- and postoperative FE, ER, 10-point visual analog scale (VAS) scores for pain, ASES scores, and Constant scores. In the studies by Wellmann et al13 and Jeong et al,14 data were presented in graph format. To include these studies in the analysis, the scales of the graphs were measured and used to extract exact values. In 2 of the studies,12,15 the pain score was reported as part of the Constant score (0 to 15) or modified University of California at Los Angeles (UCLA) shoulder score (Likert scale of 0 to 10). Both pain scores were converted to a 10-point scale (with a lower value representing a favorable outcome) and these values were included in the meta-analysis. For the purpose of this systematic review, complications were defined as any intraoperative or postoperative event that was likely to have a negative influence on the patient's outcome, including infection, shoulder stiffness, failure to heal or a retear of the rotator cuff, neurovascular injury, or reoperation for any reason related to the shoulder.12

Statistical Analysis

Analysis was performed using preoperative and postoperative values, with the improvement calculated as the difference between these 2 values. Values were generated using a 1-sample t test weighted by sample size, as standard deviations were not consistently available. The combined outcomes were estimated means with 95% confidence intervals. The difference was deemed statistically significant if alpha was 0.05 or less.

Results

Study Selection and Characteristics

The search strategy returned 749 Medline and 836 Embase studies. Once duplicates were removed, a total of 927 studies remained. After independent review by 2 investigators (K.T., J.K.K.) for eligibility, 364 studies were excluded by title and 550 by abstract or full-text review, leaving 13 studies (304 cases, representing 304 shoulders) for the final analysis (Figure 2). Three of these studies14–16 implied that there were no patients with arthropathy, but this was not stated explicitly. Therefore, the authors were contacted to confirm that patients did not have arthropathy. Overall, 8 of the studies were level IV evidence, 3 were level III, and 2 were level II (Table 1).

Preferred Reporting Items for Systematic Reviews and Meta-analysis flow diagram presenting the systematic review process used in this study.

Figure 2:

Preferred Reporting Items for Systematic Reviews and Meta-analysis flow diagram presenting the systematic review process used in this study.

Summary of Studies Included in This Systematic Review

Table 1:

Summary of Studies Included in This Systematic Review

Demographic Data

A total of 304 patients (304 shoulders) were included in the final analysis (Table 2). The mean age of the patient cohort was 63.5 years (range, 56 to 75.8 years). The mean clinical follow-up was reported in 10 of the 13 studies and calculated as 35.1 months (range, 18.8 to 71.1 months). Patient sex was reported in 12 of the 13 studies; the calculated mean percentage of female patients was 37.1% (range, 20% to 60%). Hand dominance was reported in 6 studies, with a weighted mean of 75.5% involving the dominant side.

Patient Demographics and Follow-up Data

Table 2:

Patient Demographics and Follow-up Data

Range of Motion

Data on FE were available for 236 shoulders (77.6%). The mean preoperative and postoperative FE values were 128.5° (range, 59.6° to 168°) and 153.7° (range, 140° to 163.6°), respectively. This resulted in a statistically significant improvement of 25.2° (range, −14° to 90.8°) (P=.016) (Table 3). Data on ER were available for 243 shoulders (79.9%).The mean preoperative and postoperative ER values were 43.6° (range, 16.3° to 80.5°) and 47.8° (range, 34° to 83.8°), respectively (Table 3). The mean improvement of 4.2° (range, −6.8° to 18.8°) was not statistically significant (P=.094).

Active Range of Motion, Pain Scores, and Patient-Reported Outcome Scores

Table 3:

Active Range of Motion, Pain Scores, and Patient-Reported Outcome Scores

Pain Scores

Data on VAS pain scores were available for 286 shoulders (94.1%). The mean preoperative and postoperative VAS scores were 5.9 (range, 4 to 9) and 2.5 (range, 1.2 to 6), respectively (Table 3). The mean difference of −3.4 (range, −1.2 to −7.7) was statistically significant (P<.001).

Patient-Reported Outcome Scores

Data on ASES scores were available for 184 shoulders (60.5%). The mean preoperative and postoperative ASES scores were 43.3 (range, 34 to 46.6) and 78.2 (range, 66.6 to 85.7), respectively (Table 3). The mean difference of 35 (range, 20 to 43.9) was statistically significant (P<.001). Data on Constant scores were available for 181 shoulders (59.5%). The mean preoperative and postoperative Constant scores were 53.1 (range, 36.3 to 78) and 72.5 (range, 58.2 to 91), respectively (Table 3). The mean difference of 19.3 (range, 15 to 33.6) was statistically significant (P=.001).

Complications

Eight of 13 studies (61.5%) included in the final analysis reported on whether an intraoperative or postoperative complication was encountered, with a complication rate of 22% (ie, 48 of 218 reported cases experienced 1 or more complications or underwent reoperation) (Table 4). Berth et al17 analyzed the integrity of the repair with ultrasound and found structural failure in 11 of 21 repairs (52.4%). One patient underwent reoperation for persistent postoperative pain (excision of hypertrophic bursal tissue and revision acromioplasty). Mori et al18 analyzed the retear rate with magnetic resonance imaging at final follow-up and found a retear in 10 of 24 patients (41.7%). Similarly, Chen et al19 used magnetic resonance imaging for postoperative evaluation of rotator cuff integrity and found a failure of repair in 15 of 37 patients (40.5%). Duralde and Bair20 reported 2 revisions in their cohort of 25 patients (8% revision rate) following a traumatic injury in 1 patient and an acromioclavicular joint cyst in another patient. Cuff et al4 reported a failure rate of 29% (8 of 28 patients), defined as a postoperative ASES score of less than 70 (3 of 28 patients, 10.7%), inability to achieve FE of greater than 90° (2 of 28 patients, 7.1%) postoperatively, or revision to a RSA (3 of 28 patients, 10.7%). Cavalier et al21 reported a complication rate of 3%, with 1 patient with anchor migration and 1 patient with a postoperative infection. Lo and Burkhart15 and Park et al22 reported no major intraoperative complications and did not comment on postoperative complications. Overall, of the 3 studies that evaluated rotator cuff healing/integrity by means of ultrasound or magnetic resonance imaging following PR, 36 of 82 patients (43.9%) were found to have failure of the repair or a failure of tendon healing.17–19 Of the 8 studies that reported on complications and/or reoperations, 6 of 218 patients (2.8%) underwent reoperation.4,17,20 There were no documented cases of shoulder stiffness or neurovascular injury.

Reported Complications and Reoperations/Revisions Following a Partial Rotator Cuff Repaira

Table 4:

Reported Complications and Reoperations/Revisions Following a Partial Rotator Cuff Repair

Discussion

As hypothesized, performing a PR of a MRCT led to an improvement in postoperative VAS pain scores and patient-reported outcome scores (ASES and Constant scores), whereas ER was variably affected. The latter finding may have been influenced by heterogeneity of tear patterns included in this review and relative preservation of premorbid ER. The authors believe that the improvement observed in active ER would have been significant when isolating tears involving the infraspinatus and teres minor. However, tear pattern was not consistently reported within the included studies, so a subgroup analysis could not be performed. Although significant improvements in active FE were demonstrated, the postoperative change in FE between the included studies was highly variable (range, −14° to 90.8°). The data presented in this study suggest that, in general, this patient population will achieve an improvement in FE after a PR; however, the results are unclear and likely unpredictable in patients with considerable preoperative dysfunction (ie, pseudoparalysis).

In addition, concomitant procedures of the long-head biceps tendon (ie, biceps tenotomy or tenodesis) were not sufficiently reported for subgroup analysis. Therefore, the effects of these procedures on pain scores were not elucidated. Overall, the improvements in range of motion and pain scores observed following a PR would result in adequate function for most activities of daily living.23 Therefore, the data in this review support the theory that a PR can produce favorable functional results in this patient population.

Patients with a MRCT often experience a disruption in the balance of forces acting on the GHJ, which compromises the normal shoulder kinematics and the ability to actively elevate the arm. In the coronal (ie, vertical) plane, the deltoid and supraspinatus are balanced by the portion of rotator cuff inferior to the equator of the humeral head. In the transverse (ie, horizontal) plane, the subscapularis is balanced by the infraspinatus and teres minor.7 When the rotator cable is disrupted, patients commonly lose the ability to elevate the arm to a functional level and are considered to have clinical pseudoparalysis.24 The definition of pseudoparalysis varies in the English literature.25 The presence of true pseudoparalysis and anterosuperior escape has traditionally been an indication for RSA8; however, the potential for PR to restore the balance of forces and stabilize the GHJ suggests that this may be a viable treatment option and an alternative to RSA in patients with a MRCT and pseudoparalysis.24,26

The current data support that a PR remains a viable option for restoring FE in patients with a MRCT when a full repair cannot be adequately achieved.7 However, due to the variability in postoperative FE results between the included studies, this outcome may be less predictable than the other outcomes reported in this review. Although pseudoparalysis was not reported separately in enough studies to be statistically analyzed, Duralde and Bair20 showed that all 6 patients with pseudoparalysis (average preoperative FE of 17.5°) regained FE beyond 90° following a PR; however, this comprised only 2.5% (6 of 236 cases) within the PR group analyzed in this review. Overall, on the basis of the available data, the current authors were unable to conduct a robust analysis of how a PR performs in the setting of pseudoparalysis because the mean preoperative FE in this study group was greater than 90°. Denard et al27 demonstrated consistent reversal of pseudoparalysis, with “complete” repair, in a group of 56 patients with at least 1 year of follow-up. Others have demonstrated similar results (ie, reversal of pseudoparalysis) in patients with MRCTs in the traumatic setting.28 Considering the biomechanical concept of force coupling that may be restored following a PR,7 these results reinforce the current authors' hypothesis that a PR may be a viable treatment option in this subset of patients with pseudoparalysis.

Regarding complications and surgical failures, Cuff et al4 revealed an overall “failure rate” of 29% (8 of 28 cases) at midterm follow-up of at least 5 years (Table 4). In this study, failure was defined as an ASES score of less than 70, loss of active FE of greater than 90°, or revision to RSA.4 Other authors have defined complications radiographically, using either ultrasound or magnetic resonance imaging to assess the integrity or healing rates of the repaired rotator cuff tendon(s), and have reported a retear rate ranging from 40.5% to 52.4%.17–19 A recently performed systematic review aimed to evaluate the reparability, retear rates, and functional outcomes in patients with chronic MRCTs (18 studies and 954 patients included).29 In that study, 81% of patients underwent complete repair and 19% underwent PR; the retear rate was a staggering 79%. Despite this, patients still demonstrated an improvement in active range of motion, pain scores, and Constant scores. Currently, the clinical significance of radiographic retear or a failure to heal is unclear, and the effect of preoperative and postoperative tear size and pattern on patient outcome is also not well described or understood. Overall, the majority of the studies included in this review reported no perioperative complications.

Limitations

This systematic review was limited by the quality of evidence, heterogeneity in reported outcome scores, and the small number of total cases (ie, 304 shoulders) included in the analysis. Sixty percent of the studies included were of level IV evidence, with the majority being case series. Furthermore, the authors did not include a comparator group in their analysis. A preliminary review was performed assessing PR vs RSA in this same patient population; however, the patient populations were rather heterogeneous, limiting the validity of results obtained from any subsequent analysis. An adequate comparator intervention would be that of arthroscopic debridement. One of the included studies did perform a prospective analysis assessing arthroscopic debridement vs PR for MRCT in patients without arthritis.17 Those authors reported comparable improvements in pain and patient satisfaction, but an increased improvement in abduction and Constant scores in the PR cohort, suggesting an advantage of performing a PR in conjunction with arthroscopic debridement. Other authors have similarly found improvements in symptomatic shoulders with irreparable MRCTs without pseudoparalysis or arthritis following biceps tenotomy or tenodesis30 and/or “smoothing of the humeroscapular interface.”31 However, there was insufficient reporting within the studies included in the current review to permit a subanalyses in patients who underwent concomitant debridement or procedures of the long-head biceps tendon. Statistical analysis was limited by the inconsistent reporting of standard deviations; therefore, estimated means were reported.

Conclusion

A partial rotator cuff repair remains a viable treatment option for patients with MRCTs without associated GHJ arthritis or pseudoparalysis, when a complete repair cannot be accomplished. This type of repair results in predictable improvements in pain and patient-reported outcome scores (ASES and Constant scores) and variable improvement in active FE and is associated with a low complication rate. Radiographic evidence of retear is commonly reported, but the clinical significance of this is unknown given the functional improvements that persist following a retear. Prospective studies are needed comparing PR with other surgical options (ie, joint preserving and arthroplasty) to facilitate robust assessment of the optimal management strategies for this challenging patient group. Such studies would enable subanalyses to assess tear type, those with pseudoparalysis, and the clinical consequences of radiographic retear.

References

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  30. Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89(4):747–757.17403796
  31. Hsu JE, Gorbaty J, Lucas R, Russ SM, Matsen FA III, . Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty. Int Orthop. 2017;41(7):1423–1430. doi:10.1007/s00264-017-3486-2 [CrossRef]28455737
  32. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10(4):363–370. doi:10.1016/S0749-8063(05)80186-0 [CrossRef]7945631
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Summary of Studies Included in This Systematic Review

Study (Year)Study Design (Level of Evidence)Study PerspectiveNo. of PatientsMean Age, yMean Follow-up, mo
Burkhart et al32 (1994)Case series (IV)Retrospective145620.8
Lo and Burkhart15 (2004)Case series (IV)Retrospective575.818.8
Duralde and Bair20 (2005)Case series (IV)Prospective256143
Costouros et al33 (2007)Case series (IV)Retrospective460.8NR
Berth et al17 (2010)Cohort (II)Prospective2162.523.8
Buess et al16 (2011)Case series (IV)Retrospective1063NR
Mori et al18 (2013)Cohort (III)Retrospective2465.435.7
Wellmann et al13 (2013)Case series (IV)Prospective386547
Cuff et al4 (2016)Case series (IV)Retrospective2865.271.1
Chen et al19 (2017)Case series (IV)Retrospective3760.329.6
Cavalier et al21 (2018)Cohort (II)Prospective4164NR
Jeong et al14 (2018)Cohort (III)Retrospective2062.831.6
Park et al22 (2018)Cohort (III)Retrospective3763.829.8

Patient Demographics and Follow-up Data

CharacteristicValue
Total patients, No.304
Total shoulders, No.304
Mean age (range), y63.5 (56–75.8)
Mean follow-up (range), moa35.1 (18.8–71.1)
Female, meana37.1%
Dominant arm, meana75.5%

Active Range of Motion, Pain Scores, and Patient-Reported Outcome Scores

OutcomeEstimated Mean (95% Confidence Interval)P

PreoperativePostoperativeChangea
Forward elevation128.5° (110.4° to 146.6°)153.7° (148.2° to 159.2°)25.2° (5.9° to 44.4°).016
External rotation43.6° (30.9° to 56.2°)47.8° (35.6° to 59.9°)4.2° (−0.9° to 9.3°).094
VAS pain score5.9 (4.9 to 6.8)2.5 (1.4 to 3.5)−3.4 (−2.3 to −4.6)<.001
ASES score43.3 (36.3 to 50.2)78.2 (72.8 to 83.7)35.0 (25.5 to 44.5)<.001
Constant score53.1 (36.6 to 69.7)72.5 (60.3 to 84.7)19.3 (12.0 to 26.7).001

Reported Complications and Reoperations/Revisions Following a Partial Rotator Cuff Repaira

Study (Year)Complication(s)Complication/Revision Rate
Lo and Burkhart15 (2004)No major intraoperative complications
Duralde and Bair20 (2005)No deep infections, nerve injuries, or deltoid detachmentRevision rate 8% (1 following a repeat traumatic injury, and 1 for an acromioclavicular joint cyst)
Berth et al17 (2010)Structural failure of repair (defined by US) in 11 of 21 patients Reoperation (excision of hypertrophic bursa and revision acromioplasty) in 1 patient for persistent pain52.4% failure of repair on US
Mori et al18 (2013)No intraoperative or perioperative complications Retear (defined by MRI) in 10 of 24 patients41.7% failure of repair on MRI
Cuff et al4 (2016)No intraoperative or postoperative complications 8 patients with postoperative “failure” during follow-up:

3 patients: ASES score of <70

2 patients: active elevation <90°

3 patients: underwent revision to RSA

29% postoperative failure 10.7% revision to RSA
Chen et al19 (2017)“Failed repair” (defined by MRI) in 15 of 37 patients40.5% failure of repair on MRI
Cavalier et al21 (2018)Anchor migration—1 patient Postoperative infection—1 patient3%
Park et al22 (2018)No complications related to the operation occurred
Authors

The authors are from the Department of Surgery (KT, JKK, YO, IKYL, AJB), Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada; and the Department of Orthopaedic Surgery (YO), Nagoya University Graduate School of Medicine, Nagoya, Japan.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Katie Thomas, MD, Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada ( katie.thomas2@ucalgary.ca).

Received: January 25, 2019
Accepted: April 09, 2019
Posted Online: November 08, 2019

10.3928/01477447-20191031-05

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