Transcript Rotator Cuff

Rotator Cuff Tears:
Indications of arthroscopic treatment
an overview
Manos Antonogiannakis
Director
center for shoulder arthroscopy
IASO 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
The History of Rotator Cuff Repair
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
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.
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
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]
How Frequent are RC Tears?
Full Thickness Tear
Age
40-60
60-70
70-80
>80
Frequency
4-13%
20%
50%
80%
Partial Thickness Tear
Age
<40
>60
Frequency
4%
25%
[Tempelhof S, JSES, 1999]
Rot cuff disease etiology and pathogenesis
1. Tendon degeneration
2. 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 migration
6. 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
DECISION
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
Patients 25 - 45 years
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
Usually small
to medium
tears not
retracted
Patients 45 - 65 years
Subacromial impingement is
common
Acute tears on chronic
Chronic pain. Night pain
In the more severe cases weak
or impossible elevation external
rotation
Usually Full
Thickness
Tear.
Good Tissue
Quality
Patients >65 years
Rot cuff tears common
Limited activities make severe
rotator cuff tears tolerable
Usually Large
or Massive
Tear
Chronic aching or acute
exaberation of symptoms after
minor trauma
Goutallier
Stage 3 or 4
Debilitating symptoms in rotator
cuff arthropathy
Retracted
Tendons
RC Treatment Options
Non-Operative
Operative
Open Surgery
Mini Open
Arthroscopy
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
Operative Treatment
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
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 only
2. In-situ Repair
3. 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
1.
2.
3.
4.
5.
6.
Tear
Age
Tissue Quality
Partial
Complete
Complete
Complete
Complete
Complete
<40
Good
<40
40-65
40-65
>65
>65
Good
Good
Bad
Good
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 decubitus
Traction3-4 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 releases
• The techniques adapted from open
surgery as described by Codmann,
Rockwood, Neer
• Refined and modernized by Esch, Snyder,
Gartsman, Burkhart and others
ANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOAD
OF THE REPAIR
Recognize the Tear Pattern
• Tears must be repaired in the
direction of greatest mobility ->
minimal strain
Tear Patterns
•
•
•
•
Crescent shaped
L-shaped (or reverse L)
U-Shaped
Massive Contracted Immobile tears
S.S. Burkhart
Crescent
Shaped Tear
S.S Burkhart
Crescent-Shaped Tear
• Double row repair,
Double Row Fixation
Restoration 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 row
Probably stronger repair
but
Time consuming and of
raised difficulty
L-Shaped & U-Shaped Tears
Greater mobility from anterior to
posterior than medial to lateral
L-Shaped & U-Shaped Tears
• Side to side sutures from medial to lateral
• Progressively converge the margin of the
tear lateral to bone bed
• Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by a
factor of 6
[S. S .Burkhart]
L or U -shaped tear
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
S. 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
Cuff repair
Side to Side Repair
Side to Side Repair
Cuff repair
Tendon to bone repair
Massive Contracted Immobile Tears
• No mobility from medial to lateral or from
anterior to posterior
• Subcategories:
– Massive Contracted Longitudinal Tears
– Massive Contracted Crescent Tears
• Represent 9.6% of massive tears
[S.Burkhart]
Massive Contractite Tears
Single and double interval slide
• Anterior Interval Slide
and/or
• Posterior Interval Slide
Subacromial view
Single and double interval slide
• Anterior slide through release in the rotator
interval (supraspinatus–coracobrachialis)
• Posterior slide through release of the
interval supraspinatus-infraspinatus
Massive Tears
associated with
Subscapularis Tears
• Subscapularis must be mobilized and
repaired prior to the rest of the cuff
• Interval slide in continuity
Subscapularis
Repair
Recognition
Subscapularis
Repair
Recognition
Subscapularis Repair
Arthroscopic 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 area
Fat < Muscle
• Stage 3
Fat=50% of cross sectioned area
Fat = Muscle
• Stage 4
Fat>50% of cross sectioned area
Fat > 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
• 95% Good to Excellent Results
independent to tear size
• With interval slide
[Burkhart, 2001]
• Improve UCLA score (10->28.3)
• Improve Active ROM, Strength
[Burkhart, 2004]
• Graft Jacket Repair
• Improve UCLA score (18->32)
[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.
2.
3.
4.
5.
6.
7.
8.
9.
Advanced age
Tear size
Fatty degeneration
Chronicity and atrophy
Poor tendon quality
Inappropriate rehabilitation
Smoking
Steroid injections
Diabetes
The quality of Functional results depends
on:
1.
2.
3.
4.
The size of the persistent defect
Associated atrophy of the muscles
Integrity of the deltoid and the
coracoacromial arch
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
www.shoulder.gr
Thank you for your attention