Adam NorfolkLock Haven University

Physician Assistant Program

A rotator cuff tear pertains to the “disease or injury to one or more of the four muscle tendon units that help secure the shoulder girdle.”

The “SITS” muscles include:-Supraspinatus (most commonly injured)-Infraspinatus-Teres Minor-Subscapularis

Codman reportedly performed the first open rotator cuff repair in 1911

Severity •Partial-thickness tear: Partial fraying or tearing of an intact RC tendon. •Full-thickness tear: tear through the entire tendon. Can be small pin-point tears or larger button hole tears that involve the majority of the tendon. (Maintains functionality)•Full-thickness tear with detachment of tendon: (Non-functioning)

Full thickness rotator cuff tear

•U-Shaped•Crescent-shaped•L-shaped

•Large chronic rotator cuff tear•Reattaching supraspinatus and infraspinatus to greater tuberosity of the proximal humerus

•Extrinsic: Subacromial bone spurring, which rubs on the tendon during arm elevation (Shoulder Impingement Syndrome), compromising the integrity of the tendon.

•Overhead activities, weight training, sports•Intrinsic: Age-related factors, such as decreased blood supply to the tendon contributing to tendon degeneration and complete tearing

•Trauma, such as direct falls, are most often associated with degenerative-type tears

•5-10% of the population will suffer from a rotator cuff tear at some point in their lives•4% < 40 years of age•50% > 60 years of age •Average age: 57.6 years

•> 40 years of age•Smokers•Multiple steroid injections•Men

•Inspection: Chronic RCT may reveal muscle atrophy/asymmetry•Pain: anterolateral aspect of shoulder distal humerus

•Studies reveal patients being diagnosed with RTC via MRI whom never complained of pain prior to exam

•Decreased strength: *Drop arm sign*•Decreased ROM:

•IR, ER, Abduction, Adduction, elevation

•Adhesive capsulitis (Frozen Shoulder•Biceps Tendinitis•Glenohumeral instability•Acromioclavicular degenerationthe joint.•Glenohumeral joint arthritis•Referred pain: MI, cervical radiculopathy, Gallbladder disease

Supraspinatus testing: external rotation and abduction•Jobe’s Test/Empty CanPlacing the arm in 90 degrees of abduction in the scapular plane with the thumbs down and asking the patient to resist downward pressure. + Test = Pain and decr strength

Subscapularis testing:•Lift-off test and Abdominal Compression Test:

•Lift-off test: Testing the superior portion of subscap•Abdominal compression test: Inferior subscapularis

Posterosuperior Rotator cuff tear•Lag Sign: placing the arm in maximal external rotation. A large massive tear will not be able to maintain this position and will swing forward in neutral position.

Teres Minor tear:•Hornblower’s Sign: unable to externally rotate to 90 degrees with the arm in abduction

•History•Physical exam•Imaging:

•MRI: Reveals retraction of the muscle, atrophy of the muscle belly and proximal migration of the humeral head in relation to the glenoid, and fatty infiltration of the around the cuff .

•X-Ray: •AP view showing < 7mm from proximal humeral head to subacromial surface due to anterior and superior migrating of the humeral head from RCT. •May also see degenerative changes and subacromial spurring.

Magnetic resonance image shows a tear within the supraspinatus tendon.

Plain radiograph of the shoulder (AP view) showing reduced subacromial space (black arrow) and acromioclavicular joint osteoarthritis (white arrow).

•Conservative (Nonsurgical)•Physical Therapy and behavior modification •Downfalls of conservative therapy:

• idecreased strength •tears increasing in size •muscle retraction

•Surgical•Open repair:•Mini-open repair (Gold Standard): 3-5cm incision•All-arthroscopic : ~1cm incisions

•No tear can be considered irreparable until a repair is attempted

1. Arthroscopically assisted open repair, which consists of

arthroscopic subacromial decompression followed by open repair of the rotator cuff through a lateral deltoid-splitting approach.

2. Mini-open arthroscopically assisted repair, which includes arthroscopic subacromial decompression, release of adhesions, placement of tagging sutures, and debridement of the tendon edges followed by a mini-open deltoid-splitting approach to obtain suture management and bone-tendon fixation.

3. Complete arthroscopic repair, in which subacromial decompression, release of adhesions, and bone-tendon fixation are all carried out in an arthroscopic fashion.

•Patient's expectations•The pathoanatomy of the cuff•Surgical experience of the surgeon

Intraoperative photograph of an open rotator cuff repair illustrating the typical size of a surgical incision.

In this intraoperative photograph, the typical incision size for a mini-open rotator cuff repair is shown in black on a patient's left shoulder. The yellow arrow indicates the incision used to perform the arthroscopy.

Arthroscopic photographs of a rotator cuff tear and the Sutures (green) used to reattach the tendon back to bone.

•Preservation of the deltoid origin•Adequate decompression of the subacromial space by resection of anteroinferior osteophytes•Surgical releases to obtain mobile muscle-tendon units•Secure fixation of the tendon to the greater tuberosity•Early rehabilitation including passive motion with a protected range

Do patients, aged 20-60 who undergo rotator cuff repair surgery, experience less morbidity from rotator cuff tears when treated Arthroscopically versus using Open and Mini-Open techniques, such as less hospital stay, decreased pain, improved cosmesis, and quicker time returning to activity or sport?

The true incidence of rotator cuff tears in the general population is difficult to determine because 5% to 40% of people without shoulder pain may have a torn rotator cuff. This reveals that it is possible to manage RCT without surgical intervention.

Meta-analysis of the surgical repair of rotator cuff tears: A comparison of arthroscopic and open techniques

Open repair results: Metcalf 2003

Mini-open repair results:

All-arthroscopic repair results:

Author Satisfied Patients Range of Motion Improved Strength Improved

Ellman 98% Yes Yes

Hawkins et al 94% Yes Yes

Cofield 77% Yes Yes

Author Satisfied Patients Range of Motion Improved Strength Improved

Lefy et al 96% Yes Yes

Paulos et al 94% Yes Yes

Blevins et al 89% Yes Yes

Author Satisfied Patients Range of Motion Improved Strength Improved

Tauro 92% Yes Yes

Gartsman 90% Yes Yes

Wilson 88% Yes Yes

•If one does decide to have their rotator cuff surgically repaired, it is important to know that 80-90% of patients will have successful outcomes.

•Adequate pain relief•Restoration or improvement of function•Improved ROM•Patient satisfaction with the procedure

•Downfalls to using arthroscopy:•Decreased comfort level due to an increase in technical skill•Higher rate of tendon re-tear with all-arthroscopic repair versus using an open procedure (6%)

•Downfalls to using open:•Deltoid detachment is an operative disaster (< 1%)•Open and Min-Open rotator cuff repair requires the dissection and manipulation of the deltoid muscle compromising its integrity. •Increased risk of infection•Axillary Nerve injury ( 1-2%)(Harryman: Repairs of the rotator cuff: Correlation of functional results with integrity of the cuff)

•Re-tear rate is 41% with individuals who have had more than two rotator cuff tendons repaired arthroscopically.

•Overall re-tear rates begin to rise when patients reach > 65 years of age

Galatz, L.M., Craig, M., Teefey, S., Middleton, W.D., Yamaguchi, K. (2004). The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears, The Journal of Bone and Joint Surgery, 86:219-224.

Arthroscopic repair of full-thickness supraspinatus tears achieves a rate of complete tendon healing equivalent to those reported in the literature with open or mini-open techniques.

Fig. 5 The prevalence of tendon healing according to age.

•Results of arthroscopic repairs of isolated supraspinatus tears are equal to those reported following open repair

•25% re-tear rate with patients associated with muscular atrophy and fatty infiltration preoperatively

•Early diagnosis and treatment of RCT prevents problems associated with chronic tears, such as atrophy and fat infiltration

Dennis Liem, MD1, Sven Lichtenberg, MD2, Petra Magosch, MD2 and Peter Habermeyer, MD2 (2007). Magnetic Resonance Imaging of Arthroscopic Supraspinatus Tendon Repair, The Journal of Bone and Joint Surgery (American). 89:1771-1776.

•Comparison of patient populations with small (<1-cm), medium (1 to 3-cm), and large (>3 cm) tears revealed no differences in University of California at Los Angeles or American Shoulder and Elbow Surgeons (ASES) scores.

Also, no difference in outcome was noted among patients of different ages, suggesting that the arthroscopic repair is equally effective in all age groups, regardless of tear size.

Stollsteimer GT, Savoie FH 3rd. Arthroscopic rotator cuff repair: current indications, limitations, techniques, and results. Instr Course Lect, 1998;47: 59-65.

Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am, 1998;80: 832-40.

Nottage W, Severud E. A comparison of all arthroscopic vs. mini-open rotator cuff repair: results at 45 months. Read at the Summer Institute Meeting of the American Academy of Orthopaedic Surgeons; 2001 Sept 6-9; San Diego, CA.

•Patients seeking pain relief may pursue arthroscopic repair •Open or mini-open repair for patients who are concerned about loss of strength that require a more solid repair. •Open and mini-open can be structurally more sound due to direct visualization of suture placement and knot tying.

Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD, Steven Klepps, MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons, The Journal of Bone and Joint Surgery (American) 85:144-155

•A patient with a repairable tear and little muscle atrophy who is seeking strength more than pain relief may wish the most mechanically secure repair, such as the mini-open or open procedure.

•An elderly patient with a very large defect and muscle atrophy, where deltoid preservation and reduced

morbidity are of paramount importance, may benefit more from the less invasive arthroscopic repair.

Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD, Steven Klepps, MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons, The Journal of Bone and Joint Surgery (American) 85:144-155

Pros for Open technique:•Direct visualization of rotator cuff (detached deltoid)•Quicker OR time•Increase in knot security

Mini-Open Advantages•“Best of both worlds approach”•Better visualization•Decreased OR time•Less post-operative pain versus Open technique•Increased security while placing your knots •Open and mini-open can be structurally more sound due to direct visualization of suture placement and knot tying.•Less scaring versus Open•Less trauma to deltoid

Pros of Arthroscopy:•Improved cosmesis•Less invasive•Decreased surgical insult to the deltoid•Decreased immediate postoperative Pain and better rehabilitation•Decreased postoperative stiffness •Any size of tear can be repaired arthroscopically without compromising the result

Multiple factors affect the outcomes of treatment of rotator cuff disease:•Understanding tear patterns•Restoring normal anatomy•Decreasing tension at the repair site

•Currently there is a lack of High-Quality Randomized Controlled trials explaining which technique is preferred, a common theme regarding surgical intervention studies. •There is clinically no long-term difference in outcome when comparing the three techniques mentioned•Less invasive techniques show improvements within the first 3 months post-operation, unlike open techniques

•Any of the three repair techniques for rotator cuff tear can be beneficial and increase patient satisfaction outcomes•It is important to decrease one’s pain, improve strength, and return to ADL•With certain factors included in an arthroscopic case, re-tear rates and defect may be encountered•Further research is require•Treatment of rotator cuff tears is dependent more on the individual expertise of the surgeon, than the technique chosen to accomplish the repair.

•Morse, K., Davis, A.D., Afra, R., Kaye, E.K., Schepsis, A., Voloshin, I. (2008). Arthroscopic Versus Mini-open Rotator Cuff Repair. The American Journal of Sports Medicine, vol. 36 no. 9 1824-1828.•Mohtadi, N.G., MD, Hollinshead, R.M., MD, Sasyniuk, T.M., MD, Fletcher, J.A., MD, Chan, D.S., MBT, Li, F.X., MD (2008). A Randomized Clinical Trial Comparing Open to Arthroscopic Acromioplasty With Mini-Open Rotator Cuff Repair for Full-Thickness Rotator Cuff Tears. The American Journal of Sports Medicine, vol. 36 no. 6 1043-1051.•Vaccaro, A.R., MD, FACS (2005). Orthopaedic Knowledge Update. Rosemont, IL: American Academy of Orthopaedic Surgeons.•“Rotator Cuff Tendinitis and Tear” UpToDate. http://www.uptodate.com/online/content/topic.do?topicKey=bone_joi/11463&selectedTitle=14~150&source=search_result#27: Archived on January 27th, 2009. “Rotator Cuff Tears and Treatment Options” •American Academy of Orthopaedic Surgeons.http://orthoinfo.aaos.org/topic.cfm?topic=A00406: Archived January 27, 2009.•Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005619. DOI: 10.1002/14651858.CD005619.pub2.• Burns, J.P., Snyder, S.J., Albritton, M., Arthoscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers, Journal of the American Academy of Orthopaedic Surgeons 2007, Vol 15, No 7, 432-444. •Green, A., Chronic Massive Rotator Cuff Tear: Evaluation and Management, Journal of the American Academy of Orthpaedic Surgeons 2003, Vol 11, No 5•Metcalf M, Savoie FS, Smith KA, Matsen FA: Meta-analysis of the surgical repair of rotator cuff tears: Comparison of open and arthroscopic techniques, in Proceedings from the AAOS 2003 Annual Meeting. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, paper 266.•Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB: Abnormal findings on magnetic resonance of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-15. 7822341

•Ianotti JP, Naranja J, Gartsman G: Surgical treatment of the intact cuff and repairable cuff defect: Arthroscopic and open techniques, in Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 151-155. •Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD, Steven Klepps, MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons, The Journal of Bone and Joint Surgery (American) 85:144-155•Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am, 1998;80: 832-40.•Weber S. Comparison of all arthroscopic and mini-open rotator cuff repairs. Read at the Annual Meeting of the Arthroscopic Association of North America; 2001 Apr 19-22; Seattle, WA. •Nottage W, Severud E. A comparison of all arthroscopic vs. mini-open rotator cuff repair: results at 45 months. Read at the Summer Institute Meeting of the American Academy of Orthopaedic Surgeons; 2001 Sept 6-9; San Diego, CA. •Stollsteimer GT, Savoie FH 3rd. Arthroscopic rotator cuff repair: current indications, limitations, techniques, and results. Instr Course Lect, 1998;47: 59-65. •Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am, 1991;73: 982-9. •Dennis Liem, MD1, Sven Lichtenberg, MD2, Petra Magosch, MD2 and Peter Habermeyer, MD2 (2007). Magnetic Resonance Imaging of Arthroscopic Supraspinatus Tendon Repair, The Journal of Bone and Joint Surgery (American). 89:1771-1776. •Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am, 1998;80: 832-40.•Andrew C. Gerdeman, MD1, MaCalus V. Hogan, MD1 and Mark D. Miller, MD (2009). What’s New in Sports Medicine, The Journal of Bone and Joint Surgery (American), 91:241256.