Rotator Cuff Disease

Rotator Cuff Disease

Current Surgical Management

Chris Pullen

Historical Aspects

Codman in 1934 Impingement syndrome Arthroscopic SAD

Shoulder Arthroscopy

Rotator Cuff Disease

Tendinopathy/Impingement

Rotator Cuff Tear

Cuff Tear Arthropathy

PARTIAL THICKNESS TEARS

(IMPINGEMENT/TENDINOPATHY)

PTT –Surgery

Open Mini – open Arthroscopic*

PTT - Arthroscopy

Advantages Visualisation Treatment

articular tears

PTT - Arthroscopy

Bursal surface tear SAD

Articular surface tear Debridement

only Repair

>50% Thickness tear

Active patients

PTT - Arthroscopy

Results Debridement +/- SAD Repair

FULL THICKNESS TEARS

FTT - Surgical Approaches

Arthroscopic* Arthroscopic assisted/mini-

open* Open

FTT - Arthroscopic RCR

Gleno-humeral Joint PTT Labral tears Ligament injuries Cartilage tears

Significant lesions in 12.5%

FTT – Arthroscopic RCR

Repair Site Preparation Removal of

ragged or degenerate tissue

Decortication of bone


Suture Placement


Anchor Placement Foot print Double row

technique


Other Tendon Lesions Infraspinatus Teres minor Subscapularis Biceps


Biceps Debridement Tenotomy Tenodesis


Post – operative Treatment Sling Cryotherapy PROM AROM Strengthening


Results 90% satisfaction 78% pain relief AROM

MASSIVE TEARS

Massive Tears – Surgery

Debridement Open Arthroscopic*

Rotator Cuff Repair* Tendon transfer* Synthetic interposition Arthrodesis Arthroplasty

Massive Tears - Debridement

Debridement alone Low demand patients Results tend to deteriorate over time

Arthroscopic debridement easier more rapid rehabilitation

Massive Tears - Debridement

Limited acromioplasty coracoacromial arch is maintained

Biceps tenotomy / tenodesis subluxation, dislocation, or partial

tearing enhance the ability to alleviate shoulder

pain

Massive Tears - RCR

Good function & pain relief 80-90% Goal of surgery is to repair the cuff

without disrupting the coraco-acromial arch

Massive Tears - RCR

Rehabilitation Sling / Abduction splint PROM AAROM Strengthening

Overall recovery may take >12 months

Massive Tears - RCR

Results Inferior Better within 6 weeks (Bassett &

Cofield 1983) Shoulder dislocation >40

85-90% good to excellent ( Bigliani 1992)

Massive Tears – Tendon transfer

Latissimus Dorsi* Pectoralis Major* Teres Minor Subscapularis Deltoid muscle flap Trapezius

Massive Tears – Latissimus Dorsi

Supraspinatus/Infraspinatus loss Restore ER & head depression

forces

Massive Tears – Latissimus Dorsi

Results 82% satisfactory (Miniaci & MacLeod

1999) Intact subscapularis Little or no restoration of strength in

overhead activity

Massive Tears – Pectoralis Major

Subscapularis tears

Massive Tears - Reconstruction

Tissue implants Autologous Autogenous

Freeze-dried cadaveric tissue

CUFF TEAR ARTHROPATHY

CTA - Surgery

Arthroscopic debridement* Humeral tuberoplasty Shoulder arthrodesis Total Shoulder Replacement Hemiarthroplasty* Reverse Shoulder Arthroplasty*

CTA - Hemiarthroplasty

Indications <70 years Active elevation

>90°

CTA Head Variation of the

hemiarthroplasty


Results Functional results limited, pain relief is excellent

(Williams & Rockwood 1996) Zuckerman et al (2000) decreased pain,

increased FF86 & ER 30. Sanchez-Sotelo et al (2001) 67%

successful at 5 year follow-up


Results intact

coracoacromial arch essential

CTA- Reverse Shoulder Arthroplasty

Semiconstrained reverse ball and socket

Grammont 1985

CTA - RSA

Biomechanics (Boileau et al 2005) Large glenosphere Medialisation of the centre of rotation Lowers humeral head

CTA - RSA

Indications > 70 years or no active elevation Low demand

CTA - RSA

Results (Boileau et al 2005, De Buttet et al 1997, Rittmeister et al 2001)

Excellent pain reduction Improved active abduction

CTA - RSA

Complications High Rate revision is

high (4.2-13%)

Not for the occasional operator

REHABILITATION

Rehabilitation -Biomechanics

Rotator Cuff Stabilises gleno-humeral joint Depresses the humeral head

Protective overlap Subscapularis

Scapulo-thoracic dyskinesia Compensatory impairment leads to

winging Alter orientation of the acromial arch

Rehabilitation – Tendon Healing

Spontaneous healing ??

Phases Inflammatory Proliferative Maturation

Maximal load to failure 12-26 weeks

Rehabilitation - Immobilisation

Early ROM Abduction splint

Shoulder immobilisation with an abduction-type splint for 4-6 weeks

Rehabilitation - Cryotherapy

Speer et al 1996 Less pain 1st 24 post-operative hours Better sleep Lesser analgesic requirement Less swelling Better able to tolerate rehabilitation

Rehabilitation - PTT

Goals Full ROM Reducing impingement

Physical therapy plus exercise program better than exercise alone

Rehabilitation - RCR

Goals Mobilise the joint early Load the repaired tendons safely Strengthen the rotator cuff

progressively

Rehabilitation - RCR

Phases1. Immediate post-operative period

(week 0-6)2. Protection & active ROM (week 6-12)3. Early strengthening (week 10-16)4. Advanced strengthening (week 16-22)

Rehabilitation – Phase 1 Goals

Maintain / Protect repair integrity Gradual increase PROM Diminish pain & inflamation Prevent muscle inhibition

Exercises Sling/abduction splint 6 weeks Immediate PROM (depends on repair

tension) Pendular exercises Cryotherapy Hydrotherapy

Rehabilitation – Phase 2

Goals Allow healing of soft tissue Do not overstress healing tissue Gradually restore full PROM

Exercises Continue PROM Introduce AAROM ADL permitted Hydrotherapy Pulleys


Goals Maintain Full PROM Full AROM Dynamic shoulder stability Restore shoulder strength & endurance Gradual return to functional activities

Exercises Continue PROM & Stretching Progressive strengthening Proprioceptive activities


Goals Maintain full AROM Advanced muscle strengthening exercises Gradual return to full functional activities

Exercises Continue stretching Continue progression of strengthening Light sports (golf chip/putt, tennis ground

strokes)

THE END

1. Yes 2. Size 3. Latissimus Dorsi 4. 12-26 weeks 5. 6 weeks

Rotator Cuff Disease

Documents

Transcript of Rotator Cuff Disease