Rotator Cuff Tear

Rotator Cuff DiseaseCurrent Surgical Management

Chris Pullen

Jon, Ladies and Gentlemen,

Thank you for inviting me to give this presentation on the current surgical management of RCD

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Historical AspectsCodman in 1934Impingement syndromeArthroscopic SAD

RCD was first described by Codman in 1934Neer in 1972 described Impingement syndrome as a mechanism for rotator cuff diseaseArthroscopic SAD (Ellman) 1985

Stress that NONOPERATIVE TREATMENT is successful in a number of cases2

Shoulder Arthroscopy

Early part of this presentation will focus on arthroscopic techniquesCurrent treatment for a number of shoulder problems including those related to the rotator cuffin particular impingement, cuff repair and debridement (preferred technique)Increasingly importantAdvantagesSmaller skin incisionsGleno-humeral joint inspectionTreat intra-articular lesions Deltoid detachment avoidedLess soft tissue dissectionLess painMore rapid rehabilitation

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Rotator Cuff DiseaseTendinopathy/Impingement

Rotator Cuff Tear

Cuff Tear Arthropathy

SpectrumStarts with Tendinopathy which may be secondary toExtrinsic mechanismsImpingement - SA spur, ACJ osteophytesIntrinsic mechanismsTendon failure secondary to aging, wear and tearCombo Tendinopathy is usually treated non-operatively

So I will move on to cuff tears and specifically PTT4

PARTIAL THICKNESS TEARS(IMPINGEMENT/TENDINOPATHY)

No consensus in regards treatment>50% Thickness (9-12mm) needs repair80% progress to FTT 40 patients at 2 year follow-up, 10% heal, 10% increase size

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PTT SurgeryOpen Mini openArthroscopic*

OpenMini-openArthroscopicDebridementSub Acromial DecompressionExcision of degenerate tendon and Repair

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PTT - ArthroscopyAdvantagesVisualisationTreatment articular tears

AdvantagesVisualise articular & bursal surface of tendonAbility to treat especially articular tearsDebrideSADRCR

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PTT - ArthroscopyBursal surface tearSADArticular surface tearDebridement onlyRepair>50% Thickness tearActive patients

Bursal surface tearAcromioplastySADArticular surface tearDebrideNo SADTear >50% Thickness repairedConsider repair in active patientsIdeal repair candidate is active individual with normal bone anatomy and a tear >50%Inactive patient with bone impingement and tear 50 % thicknessSevere degeneration92% success rate with repair of partial tears (Fukuda)

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FULL THICKNESS TEARS

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FTT - Surgical ApproachesArthroscopic*Arthroscopic assisted/mini-open*Open

Arthroscopic surgery has revolutionised the repair of the rotator cuff11

FTT - Arthroscopic RCRGleno-humeral JointPTTLabral tearsLigament injuries Cartilage tears

Significant lesions in 12.5%

Gleno-humeral joint is not viewed with traditional open surgeryThis may lead to Untreated intra-articular lesions and consequently poorer resultsAdvantage of arthroscopy is the ability to view the gleno-humeral jointGleno-humeral JointPTTLabral tearsLigament injuries Cartilage tearsRecent studies have shown treatment of intra-articular lesions does have a positive effect on outcomecomparison of UCLA shoulder scores US studyNormal 30 V Intra-articular treated 29 V Untreated 11

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FTT Arthroscopic RCRRepair Site PreparationRemoval of ragged or degenerate tissueDecortication of bone

Repair Site Preparationsimple decortication of the bone at the repair siteanterior to posterior margins of the tearimmediately lateral to the articular surface of the humerus to the lateral most margin of the greater tuberosity13

FTT Arthroscopic RCRSuture Placement

Suture Placementsutures placed 1-2 cm from the torn edge of the tendonArthrex cross-over 14

FTT Arthroscopic RCRAnchor PlacementFoot printDouble row technique

Anchor Placement1 to 4 anchors usually usedDouble row techniqueX1 row anchors just lateral to the articular surfaceX1 row on the lateral margin of the greater tuberosityRestore the cuff footprint on the tuberositySingle V Double rowin a single layer repair on the most outside (lateral) aspect of the tendon, the more you lift thearm away from your body, the more you reduce the contact of the rotator cuff tendons, to itsfootprint on the bone15

FTT Arthroscopic RCROther Tendon LesionsInfraspinatusTeres minorSubscapularisBiceps

Other Tendon LesionsInfraspinatus, Teres minor may be repairedSubscapularis if involves upper repaired arthroscopically but larger tears require open surgeryBICEPS

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FTT Arthroscopic RCRBiceps DebridementTenotomyTenodesis

Bicepsspontaneous rupture often leads to pain reliefbiceps does not play a major role as a humeral head depressoran unstable biceps may cause paradoxical upward thrust of humeral headDebridement partial tears 50% tendon thickness Tenotomy elderly patientsWalsh et al biceps tenotomy on 86 patients at 4 year follow-up 9% excellent, 43% satisfactory

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FTT Arthroscopic RCRPost operative TreatmentSlingCryotherapy PROMAROMStrengthening

Post operative TreatmentSling/ Abduction splintCryotherapy PROM elevation & ER 1-6 weeksAROM 6 weeksStrengthening 12 weeks ( deltoid, infra, supra, scapular rotators, biceps)

Rehabilitation takes 1 year

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FTT Arthroscopic RCRResults90% satisfaction78% pain reliefAROM

Results equivalent to open RCR90% satisfaction (good to excellent)78% good to excellent pain reliefBETTER SLEEPAROM Constant score 27.2/40 to 37.9/40 19

MASSIVE TEARS

Rotator cuff tears are classified according to size:small tears 5 cm

More commonly progress to arthropathyfunctional demand / disability determines treatment

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Massive Tears SurgeryDebridementOpenArthroscopic*Rotator Cuff Repair*Tendon transfer*Synthetic interpositionArthrodesisArthroplasty

50-85% patients with massive tear improved with non surgical treatment Bokor et al(1993)

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Massive Tears - DebridementDebridement alone Low demand patientsResults tend to deteriorate over timeArthroscopic debridement easier more rapid rehabilitation

Debridement alone may be adequate to manage massive cuff tears - Gartsman (1997), Rockwood et al (1995)Best suited to low demand patients unwilling or unable to perform prolonged rehabilitation.Results tend to deteriorate over time so active people are probably better served with attempted repair - Zvijac et al (1994) 3 and 6 year follow-up

Ideal candidate is relatively inactive with shoulder pain but good elevation strength and can elevate arm actively overhead and externally rotate.

Arthroscopic approach for subacromial debridement is easier and has a more rapid rehabilitation than the open approach because the deltoid origin is preserved - Gartsman (199722

Massive Tears - Debridement Limited acromioplastycoracoacromial arch is maintainedBiceps tenotomy / tenodesis subluxation, dislocation, or partial tearingenhance the ability to alleviate shoulder pain

Limited acromioplasty involves removal of undersurface spurring and rough excrescences along with smoothing of the greater tuberosity The coracoacromial arch should be maintained byavoiding excessive acromioplasty and preserving the coracoacromial ligament, which helps prevent loss of the restraint to superior humeral head subluxation.Biceps tenotomy or tenodesis been recommended as an adjunct to arthroscopic debridement of chronic massive rotator cuff tears. subluxation, dislocation, or partial tearing of the tendon of the long head of the biceps, tenotomy or tenodesis may enhance the ability to alleviate shoulder pain.23

Massive Tears - RCRGood function & pain relief 80-90%Goal of surgery is to repair the cuff without disrupting the coraco-acromial arch

good function and pain relief in 80% to 90% of cases. Bassett (1983), Biglani et al (1992)The goal of rotator cuff surgery is to repair the rotator cuff tendons to the proximal humerus and to decompressthe subacromial space without disrupting the coracoacromial arch.More recently, arthroscopy has been used to repair larger chronic rotator cuff tearsColman et al (1996) demonstrated that removal of 5.4mm of the undersurface of the anterior acromion reduces the contact pressure of the acromion on the supraspinatus tendon.

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Massive Tears - RCRRehabilitationSling / Abduction splintPROMAAROMStrengthening

Overall recovery may take >12 months

Postoperative recovery and rehabilitation is lengthy. The repair is protected with an arm sling or abduction immobilizer for 6 to 8 weeks. Abduction positioning is used to relieve tension on repairs done with the arm at the side.Passive stretching exercises to regain shoulder motion are begun the day after surgery. - passive IR and horizontal adduction are avoided for the first 6 weeks to protect the infraspinatus repair. Light active use and active-assisted range-of-motion movement are initiated after 6 weeks. Formal strengthening is delayed until 12 weeks after surgery. Overall recovery can take more than 12 months. Overly aggressive early rehabilitation has been implicated as a cause of failure

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Massive Tears - RCRResultsInferiorBetter within 6 weeks (Bassett & Cofield 1983)Shoulder dislocation >4085-90% good to excellent ( Bigliani 1992)

In general, outcomes for repair of larger tears are inferior to those for smaller ones Harryman et al (1991)

Bjrkenheim et al (1988) reported that the results of repair of large and massive rotator cuff tears were markedly inferior to the results of repair of smaller tears

Bassett and Cofield (1983) found better results when tears were repaired within 6 weeks of injury. In the case of acute massive rotator cuff tears, early repair is technically easier and probably more likely to restore shoulderstrengthBigliani et al(1992) reported 85% good and excellent long-term results.

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Massive Tears Tendon transferLatissimus Dorsi*Pectoralis Major*Teres MinorSubscapularisDeltoid muscle flapTrapezius

Approaches include transfers of the rotator cuff tendons, other muscle and tendon transfers.Subscapularis tendon transfer Cofield (1982)used to achieve complete rotator cuff repair when repair of the supraspinatus leaves a residual superior defectBut risks internal rotation weakness or internal rotation contracture.

Teres minor transfer, deltoid muscular flap transfer, and trapezius transfer they do not address or restore the balance between the anterior and posterior force couples of the rotator cuff. Paavolainen (1996)

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Massive Tears Latissimus DorsiSupraspinatus/Infraspinatus lossRestore ER & head depression forces

Latissimus dorsi muscle transfer is used to substitute for loss of the infraspinatus and supraspinatus tendons - Gerber et al (1997)used to restore external rotation and head depression forces that are lost with chronic massive rotator cuff tears

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Massive Tears Latissimus DorsiResults 82% satisfactory (Miniaci & MacLeod 1999)Intact subscapularis Little or no restoration of strength in overhead activity

Gerber (1997) reported that the results of latissimus dorsi transfer for massive rotator cuff tear were better with an intact subscapularis tendon. Miniaci and MacLeod (1999) reported 82% satisfactory results (14/17 patients) after latissimus dorsi transfer in patients

Little or no restoration of strength in overhead activity

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Massive Tears Pectoralis MajorSubscapularis tears

Pectoralis major to greater tuberosity for massive tears of subscapularis

Pectoralis major transfer is used for anterosuperior coverage of the humeral head30

Massive Tears - ReconstructionTissue implantsAutologousAutogenous

Freeze-dried cadaveric tissue

Tissue substitution with synthetic materials, as well as autologous and autogenous tissue implants, has beenattempted,Neviaser et al (1987) reported 88% good and excellent results (14/16 patients) with freeze-dried cadaveric rotatorcuff tissue used to repair chronic massive rotator cuff tears. The disadvantages of the material are the potential for foreign body reaction to synthetics and tissue rejection.

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CUFF TEAR ARTHROPATHY

Definitionrotator cuff insufficiencydegenerative changes of the gleno-humeral jointsuperior migration of the humeral head.

Pathogenesis:Massive cuff tear and biceps rupture leads to proximal migration of the humeral head and sub-acromial impingement.only a percentage of patients with massive tears progress to cuff tear arthropathy

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CTA - SurgeryArthroscopic debridement*Humeral tuberoplastyShoulder arthrodesisTotal Shoulder ReplacementHemiarthroplasty*Reverse Shoulder Arthroplasty*

Non-surgical remains the mainstay of treatment33

CTA - HemiarthroplastyIndications90

CTA HeadVariation of the hemiarthroplasty

Procedure of choice patients 90 and intact coracoacromial arch and anterior deltoid

CTA HeadVariation of the hemiarthroplasty is the cuff tear arthropathy humeral head. This implant provides an arc of >180 to allow articulation with the lateral aspect of the humeral head against the acromion

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CTA - HemiarthroplastyResults Functional results limited, pain relief is excellent (Williams & Rockwood 1996)Zuckerman et al (2000) decreased pain, increased FF86 & ER 30. Sanchez-Sotelo et al (2001) 67% successful at 5 year follow-up

Williams & Rockwood(1996) 18/22 patients satisfactory result. FF 120, ER 46 and decreased pain scores. ADL restored

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CTA - HemiarthroplastyResultsintact coracoacromial arch essential

Studies have shown a competent coracoacromial arch is essential Field et al (1997) 4/6 patients with unsuccessful results had undergone previous acromioplasty with coracoacroimial release

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CTA- Reverse Shoulder Arthroplasty

Semiconstrained reverse ball and socket Grammont 1985

Increase the efficiency of the deltoid muscle for abduction by lengthening the lever arm on which it operates. Relies on the deltoid muscle to compensate for the loss of rotator cuff function.Also semiconstrained design of the device prevents the superior migration and instability

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CTA - RSA Biomechanics (Boileau et al 2005)Large glenosphereMedialisation of the centre of rotation Lowers humeral head

Large glenosphere allows stability and increased ROMGlenosphere makes contact with the glenoid decreasing looseningMedialisation of the centre of rotation increase the power of the deltoid in abductionLowering of the humeral head increases the tension in deltoidBoileau et al (2005)

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CTA - RSAIndications> 70 years or no active elevationLow demand

RecommendationsPatients aged >70 years or have no active shoulder elevationLow functional demandsNo significant comorbidities

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CTA - RSAResults (Boileau et al 2005, De Buttet et al 1997, Rittmeister et al 2001)Excellent pain reduction Improved active abduction

Frankle et al (2005) 60 patients with CTA average follow-up 33 months. Functional score 2.7 to 6.0, Pain score 6.3 to 2.2, FF 55 to 105, Abduction 41 to 102. Complication rate 17%

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CTA - RSAComplicationsHighRate revision is high (4.2-13%)

Not for the occasional operator

Frankle et al (2005) Complication rate 17%

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REHABILITATION

Aims of Rehabilitation 1. in the immediate postoperative period to maintain and protect the repair2. followed by progression from early passive range of motion3. return to preoperative levels of function.

Typically, patients with smaller tears have better clinical outcomesPatients who have undergone rotator cuff repair do not progress in their rehabilitation at the same rate.42

Rehabilitation -BiomechanicsRotator CuffStabilises gleno-humeral jointDepresses the humeral headProtective overlapSubscapularisScapulo-thoracic dyskinesiaCompensatory impairment leads to wingingAlter orientation of the acromial arch

The rotator cuff stabilizes the glenohumeral joint and acts to depress and compress the humeral head within the glenoid concavityRotator cuff dysfunction, therefore, may result in superior elevation of the humeral head with impingement on the undersurface of the acromion

Cadaveric models have maintained normal humeral translations even with massive supraspinatus tears (up to 5 cm) as long as the infraspinatus, teres minor, and subscapularismuscles remain intact

Scapulo-thoracic dyskinesiafrequently is seen in association with rotator cuff disease (Kibler and McMullen)compensatory impairment of the scapular stabilizing musculature, which leads to subtle winging or abnormal kinematicsThis can alter the orientation of the acromial arch and lead to rotator cuff dysfunction. Management of scapular dyskinesis should focus on restoration of normal scapular musculature recruitment patterns.43

Rehabilitation Tendon HealingSpontaneous healing ??

PhasesInflammatoryProliferativeMaturation

Maximal load to failure 12-26 weeks

The potential for spontaneous tendon healing in the rotator cuff has not been established. Healing occurs only with surgical repair & principally occurs to the boneTendon healing typically is divided into three phases. The inflammatory phase occurs during the first 7 days, when platelets initiate clot formation.At 2-3 weeks the proliferative phase forms granulation which provides the scaffolding of a more permanent repair tissue.The maturation and remodeling phase begins around week 3 as scar tissue organizes.

Animal modelstendon healing takes 12 to 16 weeks to reach final tensile strengtha sheep model, repaired tendons returned to maximal failure loads after only 26 weeks of healing44

Rehabilitation - ImmobilisationEarly ROMAbduction splint

Shoulder immobilisation with an abduction-type splint for 4-6 weeks

Aggressive early motion that stresses the repair and exceeds the mechanical strength of the repair construct should be avoided.

Abduction splintRathbun and Macnab demonstrated hypovascularity of the supraspinatus with the arm adducted at the sideIn sheep postoperative immobilization has been shown to yield a normal tendon45

Rehabilitation - Cryotherapy Speer et al 1996Less pain 1st 24 post-operative hoursBetter sleepLesser analgesic requirementLess swellingBetter able to tolerate rehabilitation

Cryotherapy helps control postoperative pain, decreases swelling and muscle spasm, suppresses inflammation,and decreases metabolism.

The analgesic effects occur after tissue is cooled to between 50 and 60F

Speer et al (1996) examined the use of cryotherapy in a prospective, randomized, controlled clinical trial Less pain 1st 24 post-operative hoursBetter sleepLesser analgesic requirementLess swellingBetter able to tolerate rehabilitation 46

Rehabilitation - PTTGoals Full ROMReducing impingement

Physical therapy plus exercise program better than exercise alone

Usually treated non-surgicalRehabilitation goals include reestablishing full ROMreducing anterosuperior humeral head translation leads to impingementBy:Elimination of posterior capsular contractures decreases anterosuperior translationStrengthening of the infraspinatus, teres minor, and subscapularis permits the rotator cuff muscles to oppose superior humeral head translation

Manual physical therapy techniques (eg, joint mobilization) in conjunction with supervised exercise have been shown to be more effective than exercise alone in strengthgains, pain reduction, and improved function47

Rehabilitation - RCRGoalsMobilise the joint earlyLoad the repaired tendons safelyStrengthen the rotator cuff progressively

The goals of rehabilitation after rotator cuff repair are to achieve healing of the cuff while restoring pain-free motion and function

Initially, the repair is protected until the healing tissue is strong enough to begin active ROM

The arm should be protected for at least 4 to 6 weeks48

Rehabilitation - RCRPhasesImmediate post-operative period (week 0-6)Protection & active ROM (week 6-12)Early strengthening (week 10-16)Advanced strengthening (week 16-22)

There are four widely used and accepted phases of shoulder rehabilitationPhase 1 involves passive exercises that minimize loads across the repairPhase 2 consists of active exercises that gradually apply loads to the repair construct and begin to transfer loads back onto the healing tissuesPhase 3 consists of strengthening exercises focused on restoring power and endurance to the healed rotator cuff musclesPhase 4, advanced strengthening.49

Rehabilitation Phase 1GoalsMaintain / Protect repair integrityGradual increase PROMDiminish pain & inflamationPrevent muscle inhibitionExercisesSling/abduction splint 6 weeksImmediate PROM (depends on repair tension)Pendular exercisesCryotherapyHydrotherapy

First 2 to 4 weeks after tendon repair, loads across the repair site must be minimal Weak bond cannot withstand physiologic loads.

Gradual introduction of tensile stress during the maturation may assist in the proper orientation of mature collagen

Early PROM crucial to ensure proper tendon gliding and healing

Stretching avoided 1st 6 weeks50

Rehabilitation Phase 2Goals Allow healing of soft tissueDo not overstress healing tissueGradually restore full PROMExercisesContinue PROMIntroduce AAROMADL permittedHydrotherapyPulleys

At 6 weeks postoperatively, tendon healing to bone is sufficient to withstand applied muscle forces generated by simply raising the arm.

Low-level loading will likely increase muscle activity and restore normal patterns of muscle contraction

Resistance work is not yet permitted because tendon-to-bone healing strength is insufficient

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Rehabilitation Phase 3GoalsMaintain Full PROMFull AROMDynamic shoulder stabilityRestore shoulder strength & enduranceGradual return to functional activitiesExercisesContinue PROM & StretchingProgressive strengtheningProprioceptive activities

Strengthening phase should begin approximately 10 to 12 weeks

Tendon-to bone healing generally is strong enough to allow a gradual program of muscle strengthening

Isometric exercises safely permit the controlled application of forces across the tendons

start early for the periscapular muscles, deltoid, and trapezius because they do not stress the injured or repaired tendons

The goal of these exercises is to build muscle endurance. The four key exercises are external rotation (infraspinatus, teres minor), internal rotation (subscapularis), forward flexion (anterior deltoid, supraspinatus), and rowing motion (posterior deltoid, periscapular muscles).

A core strengthening program is also important52

Rehabilitation Phase 4GoalsMaintain full AROMAdvanced muscle strengthening exercisesGradual return to full functional activitiesExercisesContinue stretchingContinue progression of strengtheningLight sports (golf chip/putt, tennis ground strokes)

Phase 4, serves as a transition to sport specific rehabilitation activities

gradual return to sports and recreation activities is recommended

Patients who are not athletes benefit from a functional progression that simulates activities of daily living and work-specific activity.53

THE END

1. Yes 2. Size 3. Latissimus Dorsi 4. 12-26 weeks 5. 6 weeks

54I have come to the end of my presentation and am happy to take questions.