IRREPARABLE ROTATOR CUFF TEAR NADHAPORN SAENGPETCH.
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Transcript of IRREPARABLE ROTATOR CUFF TEAR NADHAPORN SAENGPETCH.
IRREPARABLEROTATOR CUFF TEAR
NADHAPORN SAENGPETCH
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
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;8:296 -9.
Cuff Atrophy & Fatty Infiltration
• 57 patients • Infraspinatus degeneration had a highly negati
ve 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. 1994 Jul;(304):78-83.
Goutallier Classification : 5 stages
0 : no fat
1: minimal fat
2 : muscle>fat
3 : muscle=fat
4 : muscle<fat
2 PHYSIOLOGICALLY DISTINCT GROUPS OF PATIENT
1. Older > 70, lower-demand who have been asymtomatic until minor trauma created symtoms
2. Younger, more active with dramatic symtoms of pain and disability after an acute event / with a history of cuff injury
2 DISTINCT ANATOMIC PATTERNS
1. Posterosuperior failure* : supraspinatus, infraspinatus and teres minor tendons
2. Anterosuperior failure : supraspinatus and subscapularis tendons ± LHB
۩ Loss of the coracoaromial arch and anterosuperior instability humeral head migration
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)
CLINICAL PRESENTATIONS
• pain
• deficit ROM
• atrophy of scapular muscles
• crepitus and hemarthrosis
• Posterosuperior disruption : AB, FE and active ER
• Anterosuperior disruption : AB, IR
Posterosuperior Disruption
External rotation lag sign
Posterosuperior Disruption
Hornblower’s sign*
Anterosuperior Disruption
Belly press test
Anterosuperior Disruption
Lift-off sign
RADIOGRAPHIC FINDINGS
• Position of the humeral head
• Evidence of glenohumeral OA
• Disorder of the AC joint
RADIOGRAPHIC FINDINGS
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. 2005 Oct;439:109-15.
MRI VS MR Arthrography
TYPE 3-4 FATTY INFILTRATION
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
NONOPERATIVE TREATMENT
• relieve pain & create biomechanically compensated function by muscle substitution
• NSAIDs
• steroid injection
• local therapeutic modalities
• strengthening exercise
• > 3 months to succeed
SURGICAL TREATMENTS
• Subacromial débridement, partial repair, cuff débridement and biceps tenotomy
• Reconstructive procedures
• Conventional and reverse arthroplasty
• Glenohumeral arthrodesis
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
SUBACROMIAL DÉBRIDEMENT
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 . 1994;10:363 -70.
PARTIAL REPAIR
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
TENOTOMY OF LHB
• Anterosuperior lesion
• No effect on the ROM or strength
Walch G. J Shoulder Elbow Surg. 2005:14: 238-46.
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;11:136 -42.
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)
TENDON TRANSFERS Latissimus dorsi Pectoralis major
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
TENDON TRANSFERS
• Latissimus dorsi : clinical results sex (male), preoperative shoulder function and general strength
(Iannotti JP. J Bone Joint Surg Am. 2006;88:342-348)
• 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;85:1944-1951)
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
ARTHROPLASTY
• Concomitant with arthritis or instability
• Conventional VS Reverse ball and socket prosthesis
CONVENTIONAL ARTHROPLASY
• HEMIARTHROPLASTY
• Indications :
intact coracoacromial arch
good deltoid function
no previous acromioplasty
no anterosuperior instability
• Contraindication : pseudoparalysis of shoulder
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
REVERSE ARTHROPLASTY
GLENOHUMERAL ARTHRODESIS
• Deltoid and RC are not function.
• High-demand, require a strong stable shoulder girdle
• Limited rotation
• nonunion
Harrison Hot Spring, British Columbia.