Transcript When to repair the rotator cuff?

When to repair the rotator
cuff?
Mr Simon Holland
Ringwood Private Hospital
www.simonholland.com.au
Take home messages
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The rotator cuff has limited healing
potential
Untreated rotator cuff tears may result in
cuff tear arthropathy
Consider in all patients less than 60 y.o.
Need a mobile shoulder
The rotator cuff has limited
healing potential
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The tendon typically tears in a
hypovascular zone of the supraspinatus
tendon
Poor blood supply = poor healing potential
Once a full thickness tear, the tendon
retracts across the humeral head with
minimal chance to adhere to this surface
Untreated rotator cuff tears may
result in cuff tear arthropathy
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This can be painful or painless
Often in patients with previous surgery
Difficult treatment options dependent on
bone anatomy and pain
Treatment aims to maximize function vs
loss of pain
Consider in all patients less
than 60 y.o.
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60% of 60 year olds will have a rotator cuff
tear on imaging
Most will will be asymptomatic
Most 70 year old rotator cuff tissue is of
questionable quality
Need a mobile shoulder
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A rotator cuff repair in a frozen shoulder is
unlikely to be successful
Aim for passive range of motion
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Physio - Jackin’s program
Hydrodilatation
Time
Surgical release
Case 1
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F53 Hairdresser self employed
Night pain, struggling with work (shoulder
height) for 12 months
Failed physio
Good ROM
Weak SS (4/5)
Acromioclavicular joint non tender
Rotator Cuff Examination
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Tenderness - tendon insertion, AC joint
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If AC joint, ? cross arm or O’Brien’s
aggravates
If posterior joint line, ? degenerative joint
ROM - exclude adhesive picture
Power (out of 5)
SS, IS, Subsc, Biceps
Imaging
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Ultrasound (not particularly useful)
Suggested no tear, and patient delayed in
presentation
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Xrays - arranged - every patient
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AP, true AP, Scapular Lateral and Axillary Lateral
Exclude other causes - OA, AC joint, fracture,
cancer
Glenohumeral Arthritis
True AP
AP
Scapula Lateral
Axillary Lateral
Imaging
MRI scans
 When diagnosis is in doubt such as when
pain is severe and patient wishes to know
now, and not wait for time
 Suspect multiple pathologies / limited
equipment inventory
 When third parties have an interest. Check
and acknowledge other pain generators
Management
Diagnosis
 SS full thickness tendon tear
Treatment Options
 More of the same with subacromial
cortisone injections
 Surgical
Treatment
Non Operative
 Much research into why most tears are
asymptomatic
 EMG studies suggest poor subscap function in
painful tears, but subscap directed treatment has
not produced clinical nor EMG results
 Equatorial theories - tear extends beyond a
certain latitude, defunctioning the intact tendons
Treatment
Operative Options
 Subacromial Decompression
 Rotator Cuff Repair
 Acromioclavicular joint excision
 Biceps Tenodesis
Subacromial Decompression
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Arthroscopic or open
Assess coracoacromial ligament and
undersurface of acromion
Smooth and débride
Resect subacromial bursa
Débride partial thickness tears of the
undersurface(articular sided) of the rotator
cuff
Rotator Cuff Repair
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Arthroscopic, Open or Combination
Complete and incomplete
Anchors vs no anchors
Single vs double row repairs
Acromioclavicular Joint Excision
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Often co-existing pathology
May contribute to SS impingement
Open or Arthroscopic
Biceps Tenodesis
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Biceps often involved, especially with
subscap tears where it subluxates and
impinges against the coracoid process
with adduction and internal rotation
Reattach or tenotomize
Can be trouble in its own rite
Principle Risks
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Unintentional stiffness - compared to
stabilization
Infection - < 1% for arthroscopic
procedures
Repair failure, often asymptomatic
Healing of collagen is weakest at 4 months
Procedure
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Overnight
Home exercise program
Analgesia and ice
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Oxycontin, oxycodone/p. forte/digesic, NSAID
Sling for 6 weeks
Recovery
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0 - 10 days - standard exercises, keep away
from work
11d to 6 weeks - sling, light duties
6 - 12 weeks - no sling, light duties
> 12 weeks - start to see a physio
> 6 months - aim for normal duties
18 month before full recovery
Recovery
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0 - 2 weeks - will not think I am a friend
6 weeks - suspect I have helped
3 months - certain that I have helped and
frustrated at the speed of healing
6 months - about 90% when look back
Case 1
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Uneventful double
row arthroscopic
supraspinatus repair
Case 2
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M45, truck driver
Fall 2 months ago while unloading truck
Sudden pain, unable to lift away from body
and not responding to non op measures
Smoker
Case 2
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Slight loss ROM
Tender - B, SS, Subsc
SS 4+. Subsc 3 (belly press), B 4
Prominent AC, non tender
Case 2
US - aPTT of SS (hoped for a clue with
biceps - need good ROM)
XR and MRI
• SS and Subsc FTT with Biceps
Subluxation
• AC arthropathy
Case 2
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3 cm subsc tear, < 1 cm SS tear
Arthroscopic Subacromial decompression
Arthroscopic AC Joint excision
Open Subscap and SS repair with biceps
tenodesis
Case 2
Case 3
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F47 Office work
Fall in garden 8 months ago
Initially not able to actively move, sling for
two weeks, gradual loss of movement
CSI of no value
NIDDM
Case 3
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Poor ROM and global cuff weakness 4/5
Tender - general, AC 
US - SS tear
XR - no OA
Case 3
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MRI - not going to change management.
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Treat as adhesive capsulitis and when
motion restored, reassess rotator cuff
clinically and radiologically as indicated.
Case 4
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M35, sales representative
Mountain bike accident on single trail
? dislocation, self reduced 6 weeks ago
Unable to elevate arm
Case 4
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Tender SS, posterior humeral head, anterior
joint line
Full passive ROM, reduced active (< 60 FE)
Anterior laxity and positive apprehension
signs
3/5 SS power
Case 4
General Rule
 50% of those > 40 y.o. with a first time
traumatic dislocation will have a rotator
cuff tear.
 Treatment is directed at the rotator cuff
first and the instability second.
 MRI is often helpful
Case 4
Case 5
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M63, farmer
Longstanding ache that was at nuisance
level for years, tripped at home and
worsening pain and function
SS 4/5, IS 3/5
Case 5
Diagnosis = Massive Rotator Cuff tear
 Xray to exclude fracture
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Likely longstanding tear that extended.
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Arthroscopic techniques offer less morbidity and
better access to tendons
Discuss possible irreparable tendon
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Case 5
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> 5 cm tear
(massive)
Double row
repair
Questions
?
Summary
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When symptoms are more than a
nuisance and non operative measures
have been explored, surgical management
and possible repair are viable treatment
options.
Contact details:
www.simonholland.com.au
[email protected]