Rotator Cuff Tears

1
Rotator Cuff Tears

• Reza Omid, M.D.
• Assistant Professor Orthopaedic Surgery
• Shoulder/Elbow Reconstruction Sports Medicine
• Keck School of Medicine
• University of Southern California

2
Anatomy

• Muscles?
• Innervation?
• Function?

3
Rotator Cuff TearsNatural History

• ?

4
Rotator Cuff TearsTreatment

• Not standardized
• When do we maximize conservative care?
• When is early surgical intervention appropriate?

5
AAOS Guidelines for Treatment of Rotator Cuff
Tears
6
Rotator Cuff Repair Surgical Indications

• Variations in Orthopaedic Surgeons Perceptions
  about Indications for Rotator Cuff Surgery
  Dunn, et al, JBJS 05
• Sig variation
• Lack of agreement
• Surgical discussion
• Role of PT
• Prevent progression of tear

7
Asymptomatic TearWhy?

• Mechanical Factors?
• Force couples
• Demographic Factors?

8
Proximal Humerus Migration

• Why Does it Happen??

9
Rotator Cuff DisordersGlenohumeral Kinematics

• Normal Cuff Head Centered
• Tendinitis, Fatigue Superior Migration
• Symptomatic RCTs Superior Migration
• Asymptomatic RCTs

?
Poppen Walker, JBJS 75
10

• Journal of Shoulder Elbow Surgery
• 200096-11

11
Results

• Normals Ball
  socket kinematics
• Symptomatic RCTs Superior head
  migration
• Asymptomatic RCTs Superior head
  migration (greater variability)

12
Conclusions

• Loss of rotator cuff integrity (both symptomatic
  and asymptomatic) was associated with superior
  head migration
• Superior head migration did not necessarily
  correlate with symptoms

13
Conclusions

• Implies normal glenohumeral kinematics do not
  need to be restored with surgery

14

•  
•  

Journal of Bone and Joint Surgery, 99A, 2009
15
Bilateral Two-Tendon RCT

• 30 Degree Abducted

16
Glenohumeral KinematicsAsympt vs Sympt RCT

• Asymptomatic w/ less superior migration (smaller
  tears)
• Both sympt/asympt superior in massive tears
• Critical size for superior migration
• 1.5 cm tear

Jay Keener, JBJS 2009
17
Journal of Shoulder and Elbow Surgery 103, 2001
18
Methods

• Shoulder Ultrasound employed at Washington
  University since 1984 (Unique Study Opportunity)
• Routine bilateral exams
• Predict large of asymptomatic tears

19
ResultsSymptomatic Progression

• 23/45 (51) became symptomatic
• avg 2.8 yrs from US

20
Conclusions

• 39 total had tear size progression
• No tears decreased in size (dont heal on their
  own)
• Relationship between symptoms and tear
  progression?

21
Journal of Bone and Joint Surgery 2006 88-A,
1699-1704
22
Methods

• Presence of unilateral shoulder pain (n588)
• Bilateral intact cuffs (n212)
• Unilateral tear (n191)
• Bilateral tears (n185)
• Demographic questionnaire data obtained for
  586/588
• Age, tear size, side, thickness, family hx
  compared between symptomatic and asymptomatic
  individuals

tear partial-thickness or full-thickness
23
Results

• Correlation with Pain
• Associated with dominant side (plt0.01)
• 65 painful tears on dominant side
• Associated with larger tears (plt0.01)
• Symptomatic side 25 larger than asymptomatic
• No other demographic feature significant

24
Results

• Cuff disease increased with age
• No tear 48.7 yo
• Unilateral tear 58.7 yo
• Bilateral tear 67.8
• 50 likelihood of bilateral tear after age 66 yr
  if present with painful tear, (plt0.01)

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Healing of RCR Influence of Age

• Outcome/tear integrity of massive tears JBJS
  2004
• Tear integrity with double-row repair AJSM 2009
• Outcome/ tear integrity of PTRCR JBJS 2009
• Outcome/tear integrity of Revision RCR JBJS
  2010

Avg patient age healed 55 yo Avg patient age not
healed 63 yo
26
Conclusions Demographics

• Unilat tear in young
• Bilat tear in older
• Tears rare before 40 yo.
• Tears common after 61 yo.

27
Conclusion

• Intrinsic etiology for Cuff Disease
• High incidence asympt./bilat disease
• Increased tear size important for pain
• High index of suspicion in high risk groups

28
Symptomatic Transition of Asymptomatic Rotator
Cuff Tears

• Mall et al JBJS 2010

29
Conclusions

1. Over a 2 year period 21 of patients with an
   asymptomatic rotator cuff tear became symptomatic
2. Symptomatic transition of asymptomatic cuff tears
   is associated with significant increases in pain
   and loss of function
3. Tear size progression may play a significant role
   in symptomatic transition.
4. No significant changes seen in glenohumeral
   kinematics or shoulder strength upon symptomatic
   transition. (early detection is key!)

30
UltrasonographyAccuracy

• Varies among institutions
• 60 accuracy JBJS86
• Not widely accepted

31

• Journal of Bone and Joint Surgery 2000
• 82-A498-504

32
Methods

• Validated accuracy
• Teefey et al, JBJS 04
• Compare to MRI
• Pricket et al, JBJS 03
• Post op shoulder
• Teefey et al, JBJS 00
• Compare to surgery
• Middleton et al, JBJS 86

33
Natural History of Fatty Degeneration of Muscles

• ?

34
Fatty Degeneration vs Fatty Infiltration

• Galatz vs Gerber
• What is the difference?
• Why does it happen?

35
Degeneration vs Infiltration

• Gerber fatty cells infiltrate the muscle once
  the pennation angle changes
• Galatz fat cells develop from pluripotent cells
  found within the muscle itself, the process of
  infiltration does not occur

36
Fatty degeneration of the rotator cuff muscles
Normal rotator cuff
Fat-infiltrated infraspinatus
37
Fatty degeneration of the rotator cuff muscles
Normal Supraspinatus
Fat-infiltrated Supraspinatus
Wall et al Accepted for pub JBJS 2012
38
What is atrophy?

• Tangent Sign?

39
What is atrophy?
40
Journal of Bone and Joint Surgery 2010
41
Methods

• 262 pts from prospective cohort
• Compare fatty degeneration to
• Tear location (relative to biceps)
• Tear size ( number of muscles)

42
Distance from Biceps Tendon
43
Results

• 35 of full tears with sig fatty degeneration
• Fatty degeneration in full-thickness tears only
• Fatty degeneration highly correlated with
  proximity of tear to biceps

44
Conclusions

• Disruption of anterior supraspinatus is strongly
  associated with development of fatty degeneration
• Supports rotator cable concept for cuff
  (Burkhart) disruption of anterior cable is key!

45
Rotator Crescent / Cable
46
Where do RCT Initiate?
47
Rotator Cuff Tears

• Conventional concept
• Start from the anterior portion of supraspinatus
  insertion near the biceps tendon
• Propagate posteriorly
• Supraspinatus almost always involved

Codman EA, 1934 Keyes EL, 1933 Hijioka A, 1993
Matsen III FA, 1998 Lehman C, 1995
48
Superior
Supraspinatus
Infraspinatus
Biceps tendon
Posterior
Anterior
Teres Minor
Humeral Head
Subscapularis
Inferior
49
Wash U Clinical Experience
DT
IS
SS
BT
HH
50

• Journal of Bone and Joint Surgery 10

51
Discussion

• Bidirectional propagation
• - Tears start 15 mm post to biceps
• - Extend in both anterior and posterior
  directions from their initiation location
• - Did not extend only in the posterior direction

52
Superior
Supraspinatus
Infraspinatus
Biceps tendon
15mm
Posterior
Anterior
Teres Minor
Humeral Head
Subscapularis
Inferior
53
Mechanism
Rotator Cable
Rotator Crescent
15 mm
BT
Anterior
Posterior
54
Epidemiologic Factors

• ?

55
Smoking Increases the Risk for Rotator Cuff Tears

• Keith M. Baumgarten, MD
• David Gerlach, MD
• Leesa M. Galatz, MD
• Sharlene A. Teefey,MD
• William D. Middleton, MD
• Konstantinos Ditsios, MD
• Ken Yamaguchi, MD

CORR 2009
56
Methods

• Hx of Cigarette Smoking

Cuff Intact vs. Cuff Tear
57
Conclusions

• Smoking increases the risk for rotator cuff
  tears
• Strong association highly statistically
  significant
• Time dependant relationship
• More recent smoking
• Cause / effect relationship?
• Dose Response relationship
• packs per day
• years smoking

58
Diabetes

• -Clement JBJSBr 2010 1112-7
• Patients with diabetes showed improvement of pain
  and function following arthroscopic rotator cuff
  repair in the short term, but less than their
  non-diabetic counterparts
• -Bedi JSES 2009 978-88
• impairs tendon-bone healing after rotator cuff
  repair

59
NSAIDS

• -Cohen AJSM 2006 362-9
• Traditional and cyclooxygenase-2-specific
  nonsteroidal anti-inflammatory drugs
  significantly inhibited tendon-to-bone healing in
  animal model

60
Obesity (?)

• -Namdari JSES 2010 1250-5
• Although obesity is considered a risk factor for
  poor postoperative outcomes after some surgical
  procedures, in our experience, obesity does not
  have an independent, significant effect on
  self-reported early outcomes after RCR
• -Warrender JSES 2011 961-7
• Obesity has a negative impact on the operative
  time of arthroscopic rotator cuff repairs, length
  of hospitalization, and functional outcomes.

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Operative Indications

• Natural History Information

Risks Benefits
62
Operative Indications

• Risks
• Operative Treatment
• Non-Operative Treatment

63
Rotator Cuff Tear

• Risks - Chronic Changes
• retraction with adhesion
• tendon morphology
• muscle atrophy
• fatty degeneration
• degenerative changes

64
Operative vs Non-Operative Tx

• Rationale
• What is the risk for development of Irreversible
  Changes?
• Risk dictates urgency for surgery

65
Early Operative Treatment

• Benefits
• Halt chronic changes?
• Most pertinent to younger pt.
• Important for acute, small or medium sized tears
• Important for tears at risk for fatty
  degeneration or altered kinematics

66
Conclusions

• Natural History
• High probability of bilateral symptoms
• High probability of tear size progression
• No evidence of spontaneous healing
• Supports large population have intrinsic etiology

67
Conclusions

• Age important factor for development of tears
• Important consideration for operative
  indications!
• High suspicion of tear extension with new pain!

68
Conclusions

• Tears start 15 mm post to biceps
• Loss of ant supra critical
• Critical size threshold 15-20 mm

69
Techniques

• Open
• Mini-Open
• Arthroscopic
• Differences???

70
Acrmioplasty with RC Repair??
71
Acrmioplasty??

• No difference in 3 RCT

72
Single vs Double Row??
73
Single vs Double Row??
74
Single vs Double Row??

• Double Row biomechanically better
• No difference clinically in 4 RCT

75
Double Row vs TOE??
76
Double Row vs TOE??
77
Double Row vs TOE??

• TOE better surface area coverage?
• Better healing?

78
Problems with Double Row or TOE???
79
Problems with Double Row or TOE???

• Tuberosity fracture
• MT junction ruptures

80
Other Techniques?

• Tension band?
• Mason-Allen?
• Rip-stop?

81
Tension Band
82
Mason-Allen Stitch
83
Cuff Re-tear (Failed Surgery)???

• When does it happen?
• How does it happen?

84
Cuff Re-tear (Failed Surgery)???

• 3 months
• Most often due to suture pull out not anchor pull
  out

85
Questions??