Rotator Cuff

Calcific Tendonitis

Definition

 

Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia

 

Supraspinatous CalciumSupaspinatous Large Deposits

 

Aetiology

 

2 groups of patients

 

1.  Degenerate Calcification

 

Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller

 

These patients do not have calcific tendonitis

- older patient group

- different histology

 

2.  Calcific Tendonitis

 

Cause

 

Reactive Hypoxic Calcification Theory

 

Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium

 

Codman proposed cuff hypoxia as the causative factor

 

Classification

 

1.  Pre-Calcific stage

 

Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia

 

2. Calcific Stage

 

A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

- crystals may be in the form of phosphates / carbonates / oxalates / hydroxyapatite

 

B. Resting Stage

- fibrocartilage surrounds deposits

 

C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma

 

3. Post-Calcific Stage

 

Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I

 

Epidemiology

 

Accounts for 10% all consultations for painful shoulder

 

Peak 40 years

- diabetes

- F > M 

 

SS most common tendon

- IS less common

- SSC rare

 

Asymptomatic patients can have cuff calcium on xray

 

Clinical Presentation

 

Usually acute pain

- Resorption Stage

- background of absent to mild chronic pain of the Formative Stage

 

Patients may present to ED

- severe pain

 

DDx infection

 

DDx

 

Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD

IHD

 

X-ray

 

Calcific Tendonitis APCalcific Tendonits Lateral

 

Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size

 

ER AP Xray

- shows SSC

 

Subscapularis CalciumSubscapularis Calcium Lateral

 

IR AP Xray

- shows IS & Tm

 

Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak

 

Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density

 

MRI 

 

Low signal on T1 

Oedema on T2

 

Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2

 

US 

- more sensitive than Xray ~100%

 

Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous

 

Bloods

 

Check serum glucose / uric acid & iron

 

Management

 

Non operative Management

 

Options

 

1.  NSAIDS

- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration

 

Extracorporeal shock wave therapy

 

Extracorporeal Shock Wave Machine

 

Peters Skeletal Radiol 2004

- RCT

- 90 patients

- treatment group complete resolution in 86%, reduction in size in 13.4%

- control group 0 disappeared completely, 9% partial reduction

- significant reduction in pain and improvement in function at 4 weeks

- no adverse affects

 

Effectiveness directly related to energy

- 0.44 mJ/mm3

 

Needle aspiration and irrigation

 

Aim

- drain a substantial portion of the calcium

- stimulate resorption of remainder

 

Indications

- resorption phase (soft, toothpaste material)

 

Contraindications

- small deposits

- formative phase (hard, chalky material)

 

Technique

- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive

 

Complications

- very painful for first 2-3 days

 

Results

 

Aina et al Radiology 2001

- excellent results in 74%

 

Serafini et al Radiology 2009

- non randomised controlled trial

- patients treated better at 1 month / 3 months and 1 year

- no difference long term

 

Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone

 

Operative Management

 

Indications

- severe disabling symptoms > 6 months

- failure of needling / ECSW

 

Issues

 

Acromioplasty

- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement

 

Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

- SAD much longer time to return to non painful shoulder activity

 

Options

 

Open

Arthroscopic and mini open

Arthroscopic

 

Arthroscopic Technique

 

Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit

 

Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon

 

Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness

 

May need to remove entire diseased section and repair

 

Calcific Tendonitis Arthroscopy 1Calcific Tendonitis Arthroscopy 2Calcific Tendonitis Arthroscopy 3Calcific Tendonitis Arthroscopy 4

 

Complications

 

Secondary stiffness

 

Pain

- secondary to calcium deposits

- careful shoulder washout at the end of the case

 

 

Cuff Tear Arthropathy

DefinitionRotator Cuff Arthropathy

 

Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch

 

History

 

Neer

- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases

 

Aetiology

 

Crystal induced arthropathy

- hydroxyapatite-mineral phase in altered capsule, synovium or degenerate articular cartilage

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally

 

Cuff tear theory

- loss of cuff leads to mechanical and nutritional alterations in shoulder

- due to loss of closed joint space and altered range of motion

 

Incidence

 

4% of massive cuff tears go on to arthroplasty

 

Theory

- tears with unbalanced force couplet go on to arthropathy 

- massive tear that are balanced & / or above equator don't go onto to arthropathy

 

Epidemiology

 

Women > men

60% bilateral

 

Symptoms

 

Recurrent swelling

Loss of Motion

Night pain

 

Xray

 

1.  Superior migration of head 

- defined as AHI / acromiohumeral interval of 7mm or less

 

Humeral Head Superior Migration

 

2.  Collapse of proximal head articular surface 

 

3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity

 

4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification

 

Acromial Acetabularisation

 

CT

 

RC Arthropathy CT

 

DDx

 

GH OA 

- no superior migration

- beard osteophytes

 

Management

 

Non-Operative

 

Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia

 

Operative Management

 

1.  Acromioplasty & tendon debridement 

 

Not indicated with superior migration

- can consider biceps tenotomy if still intact

 

2.  Arthrodesis

 

Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid

 

3.  TSR 

 

Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 

 

4.  Hemiarthroplasty

 

Indications

- < 70

- intact CA arch

- anterior deltoid muscle

 

Technique

- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape

 

Results

 

Rockwood

- 18 of 21 satisfactory

- good pain relief

- ROM often not improved

 

Neer 

- concept of limited goals category

- 20° of ER and 90° of forward elevation

 

Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency

 

5.  CTA Humeral Head

 

Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER

 

CTA HemiarthroplastyCTA Head APCTA Head 2

 

6.  Reverse TSR

 

Indications

- > 70

- functioning deltoid

 

Concept

- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder

 

 

 

 

Impingement

Arthroscopic Acromioplasty

Technique

 

Position

- beach chair / lateral

- water pump, adrenaline in bags

- block pre-op useful as easier to control BP

- often inject the SAD with combination of LA with A prior to scope

 

Posterior portal

- 2 cm inferior, 1 cm medial

- soft spot between IS and Tm

 

Enter subacromial space

- sweep to clear adhesion

- saline on pump at 30 - 40 - 50

- keep BP  100 - 110

- can increase pump pressure to 60 - 80 if needed in short bursts

 

Midlateral portal

- spinal needle

- 3cm distal to anterior acromion

- midpoint clavicle

- slightly lower to aim up

 

Bursectomy

- with shaver

 

Arthroscopic Bursectomy

 

Electrocautery / Shaver

- clear periosteum / coracoacomial Ligament off acromion

- avoid deltoid as bleeders

- beware thoroaco-acromial artery in CA ligament medial and inferior to acromion

- spinal needle ACJ to mark medial limits

- need to see anterior and lateral acromion

 

Arthroscopy Type 3 AcromionShoulder Scope Large Acromial Spur

 

Acromioplasty

- 5.5mm burr

- multiple techiques

- 5mm deep resection at midpoint clavicle

- taper anteriorly

- must ensure lateral edge is cleared

 

Arthroscopy Post AcromioplastyArthroscopy Cleared Subacromial Space

 

Residual Lateral Acromial Spur

 

 

 

 

Impingement

DefinitionLateral Acromial Spur

 

Painful impingement of rotator cuff

- on anterior 1/3 of Acromion, CA ligament & ACJ

- causes tendinosis of the RC

 

Anatomy Subacromial Space

 

1.  Roof / CA Arch

- acromion

- CA ligament

- coracoid process

- ACJ is superior & posterior to CA ligament

 

2.  Floor 

- GT & superior aspect head

- rotator cuff

 

Aetiology

 

Controversial

- extrinsic and intrinsic theories

 

1.  Extrinsic / Extra-tendinous / Bursal sided tears

 

CA arch impinges on RC

- true impingement syndrome

- causes tendinosis of the cuff

 

Factors

 

A.  Subtle GH Instability

- relationship poorly understood

- respond poorly to acromioplasty

- alteration in dynamics of shoulder

 

B.  Internal Impingement Posterior / Superior Glenoid

 

Described by Davidson 1997

- throwing athletes

- impinge in abduction & ER

- SS impinges on posterosuperior rim of glenoid 

- normally humeral head translates posterior in glenoid 

- this may be lost with instability or laxity of throwing athlete

- alternatively may be caused by posterior capsular tightness

 

See Miscellaneous/Throwing Athlete

 

C. Degeneration ACJ

 

OA Spurs

 

D.  Acromion Morphology

 

Neer = impingement on anteroinferior acromion 

 

E.  Os Acromiale

- mesoacromion most common

- hypermobile unfused epiphysis

- tilts anteriorly

- 1-15% normal population

- increased incidence with impingement

 

F.  CA Ligament Spurs 

 

Develop calcium in tendon

 

G.  CA Ligament Impingement

- common

- "Snapping shoulder"

- in flexion & IR

- SS & Biceps impinge on it

- Neer recommends division

 

H.  Coracoid Impingement

- less common

- subscapularis impingement between coracoid and LT

- may be exacerbated by anterior instability

- more medial pain with arm flexed, adducted and IR

- find SSC partial tears on arthroscopy

 

Coracoid Impingement Lateral Coracoid

 

2.  Intrinsic / Intra-tendinous / Articular sided tears

 

2° to bursal thickening or intrinsic problem in cuff

- ? Now thought to be most common

 

Factors

 

1. Muscle Fatigue

- overloaded weak muscles

- eccentric tension load

- associated with proximal humeral migration

 

2. Shoulder Overuse

- soft tissue inflammation

- repetitive microtrauma

- athletes / manual labourers

 

3. Degenerative Tendinopathy

- 1° intrinsic degeneration of RC

- ? hypovascularity

- increasing incidence with age

 

Pathology

 

Impingement Zone 

- centered on supraspinatus tendon insertion

- Codman's "Critical Zone" 1cm from insertion

- zone of hypoperfusion

 

Neer's Pathological Classification

 

Stage I

- reversible

- oedema & haemorrhage

- < 25 years

 

Stage II

- irreversible change

- fibrosis & tendinitis

- 25-40 years

 

Subdivided by Gartsman

- Stage IIA = No tear

- Stage IIB = Partial thickness tears

 

Stage III

- > 40 years

- chronic

- partial & full thickness tears

 

Acromial Morphology

 

Bigliani / Assess on Supraspinatous Outlet View / Scapula Lateral

 

Type I:  Flat

- 20% of normal population

 

Type 1 AcromionType 1 Acromion

 

Type II:  Curved

- 40% of normal population

 

Type 2 Acromion

 

Type III:  Hooked

- 40% of normal population

- 80% of RC tears

 

Type 3 AcromionAcromion Type 3Acromial Spur Type 3

 

Cadaver study

- 30% of all cadavers had a full thickness cuff tear

- 75% type III & 25% type II & 3% type I

 

Morphology does change with age

- Spur more common > 50 years

- ? 2° event to cuff process

- most hooks appear to be acquired & lie in CA ligament 

 

Symptoms

 

Painful arc

 

Weakness overhead

 

If < 40 years look for instability

 

Examination

 

Painful Arc

- 70-120°

- > 120° - ACJ OA / terminal phase pain

 

IR

- limitation of IR may suggest posterior capsular tightness

 

Neer Impingement Sign

- stabilize scapula from behind patient

- passively elevate arm in scapula plane

- pain between 70-120°

 

Hawkins Modification

- IR humerus at 90° flex

 

Neer Impingement Test 

- LA in SAD

- abolish pain & test for cuff tear / weakness

 

Always

- anterior apprehension / Jobes relocation (young patient)

- ACJ assessment

- biceps assessment

- NVI

- C spine

 

X-ray

 

AP view (True AP)

- acromio-humeral interval:  Normal 1-1.5 cm, < 0.7cm abnormal

- sclerosis greater tuberosity / acromion

- lateral Acromion spur

- OA ACJ

 

Acromial Spur AP

 

Axillary Lateral

- os acromion

- bone scan to exclude symptomatic hypermobility

 

Os Acomionale Axillary Lateral Xray

 

Supraspinatus Outlet View

- Acromion morphology / calcification Coraco-Acromial Ligament

- scapula lateral variant

- plate on affected shoulder, other turned out of way 

- 10° caudal

 

Scapular Lateral for Acromial Morphology

 

Zanca view

- ACJ

- half voltage / centred on ACJ / 10o cephalad

 

US

 

Diagnose

- dynamic impingement

- bursitis

 

Shoulder Ultrasound Bursitis

 

MRI

 

Sensitive

- assess acromial morphology

- look for tendinosis / tears

 

MRI Type 3 Acromion

 

Management

 

Non Operative

 

HCLA injection 

 

Goals

- decreases pain & inflammation

- diagnostic

 

Alvarez et al Am J Sports Med 2005

- RCT HCLA v LA in RC tendonosis

- no clinical difference between the two groups

 

Cuff Rehabilitation

 

Rockwood 3 Stages of Physio

 

1. Decrease Inflammation / Increase ROM

- rest

- gentle ROM 

- posterior capsular stretches

- scapula & trunk stabilisers

- modify activities

- NSAIDS

 

2. Cuff Stabilisation and Balancing

- strengthen humeral depressors

- work on SSC and IS

- takes load off SS

- theraband / IR / ER exercises

- avoid abduction drills

 

3. Deltoid strengthening

- task specific exercises

 

Operative Management

 

Acromioplasty

 

Theory

 

Believe primary problem is extrinsic impingement

- abnormal acromial morphology on outlet view

- spurs in CA ligament

 

Results

 

Ketola et al JBJS Br 2009

- RCT of patients with impingement

- treated with exercise program or acromioplasty + exercise program

- no difference between the two groups

 

Henkus et al JBJS Br 2009

- RCT of bursectomy alone v bursectomy + acromioplasty

- no difference between the two groups

 

Open v Arthroscopic Acromioplasty

 

Results

 

Sachhs JBJS 1997

- open v arthroscopic

- open longer return to work & in hospital stay

- results similar

 

Davis et al Am J Sports Med 2010

- meta-analysis of open v arthroscopic acromioplasty

- no significant difference in outcome

- longer return to work and inpatient stays

Open Acromioplasty

Described by Neer / modified by Rockwood

 

Two Step Acromioplasty

 

1.  Anterior acromioplasty

- resect anterior acromion back to ACJ

- prevent impingement in flexion

 

2.  Resect anteroinferior acromion 

 

Technique

 

Position

- beach chair 

- mark anatomy

- limb draped free

 

Incision 

- along anterolateral border acromion

- curve into anterolateral incision

 

Superficial Dissection 

- expose deltoid to ACJ

- find fibrous raphe at anterolateral corner acromion 

- marks anterior & middle parts of deltoid

- split raphe 3cm, ensure protect underlying cuff

- bursa is now exposed, separate subdeltoid space

 

Deep Dissection

- detach deltoid from anterior acromion to ACJ 

- release CA ligament 

- place retractor under acromion to protect cuff

- tablespoon, Langerhan's retractor turned on side

 

2 stage acromion resection with microsagittal saw

- anterior acromion level with ACJ

- antero-inferior acromion

- ensure surface smooth

 

Resect distal 2cm clavicle if OA

- < 4% of patients

- only if pain referable to ACJ 

- confirmed by LA preoperatively

 

Bursectomy

- inspect cuff & repair defects

- abduct & rotate humerus

- biceps tenodesis if > 50% torn

 

Closure

- ? repair CA ligament

- reattach Deltoid No. 2 ethibond intraosseous sutures

 

Post Op

- rendulum exercises & passive flex

- sling for comfort

- no active abduction for 6/52 to protect deltoid

 

 

 

RC Tears

Arthoscopic Supraspinatous Repair

 

Large Supraspinatous TearSS tear arthroscopy GHJSS tear arthroscopy

 

Advantages

 

Improved cosmesis

Shorter hospital stay / less immediate post operative pain

Deltoid not detached

Ability to evaluate and treat coexisting intra-articular pathology i.e. biceps

 

Disadvantage

 

No quicker to rehab or return to activities 

- limiting factor is healing of tendon to bone

- healing rates not as high especially for large to massive tears

- steep learning curve / longer surgery

 

Issues

 

1.  Footprint

- 25 x 15 mm

- healing zone

- the greater the extent a repair covers, the greater the chance for tendon bone healing

 

2.  Suture technique

 

Note:  Most common means of failure is suture cutout

 

A.  Open transosseous

 

Technique

- performed in open surgery

- captures a wide section of cuff footpring

- very secure repair with uniform compression between cuff and bone

 

B.  Single row repair

 

Technique

- anchors placed in line laterally at insertion

 

C.  Double row repair

 

Technique

- medial anchor row at articular margin

- lateral anchor row at lateral footprint

 

Kim et al Am J Sports Med 2006

- biomechanical study

- more successful at restoring footprint

- less gap formation

- increased load to failure

 

D.  Transosseous equivalent / suture bridge

 

Technique

- biomechanically replicate tradional open transosseous

- sutures crossed as below in double row

- aiming to increase contact between cuff and footprint

 

Arthroscopic Suture Bridge Cuff Repair

 

Siskoksy et al AAOS 2007

- biomechanical study suture bridge v double row

- bridge higher load to failure

- no difference in gap formation

 

Results 

 

Outcome arthroscopic

 

Lafosse et al AA Should Elbow Surgeons 2006

- 105 patients treated with double row

- 11.45 structural failure on CT / MRI

 

Sugaya et al JBJS Am 2007

- prospective study 106 FT

- arthroscopic double row

- MRI follow up

- 17% retear

- 5 % small to medium

- 40% large and massive

 

Arthrocopy v mini-open

 

Kim et al Arthroscopy 2003

- arthroscopy v mini open

- similar outcomes in each group

- poor outcome related to size of tear, not method of repair

 

Verma et al Arthroscopy 2006

- arthroscopy v mini open

- US review

- 24% retear mini-open

- 25% retear arthroscopic

- no difference in outcome

 

Bishop et al AAOS 2004

- mini open v arthroscopic

- MRI review

- tears < 3 cm: 26% retear mini open, 16% arthroscopic

- tears > 3m: 38% v 76%

- do larger tears do better with open surgery?

 

Morse et al Am J Sports Med 2008

- meta-analysis of arthroscopic v open

- no difference in outcome or complications

 

Single v Double Row

 

Francheschi et al Am J Sports Med 2007

- RCT single v double row

- 60 patient

- no difference functional outcome

- improved cuff appearance on MRI

 

Burks et al Am J Sports Med 2009

- RCT single row v double row

- 20 in each group

- 1 retear in each group

- no difference in MRI appearance or clinical outcome

 

Cost

 

Churchill et al J Should Elbow Surg

- arthroscopic took average 10 minutes longer / cost $1000 dollars more

- even at high volume centres

 

Arthroscopic Supraspinatous Repair

 

Technique

 

Position

- lateral decubitus with arm traction 10 lb or

- beachchair in Tmax / Spyder (can depress arm and ER to aid visualisation)

- water pump

- useful to have adrenalin in bags

- stable BP 110 (interscalene block can help)

- inject LA with A into subacromial space and prospective portals

 

Portals

 

Posterior Portal

- make more superior and lateral

- awkward for GHJ arthroscopy

- good visualisation in subacromial space

- will put camera over and high above tear

 

Lateral portal

- standard position

- insert large 8 mm cannula (will need to pass sutures)

- perform bursectomy +++ for visulisation

- bursa posteriorly and medially often bleeds

- perform SAD

- control bleeding with electrocautery and temporary increases in pump pressure

 

Anterior portal

- smaller 6 mm

- for suture shuttling

 

Preparation

 

Prepare insertion

- debride tendon edges

- debride footprint to punctate bleeding

 

Arthroscopic Cuff TearArthroscopic Cuff Prepare InsertionArthroscopic Cuff Prepared Footprint

 

Assess tendon mobilisation / tear geometry

- perform releases if needed

- as per open surgery

- above and below tendon 1 cm medial to glenoid

- release coracohumeral ligament

 

Repair

 

Large U shaped tendon

- insert margin convergence sutures

- put camera in lateral portal

- insert posterior cannula over switching stick

- anterior and posterior bird beaks

 

Arthroscopic Cuff Repair Margin Convergance 1Arthroscopic Cuff Repair Margin Convergance 2

 

Place medial row anchors

- anterior first

- insert 18 G spinal needle and ensure good angle

- just medial to articular cartilage

- stab incision

- insert 5 mm anchor

 

RCR arthroscopic Spinal NeedleRCR Arthroscopic TapRCR Arthroscopic AnchorRCR Arthroscopic Anchor 2

 

Pass sutures in lateral margin cuff

- camera posterior

- elite / scorpion / concept suture passer via lateral portal

- pass sutures through cuff anterior to posterior

- retrieve sutures through anterior portal

- retrieve via anterior portal

 

Suture PassageSuture Retrieval

 

Repeat with posterior anchors

 

Large Cuff Repair 1Large Cuff Repair 2Large Cuff Repair 3

 

Tie sutures

- posterior to anterior / anterior to posterior

 

Double row

- either pass second lateral row of anchors or

- use foot print anchors, retrieve previous sutures

- can make suture bridge configuration

- check repair via lateral portal

 

Arthroscopic Supraspinatous RepairArthroscopic Cuff Suture Bridge RepairArthrscopic Cuff Repair

 

 

Background

Definition

 

Full thickness tear (FTT)

- variable amount retraction from insertion

 

Rotator Cuff Tear Large

 

Partial thickness tear (PTT)

- incomplete

- bursal or articular sided

 

Articular sided tearBursal Tear

 

Epidemiology

 

Older patients

- average age 60

- uncommon < 40

- cadavers  30%

 

Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years

 

Anatomy

 

Blood Supply

 

Proximal from muscle belly

- suprascapular artery

- subscapular artery

 

Distal from bone

- branch of anterior circumflex humeral

 

Vessels more abundant on bursal side than articular side

 

NHx

 

1.  Healing

- full thickness tears don't heal because of presence of synovial fluid

 

2.  Progression

- tears do not necessarily extend

 

3.  OA

- 5% FTT go on to cuff arthropathy if untreated

 

Pathogenesis

 

Chronic Tears

- 95% 

- abnormal tendon

 

Acute tears

- trauma 

- 5% 

- normal tendon

 

Pathology

 

No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia

 

Involvement

- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn

 

Classification

 

1.  Size 

 

Cofield

- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm

 

2.  Extent

 

Partial Thickness

 

Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium

 

A.  Intra-tendinous

- in tendon

- no communication with bursa / joint

 

Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis

 

B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly

 

Supraspinatous articular sided tear

 

C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement

 

Full Thickness

 

One tendon 

- supraspinatus only

 

Multiple Tendons 

- more likely OA if multiple tendons involved

 

3.  Topography

 

Sagittal Plane

 

Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons

 

Coronal Plane

 

A. Minimal retraction

- close to insertion

 

Supraspinatous Tear Minimal Retraction

 

B. Moderate retraction

- humeral head

 

Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2

 

C.  Significant retraction

- at glenoid

 

Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1

 

History

 

Pain

 

Weakness

- 2° to tear

- can be limited by pain

- can use LA to differentiate

 

History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon

 

Chronic Tear 95%

-  long history impingement

-  no history of injury

 

Examination

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Wasting

- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears

 

Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear

 

Supraspinatus

 

1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate

 

2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o

 

3.  Shoulder hiking

- usually means massive cuff tear

 

Shoulder Hiking

 

Infraspinatus

 

1.  Resisted ER

 

2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags

 

3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor

 

Involvement of IS can often indicate a large or massive tear

 

Subscapularis

 

1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test

 

2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly

 

3. Increased ER compared with other arm

 

Subscapularis tear increased ER

 

HCLA

 

Improves pain and allows physio

 

Diagnostic

- ensures pain from shoulder pathology

 

Xray

 

Views as for impingement

- assess acromion / GHJ OA / high riding head

 

Ultrasound

 

Advantages

- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery

 

Disadvantage

- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)

 

Evidence

 

O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable

 

Normal

 

Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal

 

Tears

 

Shoulder Ultrasound Supraspinatous Tear

 

Arthrogram

 

Arthrogram Intact RC

 

MRI

 

Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 

 

Shoulder MRI Supraspinatous Fatty Infiltration

 

Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space

 

For more MRI see

- massive tears

- partial thickness tears

- full thickness tear

 

Arthroscopy

 

Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space

 

Management Guidelines

 

1. Repair all acute full thickness tears

 

2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain

 

3. Observe chronic tears with no disability

- especially in elderly

 

Non-operative Management

 

As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears

 

 

 

Full Thickness Tears

Surgical Options

 

1.  Open antero-lateral approach 

 

Large / Massive Cuff Tear

 

2.  Deltopectoral approach

 

Large Subscapularis tear

 

3.  Arthroscopic Assisted Mini-open

 

Indication

- Small / Moderate Cuff Tear < 3cm

- no retraction

 

Technique

- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split

 

Advantage

- avoids deltoid detachment from acromion

- small scar

- still have to immobilise shoulder for 6/52 to protect cuff tear

 

4.  Arthroscopic repair

 

SAD

 

Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not

 

Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs

 

Biceps / SLAP

 

Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group

 

Morphology

 

4 types of cuff tears

 

1.  Cresent shaped

- simple lateral repair

 

Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped

 

2.  U shaped

- larger

- need margin convergence, then lateral repair

 

Supraspinatous Tear U shaped

 

3.  L shaped

 

Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly

 

4.  Massive

 

Rotator cuff retracted to glenoid

 

1.  Open Rotator Cuff Repair

 

Indications

- large to massive tear

 

Concept

- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures

 

Advantage

- reliable

- good results in terms of tendon healing and outcome

 

Disadvantage

- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

- miss any intra-articular pathology if don't perform arthroscopy

- ? management of biceps

 

Technique

 

Position

- lazy beachchair

 

Incision

- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid

 

Approach

- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

- must not extend incision > 5 cm from acromion or risk damaging anterior AXN

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery

 

Acromioplasty

- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure

 

Bursectomy

 

Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint

 

Techiques to mobiise retracted SS tendon

 

1.  Release CHL (runs from coracoid to free edge SS / into rotator interval)

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

4.  Release above glenoid 1.5cm (beware suprascapular nerve)

5.  Interval slide - divide between SS and IS posteriorly, rotator interval anteriorly

6.  Medialise insertion - take away some of articular cartilage

7.  Repair SSC and IS for restoration of force couplet (if SS irrepairable)

 

Repair Options

 

1.  Direct suture of tendon

- margin convergence

 

2.  Suture of tendon to bone

 

A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across

 

Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral

 

B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors

 

C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)

 

3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head

 

Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow

 

Closure

- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery

 

Large - Massive Tear 

 

Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above

 

Post op

 

Must protect deltoid repair

- passive ROM 6/52, hand and elbow exercises, sling

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12

 

Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM

 

2.  Arthroscopic SAD + Mini open Rotator Cuff Repair

 

Concept

- perform subacromial decompression with arthroscope

- no need to detach deltoid

- made 2 - 5 cm deltoid split directly over tear and repair

 

Indication

- moderate size tear up to 3 cm

 

Technique

- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above

 

Results

 

Open v Mini-open

 

Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years

 

Tear integrity

 

Papadopolous et al J Should Elbow Surg 2011

- ultrasound evaluation of tears at 3 years in 37 mini-open patients

- 48% intact in patients who tended to have smaller original tears and be 15 years younger

- most patients had satisfactory outcome

 

Complications

 

Rerupture

- up to 50%

- increased in older patients with larger tears

 

Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head

 

Shoulder High RIding Humersu

 

Infection

 

Pain

- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)

 

Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture

 

Stiffness

 

Deltoid avulsion

 

Axillary nerve injury

 

Acromial fracture

 

RC Tear / Anchor Pullout

 

Rotator Cuff Anchor Pull Out

 

Massive Tears

DefinitionsMassive RC Tear High Riding Humeral Head MRI

 

Massive tear 

 

1.  > 5cm 

- retracted to humerus / glenoid margin

 

2.  At least 2 complete tendons

- lose SS / IS or SS / SC

 

Classification

 

Antero-Superior

- SS + SSC

 

Postero-Superior defects

- SS + IS
- more common

 

Pathogenesis

 

Cuff works to compress / depress head in glenoid while deltoid acts as prime mover

- ff still have intact force couple often good function

 

Plan is to reproduce force couple 

- if tear is below equator of head 

- get uncoupling of cuff force couple

- lose cuff depressor effect & acts as head elevator

 

Integrity of coracoacromial arch integral component of repair

- acts as check rein to proximal migration 

 

Presentation

 

Massive SS / IS wasting + rupture LHB

- weakness

- reduced active ROM

- atrophy

 

Shoulder Hiking due to massive cuff tearSupraspinatous and Infraspinatous wasting

 

2 classic signs

 

1.  ER lag sign

 

2.  Hornblowers

- 100% sensitive, 93% specific

 

Both indicate infraspinatous is torn which is usually a sign of a massive PS tear

 

DDx

 

Suprascapular nerve palsy

Brachial plexus injury

Cervical stenosis

 

X-ray

 

Reduced acromiohumeral space

- < 7 mm RC tear

- < 5 mm massive tear

 

Rotator cuff OA

- acetabularisation

 

Decreased Acromioclavicular DistanceShoulder Massive Rotator Cuff Tear CTMassive Rotator Cuff Tear

 

MRI

 

1.  Level of retraction

- past coracoid irreparable

 

MRI Supraspinatous Retracted to Glenoid Margin

 

2.  Quantify fatty infiltration Goutallier

 

Parasagittal MRI T1

- atrophy and fatty replacement in SS / IS fossa

 

0 - no fat

1 - minimal fat

2 - more muscle than fat

 

Supraspinatous fatty infiltration grade 2

 

3 - fat equal muscle

 

MRI Fatty Infiltration Supraspinatous Infraspinatous

 

4 - more fat than muscle

 

Grade 4 Fatty Atrophy

 

3 & 4 have poor prognosis

- poor functional improvement with repair

- high incidence of retear

 

3.  Atrophy

 

Also poor prognosis

 

MRI Supraspinatous Atrophy

 

Management

 

Non Operative

 

Physio /  HCLA

- improvement in 50-85%

 

Operative

 

Options

 

A.  Primary repair / Debridement

1.  Mobilisation and repair

2.  Partial repair

3.  Decompression and debride

4.  Suprascapular nerve release

 

B.  Salvage

1.  Local tendon transfer - SSC

2.  Distant tendon transfer - P. major / Lat dorsi

3.  Allograft

4.  Synthetic Graft

5.  Arthroplasty

 

Repair / Debridement

 

1.  Rotator Cuff Mobilisation and repair

 

Technique of mobilisation

- release coracohumeral ligament

- anterior slide (between SS and SSC)

- posterior slide (between SS and IS)

- release above glenoid 1 cm

- medialise insertion

- transosseous repair

 

Results

 

Bigliani et al J Should Elbow Surg 1992

- 61 patients massive cuff tears followed up 7 years

- open repair

- 50% excellent and 30% good

 

2.  Partial repair

 

Theory

- restore balanced force couplet

- SSC + partial SS / IS repair

- act in conjuction to depress humeral head

- allow deltoid to work

 

Massive Cuff TearMassive Cuff Tear Partial Repair 1Massive Cuff Tear Partial Repair 2

 

Massive Cuff Repair Partial Repair 3Massive Cuff Tear Partial Repair 4Massive Cuff Tear Partial Repair 5

 

Results

 

Rhee et al Am J Sports Med 2008

- partial repair with interposition of biceps tendon to bridge gap

- MRI of 14 / 16 cases done arthroscopically

- complete healing in 60%

 

3. Decompress & debride alone

 

Concept

- doesn't restore power

- aiming for pain relief in elderly population

 

Technique

- maintain Coracoacromial arch to prevent humeral head escape

- don't perfrom SAD to preserve CA ligament

- debride cuff edges

- debride GT / tuberoplasty to decrease impingement

- biceps tenotomy / tenodesis

 

Results

 

Boileau et al JBJS Am 2007

- demonstrated good results with tenotomy or tenodesis

- 61 patients with irreparable tears

 

Liem et al Arthroscopy 2008

- 31 patients average age 70

- debridement cuff edges + biceps tenotomy

- no SAD

- reasonable results

 

Walch et al Arthroscopy 2005

- arthroscopic tenotomy in 307 irreparable RC tears

- 87% satisfied with results

 

4.  Suprascapular nerve release

 

Theory

- retraction of cuff tethers / impinges SSN

- release of nerve arthroscopically relieves pain

 

Technique

- arthroscopic release

- see miscellaneous/suprascapular nerve for technique

 

Salvage

 

Indications for tendon transfer / Graft

 

Young patient with poor function

- failed primary repair

- significant weakness

- good deltoid function

- CA arch intact / no superior escape

- good ROM

- either posterosuperior or anterosuperior defect

 

1.  Subscapularis Transfer

 

Disadvantage

- may lose humeral depressor effect

- lose abduction with deltoid

 

Technique

- release upper 1/3 tendon from capsule

 

Results

 

Karas et al JBJS Am 1996

- 20 patients

- good results in 17

 

2.  P.  Major Transfer

 

Indication

- functional deficit from SSC tear

 

Technique

- deltopectoral approach

- use sternal head rerouted under clavicular head for better line of pull

 

Results

 

Jost et al JBJS Am 2003

- reasonable results in isolated SSC

- less so with combined SS and SSC (doesn't recommend)

 

3.  Lat Dorsii Transfer

 

Indications

- IS / SS tear

 

Technique

 

Lateral Decubitus position

- arm over mayo table

 

Standard deltoid splitting open approach to subacromial space

- acromioplasty - minimal, preserve CA arch

- ACJ excision if needed

- tag cuff edges medially with sutures to augment repair

- place lateral anchors / sutures

 

L shaped incision

- inferior margin deltoid, lateral aspect of latissimus dorsi

- arm forward flexed to 90 degrees and IR

- infraspinatous usually very wasted

- identify T major

- find L dorsi below T major, develop interval between the two

- identify tendon insertion on humerus, often have to release T major tendon from it

- place homan over humeral head

- release tendon from insertion / keep long

- is usually thin / 3 cm wide / 5 cm long

- suture each margin with strong suture, leave limbs long to pass tendon

- release muscle belly for length / above and below / must identify and preserve pedicle

- tunnel tendon under deltoid & acromion

- suture anchors repair to GT + subscapularis + medial cuff remnant

- repair with arm in abduction and ER

- maintain in abduction and external rotation splint for 6/52

 

LDTT exposureLDTT intervalLDTT find tendon

 

LDTT homanLDTT tendonLDTT tendon suture

 

LDTT ReleaseLDTT humeral headLDTT repair

 

Pre op Lat Dorsi TransferPost Op Lat Dorsi TransferLat Dorsi Transfer Lateral

 

Results

 

Miniacci JBJS Am 1999

- 14 / 17 good results regarding pain relief and ROM

 

Tauber et al JBJS Am 2010

- compared patients with tendon transfer to those with tendon + bone block

- significantly improved results in bone block

- 4/22 reruptured on MRI in tendon v 0/20 in bone block group

 

4.  Allograft

 

Results

 

Moore et al Am J Sports Med 2006

- 28 patients average age 59

- patella tendon or achilles

- sewn to tendon medially

- bone block laterally or sutured

- 15 repeat MRI - all complete failure of graft

- 1 infection and 1 allograft rejection

- similar functional results to debridement alone

- not recommended by authors

 

5.  Synthetic Allograft

 

Results

 

Nada et al JBJS Br 2010

- dacron graft for massive cuff tears in 17 patients

- sutured medially, tied through bony tunnels laterally

- 90% satisfaction

- 15/17 intact on MRI

- 1 rupture, 1 deep infection

 

6. Arthroplasty

 

CTA Hemiarthroplasty / Reverse TSR

- salvage in patients > 65 years

 

Partial Thickness Tears

Clinical

 

Pain & Stiffness

- often more pain than FT tears

 

Bursal side tears more painful than articular

 

Articular side more common

 

May see in young patient overhead throwing

 

Examination

 

Painful arc

 

Impingement signs

 

No weakness

- function good

- cable system intact

 

Classification

 

Articular sided more common than bursal

 

Ellman

- A (articular)

- B (Bursal)

 

Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed

 

Incidence

 

Sher et al JBJS Am 1995

- 19 - 39 years - 4% PT , no FT

- > 60 years - 26% PT, 28% FT

 

NHx

 

Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT

 

MRI

 

Articular Sided

 

Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear

 

Bursal Sided

 

Arthroscopy

 

Articular side

 

Minor

 

Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear

 

Major

- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage

 

PASAT Arthroscopy 1PASTA Arthroscopy 2

 

Bursal Sided

 

Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear

 

Management

 

Non Operative

 

Physio / HCLA

 

Operative

 

Indications

 

1.  Failure of non operative treatment (6-12 months)

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth

 

Options

 

1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT

 

1.  Acromioplasty + debridement

 

Indications

- < 50% tears

 

Shoulder Scope PASTA Debridement

 

Results

 

Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years

 

Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair

 

Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT

 

Conclusions

- bursal sided tears tend to do more poorly than articular sided

- repair > 50% especially in young patients

 

2.  Acromioplasty and repair

 

May be done open / arthroscopically / arthroscopically + mini open

 

Options

A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open

 

A.  Convert to FT and repair

 

Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction

 

B.  Articular sided / transtendinous PASTA repair

 

Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation

 

Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair

 

C.  Bursal sided

- can repair top layer of tear only

 

Technique Transtendinous Arthroscopic PASTA Repair 

 

Advantage

- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness

 

Technique

 

Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal

 

Shoulder Partial Articular Supraspinatous Tear PASTA

 

Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint

 

A.  Pass bird beak suture passers through cuff to retrieve sutures

 

B.  Pass 20G spinal needle and pass down 0 nylon, retrieve via anterior portal

- tie to thread, and pass suture back through tendon

- do so each time for each thread in horizontal mattress pattern

 

Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled

 

Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ

 

Shoulder PASTA Repair Sutures in Subacromial SpaceShoulder PASTA Repair Knots Tied Subacromial Space

 

Post op

- can range aggressively

- the repair is protected by the intact portion of the tendon

- prevents stiffness

 

Technique Open Articular PT Tears

 

Arthroscopy

- put spinal needle through torn portion

- pass suture through to mark tendon

 

Open approach over needle entry

- identify tear by suture

- convert to FT and repair

 

Technique Arthroscopic Bursal Sided Tear

 

Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion

 

Insert anchor

- pass sutures through top layer of torn tendon

- tie down

 

Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair

Revision Cuff Tears

Incidence

 

Variable

- may be up to 50% retear over time

- many asymptomatic

 

MRI

 

Shoulder MRI Failed Rotator Cuff RepairShoulder MRI Failed RC Repair 2

 

Options

 

1.  Debride / Biceps tenotomy or tenodesis

 

2.  Revision cuff repair

- open

- arthroscopic

 

Revision Rotator Cuff 1Revision Rotator Cuff Repair 2

 

3.  Tendon transfer

 

 

 

 

 

 

Subscapularis Arthroscopic Repair

Technique

- extra-articular

 

Portals

- posterior portal very lateral so can see anterior aspect subacromial space

- port of Wilminton at anterolateral acromion to access SSC

- anterior portal in normal position, slightly more lateral so becomes working portal

 

SSC Repair Portals 1SSC Repair Portals 2

 

GHJ

- identify tendon

- work through portal Wilmington

- grasp, forms comma sign

- perform biceps tenodesis

- tag SSC with fibrewire

 

SSC tornSSC comma sign

 

Subacromial space

- place standard lateral portal as well

- total bursectomy plus acromioplasty

- use tagging sutures to identify SSC

- release as necessary

- may need long posterior cannula to see anteriorly

- may need to move camera to lateral portal to see around corner anteriorly

- can use 70 degree scope

 

SSC Tagging Suture Subacromial SpaceSSC Debridement Anterior Subacromial

 

Prepare footprint

- debride

- insert anchors (retract port of Wilminton into subacromial space)

- pass sutures with suture passer

- tie

 

SSC Debride FootprintSSC First AnchorSSC Suture Passage

 

SSC Second AnchorSSC Repair

 

 

 

 

Subscapularis Tears

AnatomySSC Longitudinal Tear

 

Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus

 

Action

- IR (with T major, P major, Lat Dorsi)

- part of force couplet depressing humeral head

 

Incidence

 

Can be isolated event

 

More commonly seen with SS tears (2% in MRI study)

- anterosuperior tears

 

Associations

- HAGL

- biceps subluxation

- coracoid impingement

 

MOI

 

Trauma

- hyperextension and ER

 

Degenerative

 

Examination

 

Pain anterior shoulder

 

Increased ER

 

Lift off test

 

Belly Press

- elbow falls posteriorly to harvest post deltoid

 

MRI

 

Subscapularis Tear MRISubscapularis FT Tear MRI Glenoid RetractionMRI Retracted Subscapularis TearMRI SSC tear minimal retraction

 

Arthroscopy

 

Complete absence of SSC

 

Subscapularis Retracted Tear Arthroscopy

 

Comma Sign

 

SSC tornSSC Comma Sign

 

Medially Subluxed Biceps

 

Medially Subluxed Biceps

 

Management

 

Operative Indications

 

Degenerative

- failure of 6/12 non operative

 

Trauma

- fix acutely

 

Options

1.  Debridement

2.  Open Repair

3.  Arthroscopic Repair

 

Debridement

 

Results

 

Edwards et al Arthroscopy 2006

- 11 patients with SSC tears

- debridement

- tenotomy in 9 with dislocating / unstable biceps

- 9/11 good results

 

Open Repair

 

Technique

 

Deltopectoral approach

- preserve axillary nerve inferiorly

- mobilise SSC

- subscapular nerves on anterior surface medial to glenoid rim

- tenodesis LHB

- suture anchor repair to lesser tuberosity

 

Results

 

Barti et al Am J Sports Med 2010

- 30 traumatic tears, patient average age 43

- associated biceps subluxation and HAGL's seen

- repair structurally intact in 93%

- 20% still unable to perform lift off / belly press tests

- these patients had higher degree of fatty infiltration preoperatively

 

Arthroscopic Repair

 

Intra-articular technique

- camera in GHJ

- anterosuperior portal

- mobilise tendon front and back

- must remove adhesions

- roughen insertion point on LT / gentle with burr as bone is soft

- insert twinfix anchors x 2 via stab incision

- pass birdsbeak suture passer through portal and through SSC

- retrieve 3 sutures through tendon

- retrieve 4th suture over top of SSC

 

Extra-articular Technique

- see article

 

Results

 

Lafosse et al JBJS Am 2007

- isolated repair in 17 patients

- 15 intact repairs and 2 partial reruptures on CT arthrogram

- good outcomes

 

Late reconstruction

 

P. major transfer

 

Results

 

Jost et al JBJS Am 2003

- good results in isolated SSC tears

- results poor in shoulder arthroplasty