ArthroscopicManagementofRotatorCuffTears

AaronVenouziouOrthopaedic SurgeonSt.Luke’sHospital

Thessaloniki

Anatomy

SupraspinatusAbduction

InfraspinatusExt.rotation

Teres minorExt.Rotation

SubscapularisInt.Rotationadduction

RotatorCuff

Anatomy

DeltoidAbduction

Pec.MajorInt.rotation

Teres majorInt.Rotation

Lat.DorsiInt.Rotation

ExtrinsicMuscles

Function

1. Strength&Motion(50%oftheabductionstrengthisgeneratedbysupraspinatus)

2. DynamicStabilizer

ConceptofCoupleForces

Biomechanics

VerticalForces

Biomechanics

HorizontalForces

IR

ER

Biomechanics

HorizontalForces

Unstable fulcrum

Biomechanics

Rotatorcable– cresent complex

Burkhart1993

Biomechanics

Shoulder's“SuspensionBridge”

Burkhart1993

Rotator cuff disease is awidespectrum

ofclinical conditions,which range from

asymptomatic partial thickness tears to

symptomatic rotator cuff arthropathy

RotatorCuffDisease

Tears’Definitions

PartialThicknessTearsü absenceofcommunication

betweentheglenohumeral jointandthesubacromial bursa.

FullThicknessTearsü communicationbetweenthe

glenohumeral jointandthesubacromial bursa.

MassiveTearü Involving2or3tendons[Gerbers]

orbiggerthan5cm[Cofield]

PartialThicknessTear

ü Bursalsidetearsü Articularsidetearsü Intratendinus tears

PartialtearclassificationbyEllmanüGradeI <3mmdeepüGradeII 3-6mmdeepüGradeIII >6mmdeep(i.e.>50%thickness)

Incidence

üRotatorCuffFrequency:30%ofpopulation

üSignificantcorrelationwithage

Sher JS,Arthroscopy1995

HowfrequentareRCTears?

FullThicknessTearAge Frequency40-60 4-13%60-70 20%70-80 50%>80 80%

PartialThicknessTearAge Frequency<40 4%>60 25% Tempelhof S,JSES1999

EtiologyandPathogenesis

1. Tendondegeneration2. Vascularfactors3. PrimaryImpingement

– TypeofacromionasidentifiedbyBigliani– AcromialangledevisedbyToivonen– Os Acromiale,ACjoint

4. SecondaryImpingement– Glenohumeral instability– Internalimpingement– Glenohumeral internalrotationdeficit– Scapulothoracic dysfunction

5. Trauma

Intrinsic

Extrinsic

– VascularSupply

TendonDegeneration

üagerelated

üchangeinproteoglycanandcollagencontent

“criticalzone”ofhypovasculararityatarticularsurface,anterioredge,ofsupraspinatus1cmproximaltoinsertion

Whichcamefirst?

Intrinsic Extrinsic or

ü type3acromionisacquired,notdevelopmentalasaresponsetotractionappliedviatheCAligament.

ü rotatorcuffabn occurwithoutchangesofacromion.

ü articular-sidedpathologyisdominant.

EvidenceAGAINSTsubacromial externalimpingement:

ü ROMisaffectedaccordingtothetypeandsizeoftear

ü Lossofmotionmeanslargeormassivetear

Preop ClinicalAssessment

ER lag sign Hornblower’s sign

Preop ImagingAssessment

Retraction Level Medium Tear

Preop ImagingAssessment

AHD < 6mm

Retraction Level

Fatty Infiltration

Massive

Non-Operative

ü 45-80%SatisfactoryResults

BUT

ü Symptomresolution???ü Tearprogression???ü Fattydegeneration???ü ProgressiontoRC

arthropathy ???

Operative

90% Good to Excellent Results at 10 years

[Iannotti Wolf]

Treatment

RisktoBenefitRatio

ü RotcufftearsDONOThealspontaneously

ü Tearrepairability

ü PatientProfile,Age,Symptoms

ü ThinkofSize,ElasticityandChronicity

ü Fattyinfiltrationisnotfullyreversible

Treatment

GroupingthePatients

GroupI: patientswithminimalriskofprogressiontoirreversiblechangestotherotatorcuff

GroupII: patientswithhighriskofprogression

GroupIII: patientswhohaveprogressedalready

[YamaguchiK.,2006,NiceShoulderCourse]

OperativeTreatment

GroupI

ü About50yearsoldwithtendinosis ordegenerative partialarticularsidetears

ü Theyrespondverywelltononoperativetreatment(about50-60%resolutionofthesymptoms)

ü Theriskofprogressionisverylowbuttheyneedobservation

OperativeTreatment

Non operative treatment - observation

GroupII

ü Youngerthan65yearswith– Smallormediumsizetears– Acutetearsofanysize– Tearswithrecentacutelossoffunction

ü Patientsnonresponsivetoconservativetx

ü Acutetearsoroverusetearsinathletes

OperativeTreatment

Early surgical repair to avoid irreversible changes

GroupIII

üOlderthan70years– withlargeormassivetearsand– irreversibledamagetotherotcuff

OperativeTreatment

They can benefit from rotator cuff repair, even a partial repair

Yamaguchi, JBJS 2006

Burkhart, Arthroscopy 2007

ü Byfarthemostcommonpartialtearsarearticular-sided

PartialTearsTreatment

ü Traditionallypartialtearsclassificationsarebasedto50%

BUT“Howhealthyistheremaining,

intacttissue?”

üDebridementü In-situRepairü Converttofullthickness,Debride,Repairü CONSERVATIVE

PartialTearsTreatment

ü Becausemosttearsaredegenerative,option3shouldbethebestformostcases

ü Traumaoryoungathletesarecandidatesforin-siturepair

Etiology makes the decision!!!

FullThicknessTears

ü Recognitionoftearpatternü Retractionandreleasesü RepairOptions:

Anchors: metallicorabsorbable

Typeofstitch: Mason-Allen,Mattresssutures,Horizontalmattress,Simplesutures

Restorationoffootprint: DoublerowSinglerow

ArthroscopicRepair

SurgicalTechnique

Joint view Subacromial view

ü classicstandardtearsü excellentmedial-to-lateralmobilityü repairwithminimaltension

TearPattern

Crescent-shaped

ü extendmedially withtheapexofthe tearadjacenttoormedialtotheglenoid rim

ümarginconvergence suturesminimizestrainattherepairsite

TearPattern

U-shaped

ü theapexoftheLisidentifiedandthelongitudinalsplitissuturedinaside-to-sidemanner

ü theconvergedmarginisthenrepairedtobone

TearPattern

L-shaped

TearPattern

Massive Tears

Massiveretractedlongitudinal Massiveretractedcresentic

TearPattern

Massive Tears

Massiveretractedlongitudinal

AnteriorIntervalSlide

TearPattern

Massive TearsMassiveretractedcresentic

DoubleIntervalSlide

SurgicalTechnique

Tuberosity decortication Sutures anchors

ThequalityofFunctionalresultsdependson:

1. Thesizeofthepersistentdefect2. Associatedatrophyofthemuscles3. Integrityofthedeltoid4. Functionaldemandsofthepatient

FactorsaffectingRecurrenceoftear:

1. Advancedage2. Tearsize3. Fattydegeneration4. Chronicityandatrophy5. Poortendonquality6. Inappropriaterehabilitation7. Smoking8. Steroidinjections9. Diabetes

Failureofhealing

10-70%Yoo etal.Arthroscopy2009Lafosse etal.JBJS2007Habermeyer etal.Arthroscopy2008

30%retear inourseriesHantes etal,CORR2011

ResultsafterrepairofRCT

Goodexcellentresultsin85%to95%

PainreliefImprovementofmotionImprovementofstrength

Significantimprovementofshoulderfunction

ü RotCuffisextremelysignificantforthenormalfunctionoftheshoulder

ü RotCufftearscanbeasymptomatic

ü Symptomsproducedbyateardependon:– Size– Location– Functionaldemandsofthepatient

Conclusions

ü Ananatomicallydeficientbutbiomechanicalintactcuffispossible

ü Biomechanicalintactcuffisthecuffthatrestorestheequilibriumoftheforcecouples

ü Acuffteardoesnothealconservative

ü Acufftearafteroperativerepairmaynotheal

ü Partialhealingmayrestoresufficientpowertothecufftoequilibratetheforcecouples

Conclusions