Rotator Cuff Tears: Indications of arthroscopic treatment an overview Manos Antonogiannakis Director...

Rotator Cuff Tears: Indications of arthroscopic treatment

an overview

Manos AntonogiannakisDirector

center for shoulder arthroscopyIASO gen hospital

Rotator Cuff Function

1. Dynamic stabilizer of the shoulder

2. Contributes strength to the arm (50% of the abduction strength is generated by

supraspinatus)

3. Couple forces stabilize and regulate the motion of the shoulder

Rotator Cuff disease

Rotator cuff disease is a wide

spectrum of clinical

conditions, which range from

asymptomatic tears to symptomatic

rotator cuff arthropathy

First Successful RC Repair

Codman EA. Rupture of the supraspinatus tendon Boston Medical & Surgical Journal 1911 Vol clxiv (2) 708-10

McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder: the exposure and repair of tears with retraction. J Bone Joint Surg 1944;26:31-51.

First Description of RC tears

Smith JG. London. Med Gaz, 1834,14:280 Pathological appearances of seven cases of injury of the shoulder joint, with remarks. EA Codman

The History of Rotator Cuff Repair

• In 1972 Neer defined the concept of subacromial impingement

• Open Surgery

• Mini Open Surgery

• In the 90s’ the arthroscope changed the treatment

The History of Rotator Cuff Repair

Tears’ Definitions

• Partial Thickness Tears =absence of communication between the glenohumeral joint and the subacromial bursa.

• Full Thickness Tears = communication between the glenohumeral joint and the subacromial bursa.

• Massive Tear =Involving 2 or 3 tendons [Gerbers]

or bigger than 5cm [Cofield]

Partial Thickness Tear

• Bursal side tears• Articular side tears• Intratendinus tears

Partial tear classification by Ellman• Grade I <3mm deep• Grade II 3-6mm deep• Grade III >6mm deep (i.e. >50%

thickness)

How frequent are RC Tears?

• Rotator Cuff Frequency: 30% of population

• Significant correlation with age [Sher JS, Arthroscopy 1995]

Full Thickness TearAge Frequency40-60 4-13%60-70 20%70-80 50%>80 80%

Partial Thickness Tear Age Frequency

<40 4%>60 25%

[Tempelhof S, JSES, 1999]

How Frequent are RC Tears?

Rot cuff disease etiology and pathogenesis

1. Tendon degeneration2. Vascular factors 3. Impingement

• Types of acromion as identified by Bigliani• Internal impingement described by Walsh

4. Secondary impingement popularized by Jobe 5. Instability overload of the cuff - secondary superior migration6. Trauma 7. Glenohumeral instability 8. Scapulothoracic dysfunction

Natural History of a Tear

• Tears DO NOT HEAL. Some but NOT ALL of them will progress

• Rot cuff arthropathy is the end stage (4%)• 50% of newly symptomatic tears will progress in size• 20% of asymptomatic tears will progress.• No Tear seem to decrease in size.• 80% of partial tears progress in size or become full

thickness at 2 years

[Yamaguchi K., 2006, Nice Shoulder Course]

Bilateral RC Tears

• Rotator Cuff Disease is not only age related, but also bilateral

• >51% of patients with a previously asymptomatic rotator cuff tear and a contralateral symptomatic tear will develop symptoms in the non-symptomatic tear at the next 2.8 years.

[Yamaguchi K., JSES, 2001]

Current Knowledge

• RC tears DO NOT behave the same in different patients

• Patients PROFILE plays the most important role

• Size and Location of the tear DOES MATTER

RC Treatment

Patient Profile

Size & Location

Symptoms

Tissue Quality

Other Lesions

MAKE YOUR MAKE YOUR DECISIONDECISION

Patients <25 years

Aggressive athletics, high impact accident, heavy labor

Common history repetitive overhead sport or work with

repetitive overhead lifting

Symptoms during overhead activity respond to rest and are

aggravated as the patient resumes activity

Probably partial

articular side tear

Chronic overuse due to work related overhead

activity

Common history repetitive overhead sport or work with

repetitive overhead lifting

Acute trauma on chronic overuse is common

Patients 25 - 45 years

Usually small to medium tears not retracted

Subacromial impingement is common

Acute tears on chronic

Chronic pain. Night pain

Patients 45 - 65 years

In the more severe cases weak or impossible elevation external

rotation

Usually Full Thickness

Tear.

Good Tissue Quality

Rot cuff tears common

Limited activities make severe rotator cuff tears tolerable

Chronic aching or acute exaberation of symptoms after

minor trauma

Patients >65 years

Debilitating symptoms in rotator cuff arthropathy

Usually Large or Massive

Tear

Goutallier Stage 3 or 4

Retracted Tendons

RC Treatment Options

Non-Operative OperativeOpen SurgeryMini OpenArthroscopy

RC Treatment Options

Non-Operative

• 45-80% Satisfactory Results

BUT

• Symptom resolution ???• Tear progression ???• Fatty degeneration ???• Progression to rot cuff

arthropathy ???

Operative

90% Good to Excellent Results at 10 years

[Iannotti Wolf] BUT All the operated rot cuff

tears do not heal

Risk to Benefit Ratio

• Rot cuff tears DO NOT heal spontaneously• Tear repairability• Think of Size, Elasticity and Chronicity • Fatty infiltration is not fully reversible

Operative Treatment

Partial Tears Treatment

• By far the most common partial tears are Articular-side, vascular or due to secondary internal impingement

Traditionally partial tears classifications are based to 50%

BUT “How healthy is the remaining, intact tissue?”

Partial Tears Treatment Options

1. Debride partial tear only2. In-situ Repair3. Convert to full thickness, Debride, Repair

Etiology makes the decision!!!

• Because most tears are degenerative, option 3 should be the best for most cases

• Trauma or young athletes are candidates for in-situ repair

• If partial tear are limited then debridement alone[Yamaguch K, 2006 Nice Shoulder Course]

Full thickness Tear

RC Tear Classification

Acute, Chronic, Acute on chronic

Tear Age Tissue Quality

1. Partial <40 Good

2. Complete <40 Good

3. Complete 40-65 Good

4. Complete 40-65 Bad

5. Complete >65 Good

6. Complete >65 Bad

What is Bad Tissue Quality?

• Large or massive tears,

• Retracted tears,

• Coutallier three or four fatty infiltration

Bursal view before acromioplasty

Checking Tissue Quality

Surgical Technique

1. GH Joint and Subacromial Joint Inspection

2. Bursal debridement

3. Acromioplasty

4. Cuff mobilization

5. Repair (side to side, tendon to bone)

Patient position

Lateral decubitusTraction3-4 kgr Abduction 20 degrees

Portals

Outside in technique

Bleeding control

Joint Side Inspection

Bursal Side Inspection-Bursectomy

Tendon debridement- Tear morphology recognition

Acromioplasty

Techniques of releasesTechniques of releases

• The techniques adapted from open The techniques adapted from open surgery as described by Codmann, surgery as described by Codmann, Rockwood, NeerRockwood, Neer

• Refined and modernized by Esch, Snyder, Refined and modernized by Esch, Snyder, Gartsman, Burkhart and others Gartsman, Burkhart and others

ANY TYPE OF RECONSTRUCTION ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD MUST AVOID TENSION OVER-LOAD

OF THE REPAIROF THE REPAIR

Recognize the Tear PatternRecognize the Tear Pattern

• Tears must be repaired in the Tears must be repaired in the direction of greatest mobility -> direction of greatest mobility -> minimal strainminimal strain

Tear PatternsTear Patterns

• Crescent shapedCrescent shaped

• L-shaped (or reverse L)L-shaped (or reverse L)

• U-ShapedU-Shaped

• Massive Contracted Immobile tearsMassive Contracted Immobile tears

S.S. BurkhartS.S. Burkhart

Crescent Shaped Tear

S.S Burkhart

Crescent-Shaped TearCrescent-Shaped Tear

• Double row repair, Double row repair,

Double Row FixationRestoration of the footprint

Tuberoplasty

1st Anchor Insertion – Medial Row

1st suture passage- Medial row - mattress

suture passage- Medial row – post. anchor

Suture inspection – medial row - mattress

Lateral Row 1st Anchor Insertion

Lateral Row 2nd Anchor Insertion

Inspection of Suture Position

Knot Tying Lateral Row

Final Repair

Double rowDouble row

Probably stronger repair but Time consuming and of raised difficulty

L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears

Greater mobility from anterior to Greater mobility from anterior to posterior than medial to lateralposterior than medial to lateral

L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears

• Side to side sutures from medial to lateralSide to side sutures from medial to lateral

• Progressively converge the margin of the Progressively converge the margin of the tear lateral to bone bedtear lateral to bone bed

• Closing 50% of a U-Shaped tear -> Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a reduces strain at converge margin by a factor of 6 factor of 6

[[S. S .Burkhart]S. S .Burkhart]

Closing an L-shaped or U-shaped tear is much like closing a tent flap

Closure of an U-shaped tear involves first side-to-side closure of the vertical limb of the tear, then tendon-to-bone closure of the transverse limb

L or U -shaped tear

S. S .BurkhartS. S .Burkhart

Large U-shaped cuff tear extending to glenoid

Margin convergence

The free margin of the cuff is repaired to bone with suture anchors

Side to Side Repair

Cuff repair

Side to Side Repair

Cuff repairCuff repair

Tendon to bone repairTendon to bone repair

Massive Contracted Immobile TearsMassive Contracted Immobile Tears

• No mobility from medial to lateral or from No mobility from medial to lateral or from anterior to posterioranterior to posterior

• Subcategories:Subcategories:– Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears– Massive Contracted Crescent TearsMassive Contracted Crescent Tears

• Represent 9.6% of massive tearsRepresent 9.6% of massive tears

[[S.Burkhart]S.Burkhart]

Massive Contractite TearsMassive Contractite Tears

• Anterior Interval Slide Anterior Interval Slide

and/orand/or

• Posterior Interval SlidePosterior Interval Slide

Single and double interval slideSingle and double interval slide

Subacromial viewSubacromial view

Single and double interval slideSingle and double interval slide

• Anterior slide through release in the rotator Anterior slide through release in the rotator interval (supraspinatus–coracobrachialis)interval (supraspinatus–coracobrachialis)

• Posterior slide through release of the Posterior slide through release of the interval supraspinatus-infraspinatusinterval supraspinatus-infraspinatus

Massive Tears Massive Tears associated with associated with

Subscapularis TearsSubscapularis Tears

• Subscapularis must be mobilized and Subscapularis must be mobilized and repaired prior to the rest of the cuffrepaired prior to the rest of the cuff

• Interval slide in continuityInterval slide in continuity

Subscapularis Repair

Recognition

Subscapularis RepairSubscapularis Repair

Arthroscopic cuff repairArthroscopic cuff repair

Wolf, Snyder, Gartsman, Esch, Burkhart, Tauro and others reported 84%-94% excellent and good results

Today’s Knowledge

• Rot cuff has some degree of reserve that affords functional use of the arm in cases of limited tendon deficiency.

• Location rather that size of a tear maybe more important in the development of symptoms.

• Type of activities plays an important factor in the development of symptoms

Goutallier fatty degeneration of muscles

• Stage 0 Normal muscle – no fatty streaming

• Stage 1 Occasional fatty streaming

• Stage 2 Fat<50% of cross sectioned areaFat <

Muscle

• Stage 3 Fat=50% of cross sectioned areaFat = Muscle

• Stage 4 Fat>50% of cross sectioned areaFat > Muscle

What to do???

• Patients with grade 3 or 4 fatty degeneration DO NOT improve with rot cuff repair

[Goutallier]

Vs.

• Patients with grade 3 or 4 fatty degeneration improved significant at 86% of cases after arthroscopic repair

• [Burkhart]

Results for massive tears Results for massive tears

• 95% Good to Excellent Results 95% Good to Excellent Results

independent to tear size independent to tear size [Burkhart, 2001][Burkhart, 2001]

• With interval slideWith interval slide• Improve UCLA score (10->28.3)Improve UCLA score (10->28.3)• Improve Active ROM, StrengthImprove Active ROM, Strength

[Burkhart, 2004][Burkhart, 2004]

• Graft Jacket RepairGraft Jacket Repair• Improve UCLA score (18->32Improve UCLA score (18->32))

[Snyder, 2008][Snyder, 2008]

What can we Repair?

• UP to 50% of cuff repairs had a postoperative defect

• This didn’t affected patient satisfaction or pain relief • But it did affected shoulder strength

[Harryman et all J. B.J.S 1991]

Factors affecting Recurrence of tear

1. Advanced age 2. Tear size3. Fatty degeneration4. Chronicity and atrophy5. Poor tendon quality6. Inappropriate rehabilitation7. Smoking8. Steroid injections9. Diabetes

The quality of Functional results depends on:

1. The size of the persistent defect

2. Associated atrophy of the muscles

3. Integrity of the deltoid and the coracoacromial arch

4. Functional demands of the patient

How to convert a Symptomatic tear to an Asymptomatic re-tear

• Subacromial decompression and debridmeut

• Biseps tenotomy

• Partial repair and healing of the rot cuff

• Adequate post-op rehabilitation

Results - what to expect

• Pts between 50-75 years old with • pain • loss of external rotation (positive lag sign) and • inability to keep the hand externally rotated

• MRI findings: Goutallier III or IV

Arthroscopic findings: massive posterosuperior tear,

retracted tendons of bad quality


• Arthroscopic partial repair or medialized repair

•Resolution of pain but not restoration of external rotation

Results what to expect

• Patients aged 50-60 years old with painless loss of external rotation


Arthroscopic findings:

massive posterosuperior tear,



Arthroscopic partial repair or

medialized repair depending on the age and demands of the patient

Inability to restore external rotation

Tendon transfer more appropriate

in young active patients


• Pts with • acute exaberration of symptoms after minor trauma • mainly pain • loss of strength of abduction and ext rotation • age >60 years old • no or minimal symptoms before trauma



large or massive posterosuperior tear



Arthroscopic partial repair or

medialized repair

•Resolution of pain •near normal restoration of strength of abduction and external rotation •some loss of strength remaining •slow restoration of function •pts plateaus after more than a year


• Pts with • loss of function• pain after acute trauma1-3 months before• normal function before trauma

• MRI findings: Goutallier I or II


large or massive posterosuperior tear with good quality of tissues repair

with no tension


Complete resolution of symptoms

normal function

restoration of strength

Excellent Results independent of age

Results - what to expect• Young patients, athletes • or overhead workers age 20-40 years old with:

• pain

• loss of function or

• inability to perform athletics in the same level

• MRI findings: partial or complete tear of supraspinatus

Arthroscopic Findings: partial articular side or

complete tear of suprafpinatus

Double row repair:

complete resolution of symptoms


• Pts more than 60 years old with • pain • inability to raise the hand• Symptoms of long duration

• MRI findings: Goutallier III or IV complete tear and retracted tendons

• X-Ray findings: superior migration of the head and contact with the undersurface of the anterolateral acromion


No improvement

with arthroscopic treatment

Extended head or reverse arthroplasty a better option

Non-Operative Treatment

Best candidates for non-operative are:

• patients with chronic attritional RC tears • limited to one tendon • the onset not associated with significant trauma • over the age of 60 and less active

[Iannotti J.P.Disorders of the shoulder]

Conclusions

• Rot Cuf is extremely significant for the normal function of the shoulder

• Rot Cuf tears can be asymptomatic

• Symptoms Produced by a tear depend on:– Size– Location– Functional demands of the patient

Conclusions• An anatomically deficient but biomechanical intact cuff is

possible

• Biomechanical intact cuff is the cuff that restores the equilibrium of the force couples

• A cuff tear does not heal conservative

• A cuff tear after operative repair may yet not heal

• Partial healing after arthroscopic repair restores sufficient power to the cuff to equilibrate the force couples

Conclusions

• Non-operative treatment strives to optimize the function of the remaining cuff

• Rehabilitation after surgery strives to optimize the function of the partially or completely healed cuff

..so when we treat a RC tear…

We must try to:• Optimize the anatomic integrity and capacity of force

transfer of the cuff by a repair with minimal morbidity to the healthy tissues (mainly deltoid)

THEN• Rehabilitate vigorously the patient, to optimize the total

function of the shoulder

THEN

We can expect a majority of

satisfied patients

Thank you for your attention

www.shoulder.gr

Rotator Cuff Tears: Indications of arthroscopic treatment an overview Manos Antonogiannakis Director...

Documents

Transcript of Rotator Cuff Tears: Indications of arthroscopic treatment an overview Manos Antonogiannakis Director...