Rotator Cuff Tears: Frequency of Tears

1
Rotator Cuff Tears Frequency of Tears

• - surgically demonstratable full thickness RTC
  tears are present in about            1/5
  elderly patients    - MRI studies have been
  published which note a much higher prevalence of
  RTC tear    - complete supraspinatus tears may
  occur in upto 20 after age 32 yrs            -
  after age 40 years of age, approximately 30 of
  patients will have cuff tears, and             
        after age 60 yrs, there will be cuff tears
  in upto 80 of patients    - in the study by SA
  TeefeyMD et al, 100 consecutive shoulders in 98
  patients with shoulder            pain who had
  undergone preoperative US and subsequent
  arthroscopy were identified            -
  arthroscopic diagnosis was a full-thickness
  rotator cuff tear in sixty-five shoulders, a   
                  partial-thickness tear in
  fifteen, rotator cuff tendinitis in twelve,
  frozen shoulder                    in four,
  arthrosis of the acromioclavicular joint in two,
  and a superior labral tear                   
  and calcific bursitis in one shoulder each    -
  ultrasonography correctly identified all 65
  full-thickness rotator cuff tears (a sensitivity
  of 100 percent)            - there were
  seventeen true-negative and three false-positive
  ultrasonograms (a specificity of 85 percent)   
          - overall accuracy was 96 percent     
        - size of the tear on transverse
  measurement was correctly predicted in 86 percent
  of the shoulders with a full-thickness tear   
          - ultrasonography detected a tear in ten
  of fifteen shoulders with a partial-thickness
  tear that was diagnosed on arthroscopy.         
    - 5 of 6 dislocations and seven of eleven
  ruptures of the biceps tendon were identified
  correctly

2
Diff Dx of Rotator Cuff Tear

• Diff Dx    - C5-C6 lesion    - suprascapular
  nerve palsy    - biceps tendon rupture    -
  biceps tendonitis    - calcific tendinitis   
  - traumatic tear of rotator interval          -
  this lesion will demonstrate extension of dye
  into subacromial space    - axillary nerve
  palsy          - may occur from previous
  shoulder dislocation or iatrogenic injury     
      - will cause both deltoid and teres minor
  injury    - os acromiale    - posterior
  (internal) impingement (see throwing shoulder) 
    - polymyalgia rhematica

3
Rotator Cuff Tears Partial Rotator Cuff Tear

•   - etilogy of tear            - impingement
  syndrome (75)            - shoulder
  instability (anterior or multi-directional) (15)
  (should be considered in any                   
  young active patient)            - trauma   
                  - occurs in 10 of patients   
                  - note that a displaced greater
  tuberosity frx is a RTC tear equivolent    - by
  definition, partial tears involve 50 or more of
  the tendon    - in the study by SC Weber
  (Arthroscopy 1999), 32 patients with significant
  partial-thickness rotator cuff tears were treated
  with debridement and            acromioplasty
  versus 33 patients who were with mini-open
  repair            - 88 of tears were on the
  articular sidee            - acromiplasty and
  debridement group            - significant
  number of the arthroscopic group had fair results
  by UCLA score criteria            - 3 patients
  reruptured the remaining cuff later despite
  adequate acromioplasty            - healing of
  the partial tear was never observed at
  second-look arthroscopy            -
  acromioplasty alone did not prophylactically
  prevent rotator cuff tear progression         
    - the good results of arthroscopic treatment of
  significant partial-thickness tears deteriorated
  with time            - open repair group     
        - although postoperative pain was
  significantly greater and recovery slower with
  open repair, no patient was reoperated on and
  rerupture of the repair did not occur

4
Shoulder Impingement Syndrome

• Discussion    - impingement syndrome describes
  pain in subacromial space when the humerus is
  elevated or internally rotated    - during
  humeral flexion, the supraspinatus tendon and
  bursa become entrapped between the anteroinferior
  corner            of the acromion (and CA
  ligament) and the greater tuberosity    - this
  syndrome is thought to precipitate attritional
  changes in the rotator cuff, leading to RTC
  tear            - once the supraspinatus (and
  infraspinatus) tendon is disrupted there will
  often be further impingement                 
  and irritation which can lead to biceps
  tendonitis and subsequent rupture

5
outlet impingement

•   - rotator cuff and subacromial bursa can be
  impinged between the greater tuberosity and
  theanterior 1/3 of acromion    - greater
  tuberosity impinges anteriorly w/ forward flexion
  and laterally along undersurface of the acromion
  with modest abduction and neutral rotation  -
  similar phenomenon can occur after displaced AC
  separations coracoacromial ligament           
              - forced internal rotation in forward
  flexed position will drive greater tuberosity
  against the coracoacromial ligament    - AC
  joint                        - AC arthritis or
  AC joint osteophytes can result in impingement
  and mechanical irritation to the rotator cuff
  tendons                  - misc causes       
                  - greater tuburosity fractures
  can cause impingement on the rotator cuff if the
  fragment rotates superiorly                   
      - humeral neck fractures that heal in a varus
  position will cause the greater tuberosity to
  tilt more superiorly

6
non-outlet impingment

• -           - loss of normal humeral head
  depression by the rotator cuff tear or weakness
  from a C5-6 lesion or suprascapular nerve palsy,
  or biceps tendon rupture          - may occur
  due to thickening or hypertrophy of the
  subacromial bursa and rotator cuff tendons     
      - may occur in the throwing athlete due to
  posterior impingement                  - in
  these cases, patients may demonstrate excessive
  external rotation and/or recurrent anterior
  instability

7
Clinical Findings

• Clinical Findings (see shoulder exam)    -
  staging of impingement syndromes    - pain will
  often become worse at night, as the subacromial
  bursa becomes hyperemic after a day of
  activity    - impingement test is performed by
  1st eliciting positive impingement sign       
      - impingment sign pain which occurs after
  forward flexing arm to 90 deg, and forcefully
  internally rotating the shoulder            -
  10-15 ml of 1 xylocaine are the injected into
  the subacromial space, and the   impingement sign
  is again sought            - subacromial space
  should not be injected with steroids twice,
  because of the risk of tendon rupture    -
  carefully test for shoulder contractures       
      - patients w/ contracture of the posterior
  capsule (and loss of internal rotation) will be
  most                  likely to demonstrate
  signs of impingement (despite normal acromial
  anatomy)

8
Staging of Impingement Syndromes

• Stage I    - edema and hemorrhage    -
  reversible lesion usually seen in the second and
  third decade    - exam          - palpable
  tenderness over the greater tuberosity at
  supraspinitus              insertion          -
  palpalble tenderness along the anterior edge of
  the acromion          - painful arc of
  abduction between 60 and 120 deg increased with 
              resistance at 90 deg- Stage II 
    - chronic inflammation or repeated episodes of
  impingement leads to fibrosis          
  thickening of supraspinatus, biceps,
  subacromion bursa    - at this stage there is
  inability to reverse process by activity
  modification    - generally pts are between
  25-40 years, however, age is less important     
      than the duration of symptoms, which is
  usually years    - symptoms consist of an
  aching discomfort, often interfering w/ sleep   
        work, and may progress to interfere w/
  activities of daily living    - mild limitation
  to both passive and active range of motion    -
  arthroscopic acromioplasty subacromial
  decompression do not require          deltoid
  detachment are assoc w/ cost savings more
  rapid rehab    - arthroscopic acromioplasty is
  perhaps most suited for type II lesions         
  (w/ partial tears), and is less useful for those
  with no tears or          complete tears-
  Stage III    - rotator cuff tears, biceps
  ruptures, and bone changes    - following a
  prolonged history of refractory tendinitis,
  significant          tendon degeneration is the
  hallmark of stage 3    - pts are usually in the
  5th or 6th decade, and often admit to prolonged 
          periods of pain, particularly at night 
          - weakness can be bothersome    - as
  further rotator cuff degeneration occurs       
    - limitation to shoulder motion          -
  infraspinatus atrophy          - weakness of
  shoulder abduction and external rotation       
    - biceps tendon involvement with rupture or
  degenerative changes              occurring in a
  high percentage of pts with rotator cuff tears 
          - AC joint tenderness, esp if
  degenerative changes are present    - although
  pain related weakness can be present at any
  stage, injection          of 1 lidocaine within
  the subacromial space in Stage 3 will not       
    eliminate weakness and limitation of active
  motion    - radiographic changes          -
  cystic changes about the greater tuberosity     
      - sclerotic changes beneath the anterior
  third of the acromion          - osteophytes
  along the undersurface of acromion often
  associated              with the coracoacromial
  ligament          - AC joint changes         
  - late narrowing of the subacromial space

9

• Impingement Radiographic Series     - axillary
  view may reveal an Os Acromiale, which is
  associated w/ impingment     - scapular outlet
  view           - allows assessment of acromial
  morphology           - examination of cadavera
  reveal               - type 1, a flat acromion
  (17 of shoulders) 3 of all cuff tears have
  this type of acromion               - type 2, a
  curved acromion (43) 27 of all cuff tears have
  this type of acromion               - type 3, a
  hooked acromion (40) majority (70 - 90) of
  rotator cuff tears may be seen in pts w/ type-2
  or a type-3 acromion                       -
  type A less than 8 mm in thickness            
            - type B 8-12 mm thick              
          - type C greater than 12 mm in
  thickness               - references        
              - The morphology of the acromion and
  its relationship to rotator cuff disease. LU
  Bigliani et al.   Orthop. Trans. Vol 10. p 228.
  1986.                     - The clinical
  significance of variations in acromial
  morphology. DS Morrison and LU Bigliani.  
  Orthop.. Trans. Vol 11. p 234. 1987.            
          - A modified classification of the
  supraspinatus outlet view based on the
  configuration and anatomic thickness of the
  acromion. HC Wuh.   Orthop. Trans. Vol 16. p 767.
  1992-1993.     - 30 deg Caudal Tilt AP View is
  taken tangential to dome of acromion to assess
  size of anterior inferior acromial osteophyte  
    - AP of the Shoulder             - note that
  normal acromiohumeral interval is 1 to 1.5 cm  
            - other varients of the AP view is  
                  - internal rotation view      
              - 35 deg external rotation        
            - 90 deg abduction view              
      - Grashey view                         -
  obtained w/ 30 deg lateral oblique projection,
  tangential to glenohumeral joint, in order to
  obtain view directly down joint to reveal any
  degenerative changes     - Active Abduction
  View     - West Point View may be indicated in
  younger patients w/ suspected anterior
  instability

10

• Non-Operative Treatment    - as noted by D.S.
  Morrison et al 1997, 2/3 of patients can expect
  to have significant relief of symptoms with non
  operative treatment          - only half of
  patients who are over 60 years of age will have
  satisfactory result with non operative
  treatment          - 91 of patients w/ a type
  I acromion will have satisfactory result    -
  patients should specifically work on increasing
  specific deficits in their ROM such as loss of
  internal rotation (as compared to the normal
  side)    - specific techniques          -
  internal rotation is improved by having the
  patient reach the good hand behind his neck and 
                  and simultaneously place his
  painful side in maximal internal rotation up the
  back                  - a towel or a rope is
  used to connect the two hands, and the good hand
  raises up to the                        celing,
  forcing the other into maximal internal
  rotation          - flexion is improved on by
  use of overhead pulleys and use of a meter
  stick

11

• - Operative Treatment    - cases that do not
  respond to above conservative measures after 6
  months of treatment are candidates for surgery 
    - choices include open acromioplasty or
  arthroscopic acromioplasty            - note
  that Rockwood has expressed concern about
  arthroscopic decompression because it disrupts
  the lower half of the deltoid origin to the
  deltoid                  - while this concern
  has not been borne out by clinical studies, it
  may be an important consideration for type III
  acromions, since an adequate                   
        decompression would require an extension
  amount of deltoid detachment both inferiorly and
  anteiorly    - preoperative considerations   
          - be clear with the patient about the
  expected results of surgery                  -
  if the patient demonstrated excessive pain from
  the subacromial steroid injection (at the time of
  injection),                          then it is
  likely that the patient will demonstrate
  excessive postoperative pain                  -
  likewise, if the results of the steroid injection
  did not provide significant relief, then a
  decompression may not satisfy the patient's
  expectations    - cautions            - in
  the case of massive rotator cuff tear, an
  acromioplasty (w/ CA ligament release) may
  precipitate additional superior migration     
        - throwing athelets w/ impingment often do
  not benefit from acromionplasty

12
Cas 1 h 54 ans imp sy depuis 2 ansclini exam
3 inj cortiarth-scan full thic tears sup
spinatConstant Shoulder Score   poor
(27 )                  
13
4 mois P.O

• Pas doul
• Mobilité total très bien
• Constant Shoulder Score
• good (55 )

14
Cas 2 h 35 ans Masson doul depuis 3 an 2
cotéclinic exa -3 inj cortiMRI full thic
tears sup spina

• Constant Shoulder Score                    fair
  (32)    

15
(No Transcript)
16

• 3 mois p.o
• Constant Shoulder Score
•  Excellent(70)                       

17
Cas 3Une Dame 60 ansRCT full thickness

• 2 ans doul
• 2 in corti
• ةpaule score avt opé poor(27)
• Suture acromio-plastie

RCT
Coraco acromial lig
18
acromioplastie
RCT
19
Cas 4 Une dame 44 ansCRT full thic
20
(No Transcript)