Published on February 27, 2014
Rotator cuff tear: Basic understanding and treatment options Dr Rohan Vakta M.S.Ortho AASH Arthroscopy Center Ahmedabad,India
They Fuse together with the articular capsule into a common insertion on the tuberosities of the humerus, which is known as the footprint of the rotator cuff.
Action of rotator cuff Rotator cuff acts as a mechanical couple in conjunction with Deltoid in shoulder rotation & elevation
Important functions: • Counterbalance the upward pull of the deltoid on the humerus. • Hold the head of the humerus secure in the glenoid. • Externally rotate the shoulder which is important during arm elevation.
Etiology Traumatic Non-Traumatic (Age >40 years) high velocity trauma ( partial- or full-thickness tears) Repetitive microtrauma (overuse, athletic) (Age <40 years)
Non-Traumatic •Degenerative (Work related: Painters,electrician) •Subacromial Impingement syndrome •Developmental Factors : Os acromiale , Type 2 or 3 acromion
Non-Traumatic • Others: o Shoulder Instability o Inflammatory dz : Calcific tendinitis/RA/Crystal induced arthropathy o Scapulohumeral neuromuscular dysfunction: o Entrapment syndromes
Crescent Trapezoidal Reverse ‘L’ Full Thickness Tear ‘L’ Shaped Massive tear
Pathophysiology Torn Rotator Cuff Can not Counterbalance the upward pull of the deltoid on the humerus Not able to Hold the head of the humerus secure in the glenoid AHD <6mm
Leads to abutement of humeral head against acromion Acetabulization: Concave deformity of under surface of Acromion
Narrowing & Arthritis of Gleno-Humeral Joint Last stage of Cuff tear arthropathy with collapse of humerus head
Hamada and Fukuda Stages of Cuff Arthropathy
History • • • • • • • Pain around shoulder Sleep disturbed by pain Weakness during activities of daily living Previous trauma Time lag before presentation Occupation Predominant hand
Physical Examination • Passive and Active ROM • Strength of motions • Supraspinatus : Resisted elevation of arm kept in "empty can" position
• Subscapularis “ Lift-off test” •Infraspinatus : Resisted External Rotation •Teres minor:Resisted external rotation with arm abducted more than 45°.
Impingement Test • Hawkin-kennedy test • Injection test:Very effective test for diagnosis • Approx 7-10 ml of Xylocaine injected in subacromial bursa • Wait for 2-3 minutes • Pain in ROM will be minimal • D/D between impingement & RC tear
Ultrasonography •Dynamic •Non-invasive •Inexpensive •Helpful as a screening tool •USG guided Injection
MRI T2 images -Presence of fluid in the subacromial space T1 images- loss of the subacromial fat plane, and proliferative spur formation of the acromion and/or acromioclavicular joint. Discontinuity of the tendon. Size of tear , retraction of tendon
Treatment of Rotator Cuff Tears o Conservative : Physical Therapy ± Injection treatment Indication: • Medical Cormodities • Relatively Inactive lifestyle • Patients not willing for post-op rehab.
Surgical Management Open Mini-Open Arthroscopic (not recommended) four major objectives: (1) closure of the cuff defect. (2) eliminating impingement. (3) preserving the origin of the deltoid muscle. (4) preventing adhesions postoperatively without disturbing the repair by a careful exercise program
Mini open repair Cl. • Midway between open & arthroscopic repair • Less than 5 cms. incision in the line from centre of acromion • Axillary N. should be protected, 5 cm. below acromial line • Deltoid splitting approach, not erased Acr.
Mini open RC repair • Identify bursa • Mimics rotator cuff • Bursectomy • Tear evaluation • Preparing foot print • Freshning of tear • Transosseus sutures or suture anchor cuff repair • Meticulous Deltoid repair Torn cuff
Arthroscopic rotator cuff repair • Lateral or Beach chair position • Hypotensive anaesthesia • Pressure pump- Very useful • Skin marking of landmarks • GH arthroscopy- frayed intra- articular RC debrided
Arthroscopic rotator cuff repair • Scope moved to sub acromial area • Bursectomy & SAD for impingement • LAP ( Lateral acromial portal)– main viewing portal • Ant. & post. Working portals • SOS-Mini or complete distal clavicle resection
Arthroscopic rotator cuff repair • Bone at insertion site & Gr. tuberosity- lightly burred • Torn edges of cuff debrided • Tear pattern assessed- Y or V • Repaired with suture anchors & side to side sutures • Preserve CA lig. in massive tear • Repair checked- No tension repair
Arthroscopic rotator cuff repair
Arthroscopic SAD Removal of inferior part of anterolateral acromion Open SAD Arthroscopic • No morbidity • Genuine benefit
Arthroscopic rotator cuff repair Post. Op. regimen • Shoulder immobilizer for 6 weeks • Post. op physiotherapy is as important as good surgery • Recovery time 12 to 16 weeks • Total time 1 year
Arthroscopic cuff repair • Tears of all sizes can be done arthroscopically- 95% tears can be repaired by an experienced surgeon • Minimal damage to Deltoid musclepotential source of post-op morbidity in open repairs • Greater versatility for characterization, assessment, mobilization as well as fixation • Complete evaluation of Shoulder joint anatomy- PASTA, SLAP, Arthritis etc. •Day care surgery •Early & Easier postop rehabilitation Deltoid detachm ent
Arthroscopic cuff repair Despite these advantages, arthroscopic rotator cuff repair is technically demanding procedure that needs prerequisite skills as diagnostic shoulder arthroscopy, arthroscopic subacromial decompression, and arthroscopic knot tying in order for a surgeon to obtain proficiency in this procedure.
RC repairContraindications • Severe OA of Glenohumeral jt. • Medically unfit patient • Low activity level individual who can live with deficient shoulder • Adhesive capsulitis • Failed prior RC surgery • Fatty infiltration in muscles
Rotator cuff injury If not addressed in time… • Young active individuals- torn cuff cannot heal to bone- late cuff arthropathy - continuous pain & weakness • Muscles undergo atrophy & fatty degeneration • Waiting too long- repairable cuff becomes irreparable with poor tissue & poor prognosis • At >1 year of f’up, a’scopic and mini-open rotator cuff repairs produces Fatty degeneration similar results with equivalent patient satisfaction rates
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