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