CURRENT REVIEW OFROTATOR CUFF TEARSDr. Sushil Paudel
INTRODUCTION In 1834, Smith - first description of a rupture of therotator cuff tendon Among most common causes of shoulder pain andinstability. Disease severity range from inflammation andedema to irreparable ruptures Incidence 5-40% with increasing with advancingage Normal senescence process
ANATOMY made up of 4 interrelated muscles arising from thescapula and attaching to the tuberosities supraspinatus infraspinatus teres minor subscapularis Long head of biceps – functional part
FUNCTION Stabilisers of shoulder mainly anterior and posteriorcuff providing fixed fulcrum for concentric rotationof the humeral head. Neutralises shearing forces of deltoid in earlyabduction. Initiation of abduction. Rotation of shoulder.
PATHOPHYSIOLOGYThe extrinsic hypothesis : repeated impingement of rotator cuff tendon againstdifferent structures of the glenohumeral joint . Three distinct impingement syndromes Anterosuperior impingement syndrome Posterosuperior impingement syndrome Anterointernal impingement syndrome
ANTEROSUPERIOR IMPINGEMENTSYNDROME Impingement beneath the coracoacromialarch In 1972, Neer - term “impingementsyndrome” Supraspinatus tendon insertion to thegreater tuberosity and the bicipital groovemust pass beneath the arch with forwardflexion of the shoulder, especially ifinternally rotated, causing an impingement
Different shapes of acromia (Biglianni et al) -anteriorslope Type 1 - Flat ( 3 % of cuff tears) Type 2 - Curved (24 % of cuff tears) Type 3 - Hooked ( 73 % of cuff tears)
Pt with cuff tear are more likely to havecurved or hooked acromion (Toivonen DA etal 1995,Tuite et al1995) Flatow et al (1994)-stereophotogrammetry-type 3 acromia had increased contact Ozakis study on cadavers showed that theundersurface of the acromion was normalwhen the incomplete tear was on thearticular side
Neer„s stages: Stage 1- edema and hemorrhage excessive overhead use patients < 25 years. Stage 2- fibrosis and tendinitis following repeated episodes of mechanical inflammation patients - 25-40 years. Stage 3- bone spurs incomplete and complete tears of the rotator cuff and long headof the biceps tendon patients > 40 years.
POSTEROSUPERIOR IMPINGEMENTSYNDROME Impingement between the articular side of thesupraspinatus tendon and the posterosuperior edgeof the glenoid cavity Walch in 1991 May explain some of the articular side tears,especially in overhead sport athletes
POSTEROSUPERIOR IMPINGEMENTSYNDROME(CONTD) With the shoulder held at 120°of abduction, retropulsion, andin extreme external rotation(similar to the late cockingphase in throwers), the labrummoves away from the glenoidand the glenoid rim comes incontact with the deep surfaceof the tendon, producingrepeated microtrauma andleading to partial tears
ANTEROINTERNAL IMPINGEMENTSYNDROME Gerber (1985) - impingement of the cuff inthe coracohumeral interval When the shoulder is held in flexion andinternal rotation, the coracohumeraldistance is reduced from 8.6 mm when thearm is at the side to 6.7 mm Subcoracoid impingement can be idiopathic(eg, large coracoid tip), iatrogenic orfollowing a fracture (eg, humeral head orneck fracture)
THE INTRINSIC HYPOTHESIS Progressive age-related degeneration of the tendon Von Meyer -first to introduce the concept thatdegeneration of the tendon plays a major role in theproduction of cuff lesions Many histologic studies show the age-relateddegeneration of the cuff tendon
THE INTRINSIC HYPOTHESIS (CONT) “The critical zone” (Codman) -articular surface ofthe tendon, near its insertion on the greatertuberosity ? hypovascularity in critical zone Recent studies using laser doppler (Swiontkowski &associates) - normal flow in this zone of normaltendon Rathbun et al -relative avascularity of the cuff isposition-dependent and observed a poor filling onlywhen the shoulder is in adduction Normal degenerative process associatedwith aging, then, is the main factor to explain thelesions of the articular side of the cuff
CLINICAL PRESENTATIONStiffness-more common with partial tears. Stiffness can be demonstrated as limitations of Internal rotation with arm in abduction Reach up the back Cross-body adduction Flexion External rotation
CLINICAL PRESENTATION (CONTD) Pain or weakness Located anterolaterally and superior Aggravated by use of arm in overhead position orflexion Weakness Associated crepitus, clicking, clunking or grindingsensation
TESTS FOR IMPINGEMENTNeer’s signNeer’s testHawkins testNeer’s sign
NEERS‟ TEST Most diagnostic test LA 10ml lignocaine into subacromial bursa >50% relief – rotator cuff tendinitis or partial tear ofbursal surface Pain relief but weakness persists – full thickness tears No relief - incorrect diagnosis or wrong injection
TOPOGRAPHIC TESTS supraspinatus tendon The Jobe test Shoulder is placed at 90° of abduction and 30° of flexion. Shoulder elevation is resisted. Test is positive if pain is noted.
The Full Can test Shoulder is placed at 90° of flexion and 45° of externalhumeral rotation (thumb pointing upward, like someoneholding a full can, right-side-up). Shoulder elevation is resisted. Test is positive if it produces pain.
THE INFRASPINATUS TENDON The Infraspinatus Isolation test The shoulder is positioned at 0° ofelevation (elbows against the waistflexed at 90°) and 45° of internalrotation. Shoulder external rotation isresisted. The test is positive if it producespain. EMG shows that this is the optimalinfraspinatus isolation test
The Patte test The shoulder is placed at 90° of abduction, neutralrotation, and in the plane of the scapula. The examiner holds the elbow of the patient and theexternal rotation is resisted. The test is positive if it produces pain.
THE SUBSCAPULAR TENDON The Gerber lift-off test The shoulder is placed passively in internal rotation andslight extension by placing the hand 5-10 cm from theback with the palm facing outward and the elbow flexedat 90°. The test is positive when the patient cannot hold thisposition, with the back of the hand hitting the patientsback.
The Gerber push withforce test The shoulder is placedin the same position asthe lift-off test; however,the patient has to keephis hand away from theback and resists a pushin the palm of the hand.
X-RAY AP for AHI (Normal >7 mms)<5mms - poor prognosis. Y-lateral for shape of acromion Axillary for os acromiale AP of ACJ for osteophytes AP in Abd for rotator cuff dysfunction
RADIOGRAPHIC FEATURES subchondral sclerosis of humeral head flattening of the greater tuberosity sclerosis of the acromion-sourcil sign calcifications located in the presumed area ofrotator cuff tendon acromion spurs acromion type 2 and 3.
acromiohumeral space less than 6 mm chronicfull thickness tear
Bony spur on the inferior surface of the acromion
ARTHROGRAM Good for diagnosis of complete rotator cuff tear. Cost effective. Invasive Does not give information about size of tear.
presence of contrast medium inthe subdeltoid-subacromialbursa signs the presence of acomplete rotator cuff tear.channel between the articularcapsule and the subacromial-subdeltoid bursa in a completerotator cuff tear.
ULTRASOUND Cheap and quick to perform. Good definition of rotator cuff. Allows dynamic examination. Operator dependant. Findings: Nonvisualization of cuff Localized absence Discontinuity Focal abnormal echogenicity
MRI Best diagnostic aid. Defines site of cuff damage. Demonstrates fatty changes in muscle-poor quality cuff. Exact size, shape and location of tear Non-invasive
CONSERVATIVE MANAGEMENT McLaughlin in 1962 advanced reasons to avoidearly repair 25 % of cadavers had torn cuff -most of them wereasymptomatic 50 % of patients would recover comfortably Results of early and late repair are similar Repair did not always permit anatomic restoration Early diagnosis is difficult
Review of literature indicates that successrate of nonoperative treatment ranges from33% to 92% Bartolozzi et al (Clin orthop, 1994) reported66-75% good or excellent results (meanfollow up 20 months). Unfavorableprognostic factors were Tear> 1 cm2 Symptoms > 1yr Significant functional impairment
Hawkins & Dunlop (1995) reported >50%satisfactory result at avg follow up of 4 years Bokor et al (1993) reported 74% satisfactoryresult over period of 7.6 yrs in 53 pts(average age 62 yrs). 86 % of those presentwithin 3 months responded favorably whileonly 56% of those presented after 6 mntwere satisfactory Itoi and Tabata (1992) reported 82%satisfactory result in 62 shoulders followedover 3.4 yrs.
ORTHOTHERAPY Term used by Michael Wirth (OCNA 1997) Interactive exchange between patient andorthopedic surgeon directed at creating exerciseregimen that gradually improves motion andstrength in shoulder girdle. Three phases: Phase 1- restore full, painless range of motion. Codmanpendulum exercise followed by passive movements in alldirection Phase 2- designed to strengthened remaining muscles ofrotator cuff, deltoid & scapular muscles Phase 3- gradual reinstitution of normal activities includingwork, hobby and sport.
SUBACROMIAL CORTICOSTEROIDINJECTIONS Combination of localanaesthetic and steroid (5-10mls) Course: - maximum of 2 to 3injections Method: - sitting with armhanging by side- needle inserted justunder acromionfrom anterolateral,lateral, or posterolateralaspect- should have easyunrestricted flow of fluid
SUBACROMIAL CORTICOSTEROIDINJECTIONS Benefits: - short-term benefit in reducing pain andincreasing ROM Risks:- decreased tendon strength and risk of ruptureif into tendon- subcutaneous atrophy- effects on articular cartilage- may have detrimental effects on results ofsubsequent repair
OPERATIVE TREATMENT Patient selection: Samilson & Binder : Patient physiologically younger than 60 yrs Clinically or arthrographically demonstrable fullthickness cuff tear. Failure to improve on nonoperative managementfor minimum of 6 weeks Need to use shoulder in overhead elevation Full passive range of motion Ability & willingness to cooperate
POOR PROGNOSTIC FACTORS Old age group Long history No history of trauma Smoker Multiple steroid injection Diffuse osteopenia
Rotator cuff tear are classified on basis of size byGartsman: Small < 1 cm Medium-1 to 3 cm Large-3 to 5 cm Massive > 5 cm
PROCEDURES Repair of tear open or arthroscopic Tendon to tendon or tendon to bone Arthroscopic debridement and acromioplasty with mini-open repair
Neer described four major objectives Closure of cuff defect Elimination of impingement lesions of coracoacromialarch Preservation of origin of deltoid Rehabilitation to prevent postop stiffness
TECHNIQUE OF OPEN REPAIR Approach- 5 to 7 cm incision extending from lateralaspect of ant third of acromion to lateral tip ofcoracoid
ADVANTAGES OF OPEN REPAIR Easy to do No special equipment required Allows direct visualization of cuff repair andacromioplasty Good long term follow-up
DISADVANTAGES Deltoid detachment required False positive studies (arthrogram 2%, MRI 10%)will lead to unnecessary open exploration Unrepairable tear will be opened. Significant intraarticular pathology will be missed
ARTHROSCOPIC REPAIR OF ROTATOR CUFF Advantages : Lesser morbidity Ability to identify and treat other pathology Truly outpatient Allows to address small undetected tears Patient acceptance
Disadvantages : Technically difficult Implant cost-needs anchor Increased OR time High failure rate during learning curve
ARTHROSCOPIC ASSISTED MINIOPEN REPAIR Lateral portal isexpanded Useful for small &moderate shape tears Results comparable toopen repair
ARTHROSCOPIC ASSISTED MINIOPEN REPAIR Combined advantage easy to do with modest arthroscopic skills allows for arthroscopic correction of intraarticularpathology well established improvement in perioperativemorbidity in two large studies with no increase incomplication or compromise in outcome cost effective easy to “bail out” to full open procedure if desired avoid opening patients with false positive studies avoid opening patients with unrepairable defects
POST OPERATIVE PLAN Depends on1. Size of tear2. Type of repair3. Degree of retraction4. Intraoperative motion limits5. Age of patient
POST OPERATIVE PLAN (CONTD) Arthroscopic Immd active and passive ROM Avoid active abduction >60 degree for 3-4 wks Then electrical stimulation, resisting exercisesfor 3-4 mths High demand activities within 4-6 mths Open Proceed slowly (deltoid detached) Avoid active flexion or abduction for 4 wks Requires 1-2 additional months
POST OPERATIVE PLAN (CONTD) Phase 1 - protective, protecting repair butregaining movement and prevention of muscleweakening Phase 2 - strengthening, when healingsecure, and 2/3 normal range of movementachieved Phase 3 - return to work and sport, entryrequirements, full ROM, no pain or tenderness.
PARTIAL THICKNESS TEAR Three subtypes (Codman) Bursal-side Articular surface tears Intratendinous Surgical options: Debridement alone Debridement with arthroscopic subacromialdecompression Open repair with acromioplasty Arthroscopic repair Arthroscopic subacromial decompression withmini open repair
PARTIAL THICKNESS TEAR (CONTD) Ellman classification (depth of tear): Type 1 0-3 mm Type 2 3-6 mm Type 3 >6 mm
ARTHROSCOPIC DEBRIDEMENT &ACROMIOPLASTY VERSUS REPAIR Gartsman (1995) Size & depth of tear (more or less than 50 %) Patient activity level Bone structure Currently Lesions <50% thickness of tendon –debridement those >50% - excision and repair Bursal lesions with type 2 or 3 acromions -decompression
PARTIAL THICKNESS TEAR Before and after debridement
IRREPARABLE TEARS Pre operative diagnosis AHI <3 mms Profound loss of external rotation MRI-fatty degeneration of muscle
DEBRIDEMENT Indication >60 years good external rotation good flexion good relief with subacromial LA injection
DEBRIDEMENT Excise all frayed margin and tissue. Do not excise coraco-acromial ligament. antero- superior translation of humeral head. Minimal debridement of acromion.
TENDON TRANSPOSITION Transfer part of subscapularis or infraspinatussuperiorly. ? Disrupts coupling force of subscapularis andinfraspinatus.
PARTIAL REPAIR OF MASSIVEROTATOR CUFF TEAR Burkhart et al “Functional rotator cuff tear” Force couples be intact Stable fulcrum kinematic Edge stability Intact “suspension bridge”
PARTIAL REPAIR OF MASSIVEROTATOR CUFF TEAR (CONTD) Balanced force couple- inferior half ofinfraspinatous posteriorly & subscapularis anteriorly
PARTIAL REPAIR OF MASSIVEROTATOR CUFF TEAR (CONTD) Burkhart et al- partial rotator cuff repair inirreperable cuff- 2 excellent, 6 good, 5 fair & 1 poorresult Preserves normal mechanics as compared totendon transfer
MUSCLE TRANSFERS Main indication- symptomatic rotator cuffdefect that has low probability of repair Two parameters are used Static subluxation of humeral head Degree of degeneration and atrophy of rotatorcuff muscles Transfers for substitution of individualmuscle Subscapularis -Trapezius (acromialportion), pectoralis major, pectoralis minor Supraspinatus – Trapezius (acromialportion), Deltoid Infraspinatus – Latissimus dorsi, Teres major
LATISSIMUS DORSI TRANSFER Described by Gerber in 1992 Indication Irreparable rotator cuff tear involving Supraspinatus Infraspinatus Functioning subscapularis and deltoid.
REVIEW OF 16 CASES OVER 33MONTHS Average gain flexion 52 degrees abduction 50 degrees external rotation 13 degrees Overall excellent 8, good 5, fair 2, poor 2. Patients with subscapularis tear did poorly.
TERES MAJOR TRANSFER Described by Celli in 1998 Indication Isolated infraspinatus tear Functional supraspinatus Reported 6 cases with good results
COMPLICATIONS OF ROTATOR CUFF REPAIR Retear or failure of repair Infection Adhesions Fracture of acromion Denervation of deltoid Injury to suprascapular nerve Greater tuberosity fracture Stiffness – frozen shoulder Reflex sympathetic dystrophy
CUFF TEAR ARTHROPATHY End stage rotator cuff disease (4%) Age 70-80 yrs Severe shoulder pain Active elevation 40-60 degrees Severe wasting of supraspinatus and infraspinatus Effusion anteriorly Superior subluxation of humerus
CUFF TEAR ARTHROPATHY Radiograph: Superior translation ofhead of humerus Loss of articular cartilage Direct articulation of headwith coracoacromial arch “femoralisation” ofproximal humerus “acetabularization” ofupper glenoid
TREATMENT Intractable pain unresponsive to conservativetreatment is the strongest indication for surgery Options : Shoulder arthrodesis Hemi replacement arthroplasty Total shoulder replacement
TREATMENT (CONTD) Prerequisites for arthroplasty: Adequate deltoid power Preserved or reconstructed coracoacromial arch
CONCLUSION Diagnosis is usually by good history andexamination Non operative management remains the standardinitial care Surgery in selective active individuals Arthroscopy - early mobilization and decreasedmorbidity Treatment according to patients functional needs
REFERENCES The Orthopedic Clinics Of North America, Volume28, April 1997 The Orthopedic Clinics Of North America, Volume27, January 1997 The Shoulder, 2nd Edition, Rockwood and Matson-WB Saunders Pubmed online