I've been thinking this fall/early winter about a group of patients that are getting more attention recently from shoulder surgeons. These are patients who have massive rotator cuff tears, that are unfixable, but without severe arthritis. I have recently seen a couple patients like this and would like to share my thoughts.
Here is an example:
A 57 year old, active gentleman has had shoulder pain for several years (7+). He has been diagnosed with a massive rotator cuff tear (that cannot be fixed). He has been told he is "too young" for a shoulder replacement, and that he should live with it until it gets worse (not very satisfying as a patient).
Now, after a fall at home, he dislocates his shoulder.
Ouch! We sedate him and put his shoulder back in. We get an MRI to assess his rotator cuff (which 7 years ago was called unfixable)
The X-ray shows that the shoulder is back in socket, with minimal arthritis
This MRI shows that the rotator cuff (supraspinatus) is torn off the bone and retracted all the way back to the socket. The white arrows show the tendon, and the insertion (there's no way that tendon is going back!) The red arrow shows the supraspinatus tendon, which is pulling back to the left.
This MRI shows "fatty atrophy" of the rotator cuff muscles. The muscle is the dark tissue (like the meat of a steak). The fat is the white tissue. The upper circle is the supraspinatus. The other area is the infraspinatus. The supraspinatus has been nearly totally replaced by fat. The infraspinatus looks to be in slightly better shape (more muscle).
Now, comes the hard decision. He's been suffering for years. He is 57 years old and active (cutting his own wood, etc). Essentially there are three options:
Continue without surgery
Reverse total shoulder replacement
Rotator cuff repair with superior capsular reconstruction
Let's break down the options:
1. Continue without surgery
He's already been having severe pain for 7 years. Now he has a new injury, and dislocated his shoulder. It's unlikely he will be better off than he has been. It's very likely that he'll be worse...this option is out (he agrees!).
2. Reverse total shoulder replacement
This is likely the choice of most surgeons in the country currently. Introduced in the mid 2000's in the USA, this operation is outstanding for patients with severe rotator cuff tears and arthritis. Yet, we have continued concerns about longevity (it is metal and plastic). Furthermore, we typically put restrictions on patients after reverse total shoulder replacement (15-20 lbs, although this isn't set in stone). Also, pain is more reliably improved than function (many people still have some motion loss after surgery). Finally, several studies have demonstrated that young, active patients tend to be the least satisfied with reverse total shoulder replacements. While this option is great for the vast majority of patients, our patient may be set up for disappointment with this option.
3. Rotator cuff tear with superior capsular reconstruction
An emerging option for massive rotator cuff tears was invented and popularized by Terahisu Mihata in Japan. I had the fortune of visiting him in Japan last year. He has had an incredible track record with his operation, and it is exploding in popularity. It is best used on young patients, with high expectations, who are willing to go through rehab, with minimal arthritis. Our patient was perfect. Several articles have described the technique (links embeded):
Skin graft from cadaver (processed to eliminate risk of disease transmission, etc), is used to reconstruct the missing rotator cuff. This doesn't replace the rotator cuff, but replaces the capsule and helps to keep the shoulder centered in joint. This technique is a modification of Mihata's original technique.
I have done about 35 of these procedures with excellent outcomes. Pain relief has been excellent, and nearly all of my patients have regained nearly full range of motion. My longest follow up is about a year and a half (so we have a long way to go to understanding how this works in the long run). I have been enthusiastic about the success my patients have had with this. After discussion of options, our patient elected for this option - he didn't want restrictions on his shoulder, and was willing to put in the work on an extended recovery. Here's some pictures of his shoulder:
This picture shows the massive rotator cuff tear. You can see the humeral head on the bottom left, and the socket in the distance. The rotator cuff is in the distance, and is not fixable.
We have placed the graft, and fixed it to the socket (glenoid)
We have fixed the graft to the humerus. You can see large sutures that hold the graft in place.
Now, we have fixed his tendon (right of the screen) to the graft (left of the screen).
This procedure is arthroscopic, and with very low risk. He went home the same day (outpatient). While he is still recovering, he has substantial pain relief already, and is looking like he will make an excellent recovery.
Making surgical decisions is always challenging. As a surgeon, I work to make sure patients are empowered with the best information available to make decisions, as well as let them know if I have a "leaning" or idea which may be best for them. This is truly the art of medicine, and is what makes my job so challenging and fun. I look forward to seeing similar patients as they recover, and learning along with them. If you have been told your only option is a reverse total shoulder replacement - reach out to me - this is a rapidly changing world!