When to Fix a Cuff Tear
Which and How Many Tendons
Onset of Symptoms
Patient and Clinical History
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When to Fix a Cuff Tear: Surgical Indications
Stephen A. Parada, Josef K. Eichinger, and K. Aaron Shaw
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.
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.
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 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.
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.
Tendon retraction and size predicts chronicity of injury and reparability. Muscle atrophy and fatty infiltration also predict chronicity and reparability.
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