When to Fix a Cuff Tear: Surgical Indications


Chapter 9

When to Fix a Cuff Tear


Surgical Indications



Stephen A. Parada, Josef K. Eichinger, and K. Aaron Shaw

Introduction


A rotator cuff tear (RCT) is a commonly encountered diagnosis that, when symptomatic, can be treated operatively or nonoperatively. Often, it can be an incidental finding on imaging that necessitates no specific management. However, patients are often symptomatic and will require some form of treatment. The majority of patients with an atraumatic RCT will have improved pain and functional scores with a nonoperative treatment regimen. There are patients, however, who are indicated for an acute repair while others may be candidates for surgery if they fail nonoperative treatment or have concomitant injuries that require urgent operative treatment. Rotator cuff repair (RCR), whether performed in an open or an arthroscopic manner, is a widely performed procedure with successful results for the majority of patients, although complications can occur. Proper identification of the patients who should and should not be selected for surgical repair is paramount to obtaining positive results postoperatively.

Clinical Description


Effective treatment of rotator cuff pathology requires an in-depth understanding of the indications for surgical treatment. As shown by Yamaguchi and others, RCTs occur as a natural consequence of aging and as such are frequently asymptomatic and require no treatment. While degenerative/chronic tears of the supraspinatus in older individuals are normal and not necessarily symptomatic, tears of other tendons, particularly those in combination with the supraspinatus, are a frequent source of debilitating pain and dysfunction and require surgical treatment to relieve pain and restore function, particularly in younger patients and those with traumatically induced lesions.

Although there are not many absolute indications for RCR, several general principles should be considered as part of the clinical and shared decision-making for determining optimal treatment. These basic principles are introduced and explored in depth in this chapter.

Which and How Many Tendons


Degenerative tears of the supraspinatus are common in older individuals and increase in incidence by decade of age. Therefore even full-thickness, chronic tears deserve initial conservative treatment as surgical and nonsurgical treatment appear to often result in similar outcomes. Only after a failure of nonsurgical management should surgical treatment be indicated in this scenario.

Tears of the subscapularis are uncommon and usually not well tolerated. Traumatically induced tears, particularly in patients under the age of 60, should be considered for operative repair acutely.

Full-thickness tears of two or more tendons are often not well tolerated and are usually indicated for operative repair, particularly if conservative management is not successful.

Age


Age is an important factor for considering repair. Individuals older than 60–65 years of age are more likely to tolerate mild weakness while younger patients will be unsatisfied with persistent weakness.

Conversely, young patients may have a magnetic resonance imaging (MRI) diagnosis of “partial-thickness” RCTs that may not be clinically relevant. Several studies have shown that a high incidence of rotator cuff disease can be interpreted on MRIs even in young patients.

Onset of Symptoms


Acute RCTs with marked pain, weakness, or motion loss with an absence of prodromal symptoms is a consideration for surgical treatment.

Chronic, long-standing shoulder pain with preserved motion and minimal weakness is consistent with a potential RCT that may be amenable to nonoperative treatment.

Imaging Characteristics


Tendon retraction and size predicts chronicity of injury and reparability. Muscle atrophy and fatty infiltration also predict chronicity and reparability.

Patient and Clinical History





  1. • Acute versus chronic RCTs

  3. • Acute tears generally occur in the setting of a traumatic injury, such as a fall, without any prodromal symptoms of pain or weakness. Patients with chronic RCTs commonly present without a specific traumatic event and have an associated history of chronic pain and dysfunction for months or even years. There are exceptions, as patients may have a tolerable and relatively asymptomatic supraspinatus tear but develop an acute worsening via extension of the tear into the adjacent subscapularis or infraspinatus. These so-called acute-on-chronic RCTs often require treatment because the shoulder loses its ability to compensate for the single tendon cuff tear. Combination tears of two or more tendons are not well tolerated.
  4. • Presenting complaints can include


    1. • Pain with activity that progresses to resting pain.
    2. • Night pain, difficulty sleeping.
    3. • Weakness, especially in the overhead position.
    4. • Inability to raise arm overhead.
    5. • A sense of clicking or catching.
    6. • These complaints are not specific to rotator cuff pathology and may be present in osteoarthritis and adhesive capsulitis.

  6. • Prognostic patient factors that affect outcome


    1. • Smoking: although controversial, smoking has not been shown to be a negative prognostic indicator for healing rates or functional outcomes. Patients should be counseled regarding the potentially negative angiogenic effects of nicotine but this is not currently a specific contraindication as it pertains to RCR.
    2. • Age: age greater than 65 has been associated with higher rates of nonhealing of RCRs. However, age does not appear to have an effect on functional outcomes after RCR. Furthermore, successful results are not predicated on complete healing.
    3. • Workers’ compensation: workers’ compensation status does not have a consistently negative effect on outcomes after RCR. While the presence of workers’ compensation may be a potentially negative prognostic indicator for outcomes after surgery, it is not a contraindication for surgery.

Patient Examination





  1. • The examination of a patient with a RCT must be thorough, rule out other associated pathology that would influence the decision to operate, and elucidate other associated pathology that should be included in the appropriate surgical candidate.
  2. • Inspection


    1. • Should be the initial feature of the physical exam but is often not included due to cultural concerns affecting modesty of patients.
    2. • Proper draping of patients, especially females, can allow modesty and avoid patients becoming uncomfortable, but still allows a thorough examination (Figs. 9.1 and 9.2).
    3. • Atrophy of supraspinatus, infraspinatus, and subscapularis can be noted if present, as can atrophy of the deltoid and the resting position of the scapula (Fig. 9.3).
    4. • Previous surgical incisions and traumatic scars can be noted.

  4. • Palpation


    1. • Palpation of structures can lead to the diagnosis of other sources of pathology that may need to be addressed surgically at the same time as a RCR.
    2. • Specifically, the bicipital groove and the acromioclavicular (AC) joint should be palpated.

  6. • Range of motion (ROM)


    1. • Active ROM should be tested initially and then compared with passive ROM to rule out stiffness.
    2. • The patient should be asked to stand with their feet together if they are able to, which will limit truncal compensation to shoulder motion.
    3. • ROM should be tested and documented with regard to forward elevation, elevation in the plane of the scapula (abduction), and humeral rotation, both with the elbow at the side and while abducted.
    4. • A RCT without associated stiffness should demonstrate equal passive ROM compared with the contralateral side with the exception of greater passive external rotation with a complete subscapularis tear, as there is no longer an internal rotation tethering effect.
    5. • Pseudoparalysis is an important physical exam finding and documents the inability to actively forward elevate more than 90 degrees in the presence of full passive ROM (Fig. 9.4).

  8. • Strength testing


    1. • Strength-testing devices are inexpensive tools to reproducibly quantify muscle strength and compare preoperative and postoperative function, although standard grading of muscle testing can be performed without a specific testing device.
    2. • Strength testing should be completed with forward elevation, external rotation, and internal rotation to test the supraspinatus, infraspinatus, and subscapularis, respectively.




  12. image
    FIG. 9.1 Paper shorts used for examination (A) that are cut with scissors to connect the leg openings (B), which allows the shorts to be used as a “tube-top” that can be worn by female patients under their arms to allow inspection of the entire shoulder girdle (C, D).


  13. image
    FIG. 9.2 A female patient viewed from the posterior aspect wearing the modified paper shorts to allow complete visualization of the shoulder girdle.


  14. image
    FIG. 9.3 View of the posterior aspect of the right shoulder of a patient with atrophy of their supraspinatus and infraspinatus demonstrating the scalloped appearance of their supraspinatus fossa (asterisk) and infraspinatus fossa (arrow head).


  15. image
    FIG. 9.4 A patient who is unable to attain 90 degrees of forward elevation of the right shoulder despite full passive range of motion, otherwise termed “pseudoparalysis.”


  16. image
    FIG. 9.5 The patient in Fig. 9.3 performing the empty can test demonstrating the patient’s arm in 90 degrees of abduction and in 30 degrees horizontal abduction (plane of the scapula) with the thumb pointing downward and then resisting a downward pressure by the examiner.

  17. • Special tests


    1. • A multitude of special tests are available for the clinician to use to help confirm the diagnosis of a RCT and associated pathology.
    2. • They are segregated by the structure they are testing.

  19. • Supraspinatus tendon


    1. • Empty can test, also known as the supraspinatus test or the Jobe test: performed by placing the patient’s arm in 90 degrees of abduction and in 30 degrees horizontal abduction (plane of the scapula) with the thumb pointing downward and then resisting a downward pressure by the examiner. Pain or weakness is a positive test (Fig. 9.5).

    2. image
      FIG. 9.6 The patient in Fig. 9.3 performing the external rotation lag test as the elbow is flexed to 90 degrees and the shoulder is held at 20 degrees elevation in the scapular plane and in maximal external rotation minus 5 degrees by the examiner. The patient is then asked to hold this position as the physician releases the wrist while still maintaining support of the elbow. This patient has a negative lag sign.

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on When to Fix a Cuff Tear: Surgical Indications

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