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
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 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
Results - what to expect
• 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
• MRI findings: Goutallier III or IV
Arthroscopic findings:
massive posterosuperior tear,
retracted tendons of bad quality
Results what to expect
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
Results - what to expect
• 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
• MRI findings: Goutallier III or IV
Arthroscopic findings:
large or massive posterosuperior tear
retracted tendons of bad quality
Results - what to expect
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
Results what to expect
• Pts with • loss of function• pain after acute trauma1-3 months before• normal function before trauma
• MRI findings: Goutallier I or II
Arthroscopic findings:
large or massive posterosuperior tear with good quality of tissues repair
with no tension
Results - what to expect
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
Results - what to expect
• 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
Results - what to expect
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
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