IRREPARABLE ROTATOR CUFF TEAR NADHAPORN SAENGPETCH

DEFINITION Massive rotator cuff tears that are not reparable by conventional means. Their size and retraction, cannot be repaired to their insertion on the tuberosities despite conventional techniques. associates with a high-riding humeral head

FACTS unknown true incidence may have no symtoms/mild/severe pain associated with concomitant glenohumeral OA asymtomatic tears in elderly found 30-50% Zlatkin MB. J Bone Joint Surg Am.1995; 77:10 -5. age > 70 ; found FTRCT 38% Tempelhof et al. J Shoulder Elbow Surg. 1999;8:296 -9.

Cuff Atrophy & Fatty Infiltration 57 patients Infraspinatus degeneration had a highly negative influence on the outcome of supraspinatus repairs. It worsens with time. The subscapularis rarely degenerate, even when its tendon is not torn. Goutallier D.Clin Orthop Relat Res. 1994 Jul;(304):78-83.

Goutallier Classification : 5 stages 0 : no fat 1: minimal fat 2 : muscle>fat 3 : muscle=fat 4 : muscle<fat

2 PHYSIOLOGICALLY DISTINCT GROUPS OF PATIENT Older > 70, lower-demand who have been asymtomatic until minor trauma created symtoms Younger, more active with dramatic symtoms of pain and disability after an acute event / with a history of cuff injury

2 DISTINCT ANATOMIC PATTERNS Posterosuperior failure* : supraspinatus, infraspinatus and teres minor tendons Anterosuperior failure : supraspinatus and subscapularis tendons ± LHB ۩ Loss of the coracoaromial arch and anterosuperior instability humeral head migration

PATHOMECHANICS The RC acts as a dynamic stabilizer, resisting upward motion of a humeral head during deltoid contraction. Irreparable cuff : loss a force couple, allow a humeral head migrates superiorly during deltoid contracts (superior shoulder instability)

CLINICAL PRESENTATIONS pain deficit ROM atrophy of scapular muscles crepitus and hemarthrosis Posterosuperior disruption : AB, FE and active ER Anterosuperior disruption : AB, IR

Posterosuperior Disruption External rotation lag sign

Posterosuperior Disruption Hornblower’s sign*

Anterosuperior Disruption Belly press test

Anterosuperior Disruption Lift-off sign

RADIOGRAPHIC FINDINGS Position of the humeral head Evidence of glenohumeral OA Disorder of the AC joint

RADIOGRAPHIC FINDINGS

MRI VS MR Arthrography 41 shoulders had MRI followed by MR arthrography Sensitivities for detecting full-thickness rotator cuff tears by MRI and MR arthrography were 90.2 and 100% respectively. more accurate in evaluating rotator cuff tear size and morphologic features morphologic classification of the torn tendon : blunt end, tapering end, indistinct end, horizontal tear, and global tear Toyoda H. Clin Orthop Relat Res. 2005 Oct;439:109-15.

MRI VS MR Arthrography

TYPE 3-4 FATTY INFILTRATION

MANAGEMENT depends on the presenting symtoms, age and functional level medical comorbidities, an intact coracoacromial arch and concomitant arthritis no evidence-based, prospective, matched- patient studies comparing nonsurgical and surgical treatments

NONOPERATIVE TREATMENT relieve pain & create biomechanically compensated function by muscle substitution NSAIDs steroid injection local therapeutic modalities strengthening exercise > 3 months to succeed

SURGICAL TREATMENTS Subacromial débridement, partial repair, cuff débridement and biceps tenotomy Reconstructive procedures Conventional and reverse arthroplasty Glenohumeral arthrodesis

SUBACROMIAL DÉBRIDEMENT Healthy, low-demand with pain A patient with positive for impingement test is a good surgical candidate. Procedures : limited, acromial smoothening, bursectomy No release of the CA ligament

SUBACROMIAL DÉBRIDEMENT

PARTIAL REPAIR “Suspension bridge model” restore continuity between anterior and posterior portions of the tear resulted in a fibrous frame close to the equator of the head. Create a force to stabilize the head against the glenoid and enabling full function of deltoid Burkhart S. Arthroscopy . 1994;10:363 -70.

PARTIAL REPAIR

CUFF DÉBRIDEMENT Rockwood : open acromioplasty, decompression, cuff débridement Ellman : pain relief, but no significant increase in strength and ROM Zvijac and Kempf : substantial deterioration in pain relief/strength/functional outcome

TENOTOMY OF LHB Anterosuperior lesion No effect on the ROM or strength Walch G. J Shoulder Elbow Surg. 2005:14: 238-46.

TUBEROPLASTY Open surgery Shaving and reshaping of the overhanging bone at GT to create a recontoured subacromial space Fenlin JM Jr. J Shoulder Elbow Surg. 2002;11:136 -42.

TENDON TRANSFERS Transfer : the existing cuff tendons, other periscapular muscles, grafts or synthetic substitution Young, good deltoid function Posterosuperior : latissimus dorsi Anterosuperior : pectoralis major (sternal head)

TENDON TRANSFERS Latissimus dorsi Pectoralis major

TENDON TRANSFERS Gerber : good-to-excellent results > 10 yrs, better result with intact subscapularis Iannotti : EMG study in latissimus dorsi transferred patients; had activity with adduction but no activity with active FE/ER Concept of a tenodesis effect

TENDON TRANSFERS Latissimus dorsi : clinical results sex (male), preoperative shoulder function and general strength (Iannotti JP. J Bone Joint Surg Am. 2006;88:342-348) Pectoralis major : if the SS tear associated with irreparable Sup. tear, tendon transfer may not be warranted. (Jost B. J Bone Joint Surg Am.2003;85:1944-1951)

TENDON TRANSFERS Complex, need a long period of rehab, limited Not indicated for older, more debilitated patients Synthetic allograft patches : can create foreign body reactions leading to rejection & cannot replace RC functions

ARTHROPLASTY Concomitant with arthritis or instability Conventional VS Reverse ball and socket prosthesis

CONVENTIONAL ARTHROPLASY HEMIARTHROPLASTY Indications : intact coracoacromial arch good deltoid function no previous acromioplasty no anterosuperior instability Contraindication : pseudoparalysis of shoulder

REVERSE ARTHROPLASTY RC tear + arthritis + pseudoparalysis Unknown long-term results Medialize the centre of rotation Increasing the deltoid lever arm Glenoid loosening (notching), hematoma and instability

REVERSE ARTHROPLASTY

GLENOHUMERAL ARTHRODESIS Deltoid and RC are not function. High-demand, require a strong stable shoulder girdle Limited rotation nonunion

Harrison Hot Spring, British Columbia.