IRREPARABLEROTATOR CUFF TEAR

NADHAPORN SAENGPETCH

DEFINITION

• Massive rotator cuff tears that are not reparable by conventional means.

• Their size and retraction, cannot be repaired to their insertion on the tuberosities despite conventional techniques.

• associates with a high-riding humeral head

FACTS

• unknown true incidence• may have no symtoms/mild/severe pain• associated with concomitant glenohumeral OA• asymtomatic tears in elderly found 30-50%

Zlatkin MB. J Bone Joint Surg Am.1995; 77:10 -5. • age > 70 ; found FTRCT 38% Tempelhof et al. J Shoulder Elbow Surg. 1999;8:296 -9.

Cuff Atrophy & Fatty Infiltration

• 57 patients • Infraspinatus degeneration had a highly negati

ve influence on the outcome of supraspinatus repairs. It worsens with time.

• The subscapularis rarely degenerate, even when its tendon is not torn.

Goutallier D.Clin Orthop Relat Res. 1994 Jul;(304):78-83.

Goutallier Classification : 5 stages

0 : no fat

1: minimal fat

2 : muscle>fat

3 : muscle=fat

4 : muscle<fat

2 PHYSIOLOGICALLY DISTINCT GROUPS OF PATIENT

1. Older > 70, lower-demand who have been asymtomatic until minor trauma created symtoms

2. Younger, more active with dramatic symtoms of pain and disability after an acute event / with a history of cuff injury

2 DISTINCT ANATOMIC PATTERNS

1. Posterosuperior failure* : supraspinatus, infraspinatus and teres minor tendons

2. Anterosuperior failure : supraspinatus and subscapularis tendons ± LHB

۩ Loss of the coracoaromial arch and anterosuperior instability humeral head migration

PATHOMECHANICS

• The RC acts as a dynamic stabilizer, resisting upward motion of a humeral head during deltoid contraction.

• Irreparable cuff : loss a force couple, allow a humeral head migrates superiorly during deltoid contracts (superior shoulder instability)

CLINICAL PRESENTATIONS

• pain

• deficit ROM

• atrophy of scapular muscles

• crepitus and hemarthrosis

• Posterosuperior disruption : AB, FE and active ER

• Anterosuperior disruption : AB, IR

Posterosuperior Disruption

External rotation lag sign

Posterosuperior Disruption

Hornblower’s sign*

Anterosuperior Disruption

Belly press test

Anterosuperior Disruption

Lift-off sign

RADIOGRAPHIC FINDINGS

• Position of the humeral head

• Evidence of glenohumeral OA

• Disorder of the AC joint

RADIOGRAPHIC FINDINGS

MRI VS MR Arthrography• 41 shoulders had MRI followed by MR arthrography• Sensitivities for detecting full-thickness rotator cuff tears

by MRI and MR arthrography were 90.2 and 100% respectively.

• more accurate in evaluating rotator cuff tear size and morphologic features

• morphologic classification of the torn tendon : blunt end, tapering end, indistinct end, horizontal tear, and global tear

Toyoda H. Clin Orthop Relat Res. 2005 Oct;439:109-15.

MRI VS MR Arthrography

TYPE 3-4 FATTY INFILTRATION

MANAGEMENT

• depends on the presenting symtoms, age and functional level

• medical comorbidities, an intact coracoacromial arch and concomitant arthritis

• no evidence-based, prospective, matched- patient studies comparing nonsurgical and surgical treatments

NONOPERATIVE TREATMENT

• relieve pain & create biomechanically compensated function by muscle substitution

• NSAIDs

• steroid injection

• local therapeutic modalities

• strengthening exercise

• > 3 months to succeed

SURGICAL TREATMENTS

• Subacromial débridement, partial repair, cuff débridement and biceps tenotomy

• Reconstructive procedures

• Conventional and reverse arthroplasty

• Glenohumeral arthrodesis

SUBACROMIAL DÉBRIDEMENT

• Healthy, low-demand with pain

• A patient with positive for impingement test is a good surgical candidate.

• Procedures : limited, acromial smoothening, bursectomy

No release of the CA ligament

SUBACROMIAL DÉBRIDEMENT

PARTIAL REPAIR

• “Suspension bridge model” restore continuity between anterior and posterior portions of the tear resulted in a fibrous frame close to the equator of the head.

• Create a force to stabilize the head against the glenoid and enabling full function of deltoid

Burkhart S. Arthroscopy . 1994;10:363 -70.

PARTIAL REPAIR

CUFF DÉBRIDEMENT

• Rockwood : open acromioplasty, decompression, cuff débridement

• Ellman : pain relief, but no significant increase in strength and ROM

• Zvijac and Kempf : substantial deterioration in pain relief/strength/functional outcome

TENOTOMY OF LHB

• Anterosuperior lesion

• No effect on the ROM or strength

Walch G. J Shoulder Elbow Surg. 2005:14: 238-46.

TUBEROPLASTY

• Open surgery

• Shaving and reshaping of the overhanging bone at GT to create a recontoured subacromial space

Fenlin JM Jr. J Shoulder Elbow Surg. 2002;11:136 -42.

TENDON TRANSFERS

• Transfer : the existing cuff tendons, other periscapular muscles, grafts or synthetic substitution

• Young, good deltoid function

• Posterosuperior : latissimus dorsi

• Anterosuperior : pectoralis major (sternal head)

TENDON TRANSFERS Latissimus dorsi Pectoralis major

TENDON TRANSFERS

• Gerber : good-to-excellent results > 10 yrs, better result with intact subscapularis

• Iannotti : EMG study in latissimus dorsi transferred patients; had activity with adduction but no activity with active FE/ER

• Concept of a tenodesis effect

TENDON TRANSFERS

• Latissimus dorsi : clinical results sex (male), preoperative shoulder function and general strength

(Iannotti JP. J Bone Joint Surg Am. 2006;88:342-348)

• Pectoralis major : if the SS tear associated with irreparable Sup. tear, tendon transfer may not be warranted.

(Jost B. J Bone Joint Surg Am.2003;85:1944-1951)

TENDON TRANSFERS

• Complex, need a long period of rehab, limited

• Not indicated for older, more debilitated patients

• Synthetic allograft patches : can create foreign body reactions leading to rejection & cannot replace RC functions

ARTHROPLASTY

• Concomitant with arthritis or instability

• Conventional VS Reverse ball and socket prosthesis

CONVENTIONAL ARTHROPLASY

• HEMIARTHROPLASTY

• Indications :

intact coracoacromial arch

good deltoid function

no previous acromioplasty

no anterosuperior instability

• Contraindication : pseudoparalysis of shoulder

REVERSE ARTHROPLASTY

• RC tear + arthritis + pseudoparalysis

• Unknown long-term results

• Medialize the centre of rotation

• Increasing the deltoid lever arm

• Glenoid loosening (notching), hematoma and instability

REVERSE ARTHROPLASTY

GLENOHUMERAL ARTHRODESIS

• Deltoid and RC are not function.

• High-demand, require a strong stable shoulder girdle

• Limited rotation

• nonunion

Harrison Hot Spring, British Columbia.