1. IRREPARABLE ROTATOR CUFF TEAR
NADHAPORN SAENGPETCH

2. 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

3. 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:

4. 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 Jul;(304):78-83.

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

6. 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

7. 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

8. 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)

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

10. Posterosuperior Disruption
External rotation lag sign

11. Posterosuperior Disruption
Hornblower’s sign*

12. Anterosuperior Disruption
Belly press test

13. Anterosuperior Disruption
Lift-off sign

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

15. RADIOGRAPHIC FINDINGS

16. 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 Oct;439:

17. MRI VS MR Arthrography

18. TYPE 3-4 FATTY INFILTRATION

19. 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

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

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

22. 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

23. SUBACROMIAL DÉBRIDEMENT

24. 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 ;10:

25. PARTIAL REPAIR

26. 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

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

28. 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:

29. 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)

30. TENDON TRANSFERS
Latissimus dorsi
Pectoralis major

31. 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

32. TENDON TRANSFERS
Latissimus dorsi : clinical results sex (male), preoperative shoulder function and general strength
(Iannotti JP. J Bone Joint Surg Am. 2006;88: )
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: )

33. 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

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

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

36. 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

37. REVERSE ARTHROPLASTY

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

39. Harrison Hot Spring, British Columbia.