Guest EditorialFrom OT Europe

Seek scientific support for alternative techniques to manage complex rotator cuff lesions

Rotator cuff lesions can be considered complex for a variety of reasons. It might be that previous attempts at repair have been made and failed. Worse still, an infection has occurred as a complication of previous surgery.

After rotator cuff surgery, infection with Cutibacterium acnes should always be considered in patients with otherwise unexplained pain. Alternatively, it might be patient factors that create complexity — the presence of a shoulder arthroplasty, severe comorbidities or the very young patient. Most commonly, lesions are considered complex simply because of their size, with the involvement of more tendons and greater retraction greatly lessening the prospects of successful and durable repair.

With the evolution of arthroscopic techniques of release and reduction, we are getting better at repairing larger tears. Randomized trials that include routine postoperative scans continue to show disappointingly high re-tear rates of up to 30%, despite the baffling observation that patients are still usually symptomatically improved.

David Limb
David Limb

For tears that are simply too large to repair, there are new challenges to the traditional approach of balanced partial repair, which most often aims to restore a functional infraspinatus to provide a force couple with the intact supraspinatus. Under evaluation are numerous materials that can be used to bridge or patch a defect in the cuff or reinforce weak tendon. Some of these are made of artificial materials, such as polyester patches, while other solutions are biological, fabricated from dermis, for example. Encouraging results are in the press, but so are reports that suggest inconsistent results and raised complication rates, with problems such as infection.

For the truly unrepairable rotator cuff, reverse shoulder arthroplasty has transformed our approach in the elderly patient and its use in cuff deficiency accounts for reverse geometry shoulder replacement now being carried out more commonly overall than anatomic shoulder replacement. Yet, this cannot be said to have a place in the young, with the definition of young also being open to debate.

However, new techniques are being evaluated for those patients who are not considered suitable for more traditional tendon transfers. Balloon arthroplasty inserts a biodegradable balloon into the subacromial space, which is inflated with saline between the acromion and humeral head and depresses the head into a biomechanically favorable position. This allows rehabilitation of the remaining anterior and posterior cuff uncompromised by superior migration. The balloon disappears by 6 months, but some published series suggest a lasting benefit.

Superior capsular reconstruction takes a slightly different tack and fixes an artificial or biological material under tension between the superior glenoid and greater tuberosity. The effect is to provide a static restraint to superior subluxation and improve the biomechanics of shoulder elevation. Again, we have some series that suggest there is a benefit, but other series have disappointing failure rates, and we have not yet worked out how to select the most appropriate cases.

Both above alternative techniques, however, these remain untested by randomized trials. It is also true that newly developed techniques such as these derive from an idea by a surgeon, but they are developed by industry and there is a commercial investment to be recouped. We need to remain vigilant to the roles of product champions in promoting such products and approaches and seek out the science to support interventions to which we subject our patients. Presently, a lot of the techniques used to address complex rotator cuff lesions should be carried out as part of a properly constructed trial, or at least as a group audit, and should not be done simply to follow a fashion.

Disclosure: Limb reports no relevant financial disclosures.

Rotator cuff lesions can be considered complex for a variety of reasons. It might be that previous attempts at repair have been made and failed. Worse still, an infection has occurred as a complication of previous surgery.

After rotator cuff surgery, infection with Cutibacterium acnes should always be considered in patients with otherwise unexplained pain. Alternatively, it might be patient factors that create complexity — the presence of a shoulder arthroplasty, severe comorbidities or the very young patient. Most commonly, lesions are considered complex simply because of their size, with the involvement of more tendons and greater retraction greatly lessening the prospects of successful and durable repair.

With the evolution of arthroscopic techniques of release and reduction, we are getting better at repairing larger tears. Randomized trials that include routine postoperative scans continue to show disappointingly high re-tear rates of up to 30%, despite the baffling observation that patients are still usually symptomatically improved.

David Limb
David Limb

For tears that are simply too large to repair, there are new challenges to the traditional approach of balanced partial repair, which most often aims to restore a functional infraspinatus to provide a force couple with the intact supraspinatus. Under evaluation are numerous materials that can be used to bridge or patch a defect in the cuff or reinforce weak tendon. Some of these are made of artificial materials, such as polyester patches, while other solutions are biological, fabricated from dermis, for example. Encouraging results are in the press, but so are reports that suggest inconsistent results and raised complication rates, with problems such as infection.

For the truly unrepairable rotator cuff, reverse shoulder arthroplasty has transformed our approach in the elderly patient and its use in cuff deficiency accounts for reverse geometry shoulder replacement now being carried out more commonly overall than anatomic shoulder replacement. Yet, this cannot be said to have a place in the young, with the definition of young also being open to debate.

However, new techniques are being evaluated for those patients who are not considered suitable for more traditional tendon transfers. Balloon arthroplasty inserts a biodegradable balloon into the subacromial space, which is inflated with saline between the acromion and humeral head and depresses the head into a biomechanically favorable position. This allows rehabilitation of the remaining anterior and posterior cuff uncompromised by superior migration. The balloon disappears by 6 months, but some published series suggest a lasting benefit.

Superior capsular reconstruction takes a slightly different tack and fixes an artificial or biological material under tension between the superior glenoid and greater tuberosity. The effect is to provide a static restraint to superior subluxation and improve the biomechanics of shoulder elevation. Again, we have some series that suggest there is a benefit, but other series have disappointing failure rates, and we have not yet worked out how to select the most appropriate cases.

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Both above alternative techniques, however, these remain untested by randomized trials. It is also true that newly developed techniques such as these derive from an idea by a surgeon, but they are developed by industry and there is a commercial investment to be recouped. We need to remain vigilant to the roles of product champions in promoting such products and approaches and seek out the science to support interventions to which we subject our patients. Presently, a lot of the techniques used to address complex rotator cuff lesions should be carried out as part of a properly constructed trial, or at least as a group audit, and should not be done simply to follow a fashion.

Disclosure: Limb reports no relevant financial disclosures.