for Conservative Treatment

Reparable tears

General factors

Age > 72 years

Insulin-dependent diabetes

Poorly controlled hypertension longtime hypercholesterolemia

Smoking habit

Alcoholic patients

BMI ≥30 and ≤ 20

Cancer

Severe heart and lung diseases

Recent sepsis

Coagulation diseases

Neurological deficits resulting from brain disorders

Local factors

Concentric shoulder arthropathy

Scapular dyskinesis

Stiff shoulder

Supero-laterally inserted pace maker

Local dermatological diseases

Irreparable tears

General factors

Age >85 years (see general factors for reparable tears)

Local factors

Patients without arthropathy, scarce shoulder pain, with chronic rupture of the LHBT and preserved shoulder movement

Supero-laterally inserted pace maker

Local dermatological diseases

In my opinion, there are general and local factors that may contraindicate the arthroscopic or open repair of a full-thickness cuff tendon tear.

General Factors

The ensuing factors may definitively or temporarily contraindicate the surgical treatment.

Age

The age range to be considered the borderline for the choice of treatment is between 70 and 72 years (Fig. 1). Usually, surgical indication for older patients is not recommendable. The choice is motivated by the fact that elderly patients have one or more general or local factors that contraindicate surgery. The preceding indication does not change even for >72 year-old patients who are biologically young and are sportspeople.

Fig. 1

A 77-year-old male patient with massive reparable rotator cuff tear of both shoulders (forward flection and abduction: 135°; external rotation: 25°; internal rotation T12). Bilateral muscular hypotrophy. He has a slight bilateral shoulder pain and his daily activity is only scarcely compromised. A conservative treatment was suggested

Comorbidities

Only rarely does rotator cuff tear depend on extrinsic factors (hooked acromion, acromioclavicular spurs, acromial anti-tilting); most frequently, the tendon lesion is the result of tissue degeneration caused by systemic diseases that alter the peripheral microcirculation. Therefore, all those diseases that reduce the arterioles and capillaries caliber, and that consequently decrease the normal vascular supply, can represent a contraindication for the repair.

According to consistent observation, patients with large or massive rotator cuff tear and with: (a) insulin-dependent or not well-controlled diabetes; (b) poorly manageable blood hypertension; and (c) uncontrolled hypercholesterolemia are candidates to the conservative treatment. In fact, possibility that patients may experience a postoperative early recurrence of the lesion is very high. For the same reason, doubts arise when operating on patients with BMI ≥30. These patients often suffer from one or more of the abovementioned diseases (Fig. 2). In addition, the arms of the obese are very heavy. This increases the difficulties they have in raising the involved upper limb during the assisted and/or self-managed rehabilitation program. All of abovementioned facts expose the patient to develop a stiff shoulder.

Fig. 2

Prototype of a patient to which a conservative treatment should be proposed: BMI >30; alcoholic, smoker, with hypercholesterolemia, blood hypertension, and diabetes

Paradoxically, even excessively skinny patients (BMI ≤20) may be candidates to conservative treatment. In my experience, the patients with poorly represented musculature, for example, adult patients with anorexia, have enormous difficulties following a proper rehabilitation program and not only for psychological disorders (Fig. 3). Even in these cases, the percentage of postsurgical shoulder stiffness is very high.

Fig. 3

A 56-year-old patient with a large rotator cuff tear of his left shoulder. He was considered excessively skinny. Furthermore, a pacemaker was applied on the same side of the involved shoulder. A conservative treatment was proposed

The patients who are heavy smokers (>20 cigarettes per day for more than 10 years), older than 55 years, cannot be considered candidates for surgical repair. Not only does cigarette smoking predispose to cuff tear (peripheral microcirculation disorders) [1], but it also affects the cuff tear size [2]. Similar considerations may be done for alcoholics [3]. Preemptive patient information on the choice of conservative treatment is justified by the high percentage of re-rupture after surgery.

Obviously, the surgical treatment is not recommendable in patients with severe heart or lung disease, with cancer, recent sepsis, coagulation diseases, and in patients with neurological deficits resulting from brain disorders. During the clinical evaluation, the patients are always asked if they are smokers, have a cough, and if they have recently noted change of voice. In doubtful cases, a chest X-ray should be prescribed, and the patient is sent to a respiratory physician, especially if an exophthalmos occurred.

Only gold members can continue reading. Log In or Register to continue