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 Tears Natural History ?

4. Rotator Cuff Tears Treatment –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 Tear Why? –Mechanical Factors? »Force couples –Demographic Factors?

8. Proximal Humerus Migration Why Does it Happen??

9. Rotator Cuff Disorders Glenohumeral 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 Kinematics Asympt 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. Results Symptomatic 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 1.Over a 2 year period 21% of patients with an asymptomatic rotator cuff tear became symptomatic 2.Symptomatic transition of asymptomatic cuff tears is associated with significant increases in pain and loss of function 3.Tear size progression may play a significant role in symptomatic transition. 4.No significant changes seen in glenohumeral kinematics or shoulder strength upon symptomatic transition. (early detection is key!)

30. Ultrasonography Accuracy –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 cuffFat-infiltrated infraspinatus

37. Fatty degeneration of the rotator cuff muscles Normal SupraspinatusFat-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. Anterior Posterior Superior Inferior Humeral Head Subscapularis Biceps tendon Supraspinatus Infraspinatus Teres Minor

49. Wash U Clinical Experience BTHH DT SS IS

50. Journal of Bone and Joint Surgery ‘10

51. Discussion Bidirectional propagation: - Tears start 15 mm post to biceps - Extend in both anterior and posterior directions from their initiation location - Did not extend only in the posterior direction

52. Anterior Posterior Superior Inferior Humeral Head Subscapularis Biceps tendon Supraspinatus Infraspinatus Teres Minor 15mm

53. Mechanism Anterior Posterior BT Rotator Cable Rotator Crescent 15 mm

54. Epidemiologic Factors ?

55. Smoking Increases the Risk for Rotator Cuff Tears Keith M. Baumgarten, MD David Gerlach, MD Leesa M. Galatz, MD Sharlene A. Teefey,MD William D. Middleton, MD Konstantinos Ditsios, MD Ken Yamaguchi, MD CORR 2009

56. Methods Hx of Cigarette Smoking Cuff Intact vs. Cuff Tear

57. Conclusions –Smoking increases the risk for rotator cuff tears: »Strong association – highly statistically significant »Time dependant relationship More recent smoking Cause / effect relationship? »Dose Response relationship # packs per day # years smoking

58. Diabetes -Clement JBJSBr 2010: 1112-7 Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts -Bedi JSES 2009: 978-88 impairs tendon-bone healing after rotator cuff repair

59. NSAIDS -Cohen AJSM 2006: 362-9 Traditional and cyclooxygenase-2-specific nonsteroidal anti- inflammatory drugs significantly inhibited tendon-to-bone healing in animal model

60. Obesity (?) -Namdari JSES 2010: 1250-5 Although obesity is considered a risk factor for poor postoperative outcomes after some surgical procedures, in our experience, obesity does not have an independent, significant effect on self-reported early outcomes after RCR -Warrender JSES 2011: 961-7 Obesity has a negative impact on the operative time of arthroscopic rotator cuff repairs, length of hospitalization, and functional outcomes.

61. Operative Indications Natural History Information Risks Benefits

62. Operative Indications Risks –Operative Treatment –Non-Operative Treatment

63. Rotator Cuff Tear Risks - Chronic Changes –retraction with adhesion –tendon morphology –muscle atrophy –fatty degeneration –degenerative changes

64. Operative vs Non-Operative Tx Rationale –What is the risk for development of Irreversible Changes? –Risk dictates urgency for surgery

65. Early Operative Treatment Benefits –Halt chronic changes? »Most pertinent to younger pt. »Important for acute, small or medium sized tears »Important for tears at risk for fatty degeneration or altered kinematics

66. Conclusions Natural History –High probability of bilateral symptoms –High probability of tear size progression –No evidence of spontaneous healing –Supports large population have intrinsic etiology

67. Conclusions –Age important factor for development of tears »Important consideration for operative indications! –High suspicion of tear extension with new pain!

68. Conclusions –Tears start 15 mm post to biceps –Loss of ant supra critical –Critical size threshold 15-20 mm

69. Techniques Open Mini-Open Arthroscopic Differences???

70. Acrmioplasty with RC Repair??

71. Acrmioplasty?? No difference in 3 RCT

72. Single vs Double Row??

74. Double Row biomechanically better No difference clinically in 4 RCT

75. Double Row vs TOE??

77. TOE better surface area coverage? Better healing?

78. Problems with Double Row or TOE???

79. Tuberosity fracture MT junction ruptures

80. Other Techniques? Tension band? Mason-Allen? Rip-stop?

81. Tension Band

82. Mason-Allen Stitch

83. Cuff Re-tear (Failed Surgery)??? When does it happen? How does it happen?

84. Cuff Re-tear (Failed Surgery)??? 3 months Most often due to suture pull out not anchor pull out

85. Questions??