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
?
Rotator Cuff Tears
Treatment
–Not standardized
–When do we maximize conservative
care?
–When is early surgical intervention
appropriate?
AAOS Guidelines for
Treatment of Rotator Cuff
Tears
Rotator Cuff Repair Surgical
Indications
– Variations in Orthopaedic Surgeon’s Perceptions about
Indications for Rotator Cuff Surgery – Dunn, et al, JBJS ’05
» Sig variation
» Lack of agreement
• Surgical discussion
• Role of PT
• Prevent progression of tear
Asymptomatic Tear
Why?
– Mechanical Factors?
» Force couples
– Demographic Factors?
Proximal Humerus Migration
Why Does it Happen??
Rotator Cuff Disorders
Glenohumeral Kinematics
–Normal Cuff
Head Centered
–Tendinitis, Fatigue
Superior Migration
–Symptomatic RCT’s
Superior Migration
–Asymptomatic RCT’s
?
Poppen & Walker, JBJS ‘75
Journal of Shoulder & Elbow Surgery
2000;9:6-11
Results
Normals
Symptomatic RCT’s
Asymptomatic RCT’s
Ball & socket kinematics
Superior head migration
Superior head migration
(greater variability)
Conclusions
–Loss of rotator cuff integrity (both
symptomatic and asymptomatic) was
associated with superior head migration
–Superior 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 RCT
30 Degree Abducted
Glenohumeral Kinematics
Asympt vs Sympt RCT
– Asymptomatic w/ less superior migration (smaller tears)
– Both sympt/asympt superior in massive tears
– Critical size for superior migration
» 1.5 cm tear
Jay Keener, JBJS 2009
Journal of Shoulder and Elbow Surgery
10:3, 2001
Methods
– Shoulder Ultrasound employed at Washington University
since 1984 (Unique Study Opportunity)
– Routine bilateral exams
– Predict large # of asymptomatic tears
Results
Symptomatic Progression
–23/45 (51%) became
symptomatic
–avg 2.8 yrs from US
Conclusions
–39% total had tear size progression
–No tears decreased in size (don’t 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
Results
Correlation with Pain
– Associated with dominant side (p<0.01)
» 65% painful tears on dominant side
– Associated with larger tears (p<0.01)
» Symptomatic side 25% larger than asymptomatic
» No other demographic feature significant
Results
– Cuff disease increased with age
» No tear – 48.7 yo
» Unilateral tear – 58.7 yo
» Bilateral tear – 67.8
– 50% likelihood of bilateral tear
after age 66 yr if present with
painful tear, (p<0.01)
Healing of RCR Influence of Age
– Outcome/tear integrity of massive tears – JBJS 2004
– Tear integrity with double-row repair – AJSM 2009
– Outcome/ tear integrity of PTRCR – JBJS 2009
– Outcome/tear integrity of Revision RCR – JBJS 2010
Avg patient age healed: 55 yo
Avg patient age not healed: 63 yo
Conclusions Demographics
– Unilat tear in young
– Bilat tear in older
– Tears rare before 40 yo.
– Tears common after 61 yo.
Conclusion
–Intrinsic 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 Tears
Mall et al JBJS 2010
Conclusions
1.
2.
3.
4.
Over a 2 year period 21% of patients with an
asymptomatic rotator cuff tear became
symptomatic
Symptomatic 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!)
Ultrasonography
Accuracy
– Varies among institutions
» 60% accuracy JBJS’86
– Not widely accepted
Journal of Bone and Joint Surgery 2000
82-A:498-504
Methods
Validated accuracy
»Teefey et al, JBJS ’04
• Compare to MRI
»Pricket et al, JBJS ’03
• Post op shoulder
»Teefey et al, JBJS ’00
• Compare to surgery
»Middleton et al, JBJS ’86
Natural History of Fatty
Degeneration of Muscles
?
Fatty Degeneration vs Fatty
Infiltration
Galatz vs Gerber
What is the difference?
Why does it happen?
Degeneration vs
Infiltration
• Gerber: fatty cells infiltrate the
muscle once the pennation angle
changes
• Galatz: fat cells develop from
pluripotent cells found within the
muscle itself, the process of
infiltration does not occur
Fatty degeneration of the rotator
cuff muscles
Normal rotator cuff
Fat-infiltrated infraspinatus
Fatty degeneration of the rotator cuff
muscles
Normal Supraspinatus
Wall et al Accepted for pub JBJS 2012
Fat-infiltrated Supraspinatus
What is atrophy?
• Tangent Sign?
What is atrophy?
Journal of Bone and Joint Surgery
2010
Methods
–262 pts from prospective cohort
–Compare fatty degeneration to :
»Tear location (relative to biceps)
»Tear size ( number of muscles)
Distance from Biceps Tendon
Results
–35% of full tears with sig
fatty degeneration
–Fatty degeneration in fullthickness tears only
–Fatty degeneration highly
correlated with proximity of
tear to biceps
Conclusions
–Disruption of anterior
supraspinatus is strongly
associated with development of
fatty degeneration
–Supports rotator cable concept
for cuff (Burkhart): disruption
of anterior cable is key!
Rotator Crescent / Cable
Where do RCT Initiate?
Rotator Cuff Tears
Conventional concept:
– Start from the anterior portion of
supraspinatus insertion near the biceps
tendon
– Propagate posteriorly
– Supraspinatus – almost always involved
Codman EA, 1934; Keyes EL, 1933; Hijioka A, 1993; Matsen III FA, 1998; Lehman C, 1995
Superior
Supraspinatus
Infraspinatus
Biceps tendon
Posterior
Anterior
Humeral Head
Subscapularis
Inferior
Teres Minor
Wash U Clinical Experience
DT
BT
HH
Journal of Bone and Joint Surgery ‘10
Discussion
Bidirectional 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
Superior
Supraspinatus
Infraspinatus
Biceps tendon
Posterior
Anterior
Humeral Head
Subscapularis
Inferior
Teres Minor
Mechanism
Rotator Cable
Rotator Crescent
BT
Anterior
15 mm
Posterior
Epidemiologic Factors
?
Smoking Increases the Risk for Rotator
Cuff Tears
Keith M. Baumgarten, MD
David Gerlach, MD
Leesa M. Galatz, MD
Sharlene A. Teefey,MD
William D. Middleton, MD
Konstantinos Ditsios, MD
Ken Yamaguchi, MD
CORR 2009
Methods
Hx of Cigarette Smoking
Cuff Intact
vs.
Cuff Tear
Conclusions
–Smoking increases the risk for rotator cuff tears:
»Strong association – highly statistically significant
»Time dependant relationship
• More recent smoking
• Cause / effect relationship?
»Dose Response relationship
• # packs per day
• # years smoking
Diabetes
-Clement JBJSBr 2010: 1112-7
• Patients 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: 978-88
• impairs tendon-bone healing after rotator cuff repair
NSAIDS
-Cohen AJSM 2006: 362-9
• Traditional and cyclooxygenase-2-specific nonsteroidal antiinflammatory drugs significantly inhibited tendon-to-bone
healing in animal model
Obesity (?)
-Namdari JSES 2010: 1250-5
• Although 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: 961-7
• Obesity has a negative impact on the operative time of
arthroscopic rotator cuff repairs, length of hospitalization, and
functional outcomes.
Operative Indications
Natural History Information
Risks
Benefits
Operative Indications
Risks
–Operative Treatment
–Non-Operative Treatment
Rotator Cuff Tear
Risks - Chronic Changes
–
–
–
–
–
retraction with adhesion
tendon morphology
muscle atrophy
fatty degeneration
degenerative changes
Operative vs Non-Operative Tx
Rationale
–What is the risk for development of
Irreversible Changes?
–Risk dictates urgency for surgery
Early Operative
Treatment
Benefits
–Halt chronic changes?
»Most pertinent to younger pt.
»Important for acute, small or medium sized
tears
»Important for tears at risk for fatty
degeneration or altered kinematics
Conclusions
Natural History
–High probability of bilateral symptoms
–High probability of tear size progression
–No evidence of spontaneous healing
–Supports large population have intrinsic
etiology
Conclusions
–Age important factor for development of
tears
»Important consideration for operative
indications!
–High suspicion of tear extension with new
pain!
Conclusions
–Tears start 15 mm post to biceps
–Loss of ant supra critical
–Critical size threshold 15-20 mm
Techniques
• Open
• Mini-Open
• Arthroscopic
• 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
better
• No 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 fracture
• MT 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 months
• Most often due to suture pull out
not anchor pull out
Questions??