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1 Institut de Diagnòstic per la Imatge, Hospital Universitari de
Tarragona Joan XXIII, Carrer Doctor Mallafrè Guasch, 4,
43007-Tarragona, Spain.
2 Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari de
Tarragona Joan XXIII, Tarragona, Spain.
3 Servei de Medicina Preventiva i Epidemiologia, Hospital Universitari de
Tarragona Joan XXIII, Tarragona, Spain.
4 Servei de Radiologia, Pius Hospital de Valls, Tarragona, Spain.
Received June 25, 2004;
accepted after revision September 9, 2004.
Address correspondence to J. M. Mellado
(jmellado{at}hjxxiii.scs.es).
Abstract
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MATERIALS AND METHODS. Twenty-eight surgically proven massive rotator cuff tears were retrospectively included in the study. Twenty-two patients underwent complete repair, and six patients underwent partial repair. Preoperative and postoperative clinical assessment was performed by using the University of California at Los Angeles score. Preoperative and postoperative MRI studies were evaluated for the presence and extent of rotator cuff tear and for the degree of fatty degeneration and atrophy of the rotator cuff muscles.
RESULTS. At a mean 44.4 months' follow-up, 20 patients (71.4%) had a favorable result. A total of 25 patients (89.2%) showed postoperative full-thickness rotator cuff tear, 19 of which were reruptures. A sagittal preoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 100% for predicting a favorable outcome. A coronal postoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 85.7% and a positive predictive value of 92.9% for predicting a favorable outcome. A postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 had a specificity of 87.5% and a positive predictive value of 90.9% for predicting a favorable outcome.
CONCLUSION. Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears. Oblique coronal sizes of the recurrent or residual tear of less than or equal to 34 mm and postoperative fatty degenerations of infraspinatus muscle of less than or equal to 2 may allow a favorable outcome.
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50 mm) and
involve two or three tendons
[1]. Complete repair of a
massive RCT, although technically challenging, may be accomplished by open or
arthroscopic procedures. However, partial repair, simple decompression and
debridement, and conservative management also may be considered
[1–10].
Massive RCTs have been traditionally associated with a poor prognosis, but
surgical treatment may actually provide high rates of success
[1–4,
8]. Recent investigations have
concentrated on various predictors of outcome after repair of RCT
[9–28],
particularly tendon rerupture
[9,
13–19],
muscle fatty degeneration [15,
19,
20,
24,
28], and muscle atrophy
[21–23,
25–27]. MRI is considered useful for preoperative [29–31] and postoperative [32–34] evaluation of the rotator cuff. MRI can efficiently determine the size and location of postoperative rerupture [17–19, 28, 32–35]. In addition, MRI may be crucial for evaluating muscle fatty degeneration [15, 19, 20, 24, 28] and muscle atrophy [21–23, 25–27, 34, 35].
No studies focusing on the prognostic significance of MRI for monitoring surgically repaired massive RCTs are available. Consequently, our objective was to perform an MRI-based assessment of massive RCTs treated by open surgical repair, to investigate the presence and extent of tendinous rerupture and the degree of muscle fatty degeneration and muscle atrophy, and to correlate these and other prognostic factors with intraoperative and clinical findings.
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Patient Selection and Clinical Assessment
Thirty-two massive RCTs in 32 patients were treated by a senior orthopedic
surgeon with open surgical repair between January 1, 1996, and December 31,
2002. Of these patients, 28 were retrospectively included in the study (the
additional four patients could not be contacted). The ages of the patients at
the time of the surgical procedure and at the time of the last postoperative
follow-up were recorded. The preoperative duration of symptoms and the
follow-up interval also were recorded. Preoperative and postoperative clinical
assessment was performed by an orthopedic surgeon (who was not involved in the
surgical procedures) using the University of California at Los Angeles (UCLA)
score [11]. This system
assigns a maximum of 10 points each for pain and function and a maximum of
five points each for range of active forward elevation, strength of forward
elevation, and overall patient satisfaction, for a total possible score of 35
points. The strength of the shoulder was graded according to standard manual
muscle testing. The clinical evaluation was considered excellent if the
patient's score was between 34 and 35 points, good if it was between 28 and 33
points, intermediate if it was between 21 and 27 points, and bad if it was
between zero and 20 points.
Surgical Indication and Technique
The surgical procedure was indicated whenever intense pain or disability
after a 4-month period of conservative treatment occurred, whenever the
absence of rotator cuff arthropathy was shown, and whenever the patient's
demands made it advisable. The diagnosis of massive RCT was intraoperatively
done by using a hand-held ruler. RCTs of greater than or equal to 50 mm were
considered massive. Identification and recording of torn tendons were
systematically performed. Mobilization of the torn tendons and suture by
convergence of margins to the greater tuberosity, using nonresorbable sutures
and suture anchors, were performed. Complete repair was performed whenever
possible. Complete repairs were verified by intraoperative inspection, but no
postoperative arthrography was performed to show a watertight seal. When
complete repair could not be achieved because of excessive tendon deficit or
tendon strain, partial repair was performed. Neer acromioplasty was performed
in all cases. Acromioclavicular arthroplasty was performed in cases of
symptomatic acromioclavicular osteoarthritis.
MRI Acquisition
Preoperative MRI was performed and available in 25 patients. The interval
between the preoperative MRI study and the surgical procedure was recorded.
Postoperative MRI was performed in all patients the same day of the last
postoperative clinical evaluation. Owing to the retrospective nature of the
study, the preoperative MRI studies were performed in two different MRI units,
including a 1.5-T (Signa, GE Healthcare) and a 1.0-T (Harmony, Siemens Medical
Systems) imagers. The 28 postoperative MRI studies were performed in a 1.0-T
imager (Harmony). A send–receive flexible coil was used in all cases,
with the arm positioned in neutral or slightly external rotation.
The imaging protocol included the following sequences: axial gradient-recalled-echo T2-weighted imaging (TR/TE, 700/18 msec; field of view, 180 x 180 mm, 1 signal acquired; matrix, 168 x 256; section thickness, 4.0 mm; intersection gap, 0.8 mm); oblique coronal and oblique sagittal fast proton-density-weighted and T2-weighted MRI (TR/TE, 3,500/15– 96 msec; field of view, 170 x 170 mm; 1 signal acquired; matrix, 336 x 512; section thickness, 4.0 mm; intersection gap, 0.8 mm); fast STIR imaging (TR/TE, 4,000–4,600/30 msec; inversion time, 130–150 msec; field of view, 170 x 170 mm; 2 signals acquired; matrix, 154 x 256; section thickness, 4.0 mm; intersection gap, 0.8 mm); and oblique sagittal T1-weighted MRI (TR/TE, 505–550/15–16 msec; field of view, 160 x 160 mm; 1 signal acquired; matrix, 224 x 256; section thickness, 4.0 mm; intersection gap, 0.8 mm).
MRI Evaluation
Preoperative and postoperative MRI studies were randomly mixed for imaging
review. Two radiologists with 8 and 3 years of experience, respectively, in
musculoskeletal MRI analyzed the MR images without previous knowledge of
intraoperative findings or clinical outcomes. For imaging review, the
manufacturer's workstation (Magic View 300, Siemens Medical Systems) and
software (Syngo MR 2002B, Siemens Medical Systems) were used. The quantitative
parameters were independently measured by the two radiologists for further
evaluation of interobserver agreement. The qualitative parameters were
subjectively evaluated and discussed by the two observers in order to reach a
consensus.
Oblique coronal and oblique sagittal fluid-sensitive sequences were evaluated for the presence and largest size (in millimeters) of full-thickness RCT. The measurement was made by following the contour of the humeral head. In tears involving subscapularis and supraspinatus tendons, the measurement was made across the interval region. Whenever fluid-equivalent signal was found in the way of a tendon, or complete nonvisualization of a tendon was found in at least one section of a fluid-sensitive sequence, the diagnosis of full-thickness RCT was made [31–33]. The different components of the rotator cuff were evaluated separately and were considered torn even if only a portion was torn. Intratendinous signal alterations other than fluid equivalent or altered thickness of the tendons other than full-thickness tears systematically were ignored.
Muscle fatty degeneration was evaluated in the most lateral oblique sagittal T1-weighted MR image in which the scapular spine was seen in contact with the scapular body (the so-called Y-shaped view) (Fig. 1A). In preoperative studies in which oblique-sagittal T1-weighted MR sequences were not available, oblique sagittal T2-weighted MR sequences were used instead, after we verified in the fast STIR sequence that no pattern of muscle edema was present. A five-stage grading system was used to reach a subjective consensus about fatty degeneration of supraspinatus, infraspinatus, and subscapularis muscles [15, 24]. In this grading system, which focuses on the amount of fatty deposition within the muscle, stage 0 corresponds to a muscle with no fat; in stage 1 the muscle contains some fatty streaks; in stage 2 the fatty infiltration is important, but there is still more muscle than fat; in stage 3, there is as much fat as muscle; and in stage 4 there is more fat than muscle.
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Muscle atrophy also was evaluated in the Y-shaped view by drawing regions of interest around the different components of the rotator cuff (ignoring the fatty deposition around the muscle bellies) and measuring their cross-sectional areas in square millimeters. Because the border between the infraspinatus and teres minor may not be easily determined, their cross-sectional areas were combined in a single measurement (Fig. 1B). To compensate for individual body constitution, standardized areas were calculated by dividing areas of the rotator cuff muscle bellies by the area of the supraspinatus fossa [23] (Fig. 1C). Muscle atrophy of the supraspinatus muscle also was evaluated by using the tangent sign in the Y-shaped view [23] (Fig. 1D). The tangent sign was considered positive when the superior border of the supraspinatus was inferior in relation to the line tangential to the coracoid and scapular spine.
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Statistical Methods
For descriptive analysis, the quantitative parameters were evaluated by
calculating the mean value, SD, and range, and the categoric parameters were
evaluated by determining the absolute and relative frequencies. Spearman's
correlation coefficient was used to test the correlation between quantitative
parameters. The nonparametric test of Kruskal-Wallis was used to compare
quantitative variables of different groups of patients. Wilcoxon's
nonparametric test was used to analyze repeated measurements with one or two
factors. The most suitable threshold values of postoperative RCT and muscle
fatty degeneration for predicting a favorable clinical outcome were
determined, and their accuracy was evaluated by calculating the sensitivity,
specificity, positive predictive value, and negative predictive value. The
level of accepted statistical significance was p 
0.05.
Statistical analyses were performed by using commercially available software,
including SPSS 6.1 (SPSS, 1990) and CIA 1.0 (BMJ, 1989).
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Intraoperative Findings and Surgical Procedure
At the time of the surgical procedure, the mean age was 59.8 years (SD =
6.8; range, 43–70). The intraoperative size of the RCTs averaged 65.7 mm
(SD = 11.9; range, 50–80) (Table
2). A total of 22 patients underwent complete repair, and six
patients underwent partial repair. The intraoperative size of the RCT
significantly differed among patients with different combinations of torn
tendons and with different types of tendon repair (p = 0.007 and
p = 0.009, respectively). The intraoperative size of the RCT showed
no correlation with the preoperative UCLA score.
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Postoperative Clinical Evaluation
At the time of the postoperative follow-up, the mean age was 63.6 years (SD
= 6.3; range, 47–73). The postoperative follow-up interval averaged 44.4
months (SD = 23.2; range, 13–96). The postoperative UCLA score averaged
30.1 points (SD = 5.1; range, 13–96)
(Table 1). All patients showed
UCLA score improvement, and 27 patients (96.4%) experienced pain relief. The
clinical outcome was excellent in 11 patients (39.2%), good in nine patients
(32.1%), fair in seven patients (25%), and bad in one patient (3.5%).
Preoperative and postoperative UCLA scores showed statistically significant
differences (p < 0.0001). The postoperative UCLA score showed no
significant correlation with the intraoperative size of the RCT, with the type
and number of torn tendons, or with the type of repair.
MRI of Rotator Cuff Integrity
The interval between the preoperative MRI study and the surgical procedure
averaged 9.5 months (SD = 9.4; range, 1–36). The interobserver agreement
for the coronal and sagittal sizes of the preoperative and postoperative RCTs
was found to be significant (r = 0.9, p < 0.0001;
r = 0.9; p < 0.0001; r = 0.9, p <
0.0001; and r = 0.8, p < 0.0001).
The size of the preoperative RCT (Table 2) was smaller than the intraoperative size in all patients. The coronal sizes of the preoperative RCTs significantly differed among patients with different combinations of torn tendons (p = 0.03) but not with different types of repair. The dimensions of the preoperative RCTs showed no correlation with preoperative UCLA score, but the preoperative sagittal sizes correlated with the postoperative UCLA score (r = –0.5, p = 0.02). Postoperative RCT of less than or equal to 34 mm in the sagittal view predicted a postoperative UCLA score of greater than 27 with a sensitivity of 58.8%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 54% (p = 0.0005).
In the postoperative MRI studies (Table 2), three patients (10.7%) showed integrity of the rotator cuff (Fig. 2A) and 25 patients (89.2%) showed full-thickness defects (Fig. 2B), including six residual RCTs after partial repair and 19 true reruptures (according to the MRI data, 86% of complete repairs underwent a rerupture). In the group of partial repairs, five patients showed a one-tendon RCT, and one patient showed a two-tendon tear. In the group of 19 reruptures, 13 patients showed a one-tendon RCT, five patients showed a two-tendon tear, and one patient showed a three-tendon tear. The largest size of the postoperative RCT was smaller than the intraoperative size in 27 patients (96.4%) and alike in one patient (3.5%). The coronal and sagittal sizes of the postoperative RCTs correlated with the intraoperative size (r = 0.5, p = 0.001; and r = 0.5, p = 0.001).
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The coronal and sagittal sizes of the postoperative RCTs significantly differed among patients with different combinations of torn tendons (p = 0.02 and p = 0.02) but not with different types of repair (Table 2). The coronal sizes of the postoperative RCTs correlated with the postoperative UCLA score (r = –0.4; p = 0.02). Preoperative RCT of less than or equal to 34 mm in the coronal view predicted a postoperative UCLA score of greater than 27 with a sensitivity of 65%, a specificity of 85.7%, a positive predictive value of 92.9%, and a negative predictive value of 46.2% (p = 0.03).
MRI of Muscle Fatty Degeneration
Fatty degeneration of supraspinatus, infraspinatus, and subscapularis
muscles progressed in 15 (53.5%), 17 (60.7%), and 11 (39.2%) patients,
respectively (Table 3). Fatty
degeneration of the subscapularis muscle decreased in one patient (3.5%).
Fatty degeneration of the supraspinatus, infraspinatus, and subscapularis
muscles progressed significantly in the entire series (p = 0.0002,
p = 0.0004, and p = 0.0002) (Fig.
3A,
3B). Preoperative and
postoperative muscle fatty degeneration of the evaluated components of the
rotator cuff showed significant correlation (r = 0.8, p <
0.0001; r = 0.9, p < 0.0001; and r = 0.7,
p < 0.0001). The preoperative fatty degeneration of the
infraspinatus muscle correlated with the postoperative UCLA score (r
= –0.4, p = 0.03).
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Postoperative fatty degeneration of the evaluated components of the rotator cuff differed significantly among patients with different combinations of torn tendons (p = 0.004, p = 0.02, and p = 0.01) but not with different types of repair (Table 3). The postoperative fatty degeneration of infraspinatus muscle correlated with the postoperative UCLA score (r = –0.5, p = 0.01). A threshold value of postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 for predicting a postoperative UCLA score of greater than 27 reached a sensitivity of 50%, a specificity of 87.5%, a positive predictive value of 90.9%, and a negative predictive value of 41.2% (p = 0.06). The postoperative fatty degeneration of supraspinatus muscle and infraspinatus muscle correlated with the intraoperative size of the RCTs (r = 0.5, p = 0.008; and r = 0.6, p = 0.02).
MRI of Muscle Atrophy
The interobserver agreement for the postoperative muscle atrophy of the
evaluated components of the rotator cuff was found to be statistically
significant (r = 0.9, p < 0.0001; r = 0.9,
p < 0.0001; and r = 0.9, p < 0.0001). The
postoperative atrophy of the infraspinatus/teres minor muscle significantly
varied among patients with different combinations of torn tendons and
different types of repair (p = 0.02 and p = 0.01)
(Table 4). The postoperative
muscle atrophy of the evaluated components of the rotator cuff showed no
correlation with the postoperative UCLA score. However, the postoperative
atrophy of the infraspinatus/teres minor and subscapularis muscles correlated
with the preoperative and postoperative corresponding indicators of muscle
fatty degeneration (r = –0.6, p = 0.002; r =
–0.6, p = 0.001; r = –0.6, p = 0.001;
and r = –0.5, p = 0.0003) (Fig.
4A,
4B).
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The preoperative and postoperative tangent signs were positive in eight (32%) and 18 (54.2%) patients, respectively. The preoperative and postoperative tangent signs correlated with the preoperative and postoperative fatty degeneration of the supraspinatus muscle (r = 0.7, p < 0.0001; and r = 0.6, p = 0.001). In addition, the postoperative tangent sign correlated with the postoperative atrophy of the supraspinatus muscle (r = –0.6, p = 0.002) but not with the postoperative UCLA score.
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In our study, the clinical outcome was independent of the intraoperative size of the RCT, which is not the rule when RCTs of different sizes are evaluated in a single study [11, 12]. Outcomes were slightly better, although not in a statistically significant fashion, for the combined tear of subscapularis and supraspinatus tendons and slightly worse for the combined tear of subscapularis, supraspinatus, and infraspinatus tendons. This is not surprising, since the types and numbers of torn tendons were associated with significant differences in the preoperative, intraoperative, and postoperative sizes of the RCTs, as well as in the degree of muscle fatty degeneration and muscle atrophy [26], which are said to be influential in clinical outcome [19–28].
In the preoperative MRI studies, the size of the RCT was discrepant with the intraoperative measurement. This finding may have reflected the occasionally long interval between the preoperative MRI study and the surgery. The discrepancy may also have resulted from the lack of spatial coincidence between the greatest length of intraoperative measurement and the MR measurements in the oblique coronal and oblique sagittal planes. Nevertheless, we found that the sagittal size of the preoperative RCT may have prognostic significance in predicting a good clinical outcome when it is less than or equal to 34 mm.
The rate of rerupture after repair of large and massive RCTs may be as high as 94% [9]. In our series, the rate of rerupture after complete repair was 86%. As previously noted, we found that the larger the intraoperative size of the RCT the higher the probability of there also being a very large postoperative coronal recurrent tear [14]. In our opinion, this does not necessarily imply that complete repair of very large RCTs involves excessive tendon strain, leading to a greater probability of rerupture. In our series, we carefully avoided excessive tendon strain during surgery, which led to the performance of partial repairs in selected cases. In addition, we could not prove that larger tears are associated with increased risk of rerupture [13] because we only studied massive tears.
The integrity of the repaired cuff is traditionally thought to be relevant for the clinical outcome [13], although this has been disputed [9, 16, 18, 19]. In fact, Zanetti et al. [33] found that reruptures of less than 10 mm may be entirely asymptomatic. In our series, reruptures also allowed a favorable outcome in many patients. We have shown that a postoperative RCT coronal size of less than or equal to 34 mm tends to coexist with favorable outcomes (although some reruptures or residual defects of > 34 mm also reached a good outcome). This means that postoperative RCTs measuring less than or equal to 34 mm in the oblique coronal MRI plane can probably be dismissed as the causative agent of a poor clinical outcome. If a second intervention is planned, other causes of clinical failure should be investigated, such as persistent subacromial compromise, deltoid dehiscence, or long biceps tendon injury [12]. Interestingly, the only three patients who showed postoperative integrity of the rotator cuff failed to reach the highest UCLA scores.
Due to the high rate of reruptures after complete repair of massive RCTs and the favorable outcome of many partial repairs, it is clear that useful therapeutic alternatives, namely, partial repair or subacromial decompression and debridement, should be further investigated. Our study did not focus on evaluating the potential advantages of various treatment options. Although the preference for complete repair has been expressed by some authors [1–3, 9], we acknowledge that some of our results may provide useful insight into the academic debate regarding the optimal surgical approach for massive RCT.
In our series, we found that a low preoperative stage of fatty degeneration of the infraspinatus muscle may predict a good clinical outcome [15, 28], although calculation of a threshold value was impossible because of insufficient data. We noticed that fatty degeneration of infraspinatus muscle might indeed occur with large anterosuperior RCTs [15, 27]. In addition, we found that muscle fatty degeneration almost never improved after surgery, although fatty degeneration of supraspinatus muscle has been found partially to revert in other series [15]. In fact, muscle fatty degeneration progressed significantly in our entire series (Fig. 3A, 3B), with an evolutionary pattern not only influenced by the size of the tears but also by the type and number of torn tendons and by the preoperative stage of fatty degeneration. As previously stated, we found that the degree of postoperative fatty degeneration of the infraspinatus muscle may predict a good clinical outcome when it is less than or equal to 2 [15], although more advanced degrees occasionally allow good clinical results (Fig. 4A, 4B).
In our study, postoperative atrophy of the infraspinatus muscle failed to correlate with overall clinical outcome [23, 25]. However, we found that postoperative fatty infiltration and atrophy of infraspinatus muscle correlated with each other. This is in agreement with the literature, which has shown that both processes occur in parallel [24]. Interestingly, the postoperative atrophy of the infraspinatus muscle was significantly more advanced in the group of partial repairs, although this did not influence the clinical outcome. The positive tangent sign correlated with the postoperative supraspinatus muscle fatty degeneration and atrophy but failed to prove clinical usefulness.
Our study has some limitations, which are basically inherent to the retrospective nature of the study and to the nature of the disease. We acknowledge that the lack of oblique sagittal T1-weighted sequences in some of the preoperative studies is a handicap that may have altered the reproducibility of fatty degeneration staging, although observation in consensus and review of STIR images was performed to minimize such shortcomings. We also acknowledge that patient selection, with lack of a control group, may have introduced a bias in the evaluation of images. Evaluating pre- and postoperative studies in a truly randomized fashion was difficult, given the conspicuity of the postoperative signs on MR images. Finally, the population size may not have been large enough to reach definitive conclusions in many regards.
In summary, we have shown that MRI of surgically repaired massive RCTs may improve our understanding of the disease and may highlight specific prognostic features that are of potential interest for monitoring the response to treatment. We have shown that open repair of massive RCTs may result in a good clinical outcome in a significant proportion of patients despite a high rate of recurrent or residual tears. MRI of a recurrent or residual coronal RCT of less than or equal to 34 mm and of postoperative fatty degeneration of infraspinatus muscle of less than or equal to 2 may help to predict a favorable outcome (or may be occasionally excluded as potential factors involved in poor outcomes). MRI of postoperative muscle atrophy, as described above, is cumbersome and time-consuming and does not add clinically significant information.
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