the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury. there are multiple options thrown into the mix here which we need to consider for an individual patient. The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients. A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable. 
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer. For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated. If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial. For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option. The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands. For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.

1. Self Pay Partnership

4. ● ROTATOR CUFF TEARS & REPAIRS
- UPDATE 2022
● LENNARD FUNK
● Wrightington Hospital, NHS
● The Arm Clinic, Private

5. medbelle.com
Topics to cover:
Should we repair rotator cuff tears?
Which ones? & Why?
How?

6. Common
Questions
What caused my
Tear?
What can you do to fix
it?
How can I get better if
it’s not fixed?
Do I really need to
have an operation?
I’ve already had
Physio.
It didn’t fix it!

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Tradition
ASES:
“The aim of treating a
rotator cuff tear is to get it
to heal”
‣ Tear = Repair:
‣ Surgeon:
‣ 80% of Asymptomatic cuff tears get bigger [Hirahara]
‣ Cuff tear can become irreparable [?]
‣ Cuff tear will progress to Cuff Arthropathy [?]
‣ Patient:
‣ ‘Tear’ = to rip apart
‣ Rip = Repair

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Evidence - Natural History
✴‘Tears’ can be normal
✴Cuff tears can heal
‣ Age:
‣ 54% Asymptomatic cuff tears over 60yrs [Sher. 1995]
‣ 28% - Full thickness (on MRI)
‣ 34% Apoptosis in Degenerate Supraspinatus [Yuan &
Murrell. 2002]
‣ Tendon Matrix Degeneration increases with Age [Riley et
al. 2001]
‣ Healing:
‣ Small tears attempt to heal:
‣ Incr. fibroblasts, Blood capillaries, inflammation
‣ Healing diminishes as the size of the tear and the
amount of tendon degeneration increase.

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Evidence - Pain & Function
Brindisino, F., Salomon, M., Giagio, S., Pastore, C. and Innocenti, T., 2021. Rotator
cuff repair vs. nonoperative treatment: a systematic review with meta-
analysis. Journal of Shoulder and Elbow Surgery, 30(11), pp.2648-2659.
✴Repair:
Better Pain & Function
✴But:
? Clinically Meaningful?
‣ 2021 Systematic Review & Meta-analysis:
‣ After screening & evaluating bias - 6 RCT’s,
but all low numbers
‣ ‘Statistically, but not clinical meaningful difference in
favour of Repair at 6, 12 and 24 months - for pain
and function.’

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Evidence - QOL
‣ QOL RCT 5yrs Op vs NonOp:
‣ 75% of patients remained successfully treated with
nonop treatment at 5 years; QOL 83/100 (SD, 16).
‣ Between 2 and 5 years, only 3 patients became more
symptomatic and underwent cuff repair.
‣ Surgical repair QOL 89/100 (SD, 11) at 5-year follow-
up.
‣ The op and nonop groups at 5-year follow-up were
not significantly different (P = .11).
Boorman, R.S., More, K.D., Hollinshead, R.M., Wiley, J.P., Mohtadi, N.G., Lo, I.K. and
Brett, K.R., 2018. What happens to patients when we do not repair their cuff tears?
Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment
of patients with full-thickness rotator cuff tears. Journal of shoulder and elbow surgery,
27(3), pp.444-448.
✴Quality of Life Outcomes
very good at 5 years
with Operative and
Nonoperative
Treatment

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Evidence - Failure of NonOp
‣ Multicentre Study:
‣ > 400 patients; 8 centres
‣ Prospective
‣ Home Rehab = 75% Success at 2yrs
‣ Patients with low expectations of rehab success were
more likely to fail and convert to surgery
‣ Conversions were within 12 weeks
‣ Not related to tear size, pain or duration of symptoms
‣ Estimated that 73-80% could be managed nonop
Kuhn, J.E., Dunn, W.R., Sanders, R., An, Q., Baumgarten, K.M., Bishop, J.Y., Brophy,
R.H., Carey, J.L., Holloway, B.G., Jones, G.L. and Ma, C.B., 2013. Effectiveness of
physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter
prospective cohort study. Journal of shoulder and elbow surgery, 22(10), pp.1371-
1379.
✴Non-operative has
high success rates for
Non-traumatic tears.
✴Low expectation of
rehab = Poor Outcome

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Traumatic vs Non-traumatic
‣ Traumatic:
‣ Younger, less muscle atrophy,
fatty degen, tendon retraction
‣ Chronicity of tear negatively affected healing
‣ Muscle atrophy = poorer healing in Atraumatic
‣ Repair results the same
‣ Constant Score [Kukkonen, 2013] [Braune, 2003]
‣ UCLA [Abechain 2017]
‣ Age Matched
✴Traumatic tears affect
Younger
✴But
Repair outcomes the
same (age matched)

14. Influence of Age & Tear Size on Healing
• Rashid et al. Acta Orthopaedica, 2017
Small Medium Large Massive
50 74% 78% 63% 43%
60 65% 70% 52% 33%
70 54% 60% 41% 24%
80 43% 49% 31% 17%

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Failed Cuff Repairs
‣ Pain, function, quality of life, and satisfaction with
repair remained high and were not influenced by cuff
integrity
‣ [Elliot, 2019] [Russell, 2014][Slabaugh, 2010]
‣ “Patient’s categorisation referring to only diagnostic
factors (eg, type, location of the tear, number of
tendons involved, Goutallier fatty infiltration, or
retraction) seems to imply that additional
explanatory models are needed for better choosing
the best management for RC tear patients.”
Non-Healing
does not
equate with
Poor Clinical Outcome
Brindisino, F., Salomon, M., Giagio, S., Pastore, C. and Innocenti, T., 2021. Rotator
cuff repair vs. nonoperative treatment: a systematic review with meta-
analysis. Journal of Shoulder and Elbow Surgery, 30(11), pp.2648-2659.

16. Summary of the Evidence
✓ ‘Tear' = to rip apart - try avoid in non-traumatic cases.
✓ 75% of non-traumatic tears can be managed with Rehab
✓ Strongest predictor of failed Rehab = Patient Expectations
✓ Conversion to surgery is within 12 weeks
✓ Clinical outcomes of Cuff Repair are excellent in traumatic & non-
traumatic
✓ Strongest predictor of healing = Age & Tear size
✓ But: Healing does not correlate with clinical outcome

17. Summary of the Evidence
✓Indications for Surgery =
1. Patient Expectations
2. Trauma
a. (Age)
b. (Tear Size)

19. Surgical Advances
✓Repairs:
✓Strength
✓Double row repairs
✓Sutures & Anchors
✓Healing
✓Microfracture
✓Platelet Rich Plasma
✓Massive Tears:
✓Tendon Transfers
✓Augments
✓Superior Capsular
Reconstruction
✓Subacromial Balloon
✓Reverse Arthroplasty
✓Suprascapular Nerve Ablations

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‣ Concentrated growth factors
‣ Safe, inexpensive, technically simple
‣ Evidence for cuff repair:
‣ 2021 Arthroscopy Editorial on meta-analysis*:
‣ “…provides compelling evidence to this effect when
platelet-rich plasma is used as an adjuvant to linked,
double-row rotator cuff repairs.” [Sheean AJ. Arthroscopy. 2021]
Platelet Rich Plasma
PRP appears to
improve healing &
outcomes in
large and revision
rotator cuff repairs
* Villarreal-Villarreal GA, et al. Double-Row Rotator Cuff Repair Enhanced With
Platelet-Rich Therapy Reduces Retear Rate: A Systematic Review and Meta-analysis
of Randomized Controlled Trials. Arthroscopy. 2021 Jun;37(6):1937-1947.
https://mtviewortho.com/platelet-rich-plasma-prp-therapy/

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‣ Dermal Allograft most common
‣ Also synthetics & autograft
‣ Evidence (Early):
‣ Improved healing and clinical outcomes for large to
massive partially reparable tears
‣ Small studies with many variables & bias
Biological Augments
Biological Augment
scaffolds
may improve
strength, healing
& clinical outcomes
for Large & Massive
Cuff Repairs
1. Namdari, et al. Healing and functional results of dermal allograft augmentation of
complex and revision rotator cuff repairs. AJSM, 49(8), pp.2042-2047. 2021
2. Ferguson et al. Graft utilization in the augmentation of large-to-massive rotator cuff
repairs: a systematic review. The American journal of sports medicine, 44(11),
pp.2984-2992.2016

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‣ Salvage for young Massive Irreparable Superior tears
‣ Restores centralising & depressor effect
‣ Outcomes (Early):
‣ >70% clinical improvement
‣ 12% failure rate
‣ Poor prognostic factors:
‣ Age, revision, head position, fatty atrophy, subscap, teres
Superior Capsular Recon.
Prinja, A., Mohan, H., Singh, J., Walton, M., Funk, L. and Monga, P., 2021. Superior capsular
reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report.
Journal of Clinical Orthopaedics and Trauma, 19, pp.62-66.
SCR is a promising
salvage procedure
for
- younger, active,
- massive, irreparable,
- superior cuff tears

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‣ Designed to replace large cuff repairs,
but mainly used for irreparable tears
‣ Temporarily restores depressor effect to optimise deltoid
‣ Evidence (Early):
‣ Similar pain relief to cuff repair, but not function
‣ ‘produced non-inferior outcomes when compared to
partial rotator cuff repair for patients with MRCTs at
24 month follow up’
Subacromial Spacer Balloon
Subacromial Balloon
may have a place for
- older
- non-traumatic
- large / massive
cuff tears
Srikumaran et al. Subacromial Balloon Spacer versus Partial Repair for Massive Rotator Cuff Tears:
A Prospective, Randomized, Multi-center Trial. Orthopaedic Journal of Sports Medicine,
9(7_suppl4),2021.

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Tendon Transfers
Latissimus Dorsi
transfer for
Irreperable
Postero-superior
Cuff Tear

25. Introduction to
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Tendon Transfers
Pectoralis Major
transfer for
Irreparable
Subscapularis
Cuff Tear

26. Introduction to
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‣ For single tendon / functional loss failure
‣ Younger active patient
‣ Salvage surgery
‣ Large surgery, long recovery
‣ Evidence:
‣ 70% restoration of function & pain relief in correct
patient
‣ Poor outcomes in older, subscap failure,
non-compliant, co-morbidities
Tendon Transfers
Tendon Transfers:
- Young
- Active
- Compliant
- Single function loss
* Memon, et al. Arthroscopic-assisted latissimus dorsi tendon transfer for massive rotator cuff
tears: a systematic review. Orthopaedic journal of sports medicine, 6(6), 2018.
* Nové-Josserand, et al. Results of latissimus dorsi tendon transfer for irreparable cuff tears.
Orthopaedics & Traumatology: Surgery & Research, 95(2), pp.108-113. 2009

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‣ Reverse geometry
‣ Lateralise deltoid -> improved function
‣ Salvage surgery
‣ Older patient
‣ Large surgery, shorter recovery
‣ Evidence (good):
‣ Salvage, excellent outcomes pain & function
‣ High risk surgery
‣ Better outcomes = High volume centres / surgeons
Reverse Arthroplasty
Reverse Arthroplasty
Excellent outcomes
for older, low demand,
massive, irreparable
cuff tears
Outcome = Surgeon
Murena, L., Hoxhaj, B., Fattori, R. and Canton, G., 2019. Epidemiology and demographics of
reverse shoulder arthroplasty. In Reverse Shoulder Arthroplasty (pp. 59-67). Springer, Cham.

28. Options

30. Repair
Augm
ent
YOUN
G
OLD
LAT
DORS
I
SSN
inj.
DELTOI
D
REHAB
REVE
RSE
Augm
entSC
R
BALLO
ON
PAIN WEAK
HORN
-
BLOW
ER
AGE
Massive Cuff Tear

31. Key Points

32. CONFIDENTIAL

33. ● THANK YOU
● lenfunk@shoulderdoc.co.uk

34. medbelle.com
Leander de Laporte
Founder & Managing Director
leander@medbelle.com
Phone: +49 (0) 176 6417 9408
Joseph Ashley
Head of Operations
joseph.ashley@medbelle.com
Phone: +49 (0) 1590 1364848
Dan Howcroft
FRCS (Tr&Orth)
Chief Medical Officer
dan.howcroft@medbelle.com
Phone: +44 (0) 7405038562
Benjamin Leitz
Head of Product
benjamin.leitz@medbelle.com
Phone: +49 (0) 157 56057688
Sarah O’Connell
Head of Patient Care
sarah@medbelle.com
Phone: +49 (0) 157 56057688
Danny Smith
Operations Manager
daniel.smith@medbelle.com
Phone: +44 (0) 20 3318 9161
Dan Smith
Patient Care Adviser
dan.smith@medbelle.com
Phone: +44 (0) 20 3868 0638
Dr Lizzie Tuckey
Chief Commercial Officer
lizzie.tuckey@medbelle.com
Phone: +44 (1) 79609131956
We are here to help - please feel free to reach out directly
Contact information
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35. Introduction to
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Post-op Rehabilitation
Header
‣ No Immobilisation! Sling for comfort
‣ Effects of Immobilisation:
‣ Collagen:
‣ Poor secretion
‣ Type 3 > Type 1
‣ Disorganised
‣ Slow Healing
‣ Mucoid degeneration
‣ Decr. Tendon weight

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Early SAFE Movement
Header
‣ Based on EMG exercise studies [Uhl & Kibler]
‣ 3 Phases:
‣ Level 1 - Closed Chain ROM & Isometrics
‣ Level 2 - Open Chain Active Assisted ROM
‣ Level 3 - Active Open Chain