Rotator cuff tear

1. Rotator cuff tear

2. Treatment
• activity and age of patient
• mechanism of tear (degenerative or traumatic
avulsion)
• characteristics of tear (size, depth, retraction,
muscle atrophy)
• partial thickness tears vs. complete tear
• articular sided (PASTA lesion) vs. bursal sided
• bursal sided tears treated more aggressively

3. Nonoperative
• physical therapy, NSAIDS, subacromial corticosteroid
injections
• first line of treatment for most tears
• partial tears often can be managed with therapy
• technique
• avoidance of overhead activities
• physical therapy with aggressive rotator cuff and
scapular-stabilizer strengthening over a 3-6 month
treatment course
• subacromial injections if impingement thought to be
major cause of symptoms

4. Operative
subacromial decompression and rotator cuff debridement alone
indications:
• select patients with a low-grade partial articular sided rotator cuff tear
rotator cuff repair (arthroscopic or mini-open)
indications
• acute full-thickness tears
•
• bursal-sided tears >3 mm (>25%) in depth
• release remaining tendon and debride degenerative tissue
• partial articular-side tears>50% can be treated with tear completion and repair
• Partial articular-side tears <50% treated with debridement alone
• PASTA with >7mm of exposed bony footprint between the articular surface and intact tendon
represents significant (>50%) cuff tear (must have at least 25% healthy bursal sided tissue)
• younger patients with acute, traumatic tears
• in situ repair leave bursal sided tissue intact
• older patients with degenerative tears
• tendon release, debridement of degenerative tissue and repair

5. Postoperative
• rate-limiting step for recovery is biologic healing of RTC
tendon to greater tuberosity, which is believed to take 8-12
weeks
• peribursal tissue and holes drilled in greater tuberosity are
major source of vascularity to repaired rotator cuff
• vascularity can increase with exercise
• postop with limited passive ROM (no active ROM)
outcomes
• Worker's Compensation patients report worse outcomes
• higher postop disability and lower patient satisfaction
• patients should expect to return to full work duty by 6-10
months after surgery

6. Tendon transfer
Indications
• massive cuff tears
techniques
• pectoralis major transfer
• latissimus dorsi transfer - best for irreparable posterosuperior tears with
intact subscapularis
superior capsular reconstruction
indications
• massive irreparable rotator cuff tear with intact subscapularis
reverse total shoulder arthroplasty
indications
• massive cuff tears with glenohumeral arthritis with intact deltoid

7. TECHNIQUE
Mini-open rotator cuff repair
• once was gold standard but has been largely been replaced by
arthroscopic techniques
• approach
• small horizontal variant of shoulder lateral (deltoid splitting)
approach
• advantages over open approach
• decreased risk of deltoid avulsion
• faster rehabilitation (do not need to protect deltoid repair)
• may begin passive ROM immediately to prevent adhesive
capsulitis
• most surgeons wait ~6 weeks before initiating active ROM

8. Arthroscopic rotator cuff repair
advantages
• studies now show equivalent results to open or mini-open repair
important concepts
margin convergence
• shown to decrease strain on lateral margin in U shaped tears
anterior interval slide
• release supraspinatus from the rotator interval (effectively incising
coracohumeral ligament). This increases the mobility of
supraspinatus and allows it to be fixed to the lateral footprint.
posterior interval slide
• release supraspinatus from infraspinatus. This further increases the
mobility of supraspinatus and allows it to be fixed to the lateral
footprint. Then repair supraspinatus to infraspinatus with margin
convergence.

9. subscapularis repair
• although arthroscopic repair is technically challenging, new
studies show superior outcomes (motion and pain) compared to
open repair
• stabilize biceps tendon with tenodesis
• posterior lever push maneuver useful to identify insertional
humeral footprint tears
• superolateral margin of subscapularis identified by the "comma
sign"
• superior glenohumeral and coracohumeral ligaments attach to
the subscapularis tendon
long head biceps tendon repair
• most studies show negligible difference between tenotomy vs.
tenodesis after concurrent rotator cuff repair

10. Footprint restoration
• it is hypothesized that a larger footprint will
improve healing and the mechanical strength of the
rotator cuff repair
• double row suture techniques (mattress sutures in
medial row and simple sutures in lateral row) have
been shown to create a more anatomic repair of
the footprint
• lower retear rate compared with single row
• no difference in functional score, pain score, time
to healing (compared to single row)

11. coracoacromial ligament release
• release leads to an increased anterior/inferior
translation of the glenohumeral joint

12. Tendon transfer
• indicated for massive and irreparable rotator cuff
tears
pectoralis major transfer
• indicated in chronic subscapularis tears
• transferring pectoralis major under the conjoined
tendon more closely replicates the vector forces of
the native subscapularis
• requires 4-6 weeks of rigid immobilization

13. latissimus dorsi transfer
• indicated in large supraspinatus and infraspinatus tears
• best candidate is young laborer
• attach to cuff muscles, subscapularis, and GT
• brace immobilize for 6 wks. in 45° abduction and 30° ER.
• nerves at risk - radial nerve
• runs along anterior surface of latissimus dorsi, ~3cm medial to
humeral insertion
• at risk during tenotomy
• posterior branch of the axillary nerve
• runs in deep fascia of posterior deltoid
• at risk during passage of tendon deep to deltoid to
subacromial space

14. Superior capsular reconstruction with biologic or synthetic
grafts
• some recent evidence of improved outcomes with the use of
xenograft, allograft, or synthetic patches for massive cuff tears
• limited human and long-term studies
xenograft
• from bovine dermis or intestine
• mixed functional outcomes and graft incorporation
allograft
• from human skin or muscular fascia
• some evidence of good function and survival at short-term
synthetics
• concern for foreign body reaction
• mixed functional results

15. Lateral acromionectomy
• historic significance only
• contraindicated due to high complication rate

16. Thank you