Friday February 23, 1996

New technique improves rotator cuff outcomes

A new treatment for rotator cuff tears returns the majority of patients back to their daily activities quickly, according to a study presented Thursday in scientific exhibit S 52.

Among 86 patients with full thickness rotator cuff tears, orthopaedic researchers repaired the tears but preserved the acromial section of the shoulder blade, part of which is often removed with traditional treatment.

"The new surgical technique speeded recovery time and improved long-term results," said Robert P. Nirschl, MD, MS, associate clinical professor of orthopaedic surgery, Georgetown University, Washington, D.C.

The rotator cuff, comprised of four muscles, helps hold the shoulder together. Workers' and athletes' extensive overhead activity puts a high demand on rotator cuff tendons, causing degeneration, which may trigger a tear.

The injury often occurs in baseball pitchers, people working on conveyor belts, longshoremen, tennis players, etc.

"With our new approach, we also left intact the coracoacromial ligament-a ligament under the collar bone usually resected for this condition," said Dr. Nirschl.

Eighty-three percent of patients experienced minimal or no complaints of pain, weakness or limitation of function. They started rehabilitation exercises three to four days after surgery. Gradual return to activities beyond those of daily living (including tennis) was initiated, on average, at three months. Dr. Nirschl noted that the speed of return to activities is greatly improved over that of traditional surgery.

"Few patients complained of pain or significant tenderness, and range of motion was good," he said. "Seventy percent returned to their pre-injury level of activity without major limitations. Ninety-two percent of overall results were rated good or excellent; 1 percent, fair; and 7 percent, poor. Poor results were most often related to frail, weak tendons unable to hold sutures. Overall patient satisfaction was 93 percent."

In the second part of this study, Dr. Nirschl and colleagues analyzed the medical records of 62 patients (average age: 37.5 years) who had been treated for partial thickness rotator cuff tears between 1989 and 1992.

The acromial part of the shoulder blade and the coracoacromial ligament had also been preserved in this group. Traditionally, these tissues were thought to impinge on the rotator cuff tendons. However, 92 percent of the partial thickness rotator cuff tear patients had a normal coracoacromial ligament and 93 percent, a normal acromion.

"The majority of these tears are related to overuse fatigue failure and subtle shoulder instability," said Dr. Nirschl.

The patients had associated abnormalities accompanying their rotator cuff tears, suggesting etiological factors other than primary impingement in its pathogenesis. Eighty-seven percent of patients had inside tendon tears in an area not subjected to impingement; 90 percent demonstrated injury to the rim of the shoulder socket which is most likely due to instability.

"These results show that tension overload is the major problem, rather than the traditional concept of impingement, where pressure is transmitted from one tissue to the next. Failure occurs first in the tendons, followed by impingement after instability occurs-not the other way around, as commonly thought," Dr. Nirschl said.

Heredity also plays an important role in the quality and durability of tendons; but how a person uses the tendon also influences its condition. One person's tendon wears out at a different rate than the next person's, said Dr. Nirschl, who draws an analogy between tendons and tires.

"Some of us are born with a 60,000-mile tire, others are born with the 30,000-mile kind," he said.

Co-authors of the study with Dr. Nirschl are Eric J. Guidi, MD, and Andrew J. Siekanowicz, MD, both attending orthopaedic surgeons, Arlington Hospital, Arlington, Va.; and Scott W. Organ, MD, attending orthopaedic surgeon, Bristol Hospital, Bristol, Conn.

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Last modified 27/September/1996