Rotator Cuff Tears: Indications of arthroscopic treatment an overview Manos Antonogiannakis Director center for shoulder arthroscopy IASO gen hospital

Rotator Cuff Function Dynamic stabilizer of the shoulder Contributes strength to the arm (50% of the abduction strength is generated by supraspinatus) Couple forces stabilize and regulate the motion of the shoulder

Rotator Cuff disease Rotator cuff disease is a wide spectrum of clinical conditions, which range from asymptomatic tears to symptomatic rotator cuff arthropathy

The History of Rotator Cuff Repair First Description of RC tears Smith JG. London. Med Gaz, 1834,14:280 Pathological appearances of seven cases of injury of the shoulder joint, with remarks. EA Codman First Successful RC Repair Codman EA. Rupture of the supraspinatus tendon Boston Medical & Surgical Journal 1911 Vol clxiv (2) 708-10 McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder: the exposure and repair of tears with retraction. J Bone Joint Surg 1944;26:31-51.

The History of Rotator Cuff Repair In 1972 Neer defined the concept of subacromial impingement Open Surgery Mini Open Surgery In the 90s’ the arthroscope changed the treatment

Tears’ Definitions Partial Thickness Tears = absence of communication between the glenohumeral joint and the subacromial bursa. Full Thickness Tears = communication between the glenohumeral joint and the subacromial bursa. Massive Tear = Involving 2 or 3 tendons [Gerbers] or bigger than 5cm [Cofield]

Partial Thickness Tear Bursal side tears Articular side tears Intratendinus tears Partial tear classification by Ellman Grade I <3mm deep Grade II 3-6mm deep Grade III >6mm deep (i.e. >50% thickness)

How frequent are RC Tears? Rotator Cuff Frequency: 30% of population Significant correlation with age [Sher JS, Arthroscopy 1995]

How Frequent are RC Tears? Full Thickness Tear Age Frequency 40-60 4-13% 60-70 20% 70-80 50% >80 80% Partial Thickness Tear <40 4% >60 25% [Tempelhof S, JSES, 1999]

Rot cuff disease etiology and pathogenesis Tendon degeneration Vascular factors Impingement Types of acromion as identified by Bigliani Internal impingement described by Walsh Secondary impingement popularized by Jobe Instability overload of the cuff - secondary superior migration Trauma Glenohumeral instability Scapulothoracic dysfunction

Natural History of a Tear Tears DO NOT HEAL. Some but NOT ALL of them will progress Rot cuff arthropathy is the end stage (4%) 50% of newly symptomatic tears will progress in size 20% of asymptomatic tears will progress. No Tear seem to decrease in size. 80% of partial tears progress in size or become full thickness at 2 years [Yamaguchi K., 2006, Nice Shoulder Course]

Bilateral RC Tears Rotator Cuff Disease is not only age related, but also bilateral >51% of patients with a previously asymptomatic rotator cuff tear and a contralateral symptomatic tear will develop symptoms in the non-symptomatic tear at the next 2.8 years. [Yamaguchi K., JSES, 2001]

Current Knowledge RC tears DO NOT behave the same in different patients Patients PROFILE plays the most important role Size and Location of the tear DOES MATTER

RC Treatment Patient Profile Size & Location MAKE YOUR DECISION Symptoms Tissue Quality Other Lesions

Probably partial articular side tear Patients <25 years Aggressive athletics, high impact accident, heavy labor Probably partial articular side tear Common history repetitive overhead sport or work with repetitive overhead lifting Symptoms during overhead activity respond to rest and are aggravated as the patient resumes activity

Patients 25 - 45 years Chronic overuse due to work related overhead activity Usually small to medium tears not retracted Common history repetitive overhead sport or work with repetitive overhead lifting Acute trauma on chronic overuse is common

Patients 45 - 65 years Subacromial impingement is common Usually Full Thickness Tear. Good Tissue Quality Acute tears on chronic Chronic pain. Night pain In the more severe cases weak or impossible elevation external rotation

Patients >65 years Rot cuff tears common Usually Large or Massive Tear Goutallier Stage 3 or 4 Retracted Tendons Limited activities make severe rotator cuff tears tolerable Chronic aching or acute exaberation of symptoms after minor trauma Debilitating symptoms in rotator cuff arthropathy

Operative Non-Operative RC Treatment Options Open Surgery Mini Open Arthroscopy Non-Operative

RC Treatment Options BUT Non-Operative 45-80% Satisfactory Results BUT Symptom resolution ??? Tear progression ??? Fatty degeneration ??? Progression to rot cuff arthropathy ??? Operative 90% Good to Excellent Results at 10 years [Iannotti Wolf] BUT All the operated rot cuff tears do not heal

Risk to Benefit Ratio Operative Treatment Rot cuff tears DO NOT heal spontaneously Tear repairability Think of Size, Elasticity and Chronicity Fatty infiltration is not fully reversible

Partial Tears Treatment By far the most common partial tears are Articular-side, vascular or due to secondary internal impingement Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”

Partial Tears Treatment Options Debride partial tear only In-situ Repair Convert to full thickness, Debride, Repair Etiology makes the decision!!! Because most tears are degenerative, option 3 should be the best for most cases Trauma or young athletes are candidates for in-situ repair If partial tear are limited then debridement alone [Yamaguch K, 2006 Nice Shoulder Course]

Full thickness Tear

RC Tear Classification Acute, Chronic, Acute on chronic Tear Age Tissue Quality Partial <40 Good Complete <40 Good Complete 40-65 Good Complete 40-65 Bad Complete >65 Good Complete >65 Bad

What is Bad Tissue Quality? Large or massive tears, Retracted tears, Coutallier three or four fatty infiltration

Bursal view before acromioplasty

Checking Tissue Quality

Surgical Technique GH Joint and Subacromial Joint Inspection Bursal debridement Acromioplasty Cuff mobilization Repair (side to side, tendon to bone)

Patient position Lateral decubitus Traction3-4 kgr Abduction 20 degrees

Portals Outside in technique

Bleeding control

Bleeding control

Joint Side Inspection

Bursal Side Inspection-Bursectomy

Tendon debridement- Tear morphology recognition

Acromioplasty

Techniques of releases The techniques adapted from open surgery as described by Codmann, Rockwood, Neer Refined and modernized by Esch, Snyder, Gartsman, Burkhart and others

ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR

Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain

Tear Patterns Crescent shaped L-shaped (or reverse L) U-Shaped Massive Contracted Immobile tears S.S. Burkhart

Crescent Shaped Tear S.S Burkhart

Crescent-Shaped Tear Double row repair,

Double Row Fixation Restoration of the footprint

Tuberoplasty

1st Anchor Insertion – Medial Row

1st suture passage- Medial row - mattress

suture passage- Medial row – post. anchor

Suture inspection – medial row - mattress

Lateral Row 1st Anchor Insertion

Lateral Row 2nd Anchor Insertion

Inspection of Suture Position

Knot Tying Lateral Row

Probably stronger repair but Time consuming and of raised difficulty Final Repair Double row Probably stronger repair but Time consuming and of raised difficulty

L-Shaped & U-Shaped Tears Greater mobility from anterior to posterior than medial to lateral

L-Shaped & U-Shaped Tears Side to side sutures from medial to lateral Progressively converge the margin of the tear lateral to bone bed Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [S. S .Burkhart]

L or U -shaped tear Closing an L-shaped or U-shaped tear is much like closing a tent flap Closure of an U-shaped tear involves first side-to-side closure of the vertical limb of the tear, then tendon-to-bone closure of the transverse limb S. S .Burkhart

Large U-shaped cuff tear extending to glenoid Margin convergence The free margin of the cuff is repaired to bone with suture anchors

Cuff repair Side to Side Repair

Side to Side Repair

Cuff repair Tendon to bone repair

Massive Contracted Immobile Tears No mobility from medial to lateral or from anterior to posterior Subcategories: Massive Contracted Longitudinal Tears Massive Contracted Crescent Tears Represent 9.6% of massive tears [S.Burkhart]

Massive Contractite Tears Single and double interval slide Anterior Interval Slide and/or Posterior Interval Slide

Subacromial view

Single and double interval slide Anterior slide through release in the rotator interval (supraspinatus–coracobrachialis) Posterior slide through release of the interval supraspinatus-infraspinatus

Massive Tears associated with Subscapularis Tears Subscapularis must be mobilized and repaired prior to the rest of the cuff Interval slide in continuity

Subscapularis Repair Recognition

Subscapularis Repair Recognition

Subscapularis Repair

Arthroscopic cuff repair Wolf, Snyder, Gartsman, Esch, Burkhart, Tauro and others reported 84%-94% excellent and good results

Today’s Knowledge Rot cuff has some degree of reserve that affords functional use of the arm in cases of limited tendon deficiency. Location rather that size of a tear maybe more important in the development of symptoms. Type of activities plays an important factor in the development of symptoms

Goutallier fatty degeneration of muscles Stage 0 Normal muscle – no fatty streaming Stage 1 Occasional fatty streaming Stage 2 Fat<50% of cross sectioned area Fat < Muscle Stage 3 Fat=50% of cross sectioned area Fat = Muscle Stage 4 Fat>50% of cross sectioned area Fat > Muscle

What to do??? Patients with grade 3 or 4 fatty degeneration DO NOT improve with rot cuff repair [Goutallier] Vs. Patients with grade 3 or 4 fatty degeneration improved significant at 86% of cases after arthroscopic repair [Burkhart]

Results for massive tears 95% Good to Excellent Results independent to tear size [Burkhart, 2001] With interval slide Improve UCLA score (10->28.3) Improve Active ROM, Strength [Burkhart, 2004] Graft Jacket Repair Improve UCLA score (18->32) [Snyder, 2008]

What can we Repair? UP to 50% of cuff repairs had a postoperative defect This didn’t affected patient satisfaction or pain relief But it did affected shoulder strength [Harryman et all J. B.J.S 1991]

Factors affecting Recurrence of tear Advanced age Tear size Fatty degeneration Chronicity and atrophy Poor tendon quality Inappropriate rehabilitation Smoking Steroid injections Diabetes

The quality of Functional results depends on: The size of the persistent defect Associated atrophy of the muscles Integrity of the deltoid and the coracoacromial arch Functional demands of the patient

How to convert a Symptomatic tear to an Asymptomatic re-tear Subacromial decompression and debridmeut Biseps tenotomy Partial repair and healing of the rot cuff Adequate post-op rehabilitation

Results - what to expect Pts between 50-75 years old with pain loss of external rotation (positive lag sign) and inability to keep the hand externally rotated MRI findings: Goutallier III or IV Arthroscopic findings: massive posterosuperior tear, retracted tendons of bad quality

Results - what to expect Arthroscopic partial repair or medialized repair Resolution of pain but not restoration of external rotation

Results what to expect Patients aged 50-60 years old with painless loss of external rotation MRI findings: Goutallier III or IV Arthroscopic findings: massive posterosuperior tear, retracted tendons of bad quality

Results what to expect Arthroscopic partial repair or medialized repair depending on the age and demands of the patient Inability to restore external rotation Tendon transfer more appropriate in young active patients

Results - what to expect Pts with acute exaberration of symptoms after minor trauma mainly pain loss of strength of abduction and ext rotation age >60 years old no or minimal symptoms before trauma MRI findings: Goutallier III or IV Arthroscopic findings: large or massive posterosuperior tear retracted tendons of bad quality

Results - what to expect Arthroscopic partial repair or medialized repair Resolution of pain near normal restoration of strength of abduction and external rotation some loss of strength remaining slow restoration of function pts plateaus after more than a year

Arthroscopic findings: Results what to expect Pts with loss of function pain after acute trauma1-3 months before normal function before trauma MRI findings: Goutallier I or II Arthroscopic findings: large or massive posterosuperior tear with good quality of tissues repair with no tension

Results - what to expect Complete resolution of symptoms normal function restoration of strength Excellent Results independent of age

Results - what to expect Young patients, athletes or overhead workers age 20-40 years old with: pain loss of function or inability to perform athletics in the same level MRI findings: partial or complete tear of supraspinatus Arthroscopic Findings: partial articular side or complete tear of suprafpinatus Double row repair: complete resolution of symptoms

Results - what to expect Pts more than 60 years old with pain inability to raise the hand Symptoms of long duration MRI findings: Goutallier III or IV complete tear and retracted tendons X-Ray findings: superior migration of the head and contact with the undersurface of the anterolateral acromion

Results - what to expect No improvement with arthroscopic treatment Extended head or reverse arthroplasty a better option

Non-Operative Treatment Best candidates for non-operative are: patients with chronic attritional RC tears limited to one tendon the onset not associated with significant trauma over the age of 60 and less active [Iannotti J.P.Disorders of the shoulder]

Conclusions Rot Cuf is extremely significant for the normal function of the shoulder Rot Cuf tears can be asymptomatic Symptoms Produced by a tear depend on: Size Location Functional demands of the patient

Conclusions An anatomically deficient but biomechanical intact cuff is possible Biomechanical intact cuff is the cuff that restores the equilibrium of the force couples A cuff tear does not heal conservative A cuff tear after operative repair may yet not heal Partial healing after arthroscopic repair restores sufficient power to the cuff to equilibrate the force couples

Conclusions Non-operative treatment strives to optimize the function of the remaining cuff Rehabilitation after surgery strives to optimize the function of the partially or completely healed cuff

..so when we treat a RC tear… We must try to: Optimize the anatomic integrity and capacity of force transfer of the cuff by a repair with minimal morbidity to the healthy tissues (mainly deltoid) THEN Rehabilitate vigorously the patient, to optimize the total function of the shoulder We can expect a majority of satisfied patients

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