Comparative Studies of Conservative and Operative Treatments for Massive Rotator Cuff Tears Purpose by N. Yamada, K. Hamada, T. Nakajima, H. Miyake, A

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1 Comparative Studies of Conservative and Operative Treatments for Massive Rotator Cuff Tears Purpose by N. Yamada, K. Hamada, T. Nakajima, H. Miyake, A. Tomonaga, M. Goto and H. Fukuda Deptartment. of Orthopaedic Surgery, Tokai University The purpose of this study is to evaluate the results of conservative and operative treatments for massive rotator cuff tears. Patients and Methods Ten patients, 9 men and 5 women of a mean age of 71, were treated conservatively and followedup for 3.7 years on the average (Group I ). These patients were of Grade 4 arthrogram of Hamada's arthrographic classification. Twenty patients, 17 men and 3 women, comprised the operative group which had cuff tears of more than 5.0 cm in the longest dimension (Group II). The mean age at operation was 63 years. Anterior acromioplasty was performed in all the cases. The additional procedures were tenorrhaphies (tendon to bone) in 14, fascia grafts in 4 and Bush's procedure in 2. The mean follow-up period was 3.1 years. The results were assessed by the JOA score. The muscle strength was evaluated by Cybex in 9 operated patients. Results The JOA score in Group I increased from 52.9 to 71.7, while in Group II from a preoperative 50.1 to More pain relief was obtained in Group II than Group I, especially motion pain. Muscle stength and range of motion had recovered more in Group II than in Group I at follow-up. There was no statistically significant difference of age factor for the end results of those above 70 years of age between Goup I and Group II. Reasonable operative results were obtained within one year after the symptom started. There was no statistically significant difference of JOA score between a water-tight and non-water-tight closure. There was a statisticil difference of JOA score between a ruptured and non-ruptured LHB. The peak torque ratio recovered gradually as time elapsed postoperatively. 389

The Shoulder Joint, Vol. 19, No. 2, 389-395, 1995.

2 The Shoulder Joint, Vol. 19, No. 2, , Conclusion Although the two groups were not entirely comparable, pain relief, range of motion and muscle strength recovered more favorably in the operated group than in the conservatively treated one. Reasonable operative results may be expected if done within one year after the symptoms had started. The mode of closure did not affect the end result. Those with an intact long head of the biceps branchii did better in both groups than did those without. Most patients treated conservatively were limiting the ADL by themselves. If at all possible, a massive cuff tear should be treated operatively.

Fig. 1 Hamada's Group 4 Arthrogram : Contours of humeral head and subacromial bursa are cotinuous in projections of neutral, external, and internal rotations.

3 Fig. 1 Hamada's Group 4 Arthrogram : Contours of humeral head and subacromial bursa are cotinuous in projections of neutral, external, and internal rotations. 98% of these arthrograms were verified as massive cuff tears at surgery. Fig. 2 There was a statistically significant difference of JOA score in the conservatively treated patients between initial examination and follow-up. Fig. 3 Pain relief revealed 45.2% improvement in JOA score over other factors in coservatively treated patients. 391

4 The Shoulder Joint, Vol. 19, No. 2, , JOA score (Group II) n = 20 Age Factor Initial Exam Follow- up Fig. 4 There was a statistically significant difference of JOA score in the operated patients between initial examination and follow-up. Fig. 6 There was no statistically significant difference of JOA score in age factor between below and above 70 years of age, when treatment was started. JOA score (Group II) n = 20 Duration of Pain JOA score Group I Group D (Initial Exam ---. Follow-up) Fig. 7 Reasonable conservative results were Pain MMT Endurance ADL ROM X-ray Stability Fig. 5 Pain relief revealed 85.1% improvement in JOA score over other factors in operated JOA score. obtained within six months since symtom started. Reasonable operative results were obtained within a year since symptom started. 392

5 Mode of Closure Initial Exam Follow- up Fig. 8 There was no statistically significant difference of JOA score in the results between water-tight and non-water-tight closure. State of LHB Tendon Non - ruptured Ruptured isokinetic Evaluation (Flex : supine) 60 dog/sec n = Group I Group U Group I Group II (n = 10) (n = 16) (n = 4) (n = 4) Fig. 9 There was a statistically significant difference of JOA score in the state of LHB tendon ruptured and non-ruptured. between Fig. 10 There was a statistically significant difference of isokinetic evaluation between preoperative condition and follow-up. Isokinetic Evaluation (ER 0 Abduction, standing) n = 9 60 deg/sec Isokinetic Evaluation (IR 0 Abduction, standing) n = 9 60 deg/sec Preop Follow- up Preop Follow- up Figs. 11 & 12 In isokinetic evaluation, there was a statistically significant difference of preoperative condition between uninvolved and involved sides. There was a statistically significant difference of involved side between preoperative condition and follow-up. But there was no statistically significant difference of postoperative condition between uninvloved and involved sides. 393

6 The Shoulder Joint, Vol. 19, No. 2, , 1995.

7 procedure and result of repair of massive tears of the rotator cuff. Clin. Orthop. 304 : 54, ) Post, M. et al. : Rotator cuff tear ; diagnosis and treatment. Clin. Orthop. 173 : 78, ) Burkhart, S. S. : Arthroscopic treatment of massive rotator cuff taers clinical results and biomechanical rationale. Clin. Orthop. 267 : 45, ) Hamada, K., Fukuda, H., Mikasa, M. and Kobayashi, Y.: Roentgengraphic findings in massive rotator cuff tears A long-term observation. Clin. Orthop. 254 : 92, ) Kumar, V. P., Satku, P. K., Balasubraniam, P. : The role of the long head of biceps brachii in the stabilization of the head of the humerus. Clin. Orthop. 244 : 172, ) Neer, II. C. S., Craig, E. V. and Fukuda, H. : Cufftear arthropathy J. Bone Joint Surg A(9) : 1232, ) Nobuhara, K., Hata, Y. and Kornai, M. : Surgical

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