rotator cuff evidence update
TRANSCRIPT
Evidence Update- Rotator Cuff Disorders
Mr Puneet MongaConsultant Orthopaedic Shoulder Surgeon
Wrightington Hospital
Understanding Cuff Function & Tears
Kinematics -Vectors
Supraspinatus
Subscap + Infra
Deltoid
Text
Denard PJ et al. 2012 Nov;28(11):1587-91.Inman et l 1996
Equatorial Concept
Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
Equatorial Concept
Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
Transverse plane couple
Restoring RC function is all about keeping the ball under water !
(and not just “covering the Hole”)
The Pathology of RC disease
Rotator Cuff Disorders
• Impingement - • Tendonitis / Tendinosis / Bursitis / Tendon
Entrapment
• Rotator Cuff Tears• Calcific Tendonitis
Causation of Cuff Disease
• Mechanical (Extrinsic)• Degenerative / Vascular
(Intrinsic)
Progression• Stage 1- Edema and Hemorrhage.
• Age <25 year• Stage 2- Fibrosis and Tendinosis.
• Age 25-40 years• Stage 3 - Bone spurs and Tendon
rupture.• Age>40 years
Cuff Disease Progression
BursitisTendinosis
ImpingementCalcific Tendonosis
OedemaHemorrha
gePartial Tears Spurs
Full Thickness Tears
Cuff tear Arthritis
Acromial shapes
Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its
relationship to rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986
Higher proportion of RC tears seen in Curved and Hooked Acromions
Image courtesy- Shoulderdoc.co.uk
Sub-acromial Wringer
Coronal Plane Patho-anatomy
AbductionNeutral Position
Post- Decompression
Sagittal - oblique Plane Pathoanatomy
Sub-Acromial volume
Arch Decompression
Sub-Acromial volume
Intrinsic TheoryExtrinsic Theory doesn’t explain• RCT- Bursectomy vs Bursectomy + acromioplasty- No
Difference • Articular surface tendon damage more common• No direct relation between acromial shape and
impingement symptoms• Outcomes not proportional to extent of acromioplasty
Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-
98. 2011
Hence Tendon degeneration likely to play important role
Making a Diagnosis
Positive Special Test = Diagnosis!
Using a Cluster approach recommended
• History• Look Feel Move + Special
Tests• Investigations
Making a Diagnosis
History and physical examination provide little
guidance on diagnosis of rotator cuff tears.
Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.
Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. doi: 10.1002/14651858.CD007427.pub2.
Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may
accompany impingement.Hanchard NC, Lenza M, Handoll HH, Takwoingi Y.
Cochrane Database review33 Studies - 4002 shoulders170 Target Conditions / test
combinations !
Only 6 instances where the test was performed and interpreted similarly
No Clear Evidence to support a test
Subscapularis• Bear Hug Sensitivity 60% Specificity 100%
• Belly Press Sensitivity 40% Specificity 97.9%
• Napolean Sensitivity 25% Specificity 97.9%
• Lift off Sensitivity 17.6% Specificity 91.7%
• Internal Rotation Resistance test at Maximal Abduction (IRRTM) 76.5% sensitivity
Bear Hug Test: A new and sensitive test for subscap tears. Barth et al. Arthroscopy 2006Lin Et al 2015 Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions.
Supraspinatus
• Hug Up Test 94% sensitivity, 76% specificity
• Empty Can 84% sensitivity 74% specificity
• Full Can 74% sensitivity 81% specificity
• Lag Signs are not conclusive
The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears. Chin Med J (Engl). 2016 20th Jan;129(2):147-153. doi:
10.4103/0366-6999.173461. Liu YL, Ao YF, Yan H, Cui GQ
Miller CA1, Forrester GA, Lewis JS The validity of the lag signs in diagnosing full-thickness tears of the rotator
cuff: a preliminary investigation. . Arch Phys Med Rehabil. 2008 Jun;89(6):1162-8.
Infraspinatus
• Ext Rotation Resistance• Lag sign
Merolla, G., De Santis, E., Campi, F., Paladini, P., & Porcellini, G. (2010). Infraspinatus scapular
retraction test: a reliable and practical method to assess infraspinatus strength in overhead
athletes with scapular dyskinesis.Journal of Orthopaedics and Traumatology : Official Journal of the
Italian Society of Orthopaedics and Traumatology, 11(2), 105–110.
Teres Minor
• ER Lag sign >40’ 100% sensitivity 92% specificity
• ER Lag Sign >10’ 100% sensitivity 52% specificity
• Patte Sign (Hornblower) 93% Sensitivity 72% specificity
• Drop Sign 87% sensitivity 88% specificity
Collin P1, Treseder T, Denard PJ, Neyton L, Walch G, Lädermann A. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?
Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.
Role of Investigations• Ultrasound - Good for soft tissues &
dynamic
• Xray- Good screening tool for Bone / joint
• CT- Good for bone
• MRI- Good for soft tissues and cross sectional
Ultrasound Versus MRI
Ultrasound• One Stop clinic
• Operator dependent
• Post op assessment
• Interactive
• Dynamic
MRI• Cross sectional anatomy
• Bone and Joint
• Partial Thickness & Interstitial Tears
• Visual record
• Muscle wasting and Fatty Atrophy
When to use Ultrasound
• “Go-to” Investigation for Impingement and Rotator Cuff Syndrome.
• Check integrity of Cuff repair within 1 year of surgery
• Guided injections
When to use MRI scan
• Pre-operatively to assess for Muscle Wasting and Fatty atrophy
• Atypical symptoms• Large patients
Management
First line Management
• Rest• Simple Analgesia• NSAIDs• Physiotherapy- Posture, motor
control, stretching, strengthening, Manual therapy- 6 weeks
• Sub-acromial Steroid Injection- 1 onlyBOA/ BESS commissioning guide
Indications for Surgery
Failure of First line treatment
Notable ExceptionAcute Rotator Cuff Tears
Early surgery has better outcomes
Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves
outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.
Factors affecting Outcomes
Age
Age > 65 years associated with relatively inferior outcomes
Cho NS, Lee BG, Rhee YG. Arthroscopic cuff repair using suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011; 39: 2108-16
Tendon VascularityHypovascular Zone 10-15 mm prox to insertion (Codman)
Vascularity at edge of torn tendon normal...? artifact in earlier studies (Goodmurphy et al)
Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, Mass.: T. Todd company; 1934: 123-37
Goodmurphy CW, Osborn J, Akesson EJ et al. An immunohistochemical analysis of torn rotator cuff tendon taken at the time of repair. J Shoulder Elbow Surg 2003; 12:368-74.
Tear Size
Large / Massive tear have inferior healing / poorer outcomes
Good function still possible in cases of non healing repairs
D Factor and B Dale. Current concepts of rotator cuff tendinopathy. The International Journal of sports physical therapy 2014; 9(2): 274-82.
Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Tendon RetractionInitial retraction due to Muscle contraction and secondarily involves tendon shortening
Increasing Gap associated with inferior outcomes
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012; 40:2242-2247
Fatty Atrophy / Wasting
Fatty Atrophy, Muscle Wasting
Both independent risk factors
Higher re-operation rates, poor outcomes and poor tendon healing in presence of fatty atrophy
Goutallier D, Postel JM, Gleyze P, Leguillox P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 2003; 12:550-554.
Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after cuff repair and correlate with poor functional outcome. Am J Sports Med 2007; 35: 719-728.
Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
Reversibility of FA/ Wasting
Fatty Atrophy Irreversible but halts after successful RC Healing
Muscle wasting potentially reversible but usually halts after successful RC healing
Fatty Atrophy / Wasting worsen in cases where RC does not heal.
Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
Smoking
Higher Risk of Cuff DiseaseInferior Outcome
Baumgarten KM, Gerlach D, Galatz LM, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical orthopaedics and related research. Jun 2010;468(6):1534-1541.
Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Mar-Apr 2004;13(2):129-132.
Acromial Shape
Related to Risk of RC tears
No difference in outcomes of decompression with / out acromioplasty
Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture
to rotator cuff disease. Clinics in sports medicine. 1991;10(4):823-838
Henkus HE1, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management
of subacromial impingement syndrome: a prospective randomised study.J Bone Joint Surg Br. 2009 Apr;91(4):504-10.
Single vs Double Row repair
Double Row has better biomechanical characteristics- decreased gap formation and higher load to failure Improved outcomes in large / massive tears
No difference in clinical outcomes in small / medium size tears
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med 2008; 36: 1310-1316
Repair configurations
Knotted / KnotlessNumber of suturesDifferent Suture configuations
No difference
Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012; 94: e48
Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs. Arthroscopy 2010; 26: 316-323
Post op Rehab
Early vs DelayedNo Difference
Better pain relief and ROM in short term
Slightly higher retear in early mobilization in large / massive tears
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med 2012; 40: 815-821
Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg 2012; 21:1450-1455
Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: 1034-1039.
Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy 2012; 28: 34-42
Addition of Growth factors
BMP
PDGF - Promising
FGF
TGF-β - Promising
Gulotta LV, Kovacevic D, Packer JD, Ehteshami JR, Rodeo SA. Adenoviral mediated gene transfer of human bone morphogenic protein -13 does not improve rotator cuff healing in rat model. Am J Sports Med 2011.; 39: 180-7
Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497
Uggen JC, Dines J, Uggen C.W et al.Tendon gene therapy modulates the local repair environment in the shoulder. The Journal of the American Osteopathic Association 2005, 105: 20–21
M. Kobayashi, E. Itoi,H.Minagawa et al. Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits. Journal of Shoulder and Elbow Surgery 2006; 15: 371–377.
Thomopoulos S, Harwood FL, Silva MJ, Amiel D, Gelberman RH. Effect of several growth factors on canine flexor tendon fibroblast proliferation and collagen synthesis in vitro. J Hand Surg Am 2005; 30: 441–7.
Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med 2009; 28:13–23
C. N. Manning, H. M. Kim, S. Sakiyama-Elbert, L. M. Galatz, N. Havlioglu, and S. Thomopoulos, Sustained delivery of transforming growth factor beta three enhances tendon-to bone healing in a rat model. Journal of Orthopaedic Research 2011; 29: 1099–1105.
Kovacevic D, Fox A J, Bedi A et al. Calcium-phosphate matrix with or without TGF-𝛽3 improves tendon-bone healing after rotator cuff repair. American Journal of Sports Medicine 2011; 39: 811–819
PRPNo difference (2) / improved
outcomes (2)
Currently role unclear
Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497
Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study. Am J Sports Med 2013; 41: 263-270
Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy 2011; 27: 1029-1035
Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med 2013; 41: 2240-2248
Mesenchymal stem cells
Bone Marrow injection - promising45 patients10 year FU
Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop 2014; 38: 1811-1818
Augmentation / scaffolds
• Biological (Type I Collagen) /Artificial
• Higher Resistance to Failure
• RCT - Better Scores and healing when Graftjacket Augmentation used along with Cuff repair
Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15
Massive Cuff tears
Massive Cuff TearsBiceps tenotomy/Tenodesis Boileau et al 2007 68 78%good Good for pain relief.
Tendon Transfer Tauber et al, 2010 42 10-27% poor resultsNot applicable with subscap / teres minor tears
Dermal Subsitute Gupta et al, 2012 24 76% intact All reported pain relief. Costly.
InSpace Balloon Savarese et al 20 ? Scores improved on average. Under trial.
Suprascapular nerve ablation Nizian et al 2009 20 75% good to excellent Indication intractable shoulder pain
Superior Capsular Reconstruction Mihata et al 2013 24 83% healing. ? early days
Partial Repair Monga et al personal audit 19 82% reversal of psudoparalysis Practical
Reverse geometry Ek et al, 2013 46 37.5% had complications Salvage option
Over to Julia, Chrissy and Tanya…
Credits- A Desai