Rotator Cuff Disease

Current Surgical Management

Chris Pullen

Historical Aspects

Codman in 1934 Impingement syndrome Arthroscopic SAD

Shoulder Arthroscopy

Rotator Cuff Disease

Tendinopathy/Impingement

Rotator Cuff Tear

Cuff Tear Arthropathy

PARTIAL THICKNESS TEARS

(IMPINGEMENT/TENDINOPATHY)

PTT –Surgery

Open Mini – open Arthroscopic*

PTT - Arthroscopy

Advantages Visualisation Treatment

articular tears

PTT - Arthroscopy

Bursal surface tear SAD

Articular surface tear Debridement

only Repair

>50% Thickness tear

Active patients

PTT - Arthroscopy

Results Debridement +/- SAD Repair

FULL THICKNESS TEARS

FTT - Surgical Approaches

Arthroscopic* Arthroscopic assisted/mini-

open* Open

FTT - Arthroscopic RCR

Gleno-humeral Joint PTT Labral tears Ligament injuries Cartilage tears

Significant lesions in 12.5%

FTT – Arthroscopic RCR

Repair Site Preparation Removal of

ragged or degenerate tissue

Decortication of bone

FTT – Arthroscopic RCR

Suture Placement

FTT – Arthroscopic RCR

Anchor Placement Foot print Double row

technique

FTT – Arthroscopic RCR

Other Tendon Lesions Infraspinatus Teres minor Subscapularis Biceps

FTT – Arthroscopic RCR

Biceps Debridement Tenotomy Tenodesis

FTT – Arthroscopic RCR

Post – operative Treatment Sling Cryotherapy PROM AROM Strengthening

FTT – Arthroscopic RCR

Results 90% satisfaction 78% pain relief AROM

MASSIVE TEARS

Massive Tears – Surgery

Debridement Open Arthroscopic*

Rotator Cuff Repair* Tendon transfer* Synthetic interposition Arthrodesis Arthroplasty

Massive Tears - Debridement

Debridement alone Low demand patients Results tend to deteriorate over time

Arthroscopic debridement easier more rapid rehabilitation 

Massive Tears - Debridement

Limited acromioplasty coracoacromial arch is maintained 

Biceps tenotomy / tenodesis subluxation, dislocation, or partial

tearing enhance the ability to alleviate shoulder

pain

Massive Tears - RCR

Good function & pain relief 80-90% Goal of surgery is to repair the cuff

without disrupting the coraco-acromial arch

Massive Tears - RCR

Rehabilitation Sling / Abduction splint PROM AAROM Strengthening

Overall recovery may take >12 months

Massive Tears - RCR

Results Inferior Better within 6 weeks (Bassett &

Cofield 1983) Shoulder dislocation >40

85-90% good to excellent ( Bigliani 1992)

Massive Tears – Tendon transfer

Latissimus Dorsi* Pectoralis Major* Teres Minor Subscapularis Deltoid muscle flap Trapezius

Massive Tears – Latissimus Dorsi

Supraspinatus/Infraspinatus loss Restore ER & head depression

forces

Massive Tears – Latissimus Dorsi

Results 82% satisfactory (Miniaci & MacLeod

1999) Intact subscapularis Little or no restoration of strength in

overhead activity

Massive Tears – Pectoralis Major

Subscapularis tears

Massive Tears - Reconstruction

Tissue implants Autologous Autogenous

Freeze-dried cadaveric tissue

CUFF TEAR ARTHROPATHY

CTA - Surgery

Arthroscopic debridement* Humeral tuberoplasty Shoulder arthrodesis Total Shoulder Replacement Hemiarthroplasty* Reverse Shoulder Arthroplasty*

CTA - Hemiarthroplasty

Indications <70 years Active elevation

>90°

CTA Head Variation of the

hemiarthroplasty

CTA - Hemiarthroplasty

Results Functional results limited, pain relief is excellent

(Williams & Rockwood 1996) Zuckerman et al (2000) decreased pain,

increased FF86 & ER 30. Sanchez-Sotelo et al (2001) 67%

successful at 5 year follow-up

CTA - Hemiarthroplasty

Results intact

coracoacromial arch essential

CTA- Reverse Shoulder Arthroplasty

Semiconstrained reverse ball and socket

Grammont 1985

CTA - RSA

Biomechanics (Boileau et al 2005) Large glenosphere Medialisation of the centre of rotation Lowers humeral head

CTA - RSA

Indications > 70 years or no active elevation Low demand

CTA - RSA

Results (Boileau et al 2005, De Buttet et al 1997, Rittmeister et al 2001)

Excellent pain reduction Improved active abduction

CTA - RSA

Complications High Rate revision is

high (4.2-13%)

Not for the occasional operator

REHABILITATION

Rehabilitation -Biomechanics

Rotator Cuff Stabilises gleno-humeral joint Depresses the humeral head

Protective overlap Subscapularis

Scapulo-thoracic dyskinesia Compensatory impairment leads to

winging Alter orientation of the acromial arch

Rehabilitation – Tendon Healing

Spontaneous healing ??

Phases Inflammatory Proliferative Maturation

Maximal load to failure 12-26 weeks

Rehabilitation - Immobilisation

Early ROM Abduction splint

Shoulder immobilisation with an abduction-type splint for 4-6 weeks

Rehabilitation - Cryotherapy

Speer et al 1996 Less pain 1st 24 post-operative hours Better sleep Lesser analgesic requirement Less swelling Better able to tolerate rehabilitation

Rehabilitation - PTT

Goals Full ROM Reducing impingement

Physical therapy plus exercise program better than exercise alone

Rehabilitation - RCR

Goals Mobilise the joint early Load the repaired tendons safely Strengthen the rotator cuff

progressively

Rehabilitation - RCR

Phases1. Immediate post-operative period

(week 0-6)2. Protection & active ROM (week 6-12)3. Early strengthening (week 10-16)4. Advanced strengthening (week 16-22)

Rehabilitation – Phase 1 Goals

Maintain / Protect repair integrity Gradual increase PROM Diminish pain & inflamation Prevent muscle inhibition

Exercises Sling/abduction splint 6 weeks Immediate PROM (depends on repair

tension) Pendular exercises Cryotherapy Hydrotherapy

Rehabilitation – Phase 2

Goals Allow healing of soft tissue Do not overstress healing tissue Gradually restore full PROM

Exercises Continue PROM Introduce AAROM ADL permitted Hydrotherapy Pulleys

Rehabilitation – Phase 3

Goals Maintain Full PROM Full AROM Dynamic shoulder stability Restore shoulder strength & endurance Gradual return to functional activities

Exercises Continue PROM & Stretching Progressive strengthening Proprioceptive activities

Rehabilitation – Phase 4

Goals Maintain full AROM Advanced muscle strengthening exercises Gradual return to full functional activities

Exercises Continue stretching Continue progression of strengthening Light sports (golf chip/putt, tennis ground

strokes)

THE END

1. Yes 2. Size 3. Latissimus Dorsi 4. 12-26 weeks 5. 6 weeks