1. Rotator Cuff Tears: Indications of arthroscopic treatment an 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 spectrum of clinical conditions, which range from asymptomatic 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.

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. 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 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 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]
BUT
All the operated rot cuff tears do not heal

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. 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 Good
Complete 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
Abduction 20 degrees

31. Portals
Outside in technique

32. Bleeding control

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

51. Lateral Row 2nd Anchor Insertion

52. Inspection of Suture Position

53. Knot Tying Lateral Row

54. Probably stronger repair but Time consuming and of raised difficulty
Final Repair
Double row
Probably stronger repair
but
Time consuming and of
raised difficulty

55. L-Shaped & U-Shaped Tears
Greater mobility from anterior to posterior than medial to lateral

56. L-Shaped & U-Shaped Tears
Side to side sutures from medial to lateral
Progressively converge the margin of the tear lateral to bone bed
Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6
[S. S .Burkhart]

57. L or U -shaped tear
Closing an L-shaped or U-shaped tear is much like closing a tent flap
Closure of an U-shaped tear involves first side-to-side closure of the vertical limb of the tear, then tendon-to-bone closure of the transverse limb
S. S .Burkhart

58. Large U-shaped cuff tear extending to glenoid
Margin convergence
The free margin of the cuff is repaired to bone with suture anchors

59. Cuff repair
Side to Side Repair

60. Side to Side Repair

61. Cuff repair
Tendon to bone repair

62. Massive Contracted Immobile Tears
No mobility from medial to lateral or from anterior to posterior
Subcategories:
Massive Contracted Longitudinal Tears
Massive Contracted Crescent Tears
Represent 9.6% of massive tears
[S.Burkhart]

63. Massive Contractite Tears
Single and double interval slide
Anterior Interval Slide
and/or
Posterior Interval Slide

64. Subacromial view

65. Single and double interval slide
Anterior slide through release in the rotator interval (supraspinatus–coracobrachialis)
Posterior slide through release of the interval supraspinatus-infraspinatus

66. Massive Tears associated with Subscapularis Tears
Subscapularis must be mobilized and repaired prior to the rest of the cuff
Interval slide in continuity

67. Subscapularis Repair
Recognition

68. Subscapularis Repair
Recognition

69. Subscapularis Repair

70. Arthroscopic cuff repair
Wolf, Snyder, Gartsman, Esch, Burkhart, Tauro and others reported 84%-94% excellent and good results

71. 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

72. 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

73. 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]

74. Results for massive tears
95% Good to Excellent Results
independent to tear size [Burkhart, 2001]
With interval slide
Improve UCLA score (10->28.3)
Improve Active ROM, Strength
[Burkhart, 2004]
Graft Jacket Repair
Improve UCLA score (18->32)
[Snyder, 2008]

75. 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]

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

77. 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

78. 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

79. 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
MRI findings: Goutallier III or IV
Arthroscopic findings:
massive posterosuperior tear,
retracted tendons of bad quality

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

81. 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

82. Results what to expect Arthroscopic partial repair or
medialized repair depending on the age and demands of the patient
Inability to restore external rotation
Tendon transfer more appropriate
in young active patients

83. 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 III or IV
Arthroscopic findings:
large or massive posterosuperior tear
retracted tendons of bad quality

84. 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

85. 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

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

87. 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

88. 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

89. Results - what to expect
No improvement
with arthroscopic treatment
Extended head or reverse arthroplasty a better option

90. 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]

91. 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

92. 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 after arthroscopic repair restores sufficient power to the cuff to equilibrate the force couples

93. 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

94. ..so when we treat a RC tear…
We must try to:
Optimize the anatomic integrity and capacity of force transfer 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

95. Thank you for your attention
Thank you for your attention