Shoulder & Elbow Clinical Paper
Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion

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Background

Management of massive chronic rotator cuff tears remains controversial, with no clearly defined clinical presentation as yet. The purpose of the study was to evaluate the effect of tear size and location on active motion in patients with chronic and massive rotator cuff tears with severe muscle degeneration.

Methods

One hundred patients with massive rotator cuff tears accompanied by muscle fatty infiltration beyond Goutallier stage 3 were prospectively included in this study. All patients were divided into 5 groups on the basis of tear pattern (supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor). Active range of shoulder motion was assessed in each group and differences were analyzed.

Results

Active elevation was significantly decreased in patients with 3 tear patterns involved. Pseudoparalysis was found in 80% of the cases with supraspinatus and complete subscapularis tears and in 45% of the cases with tears involving the supraspinatus, infraspinatus, and superior subscapularis. Loss of active external rotation was related to tears involving the infraspinatus and teres minor; loss of active internal rotation was related to tears of the subscapularis.

Conclusions

This study revealed that dysfunction of the entire subscapularis and supraspinatus or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis or involvement of more than 2 rotator cuff muscles.

Section snippets

Patient selection

Between March 2008 and April 2011, all patients with a rotator cuff tear evaluated in a shoulder clinic were considered potentially eligible for inclusion in this prospective study. Patients with rotator cuff tears defined as 2 or more tendons, with muscle fatty infiltration beyond grade 3 diagnosed by computed tomography (CT) arthrography according to Goutallier's criteria, were included in the study.17 To ensure that the tendon was nonfunctional, fatty infiltration beyond grade 3 was used as

Results

The study inclusion criteria were met by 112 patients; 12 patients were excluded from the study because of incomplete documentation, and no patients declined to participate. Thus, 100 patients (50 men and 50 women) with a mean age of 67.7 ± 8.2 years (range, 50-84 years) were available for the analysis. Baseline characteristics are summarized in Table I.

The average κ value for interobserver agreement of fatty infiltration evaluation by the Goutallier system was 0.92, representing a good

Discussion

The ideal management of massive chronic rotator cuff tears remains controversial. Multiple treatment options have been proposed without any consensus.1, 16 Several factors may contribute to this lack of consensus. First, the definition of a “massive” tear has not yet been clearly standardized. Cofield et al6, 7 defined massive tears as >5 cm in either the anterior-posterior or medial-lateral dimension, whereas Gerber et al14 defined massive as a complete tear of at least 2 tendons. In the

Conclusions

This study suggests that dysfunction of the entire subscapularis or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis tendon or involvement of more than 2 rotator cuff muscles.

Acknowledgment

Editorial assistance was provided by Mark English, PhD, of BellBird Editing.

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

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    The Institutional Review Board of the ethical committee of the Hôpital Privé Jean Mermoz and the Centre Orthopédique Santy approved this study.

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