Irrepairable tears - and how to fix them!
Much is written about the problem of irrepairable rotator cuff tears, particularly with young and active patients. However, what is less clear is what makes a tear irreparable.As with a car, have a smash and one auto-shop will say it's beyond repair, whereas another might have a way of economically fixing the damage to where you have a usable vehicle again.
Having retorn my rotator cuff in the same shoulder more than once, I have been told by some surgeons that what I have is irreparable, so this motivated me to understand why. Turns out it's not simple.
The classic definition of an irreparable rotator cuff tear is a tear that is large enough that the muscle has actually retracted and can no longer be pulled or stretched close enough to the bone to anchor it back down again. Typically, this means that:
- The tendon on the end of the muscle is either withered, scarrey or there is little of it there
- The muscle is weakened and atrophied with fatty infiltration
- There is a gap of 3cm or more between the remaining tendon ends and their origin on the bone
The Boston Shoulder Institute decribe this here: http://bostonshoulderinstitute.com/patient-resources/modules/irreparable-rotator-cuff-tears/
The thinking here is that the tendon is of insufficient quality to effect a repair that would heal - and even if it could be reattached and it did heal, the muscle is unlikely to be able to contract powerfully enough to stabilise the glenohumeral joint. So we leave it alone.
However, what if the patient is 30 years old, has suffered a traumatic injury, torn their rotator cuff to 3cm or more and has been in this condition for long enough for muscle atrophy to begin? Do we wright them off as irreparable? Some surgeons do, but at 30 years of age, options are limited.
The last resort for these kinds of tears is a reverse shoulder replacement in which the ball and socket is switched for a socket and ball and the rotator cuff is done away with - the deltoid does all the work. Given the life span of a replacement like this is about 15 years, this doesn't present a great outlook for our younger, active patient. Reverse shoulder replacements are indicated for the older population of 70 years or more and are not without their own unique issues and complications i.e. they are not well suited to the younger active patient
It is this particular group of patients that may benifit from an allograft (such as GraftJacket) used as an interposition graft.
An interposition graft is one where the graft or patch is used to bridge a gap or hole in the rotator cuff tendon, effectively replacing tendon tissue that is not there anymore. This is in contrast to the augmentation approach which is where the graft is placed over a conventional repair in order to reinforce it and help it heal. The interposition approach is only used when the existing cuff cannot be bought back to it's original footprint on the bone without undue tension, which would cause imbalance in the cuff.
A few surgeons are doing interposition grafts on shoulders in the UK - four of them in Leicester and one in Cambridge. There are a few more doing this in the United States and in other countries, but when looking for a surgeon who is doing this, it is important to ask whether they have performed these repairs using the interposition approach, because not all do; some will only have experience of the augmentation style of graft repair.
