Rotator cuff repair – One step back, two steps forward

Abstract

Rotator cuff tears are one of the more common disorders of the shoulder and increase in incidence with age. There is now good data that there appears to be a natural progression from overuse tendinopathy on the under-surface of supraspinatus that progresses to under-surface partial thickness tear, then a small full thickness tear, then a larger rotator cuff tear and eventually cuff tear arthropathy. The techniques for repairing torn tendons have improved significantly over the last 10 years. When we and others first evaluated our outcomes we were surprised at how poorly they did, from a repair integrity point of view, with over 80% re-tear/failure to heal rate at 6 months. Over the last 10 years we have sequentially adapted techniques (to less invasive) and the rehab programme (to more conservative) to try to improve this outcome and we now have re-tear rates of less than 5%. The factors we found to be important in whether a tear heals or not are related to the tear size; large tears are more likely to re-tear than small tears; patient age, older patients, particularly those over 70, are more likely to re-tear than younger patients; the learning curve of the surgical team, the re-tear rate has improved as an independent factor with surgical experience, and the hospital; procedures performed at public hospitals are more likely to re-tear than those in private day surgery facilities. Other advances have been methods to deal with large tears and missing tendons using synthetic patches to bridge those defects. Reverse total shoulders have been a major innovation in term of dealing with cuff tear arthropathy. There is still much work to be done, in terms of improving methods to treat tendinopathy, small partial thickness tears, and massive rotator cuff tears; but there are more steps forward than backward.