Current Concepts in Rotator Cuff Management
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1 Current Concepts in Rotator Cuff Management Karen J. Boselli, MD NHAFP Continuing Clinical Excellence April 5, 2014 Mountain View Grand Resort
2 Prevalence History Pathogenesis Anatomy Examination Imaging Treatment Rehabilitation RC Management Overview
3 Introduction There is a LOT that we do not know about rotator cuff tears, even in 2013! Centuries of research on anatomy, biomechanics, modes of failure, and repair techniques» Can be frustrating for both surgeons and patients alike, but also rewarding
4 Prevalence Prevalence of cuff tear quite high even in asymptomatic populations» Increasing prevalence with age» MRI in patients over 60 years 54% Sher et al. JBJS 1995 One of the most prevalent orthopedic conditions 400,000 surgeries a year in US
5 History 1 st described in1834 by JG Smith 1 st repair performed in 1909 by Codman 1 st published results 1944 by McLaughlin
6 Pathogenesis Originally thought to be due to impingement» Impingement coined 1972 by Charles Neer Compression of rotator cuff on CA arch:» Anterior edge acromion, CA ligament, AC joint» Chronic repetitive syndrome» Leads to degeneration of tendon
7 Pathogenesis Newer understanding of pathogenesis suggests rotator cuff disease as continuum Start with tendon strain Progress to inflammation and fibrosis Leads to tendon failure
8 Pathogenesis Precise cause of degeneration unknown Other proposed causes include advanced age, elevated BMI, even high cholesterol Probable decreased vascularity and ischemia
9 Smoking RC Management Pathogenesis» Proposed to important risk factor» Nicotine is vasoconstrictor» Carbon monoxide decreases cellular oxygen» Leads to tendon degeneration Baumgarten et al. CORR 2010 Smoking correlates with tear presence and tear size Carbone et al. JSES 2012
10 Pathogenesis Controversy about interplay between intrinsic (cuff tissue) and extrinsic (impingement) factors in rotator cuff disease Still not clear what is the primary cause Without knowing the cause it is difficult to know the right solution!
11 Anatomy Subscapularis» Largest tendon» Anterior shoulder» Lesser tuberosity» Internal rotation
12 Anatomy Supraspinatus» Most commonly involved» Large 23 x 16 mm footprint» Greater tuberosity» Forward flexion
13 Infraspinatus» Second largest tendon, interdigitates w/ supraspinatus» External rotation RC Management Anatomy
14 Teres minor RC Management Anatomy» Smallest muscle-tendon unit» External rotation of abducted arm
15 History Pain» Location» Duration» Factors that exacerbate» Factors that alleviate Weakness Traumatic versus insidious onset Prior treatment
16 Examination Check cervical spine for referred pain Inspect for muscle atrophy ROM and strength testing My red flags for RCT are:» History of trauma» Crepitus with motion» RC weakness
17 Examination Special Tests»Neer and Hawkins for Impingement»Jobe (empty can, drop arm) for RCT»External rotation lag
18 Imaging Acromial Spur Standard radiographs Arthrogram Ultrasound MRI» Best to assess early degeneration, partial tear, other pathology in shoulder
19 Imaging Small Full Thickness Partial Articular Tear Large Full Thickness
20 Imaging Normal Muscle Belly
21 Treatment Controversy rotator cuff management Consensus statement from AAOS 2012
22 Nonoperative Measures» Physical therapy» NSAIDs» Injection RC Management Treatment
23 Treatment Issue #1» Should we attempt nonoperative treatment for acute tears? Not often in my opinion Some exceptions including elderly patients and small tears
24 Issue #2 RC Management Treatment» Should we attempt nonoperative treatment for chronic tears? Depends on many factors Size of the tear Duration of symptoms Patient characteristics including expectations and activity level
25 Treatment Issue #3» Should we inject known rotator cuff tears? Not a black and white issue Each surgeon has preference Depends on many factors
26 Treatment Issue #4» Should we recommend PT or home exercise for full thickness rotator cuff tears? In select patients yes My opinion is that it may be effective in some
27 We know that tears have a high prevalence, but know relatively little about progression of tear size or tear symptoms Zingg et al. JBJS 2007 RC Management Natural History Large rotator cuff tears Motion stayed the same but» arthritis, size tear, atrophy 50% of tears became surgically irreparable
28 Natural History Yamaguchi et al. JBJS % of tears even if non painful will progress Patients treated without surgery should be followed regularly Change in symptoms may indicate tear enlargement
29 Mall et al. JBJS 2010 RC Management Natural History With development of pain,, size of cuff tear increased significantly» 40% of partial tears had progressed to full Those who remained asymptomatic had no change in tear size» Rate of tear progression 23% in symptomatic group versus 4% in asymptomatic group
30 Natural History Safran et al. AJSM 2011 Tear progression in symptomatic patients age 60 or less over 29 months» Tear progression more than 5 mm in 49%» No change tear size 43% Found correlation between in pain and increase in tear size at final ultrasound eval
31 Consensus Guidelines
32 Surgical Management Multiple ways to repair open and arthroscopic More ways to fix something usually means we don t t have the answer
33 Surgical Management OPEN versus Mini OPEN Outcomes at 3 months better in mini open Final follow up no difference JBJS 2009
34 RC Management Mini Open versus Arthroscopic Mini-open good record» Reports of stiffness» 85-93% satisfaction Arthroscopic repairs» Less stiffness» Functional results equal to open» 90% Satisfied
35 Arthroscopic Repair RC Management Arthroscopic Repair» Started early 1990s» Avoid open complications» Diagnostic and therapeutic benefits» Decreased pain» Possible earlier rehab
36 Arthroscopic Repair Tear Configuration
37 Arthroscopic Repair Double Row Repair
38
39 Consensus Guidelines
40 Rehabilitation Depends on tear size and surgeon preference New concern about failure of tendon healing Galatz et al. JBJS 2004» 2 cm months after arthroscopic repair» ROM started POD #1» 17 of 18 did not heal» Excellent pain relief and function Results deteriorate at 2 years
41 Lee et al. Arthroscopy 2012 RC Management Rehabilitation Compared ROM and healing rates between 2 protocols after arthroscopic RCR Group 1» Early immediate rehab with unlimited PROM» Sling for 6 weeks then start AROM Group 2» Minimum PROM to prevent stiffness» Sling for 6 weeks then AROM
42 Lee et al. Arthroscopy 2012 RC Management Rehabilitation Improved 3 months In Group A No significant 1 year Repeat MRI showed re tears in:» 23.3% of cases in Group A» 8.8% of cases in Group B» Difference not significant (p=0.1)
43 Return to Activity Very slow and all patient should be educated about this in advance Functional recovery starts 3 months Improvement over one year, then stabilization Negative predictors include» Female sex» Heavy upper body work» Poor bone quality» Lack of tendon healing
44 Outcomes Clinical outcomes of large tears less satisfactory than small ones Re rupture rate high after large tears» But to confuse the issue even more Structural failure does not necessarily define clinical failure» Functional results in patient with healed tear are usually superior to those without healed tear but not always!
45 Outcomes May small tears with mean f/u 35 months Good or excellent result 76.1% Satisfied or very satisfied in 91.3% Supraspinatus completely healed in 71.8%
46 Outcomes May 2012 Retearing is relatively common» Has no effect on clinical result i.e. satisfaction, range of motion, strength and pain» Except patients who healed had better ability to perform activities of daily living
47 Jost et al. JBJS 2006 RC Management Outcomes Measured outcomes mean 7.6 years after structurally failed rotator cuff repair Clinical outcomes remained significantly improved over the preoperative state» Including pain, function, strength, satisfaction Harryman et al. JBJS 1991 In spite of these results most would agree functional results better with healed tear
48 Outcomes Factors associated with poor results?» Smoking» Diabetes» Tear size» Older age» Obesity» Workers compensation» Cervical disease» Medical comorbidities Mallon et al. JSES 2004
49 Consensus Guidelines
50 Previous focus of research has been on repair construct (suture material, type of repair) Weakest link = understanding biology Understand process of tendon degeneration in order to optimize healing» Natural history» Genetic predisposition» Disease prevention» Mechanism of failure RC Management Future Directions
51 Continued research on biology of treatment» Biologics» Gene therapy» Tissue engineering RC Management Future Directions
52 Case #1 Case #1 40 YO male I m m a dry waller, I was lifting a heavy bucket of mud at work and felt a sudden tearing sensation in my left shoulder
53 Inspection normal RC Management Case #1 Active flexion to only 30 Crepitus with ROM + Drop Arm Test Rotator cuff strength 4/5
54 Case #1 MRI Large acute rotator cuff tear Surgical management
55 Case #2 Case #2 58 YO female My right shoulder has been sore from repetitive use at the deli counter Pain with repetitive use, significant night pain when sleeping on the right
56 Inspection normal Good ROM No crepitus + Neer + Hawkins Negative empty can RC Management Case #2 5 of 5 rotator cuff strength
57 Case #2 No weakness Chronic onset of pain Therapy and injection If no improvement after 6 weeks consider MRI to rule out RCT
58 Summary Treatment algorithm for RCT even in 2013 is constantly evolving Much we still do not know about rotator cuff tears and their treatment Can be frustrating to patient and providers Know your patient and their expectations Educate your patient about outcomes Can be rewarded with good results
59 THANK YOU
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William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd.
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