rotator cuff tear and its management

Rotator cuff tear: Basic understanding and treatment

options

Dr Rohan VaktaM.S.OrthoAASH Arthroscopy Center Ahmedabad,India

They Fuse together with the articular capsule into a common insertion on the tuberosities of the humerus, which is known as the footprint of the rotator cuff.

Action of rotator cuff

Rotator cuff acts as a mechanical couple in conjunction with Deltoid in shoulder rotation & elevation

Important functions:• Counterbalance the upward pull of the deltoid on the

humerus.• Hold the head of the humerus secure in the glenoid.• Externally rotate the shoulder which is important

during arm elevation.

Etiology

Traumatic

high velocity trauma ( partial- or full-thickness tears)

Repetitive microtrauma (overuse, athletic)

Non-Traumatic

(Age <40 years)

(Age >40 years)

Non-Traumatic

•Degenerative (Work related: Painters,electrician)•Subacromial Impingement syndrome

•Developmental Factors : Os acromiale , Type 2 or 3 acromion

• Others:o Shoulder Instabilityo Inflammatory dz : Calcific tendinitis/RA/Crystal

induced arthropathyo Scapulohumeral neuromuscular dysfunction:o Entrapment syndromes

Non-Traumatic

p

Crescent Reverse ‘L’ ‘L’ Shaped

Trapezoidal Massive tearFull Thickness Tear

Pathophysiology

Torn Rotator Cuff

Can not Counterbalance the upward pull of the deltoid on the humerus

Not able to Hold the head of the humerus secure in the glenoid

AHD <6mm

Leads to abutement of humeral head against acromion

Acetabulization: Concave deformity of under surface of Acromion

Narrowing & Arthritis of Gleno-Humeral Joint

Last stage of Cuff tear arthropathy with collapse of humerus head

Hamada and Fukuda Stages of Cuff Arthropathy

History

• Pain around shoulder• Sleep disturbed by pain• Weakness during activities of daily living• Previous trauma• Time lag before presentation• Occupation• Predominant hand

Physical Examination

• Passive and Active ROM• Strength of motions• Supraspinatus : Resisted elevation of arm kept in "empty can" position

• Subscapularis “ Lift-off test”

•Infraspinatus : Resisted External Rotation

•Teres minor:Resisted external rotation with arm abducted more than 45°.

Impingement Test

• Hawkin-kennedy test• Injection test:Very effective test

for diagnosis • Approx 7-10 ml of Xylocaine

injected in subacromial bursa• Wait for 2-3 minutes• Pain in ROM will be minimal• D/D between impingement &

RC tear

Ultrasonography•Dynamic

•Non-invasive

•Inexpensive

•Helpful as a screening tool

•USG guided Injection

M R I

T2 images -Presence of fluid in the subacromial spaceT1 images- loss of the subacromial fat plane, and proliferative spur formation of the acromion and/or acromioclavicular joint. Discontinuity of the tendon.Size of tear , retraction of tendon

Treatment of Rotator Cuff Tears

o Conservative :

Physical Therapy ± Injection treatment

Indication: • Medical Cormodities• Relatively Inactive lifestyle• Patients not willing for post-op

rehab.

Surgical Management

four major objectives: (1) closure of the cuff defect.(2) eliminating impingement.(3) preserving the origin of the deltoid muscle.(4) preventing adhesions postoperatively without

disturbing the repair by a careful exercise program

Open(not recommended)

Mini-Open Arthroscopic

Mini open repair

• Midway between open & arthroscopic repair• Less than 5 cms. incision in the line from

centre of acromion • Axillary N. should be protected, 5 cm. below

acromial line• Deltoid splitting approach, not erased

Cl. Acr.

Mini open RC repair• Identify bursa• Mimics rotator cuff• Bursectomy• Tear evaluation• Preparing foot print• Freshning of tear• Transosseus sutures or suture anchor cuff repair• Meticulous Deltoid repair

Torn cuff

Arthroscopic rotator cuff repair

• Lateral or Beach chair position• Hypotensive anaesthesia• Pressure pump- Very useful• Skin marking of landmarks• GH arthroscopy- frayed intra- articular RC debrided

Arthroscopic rotator cuff repair

• Scope moved to sub acromial area• Bursectomy & SAD for impingement• LAP ( Lateral acromial portal)– main viewing portal• Ant. & post. Working portals• SOS-Mini or complete distal clavicle resection

Arthroscopic rotator cuff repair

• Bone at insertion site & Gr. tuberosity- lightly burred• Torn edges of cuff debrided• Tear pattern assessed- Y or V• Repaired with suture anchors & side to side sutures• Preserve CA lig. in massive tear• Repair checked- No tension repair

Arthroscopic rotator cuff repair

Arthroscopic SADRemoval of inferior part of anterolateral acromion

Open SAD • No morbidity• Genuine benefit

Arthroscopic

Arthroscopic rotator cuff repair

Post. Op. regimen• Shoulder immobilizer for 6 weeks• Post. op physiotherapy is as important as good surgery• Recovery time 12 to 16 weeks• Total time 1 year

Arthroscopic cuff repair• Tears of all sizes can be done arthroscopically- 95% tears can be repaired by an experienced surgeon• Minimal damage to Deltoid muscle- potential source of post-op morbidity in open repairs• Greater versatility for characterization, assessment, mobilization as well as fixation• Complete evaluation of Shoulder joint anatomy- PASTA, SLAP, Arthritis etc.•Day care surgery•Early & Easier postop rehabilitation

Deltoid detachment

Despite these advantages, arthroscopic rotator cuff repair is technically demanding procedure that needs prerequisite skills as diagnostic shoulder arthroscopy, arthroscopic subacromial decompression, and arthroscopic knot tying in order for a surgeon to obtain proficiency in this procedure.

Arthroscopic cuff repair

RC repair- Contraindications• Severe OA of Glenohumeral jt.• Medically unfit patient• Low activity level individual who can live with deficient shoulder

• Adhesive capsulitis• Failed prior RC surgery • Fatty infiltration in muscles

Rotator cuff injuryIf not addressed in time…• Young active individuals- torn cuff cannot heal

to bone- late cuff arthropathy - continuous pain & weakness• Muscles undergo atrophy & fatty degeneration• Waiting too long- repairable cuff becomes irreparable with poor tissue & poor prognosis • At >1 year of f’up, a’scopic and mini-open rotator cuff repairs produces similar results with equivalent patient satisfaction rates

Fatty degeneration

Thank You