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Rotator Cuff Tears. Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California. Anatomy. Muscles? Innervation? Function?. Rotator Cuff Tears Natural History. ?.

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rotator cuff tears

Rotator Cuff Tears

Reza Omid, M.D.

Assistant Professor Orthopaedic Surgery

Shoulder/Elbow Reconstruction & Sports Medicine

Keck School of Medicine

University of Southern California

anatomy
Anatomy
  • Muscles?
  • Innervation?
  • Function?
rotator cuff tears treatment
Rotator Cuff TearsTreatment
  • Not standardized
  • When do we maximize conservative care?
  • When is early surgical intervention appropriate?
rotator cuff repair surgical indications
Rotator Cuff Repair Surgical Indications
  • Variations in Orthopaedic Surgeon’s 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
asymptomatic tear why
Asymptomatic TearWhy?
  • Mechanical Factors?
    • Force couples
  • Demographic Factors?
proximal humerus migration
Proximal Humerus Migration
  • Why Does it Happen??
rotator cuff disorders glenohumeral kinematics
Rotator Cuff DisordersGlenohumeral Kinematics
  • Normal Cuff Head Centered
  • Tendinitis, Fatigue Superior Migration
  • Symptomatic RCT’s Superior Migration
  • Asymptomatic RCT’s

?

Poppen & Walker, JBJS ‘75

results
Results
  • Normals Ball & socket kinematics
  • Symptomatic RCT’s Superior head migration
  • Asymptomatic RCT’s Superior head migration (greater variability)
conclusions
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
conclusions1
Conclusions
  • Implies normal glenohumeral kinematics do not need to be restored with surgery
bilateral two tendon rct
Bilateral Two-Tendon RCT
  • 30 Degree Abducted
glenohumeral kinematics asympt vs sympt rct
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

methods
Methods
  • Shoulder Ultrasound employed at Washington University since 1984 (Unique Study Opportunity)
  • Routine bilateral exams
  • Predict large # of asymptomatic tears
results symptomatic progression
ResultsSymptomatic Progression
  • 23/45 (51%) became symptomatic
  • avg 2.8 yrs from US
conclusions2
Conclusions
  • 39% total had tear size progression
  • No tears decreased in size (don’t heal on their own)
  • Relationship between symptoms and tear progression?
methods1
Methods
  • Presence of unilateral shoulder pain (n=588)
    • Bilateral intact cuffs (n=212)
    • Unilateral tear* (n=191)
    • Bilateral tears* (n=185)
  • 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

results1
Results
  • Correlation with Pain
    • Associated with dominant side (p<0.01)
      • 65% painful tears on dominant side
    • Associated with larger tears (p<0.01)
      • Symptomatic side 25% larger than asymptomatic
      • No other demographic feature significant
results2
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, (p<0.01)
healing of rcr influence of age
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

conclusions demographics
Conclusions Demographics
  • Unilat tear in young
  • Bilat tear in older
  • Tears rare before 40 yo.
  • Tears common after 61 yo.
conclusion
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
conclusions3
Conclusions
  • Over a 2 year period 21% of patients with an asymptomatic rotator cuff tear became symptomatic
  • Symptomatic transition of asymptomatic cuff tears is associated with significant increases in pain and loss of function
  • Tear size progression may play a significant role in symptomatic transition.
  • No significant changes seen in glenohumeral kinematics or shoulder strength upon symptomatic transition. (early detection is key!)
ultrasonography accuracy
UltrasonographyAccuracy
  • Varies among institutions
    • 60% accuracy JBJS’86
  • Not widely accepted
methods2
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
fatty degeneration vs fatty infiltration
Fatty Degeneration vs Fatty Infiltration
  • Galatz vs Gerber
  • What is the difference?
  • Why does it happen?
degeneration vs infiltration
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
fatty degeneration of the rotator cuff muscles
Fatty degeneration of the rotator cuff muscles

Normal rotator cuff

Fat-infiltrated infraspinatus

fatty degeneration of the rotator cuff muscles1
Fatty degeneration of the rotator cuff muscles

Normal Supraspinatus

Fat-infiltrated Supraspinatus

Wall et al Accepted for pub JBJS 2012

what is atrophy
What is atrophy?
  • Tangent Sign?
methods3
Methods
  • 262 pts from prospective cohort
  • Compare fatty degeneration to :
    • Tear location (relative to biceps)
    • Tear size ( number of muscles)
results3
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
conclusions4
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!
rotator cuff tears1
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

slide48

Superior

Supraspinatus

Infraspinatus

Biceps tendon

Posterior

Anterior

Teres Minor

Humeral Head

Subscapularis

Inferior

discussion
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
slide52

Superior

Supraspinatus

Infraspinatus

Biceps tendon

15mm

Posterior

Anterior

Teres Minor

Humeral Head

Subscapularis

Inferior

mechanism
Mechanism

Rotator Cable

Rotator Crescent

15 mm

BT

Anterior

Posterior

smoking increases the risk for rotator cuff tears

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

methods4
Methods
  • Hx of Cigarette Smoking

Cuff Intact vs. Cuff Tear

conclusions5
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
diabetes
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
nsaids
NSAIDS
  • -Cohen AJSM 2006: 362-9
    • Traditional and cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs significantly inhibited tendon-to-bone healing in animal model
obesity
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.
operative indications
Operative Indications
  • Natural History Information

Risks Benefits

operative indications1
Operative Indications
  • Risks
    • Operative Treatment
    • Non-Operative Treatment
rotator cuff tear
Rotator Cuff Tear
  • Risks - Chronic Changes
    • retraction with adhesion
    • tendon morphology
    • muscle atrophy
    • fatty degeneration
    • degenerative changes
operative vs non operative tx
Operative vs Non-Operative Tx
  • Rationale
    • What is the risk for development of Irreversible Changes?
    • Risk dictates urgency for surgery
early operative treatment
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
conclusions6
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
conclusions7
Conclusions
  • Age important factor for development of tears
    • Important consideration for operative indications!
  • High suspicion of tear extension with new pain!
conclusions8
Conclusions
  • Tears start 15 mm post to biceps
  • Loss of ant supra critical
  • Critical size threshold 15-20 mm
techniques
Techniques
  • Open
  • Mini-Open
  • Arthroscopic
  • Differences???
acrmioplasty
Acrmioplasty??
  • No difference in 3 RCT
single vs double row2
Single vs Double Row??
  • Double Row biomechanically better
  • No difference clinically in 4 RCT
double row vs toe2
Double Row vs TOE??
  • TOE better surface area coverage?
  • Better healing?
problems with double row or toe1
Problems with Double Row or TOE???
  • Tuberosity fracture
  • MT junction ruptures
other techniques
Other Techniques?
  • Tension band?
  • Mason-Allen?
  • Rip-stop?
cuff re tear failed surgery
Cuff Re-tear (Failed Surgery)???
  • When does it happen?
  • How does it happen?
cuff re tear failed surgery1
Cuff Re-tear (Failed Surgery)???
  • 3 months
  • Most often due to suture pull out not anchor pull out