Irreparable Rotator Cuff Tears

 

IRREPARABLE TENDON TEARS OF THE ROTATOR CUFF
 

                        An Owner’s Manual

 

Why is a Rotator Cuff Tendon Tear Irreparable?
Tendons that are torn chronically (over many months or years) may become irreparable through several mechanisms. First, the tendon tissue becomes thin, weak, and tears easily when the surgeon attempts a repair. Second, the muscle to which the tendon is attached becomes atrophied (smaller) and it actually changes in terms of its internal structure. Normal muscle is composed of small bands called muscle fibers. These are the parts of the muscle which contract and create the power of the muscle. As the muscle contracts it shortens and pulls on the tendon which is attached to bone. This makes the joint move. The power which is created depends on the ability of the muscle to contract and shorten. When the tendon is torn chronically the muscle actually loses this ability as it becomes fibrotic (scarred) and infiltrated with fat. Therefore, it is no longer a powerful muscle that can contract and create joint movement.

 

 

 

What are the Treatment Options?

 

1.      Physical Therapy:

 
In patients who have weakness which is not severe, physical therapy may improve pain and function by maximizing effectiveness of remaining muscles of the rotator cuff. Some patients actually may improve so they can place their hands overhead and have minimal pain.
 

2.      Arthroscopic Debridement & Biceps Tenotomy:

 
Arthroscopy allows access to the shoulder joint through small incisions and may be performed as an outpatient procedure. Debridement means removal of loose tendon tissue and inflamed bursa which may be rubbing and causing pain. The biceps tendon is also often degenerated and as it slides up and down in the front of the shoulder it may be a cause of pain. Release of this tendon has been shown to relieve pain in many cases and its release does not compromise shoulder function.
 

3.     Arthroscopic partial repair and release of the    suprascapular nerve:

 
In some patients the suprascapular nerve may be tethered by retraction of the rotator cuff tendon tear. It’s release and a partial repair of the rotator cuff in the back (posterior) shoulder has been shown to give relief of pain and improve function in select patients. The nerve may also be decompressed where it runs underneath a tight ligament into the shoulder.

 

 

4.      Tendon Transfer:

 
This is a relatively rare procedure reserved for those patients who are too weak for one of the above options to be effective, but not so severely disabled as to need a reverse prosthesis (described below).
 
This procedure when performed for loss of the supraspinatus and infraspinatus involves transfer of the latissimus dorsi tendon from the back of the shoulder so that it can now substitute in function for the rotator cuff. This requires an incision in the back of the shoulder as well as the top of the shoulder.

 

 

 

Latissimus Transfer: How well does it work:

Patient Before (massive rotator cuff tear) and 3 years after a latissimus dorsi transfer for an irreparable, massive rotator cuff tear.

 75-80% patient satisfaction after the surgical procedure

 

A few comments about Latissimus Dorsi Tendon Transfer:
1.   It is necessary to wear a special brace to keep the arm in a position away from the side so the tendon transfer can heal over 6 weeks

2.   A prolonged therapy program is required after surgery in order to train the tendon to function properly. This includes Biofeedback training

3.   The gains from the tendon transfer procedure may take up to one year to realize.

 

Tendon Transfer for Irreparable Subscapularis Tendon Tear:

In these cases, the rotator cuff tendon in the front of the shoulder is torn and irreparable. In some cases, transfer of the pectoralis major muscle will improve function and alleviate pain.

 

 

5.     Reverse Prosthesis:

 
In patients with an irreparable rotator cuff tendon tear and weakness so severe that it is similar to a paralysis of the arm, a reverse prosthesis can be placed, which will not only facilitate improvement of motion, but also relieve pain. Details of this procedure are provided here: Reverse Prosthesis. This procedure basically provides a fixed fulcrum for rotation of the arm by reversing the position of the ball and the socket.

 

 

Sometimes a tendon transfer may be combined with a reverse prosthesis in order to improve motion. This video demonstrates a patient with poor function due to a massive rotator cuff tear and also arthritis. She had a reverse prosthesis with a latissimus dorsi, teres major tendon transfer and had an excellent outcome.

Irreparable Rotator Cuff Tendon Tear (Before and After)

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