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2015 ; 6
(11
): 902-18
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Rotator cuff tears: An evidence based approach
#MMPMID26716086
Sambandam SN
; Khanna V
; Gul A
; Mounasamy V
World J Orthop
2015[Dec]; 6
(11
): 902-18
PMID26716086
show ga
Lesions of the rotator cuff (RC) are a common occurrence affecting millions of
people across all parts of the globe. RC tears are also rampantly prevalent with
an age-dependent increase in numbers. Other associated factors include a history
of trauma, limb dominance, contralateral shoulder, smoking-status,
hypercholesterolemia, posture and occupational dispositions. The challenge lies
in early diagnosis since a high proportion of patients are asymptomatic. Pain and
decreasing shoulder power and function should alert the heedful practitioner in
recognizing promptly the onset or aggravation of existing RC tears.
Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over
the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and
develop distinct chronic pathological changes due to muscle retraction, fatty
infiltration and muscle atrophy. These lead to a reduction in tendon elasticity
and viability. Eventually, the glenohumeral joint experiences a series of
degenerative alterations - cuff tear arthropathy. To avert this, a vigilant
clinician must utilize and corroborate clinical skill and radiological findings
to identify tear progression. Modern radio-diagnostic means of ultrasonography
and magnetic resonance imaging provide excellent visualization of structural
details and are crucial in determining further course of action for these
patients. Physical therapy along with activity modifications, anti-inflammatory
and analgesic medications form the pillars of nonoperative treatment. Elderly
patients with minimal functional demands can be managed conservatively and
reassessed at frequent intervals. Regular monitoring helps in isolating patients
who require surgical interventions. Early surgery should be considered in
younger, active and symptomatic, healthy patients. In addition to being
cost-effective, this helps in providing a functional shoulder with a stable cuff.
An easily reproducible technique of maximal strength and sturdiness should by
chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with
debridement while more severe lesions mandate repair either by trans-tendon
technique or repair following conversion into FTT. Early repair of repairable FTT
can avoid appearance and progression of disability and weakness. The choice of
surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the
current scenario. The double-row repairs have an edge over the single-row
technique in some patients especially those with massive tears. Stronger,
cost-effective and improved functional scores can be obtained by the former. Both
early and delayed postoperative rehabilitation programmes have led to comparable
outcomes. Guarded results may be anticipated in patients in extremes of age,
presence of comorbidities and severe tear patters. Overall, satisfactory results
are obtained with timely diagnosis and execution of the appropriate treatment
modality.
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