1. Rotator Cuff Injuries: surgical indications and techniques Ms. Ruth Delaney Consultant Orthopaedic Surgeon, Shoulder Specialist

2. Outline Brief anatomy and function Indications o Imaging o Surgery Techniques

3. Anatomy

4. Mechanics – cavity compression

6. Mechanics – bending loads

7. Rotator Cuff Tears

9. Indications for Imaging History o A young patient (<50 y/o) with no history of trauma is unlikely to have a full thickness cuff tear Clinical exam o A patient with fully intact cuff strength on exam is unlikely to have a full thickness cuff tear of any significance  Jobe test (a.k.a. empty can) - supraspinatus  Resisted ER – infraspinatus (+ teres minor)  Belly press – subscapularis Patient preference o “I really don’t want surgery” MRI: o young patient with trauma & cuff symptoms o patient with demonstrable cuff weakness on exam and who would be willing to undergo repair if a full thickness tear is found

10. When it’s gone too far…

11. Imaging X-rays are sometimes a useful starting point MRI is not appropriate for everyone Octogenarians (and over 75s) o Xray only o Yes, there may be a cuff tear on MRI but so what? o Cuff healing rates v. low so repair is often not attempted o Cuff tears usually managed with injections, physio, compensatory mechanisms e.g. anterior deltoid o If cuff tear arthropathy, Xray will demonstrate extent of arthritis and of superior migration of humeral head o Surgeon may then get CT if planning for reverse shoulder arthroplasty

12. Reverse Shoulder Arthroplasty

13. Role of CT

16. Over 75s Patient 1: o 86y M, atraumatic shoulder pain, some weakness o Arrived with MRI o Clinical appearance showed superior migration of humeral head o Exam demonstrated clear weakness of rotator cuff (supra- & infraspinatus) and pseudoparalysis o Only question to answer was whether the patient was interested in a surgery or not  If so, then Xray for cuff tear arthropathy, followed by possible CT to plan for reverse shoulder arthroplasty  If not, then symptomatic management with subacromial injection (which will also enter glenohumeral space as cuff deficient) o Patient very clearly wanted to avoid surgery  Therefore should never have had any kind of scan o Had an injection, symptoms improved (for now)

17. Over 75s Patient 2: o 83y M, atraumatic shoulder pain, some weakness o Arrived with MRI o Exam demonstrated weakness of rotator cuff (supraspinatus) o MRI showed small tear of supraspinatus  Clear from exam without ever looking at MRI o Uncertain healing of cuff repair in this age group o Not bad enough for reverse arthroplasty  Still able to actively raise arm  Minimal arthritis o Symptomatic management with subacromial injection o Patient very clearly wanted to avoid surgery anyway  Therefore should never have had any kind of scan o Had an injection, symptoms improved (for now)

18. Indications for Surgery Acute, traumatic full thickness tear o Refer early o Operate early Chronic tear that has failed conservative measures o Injections o Physio/rehab for remaining cuff, force couples, anterior deltoid Any full thickness tear in a young patient (?)

19. Timing of Surgery Pre-hab o Range of motion o Operating on a stiff shoulder with a cuff tear is sub-optimal Onset of “profound and possibly irreversible changes in the structure and phsyiological properties of the rotator cuff muscles” (C. Gerber, 2004) o Sheep study o Infraspinatus tendon released, allowed to retract for 40 weeks o Structural properties studied in detail (CT, histology, electron micro) o After release, muscle atrophy, significant increase in fatty infiltration o Repaired at 40 weeks and structural properties studied x 35 weeks o Sevenfold poorer elasticity at time of repair o Structural changes increased 6 weeks after the repair and then recovered partially at 12 and 35 weeks after repair, but only to the amount demonstrated before the repair – these were irreversible changes

20. Predicting Success of Surgery Fatty infiltration o Goutallier grading

21. Predicting Success of Surgery

23. Fatty infiltration o Goutallier grading Tendon retraction o Gerber found that combination of Goutallier grading and preoperative tendon length appears to be a more powerful predictor for the reparability of a tendon tear than Goutallier grading alone

24. Predicting Success of Surgery

25. Fatty infiltration o Goutallier grading Tendon retraction o Gerber found that combination of Goutallier grading and preoperative tendon length appears to be a more powerful predictor for the reparability of a tendon tear than Goutallier grading alone Suprascapular nerve injury o Traction

26. Predicting Success of Surgery

27. Defining Success of Surgery Structural integrity vs. clinical outcome o Galatz et al. found that in large & massive tears, there was a high rate of recurrent tendon defects on ultrasound at 1 year but the patients maintained excellent clinical scores. o Clinical results did deteriorate at 2 years in those patients with re-tear. o In a later study of a cohort of failed cuff repairs, it was found that successful clinical outcomes were achieved in 54% of patients with failed rotator cuff repair. o Those who self-identified their occupation as being labour- intensive represented a special group of patients who are at high risk for a poor outcome after a failed rotator cuff repair.

28. Surgical Techniques

44. Surgical techniques

45. Other Considerations Augmentation/subsitution o Patches, grafts Tendon transfers o Latissimus dorsi for supraspinatus or for external rotators o Pectoralis major for subscapularis

46. Summary Indications for MRI Indications for surgery Surgical techniques of repair o Repair mostly arthroscopic o Double vs. single row Irreparable tears o Reverse shoulder arthroplasty o Non-arthroplasty options  Pain relief by debridement, decompression, suprascapular nerve release  Augmentation of attempted repair or substitution of tendon with patch/graft  Tendon transfers

47. References The Shoulder, 4 th Ed. Saunders 2009. Eds: Rockwood, Matsen, Wirth, Lippitt. Ch.17 Rotator Cuff. Gerber C, Meyer DC, Schneeberger AG, Hoppeler H, von Rechenberg B. Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: an experimental study in sheep. J Bone Joint Surg Am. 2004; 86-A(9):1973-82. Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med. 2012; 40(10):2242-7. Galatz LM, Ball CM. Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004; 86-A(2):219-24. Namdari S, Donegan RP, Chamberlain AM, Galatz LM, Yamaguchi K, Keener JD. Factors affecting outcome after structural repair of repaired rotator cuff tendons. J Bone Joint Surg Am. 2014; 96(2):99-105.

48. Thank You Ms. Ruth Delaney Suite 20, Sports Surgery Clinic 01-5262335 www.shouldersurgeon.ie ruthdelaney@sportssurgeryclinic.com