rotator cuff tears

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Rotator Cuff Tears. Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California. Anatomy. Muscles? Innervation? Function?. Rotator Cuff Tears Natural History. ?. - PowerPoint PPT Presentation

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  • Rotator Cuff TearsReza Omid, M.D.Assistant Professor Orthopaedic SurgeryShoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California

  • AnatomyMuscles?Innervation?Function?

  • Rotator Cuff TearsNatural History

    ?

  • Rotator Cuff TearsTreatmentNot standardizedWhen do we maximize conservative care?When is early surgical intervention appropriate?

  • AAOS Guidelines for Treatment of Rotator Cuff Tears

  • Rotator Cuff Repair Surgical IndicationsVariations in Orthopaedic Surgeons Perceptions about Indications for Rotator Cuff Surgery Dunn, et al, JBJS 05Sig variationLack of agreementSurgical discussionRole of PTPrevent progression of tear

  • Asymptomatic TearWhy?Mechanical Factors?Force couplesDemographic Factors?

  • Proximal Humerus MigrationWhy Does it Happen??

  • Rotator Cuff DisordersGlenohumeral Kinematics

    Normal Cuff Head CenteredTendinitis, Fatigue Superior MigrationSymptomatic RCTs Superior MigrationAsymptomatic RCTsPoppen & Walker, JBJS 75?

  • Journal of Shoulder & Elbow Surgery2000;9:6-11

  • ResultsNormals Ball & socket kinematicsSymptomatic RCTs Superior head migrationAsymptomatic RCTs Superior head migration (greater variability)

  • ConclusionsLoss of rotator cuff integrity (both symptomatic and asymptomatic) was associated with superior head migrationSuperior head migration did not necessarily correlate with symptoms

  • Conclusions Implies normal glenohumeral kinematics do not need to be restored with surgery

  • Journal of Bone and Joint Surgery, 99A, 2009

  • Bilateral Two-Tendon RCT30 Degree Abducted

  • Glenohumeral KinematicsAsympt vs Sympt RCTAsymptomatic w/ less superior migration (smaller tears)Both sympt/asympt superior in massive tearsCritical size for superior migration1.5 cm tear

    Jay Keener, JBJS 2009

  • Journal of Shoulder and Elbow Surgery10:3, 2001

  • MethodsShoulder Ultrasound employed at Washington University since 1984 (Unique Study Opportunity)Routine bilateral examsPredict large # of asymptomatic tears

  • ResultsSymptomatic Progression23/45 (51%) became symptomaticavg 2.8 yrs from US

  • Conclusions39% total had tear size progressionNo tears decreased in size (dont heal on their own)Relationship between symptoms and tear progression?

  • Journal of Bone and Joint Surgery 2006; 88-A, 1699-1704

  • Methods

    Presence of unilateral shoulder pain (n=588)Bilateral intact cuffs (n=212)Unilateral tear* (n=191)Bilateral tears* (n=185)

    Demographic questionnaire data obtained for 586/588

    Age, tear size, side, thickness, family hx compared between symptomatic and asymptomatic individuals* tear: partial-thickness or full-thickness

  • ResultsCorrelation with PainAssociated with dominant side (p
  • ResultsCuff disease increased with age No tear 48.7 yoUnilateral tear 58.7 yoBilateral tear 67.8

    50% likelihood of bilateral tear after age 66 yr if present with painful tear, (p

  • Healing of RCR Influence of AgeOutcome/tear integrity of massive tears JBJS 2004Tear integrity with double-row repair AJSM 2009Outcome/ tear integrity of PTRCR JBJS 2009Outcome/tear integrity of Revision RCR JBJS 2010

    Avg patient age healed: 55 yoAvg patient age not healed: 63 yo

  • Conclusions Demographics Unilat tear in youngBilat tear in olderTears rare before 40 yo.Tears common after 61 yo.

  • ConclusionIntrinsic etiology for Cuff Disease High incidence asympt./bilat disease Increased tear size important for pain High index of suspicion in high risk groups

  • Symptomatic Transition of Asymptomatic Rotator Cuff TearsMall et al JBJS 2010

  • ConclusionsOver a 2 year period 21% of patients with an asymptomatic rotator cuff tear became symptomaticSymptomatic transition of asymptomatic cuff tears is associated with significant increases in pain and loss of function Tear size progression may play a significant role in symptomatic transition.No significant changes seen in glenohumeral kinematics or shoulder strength upon symptomatic transition. (early detection is key!)

  • UltrasonographyAccuracyVaries among institutions60% accuracy JBJS86Not widely accepted

  • Journal of Bone and Joint Surgery 200082-A:498-504

  • MethodsValidated accuracyTeefey et al, JBJS 04Compare to MRIPricket et al, JBJS 03Post op shoulderTeefey et al, JBJS 00Compare to surgeryMiddleton et al, JBJS 86

  • Natural History of Fatty Degeneration of Muscles?

  • Fatty Degeneration vs Fatty InfiltrationGalatz vs GerberWhat is the difference?Why does it happen?

  • Degeneration vs InfiltrationGerber: fatty cells infiltrate the muscle once the pennation angle changesGalatz: fat cells develop from pluripotent cells found within the muscle itself, the process of infiltration does not occur

  • Fatty degeneration of the rotator cuff musclesNormal rotator cuffFat-infiltrated infraspinatus

  • Fatty degeneration of the rotator cuff musclesNormal SupraspinatusFat-infiltrated SupraspinatusWall et al Accepted for pub JBJS 2012

  • What is atrophy?Tangent Sign?

  • What is atrophy?

  • Journal of Bone and Joint Surgery 2010

  • Methods262 pts from prospective cohortCompare fatty degeneration to :Tear location (relative to biceps)Tear size ( number of muscles)

  • Distance from Biceps Tendon

  • Results35% of full tears with sig fatty degenerationFatty degeneration in full-thickness tears onlyFatty degeneration highly correlated with proximity of tear to biceps

  • ConclusionsDisruption of anterior supraspinatus is strongly associated with development of fatty degenerationSupports rotator cable concept for cuff (Burkhart): disruption of anterior cable is key!

  • Rotator Crescent / Cable

  • Where do RCT Initiate?

  • Rotator Cuff TearsConventional concept:Start from the anterior portion of supraspinatus insertion near the biceps tendonPropagate posteriorly Supraspinatus almost always involved

    Codman EA, 1934; Keyes EL, 1933; Hijioka A, 1993; Matsen III FA, 1998; Lehman C, 1995

  • AnteriorPosteriorSuperiorInferiorHumeral HeadSubscapularisBiceps tendonSupraspinatusInfraspinatusTeres Minor

  • Wash U Clinical ExperienceBTHHDTSSIS

  • Journal of Bone and Joint Surgery 10

  • DiscussionBidirectional propagation: - Tears start 15 mm post to biceps - Extend in both anterior and posterior directions from their initiation location - Did not extend only in the posterior direction

  • AnteriorPosteriorSuperiorInferiorHumeral HeadSubscapularisBiceps tendonSupraspinatusInfraspinatusTeres Minor15mm

  • MechanismAnteriorPosteriorBTRotator CableRotator Crescent15 mm

  • Epidemiologic Factors?

  • Smoking Increases the Risk for Rotator Cuff TearsKeith M. Baumgarten, MDDavid Gerlach, MDLeesa M. Galatz, MD Sharlene A. Teefey,MD William D. Middleton, MD Konstantinos Ditsios, MDKen Yamaguchi, MD

    CORR 2009

  • MethodsHx of Cigarette SmokingCuff Intact vs. Cuff Tear

  • ConclusionsSmoking increases the risk for rotator cuff tears:Strong association highly statistically significantTime dependant relationshipMore recent smokingCause / effect relationship?Dose Response relationship# packs per day# years smoking

  • Diabetes-Clement JBJSBr 2010: 1112-7Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts-Bedi JSES 2009: 978-88impairs tendon-bone healing after rotator cuff repair

  • NSAIDS-Cohen AJSM 2006: 362-9Traditional and cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs significantly inhibited tendon-to-bone healing in animal model

  • Obesity (?)-Namdari JSES 2010: 1250-5Although obesity is considered a risk factor for poor postoperative outcomes after some surgical procedures, in our experience, obesity does not have an independent, significant effect on self-reported early outcomes after RCR-Warrender JSES 2011: 961-7Obesity has a negative impact on the operative time of arthroscopic rotator cuff repairs, length of hospitalization, and functional outcomes.

  • Operative IndicationsNatural History InformationRisks Benefits

  • Operative Indications

    RisksOperative TreatmentNon-Operative Treatment

  • Rotator Cuff TearRisks - Chronic Changesretraction with adhesiontendon morphologymuscle atrophyfatty degenerationdegenerative changes

  • Operative vs Non-Operative TxRationaleWhat is the risk for development of Irreversible Changes?Risk dictates urgency for surgery

  • Early Operative TreatmentBenefitsHalt chronic changes?Most pertinent to younger pt.Important for acute, small or medium sized tearsImportant for tears at risk for fatty degeneration or altered kinematics

  • ConclusionsNatural HistoryHigh probability of bilateral symptomsHigh probability of tear size progressionNo evidence of spontaneous healingSupports large population have intrinsic etiology

  • ConclusionsAge important factor for development of tearsImportant consideration for operative indications!High suspicion of tear extension with new pain!

  • ConclusionsTears start 15 mm post to bicepsLoss of ant supra criticalCritical size threshold 15-20 mm

  • TechniquesOpen

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