1. Rotator Cuff Tears: Indications Treatment Options and Results
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 spectrum of clinical conditions, which range from asymptomatic partial thickness tears to symptomatic rotator cuff arthropathy

4. The History of Rotator Cuff Repair
First Description of RC tears
Smith JG. London. Med Gaz, 1834,14: 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 Vol clxiv (2)
McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder: the exposure and repair of tears with retraction. J Bone Joint Surg ;26:31-51.
HL McLaughlin

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 % % %
> %
Partial Thickness Tear
<40 4%
> %
[Tempelhof S, JSES, 1999]

10. 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]

11. Rot cuff disease etiology and pathogenesis
Tendon degeneration
Vascular factors
Impingement
Type of acromion as identified by Bigliani
Acromial angle devised by Toivonen .
Type I. Angle 0-12
Type II. Angle 13-27
Type III. Angle > 27 Popularized by Neer
Secondary impingement popularized by Jobe
Instability overload of the cuff - secondary superior migration
Trauma
Glenohumeral instability
Scapulothoracic dysfunction

12. 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]

13. Current Knowledge RC tears DO NOT 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. Probably partial articular side tear
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 are 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. Operative Non-Operative RC Treatment Options Open Surgery Mini Open
Arthroscopy
Non-Operative

20. RC Treatment Options BUT
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]

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

22. Group II: patients with high risk of progression
Grouping the Patients
Group I: patients with minimal risk of progression to irreversible changes to the rotator cuff
Group II: patients with high risk of progression
Group III: patients who have progressed already
[Yamaguchi K., 2006, Nice Shoulder Course]

23. Non operative treatment
Group I patients
About 50 years with tendinosis or partial tears degenerative in nature Articular side
They respond very well to
non operative treatment
(about 50-60% resolution of the symptoms)
The risk of progression is very low but they need observation
Non operative treatment

24. Early surgical repair to avoid irreversible changes
Group II patients
Younger than 65 years with
Small or medium size tears
Acute tears of any size
Tears with recent acute loss of function
Patients non responsive to conservative treatment
Acute tears or overuse tears in athletes
Early surgical repair to avoid irreversible changes

25. They can benefit from rotator cuff repair,
Group III patients
Older than 70 years
with large or massive tears and
irreversible damage to the rot cuff
They can benefit from rotator cuff repair,
even a partial repair
[Yamaguchi K., 2006, Nice Shoulder Course]
[Burkhart, 2007, Arthroscopy]

26. Partial Tears Treatment
By far the most common partial tears are Articular-side, vascular or age relateted
Traditionally partial tears classifications
are based to 50%
BUT
“How healthy is the remaining,
intact tissue?”

27. 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 causes significant pain then debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]

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

29. Full thickness Tear

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

31. Busral view after acromioplasty

32. Checking Tissue Quality

33. RC Arthroscopic Repair
Recognition, of the type of the tear
Retraction and releases
Repair Options:
Anchors: metallic or absorbable
Type of stitch: Mason-Allen,
Mc Stitch,
Mattress sutures, Horizontal mattress, Simple sutures
Restoration of footprint: Double row or
Single row

34. Double Row Fixation
Restoration of the footprint

35. Double Row Fixation

36. What kind of Repair is NECESSARY?
An anatomically deficient RC could be biomechanically intact rot cuff
[Burkhart]
Conservative treatment of chronic painful rot cuff tears will result in a successful outcome in about 50% of patients
[Cofield]
Cuff tear arthropathy will develop in 4% of patients with complete rot cuff tears
[Neer]]

37. What can we Repair?
UP to 50% of cuff repairs had a postoperative defect
This didn’t affected patient satisfaction or pain relief
But it did affected shoulder strength
[Harryman et all J. B.J.S 1991]

38. Factors that affect RC Healing
Age
Sex
Activity
Size
Location
Tissue quality and elasticity
Muscle fat degeneration
Chronicity of the tear
Concomitant lesions
Smoking
Family history
Rehabilitation Protocol
NSAID
Surgical Technique

39. Today’s Knowledge
Rot cuff has some degree of reserve that affords functional use of the arm in cases of limited tendon deficiency.
Location rather that size of a tear maybe more important in the development of symptoms.
Type of activities plays an important factor in the development of symptoms

40. Goutallier fatty degeneration of muscles
Stage 0 Normal muscle – no fatty streaming
Stage 1 Occasional fatty streaming
Stage 2 Fat<50% of cross sectioned area
Fat < Muscle
Stage 3 Fat=50% of cross sectioned area
Fat = Muscle
Stage 4 Fat>50% of cross sectioned area
Fat > Muscle

41. What to do???
Patients with grade 3 or 4 fatty degeneration DO NOT improve with rot cuff repair
[Goutallier]
Vs.
Patients with grade 3 or 4 fatty degeneration improved significant at 86% of cases after arthroscopic repair
[Burkhart]

42. The quality of Functional results depends on:
The size of the persistent defect
Associated atrophy of the muscles
Integrity of the deltoid and the coracoacromial arch
Functional demands of the patient

43. Non-Operative Treatment
Best candidates for non-operative are:
patients with chronic attritional RC tears
limited to one tendon
the onset not associated with significant trauma
over the age of 60 and less active
[Iannotti J.P.Disorders of the shoulder]

44. Treatment of Irreparable Massive RC Tears
Pts >70 years with massive tear and major complaint pain, can function reasonably well
Criteria of Irreparability:
Profound weakness of external rotation with ext.rot lag or internal rotation lag when the subscapularis is involved
Superior displacement of the humeral head and contact with the acromion

45. Factors affecting Recurrence of tear
Advanced age
Tear size
Fatty degeneration
Chronicity and atrophy
Poor tendon quality
Inappropriate rehabilitation
Smoking
Steroid injections
Diabetes

46. How to convert a Symptomatic tear to an Asymptomatic re-tear
Subacromial decompression and debridmeut
Biseps tenotomy
Partial repair and healing of the rot cuff
Adequate post-op rehabilitation

47. Early failure of arthroscopic rot cuff repair
1. Failure of tendon-suture interface
2. Suture-anchor failure
3. Suture failure

48. RC Repair Results
The rate of structural failure after open repair varies from 20% to more 50%, while it is greater for arthroscopic repairs
First report of DOUBLE ROW repair:
Fealy S, Kingham TP, Altchek DW, Arthoscopy July 2002
Mini-open Rot cuff repair using a two row fixation technique

49. Results - what to expect
Pts between years old with
pain
loss of external rotation (positive lag sign) and
inability to keep the hand externally rotated age
MRI findings: Goutallier III or IV
Arthroscopic findings:
massive posterosuperior tear,
retracted tendons of bad quality

50. Results - what to expect
Arthroscopic partial repair or medialized repair
Resolution of pain but not restoration of external rotation

51. Results what to expect
Patients aged years old with painless loss of external rotation
MRI findings: Goutallier III or IV
Arthroscopic findings:
massive posterosuperior tear,
retracted tendons of bad quality

52. Results what to expect Arthroscopic partial repair or
medialized repair
Inability to restore external rotation
Tendon transfer more appropriate
in young active patients

53. Results - what to expect
Pts with
acute exaberration of symptoms after minor trauma
mainly pain
loss of strength of abduction and ext rotation
age >60 years old
no or minimal symptoms before trauma
MRI findings: Goutallier II or III
Arthroscopic findings:
large or massive posterosuperior tear
retracted tendons of bad quality

54. Results - what to expect
Arthroscopic partial repair or
medialized repair
Resolution of pain
near normal restoration of strength of abduction and external rotation
some loss of strength remaining
slow restoration of function
pts plateaus after more than a year

55. Arthroscopic findings:
Results what to expect
Pts with
loss of function
pain after acute trauma1-3 months before
normal function before trauma
MRI findings: Goutallier I or II
Arthroscopic findings:
large or massive posterosuperior tear with good quality of tissues repair
with no tension

56. Results - what to expect
Complete resolution of symptoms
normal function
restoration of strength
Excellent Results independent of age

57. Results - what to expect
Young patients, athletes
or overhead workers age years old with:
pain
loss of function or
inability to perform athletics in the same level
MRI findings: partial or complete tear of supraspinatus
Arthroscopic Findings:
partial articular side or
complete tear of suprafpinatus
Double row repair:
complete resolution of symptoms

58. Results - what to expect
Pts more than 60 years old with
pain
inability to raise the hand
Symptoms of long duration
MRI findings: Goutallier III or IV complete tear and retracted tendons
X-Ray findings: superior migration of the head and contact with the undersurface of the anterolateral acromion

59. Results - what to expect
No improvement
with arthroscopic treatment

60. Results - what to expect
Pts >50 years old with
minimal symptoms
Chronic symptoms
MRI findings: Small to medium tear of supraspinatus
Pts willing to accept slight restrictions of overhead activities

61. Results - what to expect
Conservative treatment may be successful

62. Conclusions
Rot Cuf is extremely significant for the normal function of the shoulder
Rot Cuf tears can be asymptomatic
Symptoms Produced by a tear depend on:
Size
Location
Functional demands of the patient

63. Conclusions
An anatomically deficient but biomechanical intact cuff is possible
Biomechanical intact cuff is the cuff that restores the equilibrium of the force couples
A cuff tear does not heal conservative
A cuff tear after operative repair may yet not heal
Partial healing may restore sufficient power to the cuff to equilibrate the force couples

64. Conclusions
Non-operative treatment strives to optimize the function of the remaining cuff
Rehabilitation after surgery strives to optimize the function of the partially or completely healed cuff

65. ..so when we treat a RC tear…
We must try to:
Optimize the anatomic integrity of the cuff by a repair with minimal morbidity to the healthy tissues (mainly deltoid)
THEN
Rehabilitate vigorously the patient, to optimize the total function of the shoulder
We can expect a majority of
satisfied patients

66. Thank you for your attention
Thank you for your attention