2. Philosophy of treatment:
restore the equilibrium between the functional demands of the patient
and the capacity of the rotator cuff
Lower the functional demands of the patient.
Increase the functional capacity of the remaining
intact cuff
repair the cuff.
www.shoulder.gr
5. www.shoulder.grwww.shoulder.gr
Partial Thickness Tear
Bursal side tears
Articular side tears
Intratendinus tears
Partial tear classification by Ellman
Grade I <3mm deep
Grade II 3-6mm deep
Grade III>6mm deep (i.e. >50% thickness)
6. www.shoulder.grwww.shoulder.gr
Partial Tears Treatment
By far the most common partial tears are Articular-
side, vascular or age related
Traditionally partial tears classifications
are based to 50%
BUT
“How healthy is the remaining,
intact tissue?”
7. www.shoulder.grwww.shoulder.gr
Partial Tears Treatment Options
1. Debride partial tear only
2. In-situ Repair
3. Convert to full thickness, Debride, Repair
Etiology drives the decision!!!
Because most tears are degenerative, option 3 should be the
best for most cases
Trauma or young athletes are candidates for in-situ repair
If partial tear causes significant pain then debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]
r
10. www.shoulder.grwww.shoulder.gr
Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear
End-to-
bone repair
Good to
excellent
2
Longitudinal
(L or U)
Long and narrow tear
Margin
convergence
Good to
excellent
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval
slides or
partial
repair
Fair to good
4
Cuff tear
arthropathy
Cuff tear arthropathy Arthroplast
y
Fair to good.
20. www.shoulder.grwww.shoulder.gr
Remove the thickened bursa till to see the posterior edge of the cuff
ending to the greater tuberosity.
Everything that goes around the tuberosity to the deltoid is bursa
Don’t suture the bursa
instead of the cuff. It
doesn’t work
22. www.shoulder.grwww.shoulder.gr
Solution
Idendify recognizable landmarks
1. the undersurface of the acromion and
the underolateral corner
2.the acromioclavicular joint
3.the spine of the scapula
4.the lateral border of the tuberosity
And remove the bursa
27. www.shoulder.grwww.shoulder.gr
Recognize the Tear Pattern
Tears must be repaired in the direction of
greatest mobility -> minimal strain
The muscle-tendon junction must be 2-3
mm medial of the edge of the cartilage
at the tuberosity after the repair
38. www.shoulder.grwww.shoulder.gr
L-Shaped & U-Shaped Tears
Side to side sutures from medial to
lateral
Progressively converge the margin of the
tear lateral to the bone bed
Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by a
factor of 6
[S. S .Burkhart]
49. www.shoulder.grwww.shoulder.gr
Arthroscopic repair yields
90-95% excellent in small and medium size tears at 4 to
10 years F.Up.
• Burkhart SS, Danaceau SM, Pearce CM Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair
technique—Margin convergence versus direct tendon to bone repair. Arthroscopy 2001;17:905-912.
• Wolf EM, Pennington WT, Agrawal V. Arthroscopic rotator cuff repair: 4- to 10-year results. Arthroscopy 2004;20:5-12.
• Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic Rotator
Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011: pp xxx
Good to excellent results in massive tears with less than
75% fatty infiltration of the infraspinatus, even at 10 years
F.Up
• Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M., Arthroscopic repair of massive rotator cuff rears with
stage 3 and 4 fatty degeneration. Arthroscopy 2007;23:347-354.
• Jones CK, Savoie FH III. Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy 2003;19:564-
571.
• Dodson CC, Kitay A, Verma NN, et al. The long-term outcome of recurrent defects after rotator cuff repair. Am J
Sports Med 2010;38:35-39.
• Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic
Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011:
pp xxx
51. www.shoulder.grwww.shoulder.gr
Complete loss of active external rotation
(external rotation lag ) is a bad
prognostic factor
Superior migration of the humeral head
in contact with the acromion – repair
attempt is going to be a failure
Rotator Cuff Arthropathy
What are the limits?
52. www.shoulder.grwww.shoulder.gr
Conclusions
Acute Crescent Tear
Standard Techniques for tendon to bone fixation
U- or L- shaped Tears
Side to side margin convergence
Partially mobile tears
Anterior / Posterior Slide
Medialized Repair
Incomplete repair
Irreparable Tears
debridement
Tendon transfers
Reverse – Extended head arthroplasty
54. www.shoulder.grwww.shoulder.gr
Single and double interval slide
Anterior slide through release in the
rotator interval (supraspinatus–
coracobrachialis)
Posterior slide through release of the
interval supraspinatus-infraspinatus
56. www.shoulder.grwww.shoulder.gr
Release of MMP and GF after
acromioplasty
Platelet-derived growth factor-AB (PDGF-AB), basic
fibroblast growth factor basic (bFGF) and transforming
growth factor beta 1 (TGF-b1) are released after
acromioplasty in the subacromial space.
Knee Surg Sports Traumatol Arthrosc (2009) 17:98–101 Release of
growth factors after arthroscopic acromioplasty . Pietro Randelli Ζ
Fabrizio Margheritini Ζ Paolo Cabitza Ζ Giada Dogliotti Ζ Massimiliano M.
Corsi
MMP-2 does not increase but MMP-9 increases after
acromioplasty and their mesurment can be a useful tool to
be monitored in parallel with growth factors level and
other bone turnover markers in order to evaluate the bone
remodelling and tissue healing.
E. Galliera , P. Randelli, G. Dogliotti, E. Dozio, A. Colombini, G. Lombardi, P.
Cabitza, M. Corsi. Matrix metalloproteases MMP-2 and MMP-9: Are they
early biomarkers of bone remodelling and healing after arthroscopic
acromioplasty? Injury, Int. J. Care Injured 41 (2010) 1204–1207
57. www.shoulder.grwww.shoulder.gr
Conclusions
Rot Cuff is extremely significant for the normal function of the
shoulder
Rot Cuff tears can be asymptomatic
Symptoms Produced by a tear depend on:
Size
Location
Functional demands of the patient
