Download Rotator Cuff

Rotator Cuff Tears:
Indications
Treatment Options and
Results
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 partial thickness 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.
HL McLaughlin
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]
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]
Rot cuff disease etiology and pathogenesis
1. Tendon degeneration
2. Vascular factors
3. Impingement
• Type of acromion as identified by Bigliani
• Acromial angle devised by Toivonen .
• Type I. Angle 0-12
• Type II. Angle 13-27
• Type III. Angle > 27 Popularized by Neer
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]
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 are 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]
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
Grouping the Patients
Group I:
patients with minimal risk of
progression to irreversible changes
to the rotator cuff
Group II:
patients with high risk of
progression
Group III:
patients who have progressed
already
[Yamaguchi K., 2006, Nice Shoulder Course]
Group I patients
• About 50 years with tendinosis or partial tears
degenerative in nature Articular side
• They respond very well to
non operative treatment
(about 50-60% resolution of the symptoms)
• The risk of progression is very low but they need
observation
Non operative treatment
Group II patients
• Younger than 65 years with
– Small or medium size tears
– Acute tears of any size
– Tears with recent acute loss of function
• Patients non responsive to conservative
treatment
• Acute tears or overuse tears in athletes
Early surgical repair to avoid irreversible changes
Group III patients
• Older than 70 years
– with large or massive tears and
– irreversible damage to the rot cuff
They can benefit from rotator cuff repair,
even a partial repair
[Yamaguchi K., 2006, Nice Shoulder Course]
[Burkhart, 2007, Arthroscopy]
Partial Tears Treatment
• By far the most common partial tears are
Articular-side, vascular or age relateted
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 causes significant pain then
debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]
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
Full thickness Tear
What is Bad Tissue Quality?
•
•
•
Large or massive tears,
Retracted tears,
Coutallier three or four fatty infiltration
Busral view after acromioplasty
Checking Tissue Quality
RC Arthroscopic Repair
1. Recognition, of the type of the tear
2. Retraction and releases
3. Repair Options:
Anchors:
Type of stitch:
metallic or absorbable
Mason-Allen,
Mc Stitch,
Mattress sutures,
Horizontal mattress,
Simple sutures
Restoration of footprint: Double row or
Single row
Double Row Fixation
Restoration of the footprint
Double Row Fixation
What kind of Repair is NECESSARY?
• An anatomically deficient RC could be biomechanically
intact rot cuff
[Burkhart]
• Conservative treatment of chronic painful rot cuff tears
will result in a successful outcome in about 50% of
patients
[Cofield]
• Cuff tear arthropathy will develop in 4% of patients with
complete rot cuff tears
[Neer]]
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 that affect RC Healing
•
•
•
•
•
•
Age
Sex
Activity
Size
Location
Tissue quality and
elasticity
• Muscle fat
degeneration
•
•
•
•
•
Chronicity of the tear
Concomitant lesions
Smoking
Family history
Rehabilitation
Protocol
• NSAID
• Surgical Technique
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
Fat=50% of cross sectioned area
Fat = Muscle
Fat>50% of cross sectioned area
Fat > Muscle
• Stage 3
• Stage 4
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]
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
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]
Treatment of
Irreparable Massive RC Tears
• Pts >70 years with massive tear and major complaint
pain, can function reasonably well
Criteria of Irreparability:
• Profound weakness of external rotation with ext.rot lag or
internal rotation lag when the subscapularis is involved
• Superior displacement of the humeral head and contact
with the acromion
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
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
Early failure
of arthroscopic rot cuff repair
1. Failure of tendon-suture interface
2. Suture-anchor failure
3. Suture failure
RC Repair Results
• The rate of structural failure after open repair varies
from 20% to more 50%, while it is greater for
arthroscopic repairs
• First report of DOUBLE ROW repair:
Fealy S, Kingham TP, Altchek DW, Arthoscopy July 2002
Mini-open Rot cuff repair using a two row fixation technique
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 age
• 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
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 II or III
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
Results - what to expect
• Pts >50 years old with
• minimal symptoms
• Chronic symptoms
• MRI findings: Small to medium tear of supraspinatus
• Pts willing to accept slight restrictions of overhead
activities
Results - what to expect
Conservative treatment
may be successful
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 may restore 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 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