Arthroscopic management of rotator cuff tears

1. Arthroscopic Management of
Rotator Cuff Tears
Aaron Venouziou
Orthopaedic Surgeon
St. Luke’s Hospital
Thessaloniki

2. Anatomy
Supraspinatus
Abduction
Infraspinatus
Ext. rotation
Teres minor
Ext. Rotation
Subscapularis
Int. Rotation
adduction
Rotator Cuff

3. Anatomy
Deltoid
Abduction
Pec. Major
Int. rotation
Teres major
Int. Rotation
Lat. Dorsi
Int. Rotation
Extrinsic Muscles

4. Function
1. Strength & Motion
(50% of the abduction strength is
generated by supraspinatus)
2. Dynamic Stabilizer
Concept of Couple Forces

5. Biomechanics
Vertical Forces

6. Biomechanics
Horizontal Forces
IR
ER

7. Biomechanics
Horizontal Forces
Unstable fulcrum

8. Biomechanics
Rotator cable – cresent complex
Burkhart 1993

9. Biomechanics
Shoulder's “Suspension Bridge”
Burkhart 1993

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

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

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

13. Incidence
üRotator Cuff Frequency:
30% of population
üSignificant correlation with age
Sher JS, Arthroscopy 1995

14. 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
Age Frequency
<40 4%
>60 25% Tempelhof S, JSES 1999

15. Etiology and Pathogenesis
1. Tendon degeneration
2. Vascular factors
3. Primary Impingement
– Type of acromion as identified by Bigliani
– Acromial angle devised by Toivonen
– Os Acromiale, AC joint
4. Secondary Impingement
– Glenohumeral instability
– Internal impingement
– Glenohumeral internal rotation deficit
– Scapulothoracic dysfunction
5. Trauma
Intrinsic
Extrinsic

16. – Vascular Supply
Tendon Degeneration
üage related
üchange in proteoglycan and
collagen content
“critical zone” of hypovasculararity
at articular surface, anterior edge,
of supraspinatus 1cm proximal to
insertion

17. Which came first?
Intrinsic Extrinsicor

18. ü type 3 acromion is acquired, not developmental as a
response to traction applied via the CA ligament.
ü rotator cuff abn occur without changes of acromion.
ü articular-sided pathology is dominant.
Evidence AGAINST subacromial external impingement:

19. ü ROM is affected according to the type
and size of tear
ü Loss of motion means large or
massive tear
Preop Clinical Assessment
ER lag sign Hornblower’s sign

20. Preop Imaging Assessment
Retraction Level Medium Tear

21. Preop Imaging Assessment
AHD < 6mm
Retraction Level
Fatty Infiltration
Massive

22. Non-Operative
ü 45-80% Satisfactory
Results
BUT
ü Symptom resolution ???
ü Tear progression ???
ü Fatty degeneration ???
ü Progression to RC
arthropathy ???
Operative
90% Good to Excellent
Results at 10 years
[Iannotti Wolf]
Treatment

23. Risk to Benefit Ratio
ü Rot cuff tears DO NOT heal spontaneously
ü Tear repairability
ü Patient Profile, Age, Symptoms
ü Think of Size, Elasticity and Chronicity
ü Fatty infiltration is not fully reversible
Treatment

24. Grouping the Patients
Group I: patients with minimal risk of
progression to irreversible
changes to the rotator cuff
Group II: patients with high risk of
progression
Group III: patients who have progressed
already
[Yamaguchi K., 2006, Nice Shoulder Course]
Operative Treatment

25. Group I
ü About 50 years old with tendinosis or
degenerative partial articular side tears
ü They respond very well to non operative
treatment (about 50-60% resolution of the
symptoms)
ü The risk of progression is very low but they
need observation
Operative Treatment
Non operative treatment - observation

26. Group II
ü Younger than 65 years with
– Small or medium size tears
– Acute tears of any size
– Tears with recent acute loss of function
ü Patients non responsive to conservative tx
ü Acute tears or overuse tears in athletes
Operative Treatment
Early surgical repair to avoid irreversible changes

27. Group III
ü Older than 70 years
– with large or massive tears and
– irreversible damage to the rot cuff
Operative Treatment
They can benefit from rotator cuff repair,
even a partial repair
Yamaguchi, JBJS 2006
Burkhart, Arthroscopy 2007

28. ü By far the most common partial
tears are articular-sided
Partial Tears Treatment
ü Traditionally partial tears
classifications are based to 50%
BUT
“How healthy is the remaining,
intact tissue?”

29. ü Debridement
ü In-situ Repair
ü Convert to full thickness, Debride, Repair
ü CONSERVATIVE
Partial Tears Treatment
ü Because most tears are degenerative, option 3 should
be the best for most cases
ü Trauma or young athletes are candidates for in-situ
repair
Etiology makes the decision!!!

30. Full Thickness Tears

31. ü Recognition of tear pattern
ü Retraction and releases
ü Repair Options:
Anchors: metallic or absorbable
Type of stitch: Mason-Allen,
Mattress sutures,
Horizontal mattress,
Simple sutures
Restoration of footprint: Double row
Single row
Arthroscopic Repair

32. Surgical Technique
Joint view Subacromial view

33. ü classic standard tears
ü excellent medial-to-lateral mobility
ü repair with minimal tension
Tear Pattern
Crescent-shaped

34. ü extend medially with the apex of the tear adjacent to
or medial to the glenoid rim
ü margin convergencesutures minimize strain at the
repair site
Tear Pattern
U-shaped

35. ü the apex of the L is identified and the longitudinal
split is sutured in a side-to-side manner
ü the converged margin is then repaired to bone
Tear Pattern
L-shaped

36. Tear Pattern
Massive Tears
Massive retracted longitudinal Massive retracted cresentic

37. Tear Pattern
Massive Tears
Massive retracted longitudinal
Anterior Interval Slide

38. Tear Pattern
Massive Tears
Massive retracted cresentic
Double Interval Slide

39. Surgical Technique
Tuberosity decortication Sutures anchors

40. The quality of Functional results depends on:
1. The size of the persistent defect
2. Associated atrophy of the muscles
3. Integrity of the deltoid
4. Functional demands of the patient

41. Factors affecting Recurrence of tear:
1. Advanced age
2. Tear size
3. Fatty degeneration
4. Chronicity and atrophy
5. Poor tendon quality
6. Inappropriate rehabilitation
7. Smoking
8. Steroid injections
9. Diabetes

42. Failure of healing
10-70%
Yoo et al. Arthroscopy 2009
Lafosse et al. JBJS 2007
Habermeyer et al. Arthroscopy 2008
30% retear in our series
Hantes et al, CORR 2011

43. Results after repair of RCT
Good excellent results in 85% to 95%
Pain relief
Improvement of motion
Improvement of strength
Significant improvement of shoulder function

44. ü Rot Cuff is extremely significant for the normal
function of the shoulder
ü Rot Cuff tears can be asymptomatic
ü Symptoms produced by a tear depend on:
– Size
– Location
– Functional demands of the patient
Conclusions

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