rotator cuff tears

85
Rotator Cuff Tears Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California

Upload: jennifer-wiggins

Post on 30-Dec-2015

90 views

Category:

Documents


0 download

DESCRIPTION

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

TRANSCRIPT

  • 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

  • TechniquesOpenMini-OpenArthroscopic

    Differences???

  • Acrmioplasty with RC Repair??

  • Acrmioplasty??No difference in 3 RCT

  • Single vs Double Row??

  • Single vs Double Row??

  • Single vs Double Row??Double Row biomechanically betterNo difference clinically in 4 RCT

  • Double Row vs TOE??

  • Double Row vs TOE??

  • Double Row vs TOE??TOE better surface area coverage?Better healing?

  • Problems with Double Row or TOE???

  • Problems with Double Row or TOE???Tuberosity fractureMT junction ruptures

  • Other Techniques?Tension band?Mason-Allen?Rip-stop?

  • Tension Band

  • Mason-Allen Stitch

  • Cuff Re-tear (Failed Surgery)???When does it happen?How does it happen?

  • Cuff Re-tear (Failed Surgery)???3 monthsMost often due to suture pull out not anchor pull out

  • Questions??

    If you find those fat-infiltrated muscles in MRI images, they will look like white streaks or flakes within the muscle. Heres a picture of the normal rotator cuff muscles. This is semi-sagittal section of the shoulder. This is the supraspinatus, this is the infraspinatus, this is the subscapularis, and this is the teres minor. This picture is from a different patient. When you look at the infraspinatus, you will see white streaks within the muscle. On the other hand, the supraspinatus, subscapularis, and teres minor look normal. So, we saw how fat-infiltrated muscles look in MRI images. Now, I am going to show you how those muscles look in ultrasound images. This is normal supraspinatus muscle. This is the skin, subcutaneous tissue, deltoid muscle, and supraspinatus muscle. In ultrasound, muscle looks dark, and fat looks white. Here, the supraspinatus clearly shows its central tendons and muscles. On the other hand, fat-infiltrated supraspinatus muscle on the right shows nothing but hazy homogenous structure. The central tendons and muscle cant be seen anymore.