Hamada and colleagues tested whether the Hamada radiographic grades of massive cuff tears, as modified by Walch, behave like stages of one disease, and whether grade predicts retear after repair.
Retrospective review of 75 massive tears involving at least supraspinatus and infraspinatus, 34 treated nonoperatively and 41 operatively, at four Japanese centers.
Key Findings
Grade 3 to 5 tears came in older patients (mean 81.2 vs 64.1 for Grade 1) and had more subscapularis and teres minor tears and biceps ruptures than Grade 1.
Subscapularis fatty degeneration was much higher in Grades 3 to 5 (mean stage 3.2) than in Grades 1 and 2 (0.9). Supraspinatus and infraspinatus fat were also higher.
Without surgery, 8 of 15 Grade 1 and 6 of 11 Grade 2 shoulders moved to a higher grade. The 9 that reached Grade 3 to 5 had been followed longer than the 17 that stayed at Grade 1 or 2 (p = 0.017), and active flexion did not fall.
Of 20 repaired shoulders with radiographs after 2 years, none progressed to Grade 3 to 5, and 7 of 10 Grade 2 shoulders improved to Grade 1.
38% of patients were lost, radiographs were irregular, and surgery was offered only to Grades 1 and 2 with varied techniques.
Board pearl
Supraspinatus retears were far more common once the interval narrowed. The supraspinatus retore in 10 of 15 Grade 2 repairs vs 6 of 21 Grade 1 repairs (p = 0.041), while infraspinatus retear did not differ. This is the basis for the authors' advice to repair before the acromiohumeral interval narrows.
Hamada classification of massive cuff tears (Walch modification)Hamada, Clin Orthop Relat Res 2011
1
Acromiohumeral interval 6 mm or more
2
Acromiohumeral interval 5 mm or less
3
Grade 2 plus acetabulization of the acromion
4A
Glenohumeral narrowing without acetabulization
4B
Glenohumeral narrowing with acetabulization
5
Humeral head collapse (cuff tear arthropathy)
Authors' conclusion
We believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al.
Hamada and colleagues tested whether the Hamada radiographic grades of massive cuff tears, as modified by Walch, behave like stages of one disease, and whether grade predicts retear after repair.
Retrospective review of 75 massive tears involving at least supraspinatus and infraspinatus, 34 treated nonoperatively and 41 operatively, at four Japanese centers.
Key Findings
Grade 3 to 5 tears came in older patients (mean 81.2 vs 64.1 for Grade 1) and had more subscapularis and teres minor tears and biceps ruptures than Grade 1.
Subscapularis fatty degeneration was much higher in Grades 3 to 5 (mean stage 3.2) than in Grades 1 and 2 (0.9). Supraspinatus and infraspinatus fat were also higher.
Without surgery, 8 of 15 Grade 1 and 6 of 11 Grade 2 shoulders moved to a higher grade. The 9 that reached Grade 3 to 5 had been followed longer than the 17 that stayed at Grade 1 or 2 (p = 0.017), and active flexion did not fall.
Of 20 repaired shoulders with radiographs after 2 years, none progressed to Grade 3 to 5, and 7 of 10 Grade 2 shoulders improved to Grade 1.
38% of patients were lost, radiographs were irregular, and surgery was offered only to Grades 1 and 2 with varied techniques.
Board pearl
Supraspinatus retears were far more common once the interval narrowed. The supraspinatus retore in 10 of 15 Grade 2 repairs vs 6 of 21 Grade 1 repairs (p = 0.041), while infraspinatus retear did not differ. This is the basis for the authors' advice to repair before the acromiohumeral interval narrows.
Hamada classification of massive cuff tears (Walch modification)Hamada, Clin Orthop Relat Res 2011
1
Acromiohumeral interval 6 mm or more
2
Acromiohumeral interval 5 mm or less
3
Grade 2 plus acetabulization of the acromion
4A
Glenohumeral narrowing without acetabulization
4B
Glenohumeral narrowing with acetabulization
5
Humeral head collapse (cuff tear arthropathy)
Authors' conclusion
We believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al.