1 / 85

Rotator Cuff Tears

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. ?.

jennifer-wiggins
Télécharger la présentation

Rotator Cuff Tears

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Rotator Cuff Tears Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California

  2. Anatomy • Muscles? • Innervation? • Function?

  3. Rotator Cuff TearsNatural History • ?

  4. Rotator Cuff TearsTreatment • Not standardized • When do we maximize conservative care? • When is early surgical intervention appropriate?

  5. AAOS Guidelines for Treatment of Rotator Cuff Tears

  6. 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

  7. Asymptomatic TearWhy? • Mechanical Factors? • Force couples • Demographic Factors?

  8. Proximal Humerus Migration • Why Does it Happen??

  9. Rotator Cuff DisordersGlenohumeral Kinematics • Normal Cuff Head Centered • Tendinitis, Fatigue Superior Migration • Symptomatic RCT’s Superior Migration • Asymptomatic RCT’s ? Poppen & Walker, JBJS ‘75

  10. Journal of Shoulder & Elbow Surgery • 2000;9:6-11

  11. Results • Normals Ball & socket kinematics • Symptomatic RCT’s Superior head migration • Asymptomatic RCT’s Superior head migration (greater variability)

  12. 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

  13. Conclusions • Implies normal glenohumeral kinematics do not need to be restored with surgery

  14. Journal of Bone and Joint Surgery, 99A, 2009

  15. Bilateral Two-Tendon RCT • 30 Degree Abducted

  16. Glenohumeral KinematicsAsympt 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

  17. Journal of Shoulder and Elbow Surgery 10:3, 2001

  18. Methods • Shoulder Ultrasound employed at Washington University since 1984 (Unique Study Opportunity) • Routine bilateral exams • Predict large # of asymptomatic tears

  19. ResultsSymptomatic Progression • 23/45 (51%) became symptomatic • avg 2.8 yrs from US

  20. Conclusions • 39% total had tear size progression • No tears decreased in size (don’t heal on their own) • Relationship between symptoms and tear progression?

  21. Journal of Bone and Joint Surgery 2006; 88-A, 1699-1704

  22. 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

  23. 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

  24. 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)

  25. 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

  26. Conclusions Demographics • Unilat tear in young • Bilat tear in older • Tears rare before 40 yo. • Tears common after 61 yo.

  27. 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

  28. Symptomatic Transition of Asymptomatic Rotator Cuff Tears Mall et al JBJS 2010

  29. Conclusions • 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!)

  30. UltrasonographyAccuracy • Varies among institutions • 60% accuracy JBJS’86 • Not widely accepted

  31. Journal of Bone and Joint Surgery 2000 • 82-A:498-504

  32. 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

  33. Natural History of Fatty Degeneration of Muscles • ?

  34. Fatty Degeneration vs Fatty Infiltration • Galatz vs Gerber • What is the difference? • Why does it happen?

  35. 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

  36. Fatty degeneration of the rotator cuff muscles Normal rotator cuff Fat-infiltrated infraspinatus

  37. Fatty degeneration of the rotator cuff muscles Normal Supraspinatus Fat-infiltrated Supraspinatus Wall et al Accepted for pub JBJS 2012

  38. What is atrophy? • Tangent Sign?

  39. What is atrophy?

  40. Journal of Bone and Joint Surgery 2010

  41. Methods • 262 pts from prospective cohort • Compare fatty degeneration to : • Tear location (relative to biceps) • Tear size ( number of muscles)

  42. Distance from Biceps Tendon

  43. Results • 35% of full tears with sig fatty degeneration • Fatty degeneration in full-thickness tears only • Fatty degeneration highly correlated with proximity of tear to biceps

  44. 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!

  45. Rotator Crescent / Cable

  46. Where do RCT Initiate?

  47. 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

  48. Superior Supraspinatus Infraspinatus Biceps tendon Posterior Anterior Teres Minor Humeral Head Subscapularis Inferior

  49. Wash U Clinical Experience DT IS SS BT HH

  50. Journal of Bone and Joint Surgery ‘10

More Related