natural history of degenerative cuff tear-decision making-dr a.n. misra

NATURAL HISTORY OF DEGENERATIVE CUFF TEAR –

DECISION MAKINGDr A.N. Misra

MS(Orth), MCh(Orth) U.K., FRCS (Edinburgh)

Shoulder & Knee SurgeonIndraprastha Apollo & Apollo Hospital Noida

www.skishoulderknee.com

The Degenerative Cuff Tear

- Epidemiology- Etiopathology- Progression- Healing Do they heal

Factors that could help healing & better outcomes

Implications on Treatment


What are we trying to replicate? –ENTHESIS on TUBEROSITY

Approx 85% - Type 1 Collagen

With increasing age – more of Type 3


CUFF PATHOLOGY

Harryman et al, JBJS 1991

Gohlke et al, Acta Orthop 2005

Microstructure at insertion – 5 layers

Varied fibre orientations

Significant shear forces

Lamellar tears www.skishoulderknee.

com

PATHOLOGY - COLLAGEN

Midsubstance – Type 1

Insertion site (compressive loads) – Type 2

Repair – Type 3 (Disorganised scar tissue)

Tears – Smooth muscle actin cells (cause retraction)


PATHOLOGY OF A TEAR

- Muscle atrophy- Fatty Infiltration- Tendon Retraction – SMA cells- Increased Tendon Stiffness – Type 3

collagen- Apoptosis – Programmed cell death


CUFF BIOMECHANICS

Increasing strain upto 60 degrees of abduction

Equal tension on both sides

Stress concentration on the critical zone

Mehta et al JBJS 2003


CUFF VASCULARITY – Doppler Studies

Fealy, Am J of Sports Med, 2006Rudzski, JSES, 2008

Most blood flow- bursal pertitendinous, medial cuff

Anchor site – least flowVascular response decreased with age time since

repairExercise increased blood flowwww.skishoulderknee.

com

CUFF MARGIN VIABILITY

Goodmurphy JSES, 2003 (Immunohistochemical staining)

Greatest viability 2.5 -5mm from the margin

Matthews JBJS(Br), 2007Cell activity & perfusion decreased at

margins and in larger tears


CUFF – Vascularity & Cellular Activity

DECREASE WITH

- Age

- At the margins vis a vis a cm medial

- Tear size


ETIOLOGY OF A TEAR - EXTRINSIC


ETIOLOGY OF A TEAR - INTRINSIC

Watershed areas

Increasing Age

Increase in type 3 collagen, GAGs,

apoptosiswww.skishoulderknee.

com

Tear- Age, Size & Symptom Progression

Yamaguchi JBJS 2006 (588 pts, Ultrasound)

Average age 48.7 – no tear, 58.7 – unilateral, 67.8 – bilateral

Almost half of the pts above 66 yrs have B/L tears B/L sym tears – significantly largerSym tears occur in a 30% elder population vs

asymIf sym tear on one side – 35% chance of asym on

otherTears do not heal spontaneously


Cuff Tear Progression

Maman JBJS 2009 (MRI Follow ups)

48% progress in size over 18 monthsFull thickness progress moreElder (>60 yrs) progress moreFatty infiltration found with

progression


CUFF TEARS

Increase with timeBecome symptomatic as size increasesAge strongly corerelates with tear sizeFatty infiltration correlates with tear

sizeNo spontaneous healing


Repairs of the Rotator Cuff

Matsen et al ,JBJS 1995 (Open Repair)65% healing rates80% healing of supraspinatus32% healing of large tearsAge related

Ken Yamaguchi, JBJS 2004 (Ascopic Repair, massive tears)

6% healing rates Majority did well despite lack of healing!!


HEALING LITERATURE

Focus on:

Surgeon – skilled/unskilledOperation – Ascopic/openConstruct – Double/Single

BiologyRehab ProtocolEnvironmental – Smoking, NSAIDs


HEALING OF CHRONIC TEARS

Fealy, Warren et al, AJSM 200650%- Ultrasound

Sugaya, Arthroscopy, 200540% - Graded MRIs

Gerber et al, JBJS 200687% - One tendon – MRI58%- Two tendon


OPEN vs ASCOPIC

Flatow et al JSES, 2006

Comparable results for small tears

Larger than 3cm – open did better


EFFECT OF REPAIR CONSTRUCT

Sugaya et al, Arthroscopy 2005Single vs Double RowSignificant improvement in structural

outcome

Ken Yamaguchi et alDouble Row Healing Rates67% - one tendon36% - two tendons vs 6% in previous studyBridged the gap by fixation strength &

cons rehabwww.skishoulderknee.

com

PARTIAL TEARS TAKEDOWNS

Ken Yamaguchi et al, JBJS 2006

88% healing rates

Age a determining factor


ENVIRONMENTAL FACTORS

Galatz, Thomopoulos, JBJS 2006Nicotine delays healing

Cohen, Rodeo, AJSM 2006Indomethacin & Celecoxib delay

healing


REPAIRS – Animal Models

Repair site histologically disorganised – Galatz, 2006

Repair tissue from epitenon of bursal surface – Kazuyoshi, 2004

Better healing in immobilised repairs Thomopoulos 2003 Uhthoff JBJS (Br) 2000 Gerber JBJS 1999


ROTATOR CUFF REPAIRS – Do they heal?

OVERALL HEALING RATES : 30-85%Gerber JBJS, 2004 (Sheep studies)Gladstone AJSM, 2007

Repair at 40 weeksApprox 7 times decreased elasticityMuscle atrophy, Fatty infiltration,

increased interstitial connective tissue – irreversible changes despite healing

Atrophy & FI – adverse functional outcomes


HEALING POTENTIAL

Consider Biology FirstAgeTear Characteristics (muscle

atrophy/FI)Co morbiditiesSmoking


BIOLOGY IN HEALING

Young patients with small tearsLimiting factors – Surgeon, construct,

rehab & smoking NOT Biology

Older patients with large tears Limiting Factor - Biology


IMPACT ON TREATMENT

Above 65 years – poor healing pain relief –

objective single row atrophy/FI – irreversible and will

affect outcome

Customise advice to patient


IMPACT ON TREATMENT

Young patients < 50 Yrs better healing

potential double

row/biology good

functional results

Yearly ultrasounds of minimally symptomatic cuff tears - progression


IMPROVED BIOLOGY

Platelet Rich Plasma

Stem Cells

Collagen coated sutures

Vents in anchors/crimson duvet of Snyder


FUTURE DIRECTIONS

Effect of muscle load on cuff healing – Galatz

Biofactors for normal enthesis development - Thomopoulos


THANK YOU

E-325 SECTOR 27, NOIDA OPPOSITE MAX HOSPITAL, NOIDA


natural history of degenerative cuff tear-decision making-dr a.n. misra

Health & Medicine

repair type

yamaguchi jbjs

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