Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53 DOI 10.1007/s12306-014-0320-5
ORIGINAL ARTICLE
Irreparable rotator cuff tears: a novel classification system R. Castricini • M. De Benedetto • N. Orlando E. Gervasi • A. Castagna
•
Received: 18 January 2014 / Accepted: 26 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Irreparable rotator cuff tears can be managed by several approaches. However, current tear classifications fail to reflect the wide variety of their presentation, which has important clinical and prognostic implications. Methods We describe a novel classification system based on preoperative imaging findings and intraoperative observation where each cuff tendon (numbered sequentially: 1-supraspinatus, 2-infraspinatus, 3-teres minor, and 4-subscapularis) is assessed intraoperatively for reducibility to the footprint; tendons with reparable lesions are assessed for fatty degeneration (which predicts healing potential) and given a plus if degeneration is\50 % (Fuchs stage I–II/Goutallier stage 0–II) or a minus if it is C50 % (Fuchs stage III/Goutallier stage III–IV). Results The proposed system (1) allows more consistent and reproducible classification of cuff tears where at least one tendon is irreparable; (2) results in more accurate diagnosis; (3) guides in treatment selection; and (4) ensures better outcomes and realistic patient expectations.
R. Castricini (&) M. De Benedetto N. Orlando Department of Orthopaedic and Trauma Surgery, Casa di Cura Villa Verde, Fermo, Italy e-mail: [email protected] E. Gervasi Department of Orthopaedic and Trauma Surgery, Ospedale Civile, Latisana, Italy A. Castagna Unit of Shoulder Surgery, Istituto Clinico Humanitas, Rozzano, Italy
Conclusions The novel classification system can contribute to develop increasingly exhaustive and reproducible classification models. Keywords Irreparable rotator cuff tear Rotator cuff tear Fatty infiltration
Introduction An irreparable rotator cuff tear (RCT) is one where size and degree of tissue retraction prevent reduction to the footprint even using tissue mobilization and release techniques [1–3]. Irreparable RCTs are characteristic of the late phase of the natural history of rotator cuff tendinopathy, which progresses in terms of tear size and symptom severity and is associated with irreversible muscle atrophy, fatty degeneration and muscle–tendon retraction [4–8]. In routine surgical practice, irreparable lesions account for up to 30 % of RCTs [9]. Eighty five out of 900 (9.4 %) RCTs managed arthroscopically at a single centre by one of the authors (RC) between January 2012 and December 2013 exhibited at least one irreparable tendon (unpublished data). Since RCTs may involve strength loss and shoulder dysfunction, clinical symptoms are extremely variable, ranging from absent or mild symptoms to severe disability and pain [10]. A number of radiological criteria have been proposed to define irreparable RCTs: reduction of the acromion-humeral space to \6 mm on X-rays [11, 12]; tendon retraction (Patte stage III) [13]; fatty degeneration (Goutallier stage III–IV) assessed on CT and MRI [14, 17]; and muscle belly atrophy (Thomazeau stage III) [18].
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An irreparable RCT (for instance of the supraspinatus) is usually associated with lesion of an adjacent tendon that may be irreparable or reparable. Reparable RCTs have variable healing potential. The risk of re-rupture has thoroughly been explored and found to depend on a number of factors that include age, tear size, repair technique used, inappropriate rehabilitation, muscle atrophy and fatty degeneration; nonetheless, outcome prediction is still inaccurate [15, 17, 19, 20]. The presence and severity of fatty infiltration have been associated with older age, tear size, degree of tendon retraction, number of tendons involved (i.e., massive tears), suprascapular neuropathy and traumatic tears [7]. Since an increased amount of fat in the muscle belly enhances the risk of failure, only low-grade infiltration (Goutallier stage I–II) of the infraspinatus and subscapularis is consistent with satisfactory healing rates [14, 15, 21]. Interestingly, Chillemi et al. [22] reported that re-rupture may reflect failed healing of the reinserted tissue. A number of different approaches are available to manage irreparable RCTs: conservative treatment, arthroscopic debridement, partial cuff repair, tendon transfer, arthroplasty, tissue interposition arthroplasty, augmentation procedures and pain-relieving LHB tenotomy [23–29]. However, such broad range of available treatments is not paralleled by diagnostic approaches offering precise and exhaustive information. Moreover, the description, functional impact and healing potential of irreparable RCTs are still inadequately investigated, and their current distinction into posterosuperior and anterosuperior is felt by many to be insufficient to base a therapeutic strategy capable of providing reasonable outcome expectations [10]. Despite the significant clinical and prognostic implications of their widely variable patterns, there are, to the best of our knowledge, no classifications specifically addressing irreparable RCTs. We describe a novel system devised to provide accurate tear diagnosis, enable consistent classification and guide the surgeon in selecting the most appropriate treatment approach.
Materials and methods The proposed system is based on preoperative MRI findings and intraoperative observation. Rupture is defined as irreparable if intraoperative tissue mobilization and release techniques cannot achieve tendon reduction to its footprint, as described by Curtis et al. [30]. Within the proposed system, the status of each rotator cuff tendon is described in terms of integrity/tearing and amenability to repair based on grade of fatty degeneration. The tendons are numbered sequentially: 1, supraspinatus;
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Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53 Fig. 1 Scheme demonstrating irreparable rotator cuff tears described according to the proposed classification system
2, infraspinatus; 3, teres minor; and 4, subscapularis. Tearing is described as follows: an intact tendon is graded as 0; a torn but reparable tear with good healing potential (Fuchs stage I–II/Goutallier stage 0–II) is given a plus sign (?); a torn but reparable tendon with poor healing potential (Fuchs stage III/Goutallier stage III–IV) is assigned a minus sign (-); and a torn but irreparable tendon is merely indicated by tendon number [6, 16]. A formula describing the state of each tendon is thus generated intraoperatively for each patient as shown in Fig. 1. For the sake of simplicity, intact tendons may be omitted. The system allows describing the great variability of possible irreparable RCTs with a practical, informative and immediate formula.
Results In the proposed system, an irreparable supraspinatus lesion associated with a reparable lesion of the infraspinatus showing good muscle trophism (Fuchs stage I–II) without further cuff lesions is reported as 1,2?. This condition is frequently managed by partial cuff repair and infraspinatus reinsertion. An irreparable tear of the supraspinatus and infraspinatus without additional cuff lesions is described as 1,2. This type of RCT is frequently managed by latissimus dorsi transfer. An irreparable tear of the supraspinatus and subscapularis is described as 1,4. Pectoralis major transfer often provides satisfactory results for this condition. The proposed system allows describing a large number of lesion types, as exemplified in Table 1.
Discussion and conclusions A variety of treatment approaches are available to manage irreparable RCTs. Yet current classification systems do not adequately reflect the extreme variability of their presentation in terms of topography, size and healing potential; the resulting joint dysfunction also induces variable clinical consequences.
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Table 1 Some typical patterns of irreparable rotator cuff tears Lesion type
Lesion characteristics
1,2?
Irreparable supraspinatus rupture, reparable infraspinatus tear with good healing potential
1,2
Irreparable tear of supraspinatus and infraspinatus
1,2,4?
Irreparable tear of supraspinatus and infraspinatus, reparable subscapularis tear with good healing potential
1,4
Irreparable tear of supraspinatus and subscapularis
1,2-
Irreparable supraspinatus tear, reparable infraspinatus tear with poor healing potential
Treatment selection would greatly benefit from a more accurate diagnostic picture. The proposed classification is based on objective intraoperative findings; it describes a rotator cuff where at least one tendon is irreparable and assesses the state and healing potential of the other tendons based on preoperative imaging findings (MRI) and intraoperative observations. A number of RCT classifications have been described in the literature, none, however, specifically addressing irreparable RCTs. With regard to size, a massive rupture is one involving at least two tendons [31] or measuring more than 5 cm [2]; the addition of localization data can make it a massive posterosuperior or anterosuperior RCT [32]. Massive tears are more complex to treat than small lesions, and outcomes are less predictable; failure rates up to 94 % have been reported [33, 34]. Massive tears may be irreparable if tissue retraction has made the muscle–tendon unit stiff and poorly mobile. Goutallier and colleagues identified fat infiltration as a critical parameter in preoperative planning and correlated five CT stages of fatty degeneration to tendon repair capacity [14]; Fuchs et al. [16] subsequently applied Goutallier’s classification system to MRI, reducing the five CT stages to three MRI stages. Although currently employed, the distinction between posterosuperior and anterosuperior RCTs is felt by many to be insufficient [10]. These lesions should be further explored also in relation to the advances made in shoulder joint biomechanics and to the growing interest attracted by the teres minor and the subscapularis, especially its inferior third [10, 35, 36]. The classification system proposed by Davidson and Burkhart, based on tear size measured on MRI, correlates tear pattern to the most appropriate treatment. Although their approach is useful and innovative, it does not allow accurate description of massive contracted RCTs, since the authors do not provide further information on this lesion type [37].
Fig. 2 Irreparable supraspinatus and infraspinatus tear (1,2 tear according to the proposed classification)
The 4D code devised by Lafosse et al. [38] provides an original contribution that addresses RCT patterns not only preoperatively but also intra- and post-operatively. However, their description of irreparable RCTs is different and more complex and has been developed for other purposes. The decision to perform a latissimus dorsi transfer rather than a partial cuff repair may generate confusion if treatment selection is merely based on a ‘massive irreparable posterosuperior cuff tear’, because current approaches do not envisage providing additional information such as the number of irreparable tendons, tear size or the tissue quality of the other tendons. A 1,2 RCT (Fig. 2) and a 1,2? RCT are both irreparable, but they have quite different features and healing potential. The proposed system thus provides for clearer RCT classification, simpler treatment selection and more reliable outcome evaluation. Its main limitation is the fact that it is based on intraoperative assessment, even though evaluation of residual tissue plasticity and direction of tendon reduction are currently not feasible preoperatively. Another limitation is the fact that associated lesions must be described separately. We believe that the proposed system contributes to the development of increasingly exhaustive and reproducible classification models. It allows for more precise and consistent classification of RCTs, where at least one tendon is irreparable, than is currently possible. By providing for more accurate diagnosis and treatment indications and guiding the surgeon in the selection of the most suitable management approach, it also ensures better outcomes and more realistic patient expectations. Further research is clearly required to assess the correlation between tear type and clinical and diagnostic imaging findings. Acknowledgments The authors are grateful to Dr. S. Modena for the language revision (www.silviamodena.com).
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S52 Conflict of interest Roberto Castricini, Massimo De Benedetto, Nicola Orlando, Enrico Gervasi, Alessandro Castagna declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.
References 1. Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr (1995) De´bridement of degenerative irreparable lesions of the rotator cuff. J Bone Jt Surg Am 77:857–866 2. Cofield RH (1985) Rotator cuff disease of the shoulder. J Bone Jt Surg Am 67(974–9):3 3. Warner JJ (2001) Management of massive irreparable rotator cuff tears:the role of tendon transfer. Instr Course Lect 50:63–71 4. Nakagaki K et al (1996) Fatty degeneration in the supraspinatus muscle after rotator cuff tear. J Shoulder Elb Surg 5(3):194–200 5. Goutallier D, Patte D (1990) Assessment of the trophicity of the muscles of the ruptured rotator cuff by CT scan. In: Post MB, Hawkins RJ (eds) Surgery of the shoulder. Mosby, St Louis, pp 11–13 6. Kang JR, Gupta R (2012) Mechanisms of fatty degeneration in massive rotator cuff tears. J Shoulder Elb Surg 21(2):175–180. doi:10.1016/j.jse.2011.11.017 7. Kuzel BR, Grindel S, Papandrea R, Ziegler D (2013) Fatty infiltration and rotator cuff atrophy. J Am Acad Orthop Surg 21(10):613–623. doi:10.5435/JAAOS-21-10-613 8. Gladstone JN, Bishop JY, Lo IK, Flatow EL (2007) Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med 35(5):719–728 9. Warner JJ (2001) Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect 50:63–71 10. Dines DM, Moynihan DP, Dines J, McCann P (2006) Irreparable rotator cuff tears: what to do and when to do it; the surgeon’s dilemma. J Bone Jt Surg Am 88:2294–2302 11. Hamada K, Fukuda H, Mikasa M, Kobayashi Y (1990) Roentgenographic findings in massive rotator cuff tears: a long-term observation. Clin Orthop Relat Res 254:92–6 12. Werner CM, Conrad SJ, Meyer DC, Keller A, Hodler J, Gerber C (2008) Intermethod agreement and interobserver correlation of radiologic acromiohumeral distance measurements. J Shoulder Elb Surg 17:237–240 13. Patte D (1990) Classification of rotator cuff lesions. Clin Orthop Relat Res 254:81–86 14. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC (1994) Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 304:78–83 15. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S (2003) Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elb Surg 12(6):550–554 16. Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C (1999) Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elb Surg 8(6):599–605
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Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53 17. Dwyer T, Razmjou H, Henry P, Gosselin-Fournier S, Holtby R (2013) Association between pre-operative magnetic resonance imaging and reparability of large and massive rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-0132745-z 18. Thomazeau H, Rolland Y, Lucas C, Duval JM, Langlais F (1996) Atrophy of the supraspinatus belly: assessment by MRI in 55 patients with rotator cuff pathology. Acta Orthop Scand 67(3):264–268 19. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG (2005) Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Jt Surg Am 87(6):1229–1240 20. Franceschi F, Ruzzini L, Longo UG, Martina FM, Zobel BB, Maffulli N, Denaro V (2007) Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: a randomized controlled trial. Am J Sports Med 35(8):1254–1260 21. Chung SW, Kim JY, Kim MH, Kim SH, Oh JH (2013) Arthroscopic repair of massive rotator cuff tears outcome and analysis of factors associated with healing e failure or poor postoperative function. Am J Sports Med 41:1674 22. Chillemi C, Petrozza V, Garro L, Sardella B, Diotallevi R, Ferrara A, Gigante A, Di Cristofano C, Castagna A, Della Rocca C (2011) Rotator cuff re-tear or non-healing: histopathological aspects and predictive factors. Knee Surg Sports Traumatol Arthrosc 19(9):1588–1596. doi:10.1007/s00167-011-1521-1 23. Davidson PA, Rivenburgh DW (2009) Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elb Surg 9(6):502–506 24. Porcellini G, Castagna A, Cesari E, Merolla G, Pellegrini A, Paladini P (2011) Partial repair of irreparable supraspinatus tendon tears: clinical and radiographic evaluations at long-term follow-up. J Shoulder Elb Surg 20:1170–1177 25. Nho SJ, Delos DD, Yadav H et al (2010) Biomechanical and biologic augmentation for the treatment of massive rotator cuff tears. Am J Sports Med 38(3):619–629 26. Nove-Josserand L, Costa P, Liotard JP, Safar JF, Walch G, Zilber S (2009) Results of latissimus dorsi transfer for irreparable cuff tears. Orthop Traumatol Surg Res 95(2):108–113 27. Gervasi E, Causero A, Parodi PC, Raimondo D, Tancredi G (2007) Arthroscopic latissimus dorsi transfer. Arthroscopy 23(11):1234e1–1234e4 28. Bond JL, Dopirak RM, Higgins J, Burns J, Snyder SJ (2008) Arthroscopic replacement of massive, irreparable rotator cuff tears using a Graft-Jacket allograft: technique and preliminary results. Arthroscopy 24(4):403–409 29. Pill SG, Walch G, Hawkins RJ, Kissenberth MJ (2012) The role of the biceps tendon in massive rotator cuff tears. Instr Course Lect 61:113–120 30. Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR (2006) The insertional footprint of the rotator cuff: an anatomic study. Arthrosc J Arthrosc Relat Surg 22(6):603–609 31. Gerber C, Fuchs B, Hodler J (2000) The results of repair of massive tears of the rotator cuff. J Bone Jt Surg Am 82:505–515 32. Neri BR, Chan KW, Kwon YW (2009) Management of massive and irreparable rotator cuff tears. J Shoulder Elb Surg 18:808–818 33. Yoo JC, Ahn JH, Koh KH, Lim KS (2009) Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage. Arthroscopy 25:1093–1100 34. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K (2004) The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Jt Surg Am 86:219–224
Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53 35. Collin P, La¨dermann A, Le Bourg M, Walch G (2013) Subscapularis minor: an analogue of the Teres minor? Orthop Traumatol Surg Res 99(4 Suppl):S255–S258. doi:10.1016/j.otsr. 2013.03.003 36. Gerber C, Rahm SA, Catanzaro S, Farshad M, Moor BK (2013) Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years. J Bone Jt Surg Am 95(21):1920–1926
S53 37. Davidson J, Burkhart SS (2010) The geometric classification of rotator cuff tears: a system linking tear pattern to treatment and prognosis. Arthroscopy 26(3):417–424 38. Lafosse L, Van Isacker T, Wilson JB, Shi LL (2012) A concise and comprehensive description of shoulder pathology and procedures: the 4d code system. Adv Orthop 2012:930543
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ORIGINAL ARTICLE
Irreparable rotator cuff tears: a novel classification system R. Castricini • M. De Benedetto • N. Orlando E. Gervasi • A. Castagna
•
Received: 18 January 2014 / Accepted: 26 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Irreparable rotator cuff tears can be managed by several approaches. However, current tear classifications fail to reflect the wide variety of their presentation, which has important clinical and prognostic implications. Methods We describe a novel classification system based on preoperative imaging findings and intraoperative observation where each cuff tendon (numbered sequentially: 1-supraspinatus, 2-infraspinatus, 3-teres minor, and 4-subscapularis) is assessed intraoperatively for reducibility to the footprint; tendons with reparable lesions are assessed for fatty degeneration (which predicts healing potential) and given a plus if degeneration is\50 % (Fuchs stage I–II/Goutallier stage 0–II) or a minus if it is C50 % (Fuchs stage III/Goutallier stage III–IV). Results The proposed system (1) allows more consistent and reproducible classification of cuff tears where at least one tendon is irreparable; (2) results in more accurate diagnosis; (3) guides in treatment selection; and (4) ensures better outcomes and realistic patient expectations.
R. Castricini (&) M. De Benedetto N. Orlando Department of Orthopaedic and Trauma Surgery, Casa di Cura Villa Verde, Fermo, Italy e-mail: [email protected] E. Gervasi Department of Orthopaedic and Trauma Surgery, Ospedale Civile, Latisana, Italy A. Castagna Unit of Shoulder Surgery, Istituto Clinico Humanitas, Rozzano, Italy
Conclusions The novel classification system can contribute to develop increasingly exhaustive and reproducible classification models. Keywords Irreparable rotator cuff tear Rotator cuff tear Fatty infiltration
Introduction An irreparable rotator cuff tear (RCT) is one where size and degree of tissue retraction prevent reduction to the footprint even using tissue mobilization and release techniques [1–3]. Irreparable RCTs are characteristic of the late phase of the natural history of rotator cuff tendinopathy, which progresses in terms of tear size and symptom severity and is associated with irreversible muscle atrophy, fatty degeneration and muscle–tendon retraction [4–8]. In routine surgical practice, irreparable lesions account for up to 30 % of RCTs [9]. Eighty five out of 900 (9.4 %) RCTs managed arthroscopically at a single centre by one of the authors (RC) between January 2012 and December 2013 exhibited at least one irreparable tendon (unpublished data). Since RCTs may involve strength loss and shoulder dysfunction, clinical symptoms are extremely variable, ranging from absent or mild symptoms to severe disability and pain [10]. A number of radiological criteria have been proposed to define irreparable RCTs: reduction of the acromion-humeral space to \6 mm on X-rays [11, 12]; tendon retraction (Patte stage III) [13]; fatty degeneration (Goutallier stage III–IV) assessed on CT and MRI [14, 17]; and muscle belly atrophy (Thomazeau stage III) [18].
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An irreparable RCT (for instance of the supraspinatus) is usually associated with lesion of an adjacent tendon that may be irreparable or reparable. Reparable RCTs have variable healing potential. The risk of re-rupture has thoroughly been explored and found to depend on a number of factors that include age, tear size, repair technique used, inappropriate rehabilitation, muscle atrophy and fatty degeneration; nonetheless, outcome prediction is still inaccurate [15, 17, 19, 20]. The presence and severity of fatty infiltration have been associated with older age, tear size, degree of tendon retraction, number of tendons involved (i.e., massive tears), suprascapular neuropathy and traumatic tears [7]. Since an increased amount of fat in the muscle belly enhances the risk of failure, only low-grade infiltration (Goutallier stage I–II) of the infraspinatus and subscapularis is consistent with satisfactory healing rates [14, 15, 21]. Interestingly, Chillemi et al. [22] reported that re-rupture may reflect failed healing of the reinserted tissue. A number of different approaches are available to manage irreparable RCTs: conservative treatment, arthroscopic debridement, partial cuff repair, tendon transfer, arthroplasty, tissue interposition arthroplasty, augmentation procedures and pain-relieving LHB tenotomy [23–29]. However, such broad range of available treatments is not paralleled by diagnostic approaches offering precise and exhaustive information. Moreover, the description, functional impact and healing potential of irreparable RCTs are still inadequately investigated, and their current distinction into posterosuperior and anterosuperior is felt by many to be insufficient to base a therapeutic strategy capable of providing reasonable outcome expectations [10]. Despite the significant clinical and prognostic implications of their widely variable patterns, there are, to the best of our knowledge, no classifications specifically addressing irreparable RCTs. We describe a novel system devised to provide accurate tear diagnosis, enable consistent classification and guide the surgeon in selecting the most appropriate treatment approach.
Materials and methods The proposed system is based on preoperative MRI findings and intraoperative observation. Rupture is defined as irreparable if intraoperative tissue mobilization and release techniques cannot achieve tendon reduction to its footprint, as described by Curtis et al. [30]. Within the proposed system, the status of each rotator cuff tendon is described in terms of integrity/tearing and amenability to repair based on grade of fatty degeneration. The tendons are numbered sequentially: 1, supraspinatus;
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Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53 Fig. 1 Scheme demonstrating irreparable rotator cuff tears described according to the proposed classification system
2, infraspinatus; 3, teres minor; and 4, subscapularis. Tearing is described as follows: an intact tendon is graded as 0; a torn but reparable tear with good healing potential (Fuchs stage I–II/Goutallier stage 0–II) is given a plus sign (?); a torn but reparable tendon with poor healing potential (Fuchs stage III/Goutallier stage III–IV) is assigned a minus sign (-); and a torn but irreparable tendon is merely indicated by tendon number [6, 16]. A formula describing the state of each tendon is thus generated intraoperatively for each patient as shown in Fig. 1. For the sake of simplicity, intact tendons may be omitted. The system allows describing the great variability of possible irreparable RCTs with a practical, informative and immediate formula.
Results In the proposed system, an irreparable supraspinatus lesion associated with a reparable lesion of the infraspinatus showing good muscle trophism (Fuchs stage I–II) without further cuff lesions is reported as 1,2?. This condition is frequently managed by partial cuff repair and infraspinatus reinsertion. An irreparable tear of the supraspinatus and infraspinatus without additional cuff lesions is described as 1,2. This type of RCT is frequently managed by latissimus dorsi transfer. An irreparable tear of the supraspinatus and subscapularis is described as 1,4. Pectoralis major transfer often provides satisfactory results for this condition. The proposed system allows describing a large number of lesion types, as exemplified in Table 1.
Discussion and conclusions A variety of treatment approaches are available to manage irreparable RCTs. Yet current classification systems do not adequately reflect the extreme variability of their presentation in terms of topography, size and healing potential; the resulting joint dysfunction also induces variable clinical consequences.
Musculoskelet Surg (2014) 98 (Suppl 1):S49–S53
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Table 1 Some typical patterns of irreparable rotator cuff tears Lesion type
Lesion characteristics
1,2?
Irreparable supraspinatus rupture, reparable infraspinatus tear with good healing potential
1,2
Irreparable tear of supraspinatus and infraspinatus
1,2,4?
Irreparable tear of supraspinatus and infraspinatus, reparable subscapularis tear with good healing potential
1,4
Irreparable tear of supraspinatus and subscapularis
1,2-
Irreparable supraspinatus tear, reparable infraspinatus tear with poor healing potential
Treatment selection would greatly benefit from a more accurate diagnostic picture. The proposed classification is based on objective intraoperative findings; it describes a rotator cuff where at least one tendon is irreparable and assesses the state and healing potential of the other tendons based on preoperative imaging findings (MRI) and intraoperative observations. A number of RCT classifications have been described in the literature, none, however, specifically addressing irreparable RCTs. With regard to size, a massive rupture is one involving at least two tendons [31] or measuring more than 5 cm [2]; the addition of localization data can make it a massive posterosuperior or anterosuperior RCT [32]. Massive tears are more complex to treat than small lesions, and outcomes are less predictable; failure rates up to 94 % have been reported [33, 34]. Massive tears may be irreparable if tissue retraction has made the muscle–tendon unit stiff and poorly mobile. Goutallier and colleagues identified fat infiltration as a critical parameter in preoperative planning and correlated five CT stages of fatty degeneration to tendon repair capacity [14]; Fuchs et al. [16] subsequently applied Goutallier’s classification system to MRI, reducing the five CT stages to three MRI stages. Although currently employed, the distinction between posterosuperior and anterosuperior RCTs is felt by many to be insufficient [10]. These lesions should be further explored also in relation to the advances made in shoulder joint biomechanics and to the growing interest attracted by the teres minor and the subscapularis, especially its inferior third [10, 35, 36]. The classification system proposed by Davidson and Burkhart, based on tear size measured on MRI, correlates tear pattern to the most appropriate treatment. Although their approach is useful and innovative, it does not allow accurate description of massive contracted RCTs, since the authors do not provide further information on this lesion type [37].
Fig. 2 Irreparable supraspinatus and infraspinatus tear (1,2 tear according to the proposed classification)
The 4D code devised by Lafosse et al. [38] provides an original contribution that addresses RCT patterns not only preoperatively but also intra- and post-operatively. However, their description of irreparable RCTs is different and more complex and has been developed for other purposes. The decision to perform a latissimus dorsi transfer rather than a partial cuff repair may generate confusion if treatment selection is merely based on a ‘massive irreparable posterosuperior cuff tear’, because current approaches do not envisage providing additional information such as the number of irreparable tendons, tear size or the tissue quality of the other tendons. A 1,2 RCT (Fig. 2) and a 1,2? RCT are both irreparable, but they have quite different features and healing potential. The proposed system thus provides for clearer RCT classification, simpler treatment selection and more reliable outcome evaluation. Its main limitation is the fact that it is based on intraoperative assessment, even though evaluation of residual tissue plasticity and direction of tendon reduction are currently not feasible preoperatively. Another limitation is the fact that associated lesions must be described separately. We believe that the proposed system contributes to the development of increasingly exhaustive and reproducible classification models. It allows for more precise and consistent classification of RCTs, where at least one tendon is irreparable, than is currently possible. By providing for more accurate diagnosis and treatment indications and guiding the surgeon in the selection of the most suitable management approach, it also ensures better outcomes and more realistic patient expectations. Further research is clearly required to assess the correlation between tear type and clinical and diagnostic imaging findings. Acknowledgments The authors are grateful to Dr. S. Modena for the language revision (www.silviamodena.com).
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S52 Conflict of interest Roberto Castricini, Massimo De Benedetto, Nicola Orlando, Enrico Gervasi, Alessandro Castagna declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.
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