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Rotator Cuff Tears

Rotator Cuff Tears. Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder/Elbow Reconstruction & Sports Medicine Keck School of Medicine University of Southern California. Anatomy. Muscles? Innervation? Function?. Rotator Cuff Tears Natural History. ?.

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Rotator Cuff Tears

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  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 TearsNatural History • ?

  4. Rotator Cuff TearsTreatment • 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 TearWhy? • Mechanical Factors? • Force couples • Demographic Factors?

  8. Proximal Humerus Migration • Why Does it Happen??

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

  30. UltrasonographyAccuracy • 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 cuff Fat-infiltrated infraspinatus

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

  49. Wash U Clinical Experience DT IS SS BT HH

  50. Journal of Bone and Joint Surgery ‘10

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