- Rotator cuff tears can be caused by extrinsic factors like repetitive use or impingement, or intrinsic factors like changes in tendon vascularity or degenerative changes.
- Physical examination involves inspection, palpation, range of motion testing and muscle strength testing. Investigations include ultrasound and MRI.
- Symptomatic rotator cuff tears tend to increase in size over time if left untreated, though some may remain stable or decrease.
- Surgery is generally indicated for failed conservative care, weakness, or acute tears in younger patients.
- Arthroscopic repair has benefits over open repair like less pain and faster recovery, though open provides direct visualization and long-term studies.
1. Prof. Bijayendra Singh
Consultant Trauma & Orthopaedic Surgeon
Medway NHS Foundation Trust
Visiting Professor, Canterbury Christ Church University
Cuff Repair
3. Extrinsic Factors
โข Repetitive use
โข Glenohumeral instability
โข Internal impingement
โข Impingement
โข Acromial spurs
โข Coracoacromial ligament
โข AC joint osteophytes
โข Coracoid process
โข Posterior superior glenoid
Acute Trauma
4. Intrinsic Factors
โข Vascular supply (? significance)
โข Distal 1cm of supraspinatus tendon (early studies)
โข Hypervascularity with tendonitis
โข Codman (1934) described critical zone
โข Rathburn (1970) position related to blood supply
โข Lohr (1990) bursal side better blood supply :
Increased incidence of articular surface tears?
โข Degenerative changes
โข Age related
โข Change in proteoglycan and collagen content in
symptomatic tendons
5. Physical Examination
โข Inspection: Atrophy, symmetry
โข Palpation: AC joint, cuff tenderness
โข Range of motion: Active, passive
โข Muscle strength
โข Special tests
7. โข Ultrasound:
โข High Accuracy for Full
Thickness Tear
โข Poor info on other
pathologies
โข Static images for
dynamic investigation
โข Operator Dependent
โข MRI:
โข Gold Standard
โข Easier to explain to patient
โข Other Shoulder Pathologies
โข Muscle Atrophy
โข Expensive/Cumbersome
โข May find pathologies of no
clinical relevnace..
11. Indications for Surgery
โข Failed conservative management
โข Significant or progressive weakness
โข Young, active
โข Acute tear
โข Early repair if age<50 years and full-thickness tear
14. Natural History of Non operatively Treated Symptomatic Rotator Cuff
Tears in <60 yrs. (5mm or more)
Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714
โข F/U: 25 - 39 months
โข Ultrasonography by same sonographer
โข 51/61 evaluated
โ30 (49%) tears increased in size
โ26 (41%) no change
โ5 (8%) reduced
โ10(25%) found to have new tears
โข No correlation between change in tear size,
โpatient age
โprior trauma
โsize of tear at index
โข Co-relation between considerable pain & increase in tear size
16. Open Repair
โข Advantages:
โข Easy
โข No special equipment required
โข Direct visualization of cuff repair and acromioplasty
โข Good long term follow-up. Several studies with >10
year follow-up show generally stable results with
time
โข UKCUFF Trial
17. Disadvantages
โข Deltoid detachment required
โข Increased perioperative morbidity
โข Unrepairable tear will be opened
โข Significant intraarticular pathology can be missed
โข Increased blood loss
โข Increased rehabilitation time
โข Large scar
18. Arthroscopic Cuff Repair
โข Deltoid preservation
โข Diagnosis and treatment of any concomitant shoulder
pathology
โข Decreased postoperative pain
โข Decreased blood loss
โข Small surgical scar
โข Shorter hospital stay
โข Earlier rehabilitation
โข Decreased postoperative stiffness
21. Principles of Repair
โข Neer JBJS-A 1972
โข Adequate subacromial decompression
โข Repair tendon to bone
โข Secure fixation of tendon to tuberosity
โข Mobilization of muscle-tendon units
โข Closely supervised rehabilitation
26. Biomechanics
โข Single Row - 220 N
โข Double Row - 320 N
โข Suture Bridge - 20 - 50% higher
โข Almost all biomechanical studies show lower re-tear
rates for double row / Suture Bridge
27. Clinical Outcomes
โข Franceschi et al:
โข 30 in each group, UCLA 32.9 vs 33.3 post op
โข MRI retear = 12/16 single, 8/26
โข Burks et al:
โข 20 in each group, No difference in UCLA, ASES, Constant
โข Retear 2 in each on MRI
โข Grasso et al
โข 40 in each group
โข No significant difference in DASH, Constant & Muscle Strength
โข No post op imaging
Level 1 studies
32. Ross et al: Rehabilitaiton Following Arthroscopic Rotator Cuff Repair - Review of
Current Literature. JAAOS, 2014, 22(1), 1 - 9
โข ROM:
โข Some studies have shown better elevation in early stages
โข Preop ROM important factor
โข NO difference at one year
โข Pain:
โข No significant difference in early vs late mobilisation
โข Muscle Strength:
โข No difference, significantly lower than other side
โข Re Tear Rates:
โข 0 - 94%
โข Variable results on radiological re-tears
โข No functional difference
33. Enhancement
โข Biology of patient & tendon (canโt be altered)
โข Techniques:
โข Microfracture of healing bed
โข Use of vented anchors
โข Doxycycline (reduces effects of MMP)
โข PRP
โข Mesenchymal stem cells
โข No definite evidence at present
34. Conclusion
โข Keys to success:
โข Pick a winner
โข Good anaesthesia
โข Tension-free reduction
โข Thorough bursectomy for visualisation
โข Work to a system
โข Variety of equipment invaluable
My choice
โข Small Tears = Single Row - Mattress Repair
โข Large > 3 cm = Double Row - Suture-bridge technique
Thank you for asking me to deliver the Dr. S.K.Lokhare Oration at the 33rd Annual Congress of MOA. Its indeed a great honour and privilege to be able to deliver this lecture. My heartfelt gratitude to the organising committee and the executive at MOA. A special thanks to Ajis & Shiva.
Fine-tuningโ muscles
Keep the humeral head centered on the
Generally work to depress the humeral head while powerful deltoid contracts
Failed conservative management
3 to 12 month course of NSAIDs, physio, corticosteroid injections, activity modification
Significant or progressive weakness, esp. acute
Early repair if <50 y.o. and full-thickness tear
Differential diagnosis confirms weakness is from rotator cuff tear (i.e. MRI findings correlate with exam, rule out other causes)