Yu Tao(于濤)，Yu Guangrong(俞光榮)

Department of Orthopaedic Surgery Affiliated Tongji Hospital of Tongji University，Shanghai 200065，China

1 Anatomy of rotator cuff

Rotator cuff is a sleeve-like structure which is composed of supraspinatus muscle，infraspinatus muscle，teres minor and subscapularis muscles.Most previous reports point out that it is supraspinatus muscle which is involved in rotator cuff tears.Tomoyuki［3］found that the region that supraspinatus muscle attached to the large nodule was not so large.Part of the areas actually is attached by infraspinatus muscle，which inferring，rotator cuff injury is not only related with the supraspinatus，but also closely related to infraspinatus muscle.

2 Classification of rotator cuff injury

Rotator cuff tear is usually divided into partial tear and complete tear.Partial tear can be divided into three categories:partial tear on the side of the bursa，partial tear between the tendons and partial tear on the side of the joints［4］.According to the depth of each type，the injury can be divided into three degrees:degree I-tear is less than 1/4 of the thickness of rotator cuff(3mm);degreeⅡ-tear is less than 1/2 of the thickness of rotator cuff(3～6mm)，degreeⅢ-tear is more than 1/2 of the thickness of rotator cuff(6mm).Complete tears can be divided into small tear(＜10mm)，moderate tear(10 ～30 mm)，large tear(31 ～50 mm)and super large tears(＞50 mm)［5］.Lo etal［6］divided the complete rotator cuff tear into 4 types:(1)crescent-shaped tear;(2)U-shaped tear;(3)L-shaped tear;(4)large contracture.The damage less than 30mm can be treated by arthroscopic surgery.For a large rotator cuff tear，open surgical repair should be performed［7］.

3 Treatment of rotator cuff injury

3.1 Conservative treatment

For a partial tear，especially less than 3 months after injury，the majority of scholars advised non-surgical treatment.Common methods:rest and immobilizing，traditional Chinese medicine，non-steroidal antiinflammatory drug，topical therapy，physiotherapy，etc［8］.

3.2 Open surgery

They are Mclaughlin method of rotator cuff repair，Neer acromioplasty and isolated rotator cuff repair and muscles transfer technique.

3.2.1 Mclaughlin method of rotator cuff repair

The tendon and bone are fixed at the anatomical neck or the proximal stump of rotator cuff buried into the bone slot at the anatomical neck.The procedure is suitable for the rotator cuff with stump too distal to coincide.Advantage of this method is that the healing anatomy is close to normal anatomy.

3.2.2 Neer acromioplasty

This method is mainly applied to rotator cuff tear with impingement syndrome.Surgical procedures involve removing the coracoacromial ligament，thickening subacromial bursa and wedge resection of the antierior part of acromion which will create a distance 1.5 ～ 2.0cm between acromion and humeral head(AH).Resultsof joint treatments of Neer acromioplasty surgery and Mclaughlin method are satisfactory［9］.

3.2.3 Muscle transfer

This method is suitable for large rotator cuff injury which can not be repaired by conventional methods.Magermans［10］pointed out that the teres major muscle had the best shape and biomechanical characteristics for transfer.But it is too small to be transferred alone.So it is often combined with latissimus dorsi transfer［11］.Tear of antierior rotator cuff can be treated by pectoralis major muscle transfer［12］.A variety of other muscle transfers confirm that the effect is very limited［13，14］.The effect of surgery is related to postoperative functional exercise，the integrity of the deltoid muscle and tendon transfer itself.

3.2.4 Isolated rotator cuff repair

This method is mainly applied to small and fresh tear not associated with other pathological changes.But this situation is uncommon.

3.3 Arthroscopy

3.3.1 Endoscopic repair of rotator cuff

Arthroscopic repair or reconstruction of a torn rotator cuff can lead to healing，resulting in reducing shoulder pain and restoring shoulder function.It is often combined with acromioplasty.

3.3.2 Endoscopic acromioplasty surgery

The subacromial space is expanded by removal of subacromial bursa，coracoacromial ligament and acromioplasty.First，with the subacromial spaceincreasing，the observation and operation become easier;second the symptoms of subacromial impingement can be alleviated.

3.3.3 Endoscopic subacromial decompression

This method is to resolve the rotator cuff problem caused by subacromial osteophyte.Subacromial decompression has not direct effect on the tendon with primary degeneration and can not stop the progress of tear.Checroun Dennis and Zuckerman［15］found that there was no significant difference in success rate between arthroscopic decompression and open decompression surgery.Spangehl etal［16］found that the patients got more significant pain relief and better functional recovery with open subacromial decompression.But there was no significant difference in the strength recovery and patient satisfaction.

3.3.4 The latest developments in arthroscopic treatment

The question whether double-row fixation is better than single-row fixation，remains controversial.Saridakis P etal［17］found that arthroscopic double row rotator cuff repair was better than a single row of suture fixation in reconstruction of anatomical structures.Duquin TR etal［18］found that recurrence rate was significantly lower with double row repair than with single for the patients with more than 1cm tear.However，there was no difference in efficacy.Koh KH found there was no significant difference in efficacy and recurrence for the 2 ～ 4cm tear［19］.After a systematic review of the literature，Strauss EJ etal［20］found that the focus on the repair of surgical intervention was successful when the tearing is greater than 50%.

3.4 Choice of treatment

3.4.1 Conservative treatment or surgery

The result of conservative therapy is good in the patients with part tear of the rotator cuff and surgery is generally considered for the patients with severe persistent symptoms and limited function.Yamada etal［21］found that:compared with conservative treat-ment，pain，muscle strength and range of activities improved with surgery are more significant.

3.4.2 Open surgery or arthroscopic surgery

The general selection criteria for open surgery or arthroscopic surgery:Bishop J［22］found that 74%were complete with the original tears of the rotator cuff repair less than 3cm，arthroscopic surgery was 84%.62%were complete with the original tears of the rotator cuff repair more than 3cm，arthroscopic surgery was merely 24%.Therefore，the current international view is that arthroscopic surgery is advised for tears less than 3cm and open surgery is applied to those over 3 cm.

3.4.3 Early surgery or after conservative treatment fails

Some scholars claim that failure after 6-week non-surgical treatment or zero traction and immobilization and large rotator cuff tear are the indications for surgical treatment.When the acute inflammation and edema subsides，the tendon repair and reconstruction become easy.But Lahteenmaki HE etal［23］carried out open surgery for rotator injury with acute symptoms.85%had no pain，the functions and activities recovered to normal in 81%.They believe that early surgery is more conducive to postoperative functional recovery.If the operation delayed，tears may be greater and the tendon will lose elasticity，making surgery more difficult.Up to now the need for early surgery remians controversial.

4 Complications

4.1 Postoperative pain

There are postoperative pain due to many causes.The major cause is that the acromioplasty is not complete.If postoperative shoulder activity range and strength improved significantly，but significant pain relief did not，this situation should be considered.

4.2 Joint adhesions

Despite the trauma by endoscopic surgery is much smaller than that by open surgery，adhesion is still possible，especially in the patients with preoperative adhesion and acute tear.For patients who are vulnerable to joint adhesions，early functional exercise should be encouraged or preventive injections of the drug preventing joint adhesions should be given［24］.

4.3 Anterior dislocation

Excessive subacromial decompression can cause anterior dislocation.The thickness of the acromion should be exactly measured to avoid excessive removal of bone before acromioplasty surgery.For removal of the acromion，the average width is 10 mm，and thickness is 5 mm.

4.4 Non-healing of the rotator cuff

The patient’s physical condition may affect tissue repair.If the patient suffers from diabetes，rheumatoid arthritis and other systemic diseases，it will affect the rotator cuff tissue healing.Preoperative steroid injections can cause tendon fragility，which affects the healing of the rotator cuff tissue［25］.More attention should be paid to the patient’s general condition before surgery.

4.5 Recurrence of rupture

Postoperative recurrence is rare，but it can be found in huge tear，tendon retraction and significantly low quality tendon.After the recurrence of rupture，re-repair of it can be done if the tendon quality is acceptable.

5 Prospects

There has been some progress in the study of rotator cuff injury，but many new problems are emerging in clinical practice.Based on current research，The following studies are expected:1.further clarifying the anatomical relationships and characteristics of rotator cuff to guide the clinical treatment;2.clarifying the indications for early surgery through further basic and clinical research;3.clearing the relationship of external mechanical factors and internal physiological factors，including the evaluation of joint function.In short，according to the requirements and conditions the choices are individualized.We should develop an appropriate individualized treatment plan as the premise of early diagnosis;for exploring the best therapeutic approach;minimizing the damage to the patients.

［1］ 劉玉杰.肩袖損傷的診斷和治療進展.中華創(chuàng)傷雜志，1998，14(5):83-85.

［2］Milgrom C，Schaffler M，Gilbert S，van HM.Rotatorcuff changes in asymptomatic adults.The effect of age，hand dominance and gender.J Bone Joint Surg Br，1995，77(2):296-298.

［3］ Mochizuki T，Sugaya H，Uomizu M，etal.Humeral insertion of the supraspinatus and infraspinatus.New anatomical findings regarding the footprint of the rotator cuff.Surgical technique.J Bone Joint Surg Am，2009，91(Suppl 2 Pt 1):1-7.

［4］Shin KM.Partial-thickness rotator cuff tears.Korean J Pain，2011，24(2):69-73.

［5］ 陳疾忤，Murrell GAC.肩袖損傷的治療進展.國外醫(yī)學.骨科學分冊，2004，25(2):92-94.

［6］Lo IK，Burkhart SS.Current concepts in arthroscopic rotator cuff repair.Am J Sports Med，2003，31(2):308-324.

［7］Zafra M，Carpintero P，Carrasco C.Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff.Int Orthop，2009，33(2):457-462.

［8］Bektaser B，Ocguder A.Solak S.Free coracoacromial ligament graft for augmentation of massive rotator cuff tears treated with mini-open repair.Acta Orthop Traumatol Turc，2010，44(6):426-430.

［9］鄭憲友，孫貴新，顧玉東.Neer法聯(lián)合McLaughlin法治療肩袖斷裂傷.中華創(chuàng)傷骨科雜志，2005，7(3):81-83.

［10］ Magermans DJ，Chadwick EK，Veeger HE，der Helm FC v，Rozing PM.Biomechanical analysis of tendon transfers for massive rotator cuff tears.Clin Biomech(Bristol，Avon)，2004，19(4):350-357.

［11］Cleeman E，Hazrati Y，Auerbach JD，Shubin SK，Hausman M，F(xiàn)latow EL.Latissimus dorsi tendon transfer for massive rotator cuff tears:a cadaveric study.JShoulder Elbow Surg，2003，12(6):539-543.

［12］Warner JJ.Management of massive irreparable rotator cuff tears:the role of tendon transfer.Instr Course Lect，2001，50:63-71.

［13］Sundine MJ，Malkani AL.The use of the long head of triceps interposition muscle flap for treatment of massive rotator cuff tears.Plast Reconstr Surg，2002，110(5):1266-1274.

［14］Vandenbussche E，Bensaida M，Mutschler C，Dart T，Augereau B.Massive tears of the rotator cuff treated with a deltoid flap.Int Orthop，2004，28(4):226-230.

［15］Checroun AJ，Dennis MG，Zuckerman JD.Open versus arthroscopic decompression for subacromial impingement.A comprehensive review of the literature from the last 25 years.Bull Hosp Jt Dis，1998，57(3):145-151.

［16］ Spangehl MJ，Hawkins RH，McCormack RG，Loomer RL.Arthroscopic versus open acromioplasty:a prospective，randomized，blinded study.JShoulder Elbow Surg，2002，11(2):101-107.

［17］Saridakis P，Jones G.Outcomes of single-row and double-row arthroscopic rotator cuff repair:a systematic review.J Bone Joint Surg Am，2010，92(3):732-742.

［18］Duquin TR，Buyea C，Bisson LJ.Which method of rotator cuff repair leads to the highest rate of structural healing?A systematic review.Am J Sports Med，2010，38(4):835-841.

［19］ Koh KH，Kang KC，Lim TK，Shon MS，Yoo JC.Prospective randomized clinical trial of single-versus double-row suture anchor repair in 2-to 4-cm rotator cuff tears:clinical and magnetic resonance imaging results.Arthroscopy，2011，27(4):453-462.

［20］Strauss EJ，Salata MJ，Kercher J，etal.The arthroscopic management of partial-thickness rotator cuff tears:a systematic review of the literature.Arthroscopy，2011，27(4):568-580.

［21］ Yamada N，Hamada K，Nakajima T，Kobayashi K，F(xiàn)ukuda H.Comparison of conservative and operative treatments of massive rotator cuff tears.Tokai J Exp Clin Med，2000，25(4-6):151-163.

［22］Bishop J，Klepps S，Lo IK，Bird J，Gladstone JN，F(xiàn)latow EL.Cuff integrity after arthroscopic versus open rotator cuff repair:a prospective study.J Shoulder Elbow Surg，2006，15(3):290-299.

［23］Lahteenmaki HE，Virolainen P，Hiltunen A，Heikkila J，Nelimarkka OI.Resultsof early operative treatment of rotator cuff tears with acute symptoms.J Shoulder Elbow Surg，2006，15(2):148-153.

［24］侯春林，張偉.幾丁糖預(yù)防肘關(guān)節(jié)粘連的臨床研究.中國修復重建外科雜志，2000，14(2):80-82.

［25］Pegreffi F，Paladini P，Campi F，Porcellini G.Conservative management of rotator cuff tear.Sports Med Arthrosc，2011，19(4):348-353.