Rotator Cuff Tears: Indications of arthroscopic treatment an overview

1. Rotator Cuff Tears: Indications of arthroscopic treatmentan overview Manos Antonogiannakis Director center for shoulder arthroscopy IASO gen hospital

2. Rotator Cuff Function • Dynamic stabilizer of the shoulder • Contributes strength to the arm • (50% of the abduction strength is generated by supraspinatus) • Couple forces stabilize and regulate the motion of the shoulder

3. Rotator Cuff disease Rotator cuff disease is a wide spectrumof clinical conditions, which range from asymptomatictears to symptomatic rotator cuff arthropathy

4. The History of Rotator Cuff Repair First Description of RC tears Smith JG. London. Med Gaz, 1834,14:280 Pathological appearances of seven cases of injury of the shoulder joint, with remarks. EA Codman First Successful RC Repair Codman EA. Rupture of the supraspinatus tendon Boston Medical & Surgical Journal 1911 Vol clxiv (2) 708-10 McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder: the exposure and repair of tears with retraction. J Bone Joint Surg 1944;26:31-51.

5. The History of Rotator Cuff Repair • In 1972 Neer defined the concept of subacromial impingement • Open Surgery • Mini Open Surgery • In the 90s’ the arthroscope changed the treatment

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

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

8. How frequent are RC Tears? • Rotator Cuff Frequency: 30% of population • Significant correlation with age [Sher JS, Arthroscopy 1995]

9. 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]

10. Rot cuff disease etiology and pathogenesis • Tendon degeneration • Vascular factors • Impingement • Types of acromion as identified by Bigliani • Internal impingement described by Walsh • Secondary impingement popularized by Jobe • Instability overload of the cuff - secondary superior migration • Trauma • Glenohumeral instability • Scapulothoracic dysfunction

11. Natural History of a Tear • Tears DO NOT HEAL. Some but NOT ALL of them will progress • Rot cuff arthropathy is the end stage (4%) • 50% of newly symptomatic tears will progress in size • 20% of asymptomatic tears will progress. • No Tear seem to decrease in size. • 80% of partial tears progress in size or become full thickness at 2 years [Yamaguchi K., 2006, Nice Shoulder Course]

12. Bilateral RC Tears • Rotator Cuff Disease is not only age related, but also bilateral • >51% of patients with a previously asymptomatic rotator cuff tear and a contralateral symptomatic tear will develop symptoms in the non-symptomatic tear at the next 2.8 years. [Yamaguchi K., JSES, 2001]

13. Current Knowledge • RC tears DONOT behave the same in different patients • Patients PROFILE plays the most important role • Size and Location of the tear DOES MATTER

14. RC Treatment Patient Profile Size & Location MAKE YOUR DECISION Symptoms Tissue Quality Other Lesions

15. Patients <25 years Aggressive athletics, high impact accident, heavy labor Probably partial articular side tear Common history repetitive overhead sport or work with repetitive overhead lifting Symptoms during overhead activity respond to rest and are aggravated as the patient resumes activity

16. Patients 25 - 45 years Chronic overuse due to work related overhead activity Usually small to medium tears not retracted Common history repetitive overhead sport or work with repetitive overhead lifting Acute trauma on chronic overuse is common

17. Patients 45 - 65 years Subacromial impingement is common Usually Full Thickness Tear. Good Tissue Quality Acute tears on chronic Chronic pain. Night pain In the more severe cases weak or impossible elevation external rotation

18. Patients >65 years Rot cuff tears common Usually Large or Massive Tear Goutallier Stage 3 or 4 Retracted Tendons Limited activities make severe rotator cuff tears tolerable Chronic aching or acute exaberation of symptoms after minor trauma Debilitating symptoms in rotator cuff arthropathy

19. RC Treatment Options Non-Operative • Operative • Open Surgery • Mini Open • Arthroscopy

20. RC Treatment Options Non-Operative • 45-80% Satisfactory Results BUT • Symptom resolution ??? • Tear progression ??? • Fatty degeneration ??? • Progression to rot cuff arthropathy ??? Operative 90% Good to Excellent Results at 10 years [Iannotti Wolf] BUT All the operated rot cuff tears do not heal

21. Operative Treatment Risk to Benefit Ratio • Rot cuff tears DO NOT heal spontaneously • Tear repairability • Think of Size, Elasticity and Chronicity • Fatty infiltration is not fully reversible

22. Partial Tears Treatment • By far the most common partial tears are Articular-side, vascular or due to secondary internal impingement Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”

23. Partial Tears Treatment Options • Debride partial tear only • In-situ Repair • Convert to full thickness, Debride, Repair Etiology makes the decision!!! • Because most tears are degenerative, option 3 should be the best for most cases • Trauma or young athletes are candidates for in-situ repair • If partial tear are limited then debridement alone [Yamaguch K, 2006 Nice Shoulder Course]

24. Full thickness Tear

25. RC Tear Classification Acute, Chronic, Acute on chronic Tear Age Tissue Quality • Partial <40 Good • Complete <40 Good • Complete 40-65 Good • Complete 40-65 Bad • Complete >65 Good • Complete >65 Bad

26. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration

27. Bursal view before acromioplasty

28. Checking Tissue Quality

29. Surgical Technique • GH Joint and Subacromial Joint Inspection • Bursal debridement • Acromioplasty • Cuff mobilization • Repair (side to side, tendon to bone)

30. Patient position Lateral decubitus Traction3-4 kgr Abduction20 degrees

31. Portals Outside in technique

32. Bleedingcontrol

33. Bleeding control

34. Joint Side Inspection

35. Bursal Side Inspection-Bursectomy

36. Tendon debridement- Tear morphology recognition

37. Acromioplasty

38. Techniques of releases The techniques adapted from open surgery as described by Codmann, Rockwood, Neer Refined and modernized by Esch, Snyder, Gartsman, Burkhart and others

39. ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR

40. Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain

41. Tear Patterns Crescent shaped L-shaped (or reverse L) U-Shaped Massive Contracted Immobile tears S.S. Burkhart

42. Crescent Shaped Tear S.S Burkhart

43. Crescent-Shaped Tear Double row repair,

44. Double Row Fixation Restoration of the footprint

45. Tuberoplasty

46. 1st Anchor Insertion – Medial Row

47. 1st suture passage- Medial row - mattress

48. suture passage- Medial row – post. anchor

49. Suture inspection – medial row - mattress

50. Lateral Row 1st Anchor Insertion