Jon, Ladies and Gentlemen,Thank you for inviting me to give this presentation on the current surgical management of RCD
RCD was first described by Codman in 1934Neer in 1972 described Impingement syndrome as a mechanism for rotator cuff diseaseArthroscopic SAD (Ellman) 1985Stress that NONOPERATIVE TREATMENT is successful in a number of cases
Early part of this presentation will focus on arthroscopic techniquesCurrent treatment for a number of shoulder problems including those related to the rotator cuff in 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
SpectrumStarts with Tendinopathy which may be secondary to Extrinsic mechanisms Impingement - SA spur, ACJ osteophytes… Intrinsic mechanisms Tendon failure secondary to aging, wear and tear Combo Tendinopathy is usually treated non-operativelySo I will move on to cuff tears and specifically PTT
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
OpenMini-openArthroscopicDebridementSub –Acromial DecompressionExcision of degenerate tendon and Repair
AdvantagesVisualise articular & bursal surface of tendonAbility to treat especially articular tearsDebrideSADRCR
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% ASAD and Debridement
Debridement +/- SADSatisfactory results 75-86%All bursal surface tears require SADArticular tears debridement alone except if evidence of impingementOverall satisfaction (Excellent – Good) 81% at 9.5 year follow-upDoes not alter natural history or disease progression Repair > 50 % thicknessSevere degeneration92% success rate with repair of partial tears (Fukuda)
Arthroscopic surgery has revolutionised the repair of the rotator cuff
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 outcome comparison of UCLA shoulder scores – US study Normal 30 V Intra-articular treated 29 V Untreated 11
Repair Site Preparation simple decortication of the bone at the repair site anterior to posterior margins of the tear immediately lateral to the articular surface of the humerus to the lateral most margin of the greater tuberosity
Suture Placement sutures placed 1-2 cm from the torn edge of the tendon Arthrex cross-over
Anchor Placement 1 to 4 anchors usually used Double row technique X1 row anchors just lateral to the articular surface X1 row on the lateral margin of the greater tuberosity Restore the cuff footprint on the tuberositySingle V Double row in 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 bone
Other Tendon LesionsInfraspinatus, Teres minor may be repairedSubscapularis if involves upper ¼ repaired arthroscopically but larger tears require open surgeryBICEPS
Biceps spontaneous rupture often leads to pain relief biceps does not play a major role as a humeral head depressor an unstable biceps may cause paradoxical upward thrust of humeral headDebridement – partial tears <50% tendonTenodesis – preferred for tears > 50% tendon thickness Tenotomy – elderly patients Walsh et al biceps tenotomy on 86 patients at 4 year follow-up 9% excellent, 43% satisfactory
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
Results equivalent to open RCR 90% satisfaction (good to excellent) 78% good to excellent pain relief BETTER SLEEP AROM – Constant score 27.2/40 to 37.9/40
Rotator cuff tears are classified according to size: small tears <1 cm medium tears 1-3 cm large 3-5 cm massive >5 cmMore commonly progress to arthropathyfunctional demand / disability determines treatment
50-85% patients with massive tear improved with non surgical treatment Bokor et al(1993)
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-upIdeal 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 (1997
Limited acromioplasty involves removal of undersurface spurring and rough excrescences along with smoothing of the greater tuberosity The coracoacromial arch should be maintained by avoiding 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.
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 tears Colman 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.
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
In general, outcomes for repair of larger tears are inferior to those for smaller ones – Harryman et al (1991)Björkenheim 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 tearsBassett 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 shoulderstrength Bigliani et al(1992) reported 85% good and excellent long-term results.
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 defect But 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)
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
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 patientsLittle or no restoration of strength in overhead activity
Pectoralis major to greater tuberosity for massive tears of subscapularisPectoralis majortransfer is used for anterosuperior coverage of the humeral head
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.
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
Non-surgical remains the mainstay of treatment
Procedure of choice patients <70 with active elevation >90 and intact coracoacromial arch and anterior deltoidCTA 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
Williams & Rockwood(1996) 18/22 patients satisfactory result. FF 120, ER 46 and decreased pain scores. ADL restored
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
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
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)
RecommendationsPatients aged >70 years or have no active shoulder elevationLow functional demandsNo significant comorbidities
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%
Frankle et al (2005) Complication rate 17%
Aims of Rehabilitation 1. in the immediate postoperative period to maintain and protect the repair 2. followed by progression from early passive range of motion 3. 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.
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 acromionCadaveric 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 intactScapulo-thoracic dyskinesia frequently 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 kinematics This 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.
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 models tendon healing takes 12 to 16 weeks to reach final tensile strength a sheep model, repaired tendons returned to maximal failure loads after only 26 weeks of healing
Aggressive early motion that stresses the repair and exceeds the mechanical strength of the repair construct should be avoided.Abduction splint Rathbun and Macnab demonstrated hypovascularity of the supraspinatus with the arm adducted at the side In sheep postoperative immobilization has been shown to yield a normal tendon
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 60°FSpeer 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
Usually treated non-surgicalRehabilitation goals include reestablishing full ROM reducing anterosuperior humeral head translation leads to impingementBy: Elimination of posterior capsular contractures decreases anterosuperior translation Strengthening 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 function
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 ROMThe arm should be protected for at least 4 to 6 weeks
There are four widely used and accepted phases of shoulder rehabilitation Phase 1 involves passive exercises that minimize loads across the repair Phase 2 consists of active exercises that gradually apply loads to the repair construct and begin to transfer loads back onto the healing tissues Phase 3 consists of strengthening exercises focused on restoring power and endurance to the healed rotator cuff muscles Phase 4, advanced strengthening.
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 collagenEarly PROM crucial to ensure proper tendon gliding and healingStretching avoided 1st 6 weeks
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 contractionResistance work is not yet permitted because tendon-to-bone healing strength is insufficient
Strengthening phase should begin approximately 10 to 12 weeksTendon-to bone healing generally is strong enough to allow a gradual program of muscle strengtheningIsometric exercises safely permit the controlled application of forces across the tendonsstart early for the periscapular muscles, deltoid, and trapezius because they do not stress the injured or repaired tendonsThe 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 important
Phase 4, serves as a transition to sport specific rehabilitation activitiesgradual return to sports and recreation activities is recommendedPatients who are not athletes benefit from a functional progression that simulates activities of daily living and work-specific activity.
CTA - Hemiarthroplasty<br />Indications<br /><70 years<br />Active elevation >90°<br />CTA Head<br />Variation of the hemiarthroplasty<br />
CTA - Hemiarthroplasty<br />Results <br />Functional results limited, pain relief is excellent (Williams & Rockwood 1996)<br />Zuckerman et al (2000) decreased pain, increased FF86 & ER 30. <br />Sanchez-Sotelo et al (2001) 67% successful at 5 year follow-up<br />