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Rotator cuff tears


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Rotator cuff tears

  2. 2. 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
  3. 3. 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
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7.  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)
  8. 8.  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
  9. 9.  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.
  10. 10. 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
  11. 11. 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
  12. 12. 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)
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. TESTS FOR IMPINGEMENTNeer’s signNeer’s testHawkins testNeer’s sign
  18. 18. 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
  19. 19. 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.
  21. 21.  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.
  22. 22. 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
  23. 23.  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.
  24. 24. 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.
  25. 25.  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.
  26. 26. DIFFERENTIAL DIAGNOSIS Adhesive Capsulitis Bicipital Tendinitis Cervival Disc Disease Cervical Myofascial Pain Cervical Spondylosis Fibromyalgia Osteoarthritis Rheumatoid Arthritis Thoracic Outlet Syndrome
  27. 27. 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
  28. 28. 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.
  29. 29.  Subchondral sclerosis of the humeral head
  30. 30.  acromiohumeral space less than 6 mm chronicfull thickness tear
  31. 31.  Bony spur on the inferior surface of the acromion
  32. 32. ARTHROGRAM Good for diagnosis of complete rotator cuff tear. Cost effective. Invasive Does not give information about size of tear.
  33. 33. presence of contrast medium inthe subdeltoid-subacromialbursa signs the presence of acomplete rotator cuff between the articularcapsule and the subacromial-subdeltoid bursa in a completerotator cuff tear.
  34. 34. 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
  35. 35. 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
  36. 36. MRI Normal cuff  Full thickness tear
  37. 37. 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
  38. 38.  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
  39. 39.  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.
  40. 40. 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.
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. POOR PROGNOSTIC FACTORS Old age group Long history No history of trauma Smoker Multiple steroid injection Diffuse osteopenia
  45. 45.  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
  46. 46. PROCEDURES Repair of tear open or arthroscopic Tendon to tendon or tendon to bone Arthroscopic debridement and acromioplasty with mini-open repair
  47. 47.  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
  48. 48. TECHNIQUE OF OPEN REPAIR Approach- 5 to 7 cm incision extending from lateralaspect of ant third of acromion to lateral tip ofcoracoid
  49. 49.  Subacromial decompression- Coracoacromial ligament release Anterior acromioplasty Modified acromioclavicular arthroplasty
  50. 50.  Rotator cuff repair: Assess the nature of tear Mobilisation – Release of adhesion Release of coracohumeral ligament Interval slide Subscapularis tendon transfer Repair – tendon to tendon or tendon tobone(McLaughlin technique)
  51. 51. MOBILISATION Release of capsulefrom labrum Release of cuff tendons fromcoracoid
  53. 53. ADVANTAGES OF OPEN REPAIR Easy to do No special equipment required Allows direct visualization of cuff repair andacromioplasty Good long term follow-up
  54. 54. 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
  55. 55. 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
  56. 56.  Disadvantages : Technically difficult Implant cost-needs anchor Increased OR time High failure rate during learning curve
  57. 57. OT SETUP
  58. 58. PORTALS
  61. 61. ARTHROSCOPIC ASSISTED MINIOPEN REPAIR Lateral portal isexpanded Useful for small &moderate shape tears Results comparable toopen repair
  62. 62. 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
  63. 63. POST OPERATIVE PLAN Depends on1. Size of tear2. Type of repair3. Degree of retraction4. Intraoperative motion limits5. Age of patient
  64. 64. 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
  65. 65. 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.
  66. 66. 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
  67. 67. PARTIAL THICKNESS TEAR (CONTD) Ellman classification (depth of tear): Type 1 0-3 mm Type 2 3-6 mm Type 3 >6 mm
  68. 68. 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
  69. 69. PARTIAL THICKNESS TEAR Before and after debridement
  70. 70. IRREPARABLE TEARS Pre operative diagnosis AHI <3 mms Profound loss of external rotation MRI-fatty degeneration of muscle
  71. 71. TREATMENT OPTIONS Debridement Tendon transposition Subscapularis Infraspinatus Muscle transfer Partial repair Allograft substitution
  72. 72. DEBRIDEMENT Indication >60 years good external rotation good flexion good relief with subacromial LA injection
  73. 73. DEBRIDEMENT Excise all frayed margin and tissue. Do not excise coraco-acromial ligament. antero- superior translation of humeral head. Minimal debridement of acromion.
  74. 74. TENDON TRANSPOSITION Transfer part of subscapularis or infraspinatussuperiorly. ? Disrupts coupling force of subscapularis andinfraspinatus.
  75. 75. 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”
  76. 76. PARTIAL REPAIR OF MASSIVEROTATOR CUFF TEAR (CONTD) Balanced force couple- inferior half ofinfraspinatous posteriorly & subscapularis anteriorly
  77. 77. 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
  78. 78. 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
  79. 79. LATISSIMUS DORSI TRANSFER Described by Gerber in 1992 Indication Irreparable rotator cuff tear involving Supraspinatus Infraspinatus Functioning subscapularis and deltoid.
  80. 80. 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.
  81. 81. TERES MAJOR TRANSFER Described by Celli in 1998 Indication Isolated infraspinatus tear Functional supraspinatus Reported 6 cases with good results
  82. 82. 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
  83. 83. 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
  84. 84. 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
  85. 85. TREATMENT Intractable pain unresponsive to conservativetreatment is the strongest indication for surgery Options : Shoulder arthrodesis Hemi replacement arthroplasty Total shoulder replacement
  86. 86. TREATMENT (CONTD) Prerequisites for arthroplasty: Adequate deltoid power Preserved or reconstructed coracoacromial arch
  87. 87. 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
  88. 88. 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
  89. 89. HANK YOU