Download - Rotator cuff Tear and its management
![Page 1: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/1.jpg)
Rotator cuff tear: Basic understanding and treatment
options
Dr Rohan VaktaM.S.OrthoAASH Arthroscopy Center Ahmedabad,India
![Page 2: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/2.jpg)
They Fuse together with the articular capsule into a common insertion on the tuberosities of the humerus, which is known as the footprint of the rotator cuff.
![Page 3: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/3.jpg)
Action of rotator cuff
Rotator cuff acts as a mechanical couple in conjunction with Deltoid in shoulder rotation & elevation
![Page 4: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/4.jpg)
Important functions:• Counterbalance the upward pull of the deltoid on the
humerus.• Hold the head of the humerus secure in the glenoid.• Externally rotate the shoulder which is important
during arm elevation.
![Page 5: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/5.jpg)
Etiology
Traumatic
high velocity trauma ( partial- or full-thickness tears)
Repetitive microtrauma (overuse, athletic)
Non-Traumatic
(Age <40 years)
(Age >40 years)
![Page 6: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/6.jpg)
Non-Traumatic
•Degenerative (Work related: Painters,electrician)•Subacromial Impingement syndrome
•Developmental Factors : Os acromiale , Type 2 or 3 acromion
![Page 7: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/7.jpg)
• Others:o Shoulder Instabilityo Inflammatory dz : Calcific tendinitis/RA/Crystal
induced arthropathyo Scapulohumeral neuromuscular dysfunction:o Entrapment syndromes
Non-Traumatic
![Page 8: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/8.jpg)
p
![Page 9: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/9.jpg)
Crescent Reverse ‘L’ ‘L’ Shaped
Trapezoidal Massive tearFull Thickness Tear
![Page 10: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/10.jpg)
Pathophysiology
Torn Rotator Cuff
Can not Counterbalance the upward pull of the deltoid on the humerus
Not able to Hold the head of the humerus secure in the glenoid
AHD <6mm
![Page 11: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/11.jpg)
Leads to abutement of humeral head against acromion
Acetabulization: Concave deformity of under surface of Acromion
![Page 12: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/12.jpg)
Narrowing & Arthritis of Gleno-Humeral Joint
Last stage of Cuff tear arthropathy with collapse of humerus head
![Page 13: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/13.jpg)
Hamada and Fukuda Stages of Cuff Arthropathy
![Page 14: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/14.jpg)
History
• Pain around shoulder• Sleep disturbed by pain• Weakness during activities of daily living• Previous trauma• Time lag before presentation• Occupation• Predominant hand
![Page 15: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/15.jpg)
Physical Examination
• Passive and Active ROM• Strength of motions• Supraspinatus : Resisted elevation of arm kept in "empty can" position
![Page 16: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/16.jpg)
• Subscapularis “ Lift-off test”
•Infraspinatus : Resisted External Rotation
•Teres minor:Resisted external rotation with arm abducted more than 45°.
![Page 17: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/17.jpg)
Impingement Test
• Hawkin-kennedy test• Injection test:Very effective test
for diagnosis • Approx 7-10 ml of Xylocaine
injected in subacromial bursa• Wait for 2-3 minutes• Pain in ROM will be minimal• D/D between impingement &
RC tear
![Page 18: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/18.jpg)
Ultrasonography•Dynamic
•Non-invasive
•Inexpensive
•Helpful as a screening tool
•USG guided Injection
![Page 19: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/19.jpg)
M R I
T2 images -Presence of fluid in the subacromial spaceT1 images- loss of the subacromial fat plane, and proliferative spur formation of the acromion and/or acromioclavicular joint. Discontinuity of the tendon.Size of tear , retraction of tendon
![Page 20: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/20.jpg)
Treatment of Rotator Cuff Tears
o Conservative :
Physical Therapy ± Injection treatment
Indication: • Medical Cormodities• Relatively Inactive lifestyle• Patients not willing for post-op
rehab.
![Page 21: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/21.jpg)
Surgical Management
four major objectives: (1) closure of the cuff defect.(2) eliminating impingement.(3) preserving the origin of the deltoid muscle.(4) preventing adhesions postoperatively without
disturbing the repair by a careful exercise program
Open(not recommended)
Mini-Open Arthroscopic
![Page 22: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/22.jpg)
Mini open repair
• Midway between open & arthroscopic repair• Less than 5 cms. incision in the line from
centre of acromion • Axillary N. should be protected, 5 cm. below
acromial line• Deltoid splitting approach, not erased
Cl. Acr.
![Page 23: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/23.jpg)
Mini open RC repair• Identify bursa• Mimics rotator cuff• Bursectomy• Tear evaluation• Preparing foot print• Freshning of tear• Transosseus sutures or suture anchor cuff repair• Meticulous Deltoid repair
Torn cuff
![Page 24: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/24.jpg)
Arthroscopic rotator cuff repair
• Lateral or Beach chair position• Hypotensive anaesthesia• Pressure pump- Very useful• Skin marking of landmarks• GH arthroscopy- frayed intra- articular RC debrided
![Page 25: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/25.jpg)
Arthroscopic rotator cuff repair
• Scope moved to sub acromial area• Bursectomy & SAD for impingement• LAP ( Lateral acromial portal)– main viewing portal• Ant. & post. Working portals• SOS-Mini or complete distal clavicle resection
![Page 26: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/26.jpg)
Arthroscopic rotator cuff repair
• Bone at insertion site & Gr. tuberosity- lightly burred• Torn edges of cuff debrided• Tear pattern assessed- Y or V• Repaired with suture anchors & side to side sutures• Preserve CA lig. in massive tear• Repair checked- No tension repair
![Page 27: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/27.jpg)
Arthroscopic rotator cuff repair
![Page 28: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/28.jpg)
Arthroscopic SADRemoval of inferior part of anterolateral acromion
Open SAD • No morbidity• Genuine benefit
Arthroscopic
![Page 29: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/29.jpg)
Arthroscopic rotator cuff repair
Post. Op. regimen• Shoulder immobilizer for 6 weeks• Post. op physiotherapy is as important as good surgery• Recovery time 12 to 16 weeks• Total time 1 year
![Page 30: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/30.jpg)
Arthroscopic cuff repair• Tears of all sizes can be done arthroscopically- 95% tears can be repaired by an experienced surgeon• Minimal damage to Deltoid muscle- potential source of post-op morbidity in open repairs• Greater versatility for characterization, assessment, mobilization as well as fixation• Complete evaluation of Shoulder joint anatomy- PASTA, SLAP, Arthritis etc.•Day care surgery•Early & Easier postop rehabilitation
Deltoid detachment
![Page 31: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/31.jpg)
Despite these advantages, arthroscopic rotator cuff repair is technically demanding procedure that needs prerequisite skills as diagnostic shoulder arthroscopy, arthroscopic subacromial decompression, and arthroscopic knot tying in order for a surgeon to obtain proficiency in this procedure.
Arthroscopic cuff repair
![Page 32: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/32.jpg)
RC repair- Contraindications• Severe OA of Glenohumeral jt.• Medically unfit patient• Low activity level individual who can live with deficient shoulder
• Adhesive capsulitis• Failed prior RC surgery • Fatty infiltration in muscles
![Page 33: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/33.jpg)
Rotator cuff injuryIf not addressed in time…• Young active individuals- torn cuff cannot heal
to bone- late cuff arthropathy - continuous pain & weakness• Muscles undergo atrophy & fatty degeneration• Waiting too long- repairable cuff becomes irreparable with poor tissue & poor prognosis • At >1 year of f’up, a’scopic and mini-open rotator cuff repairs produces similar results with equivalent patient satisfaction rates
Fatty degeneration
![Page 34: Rotator cuff Tear and its management](https://reader035.vdocument.in/reader035/viewer/2022062513/556c7d74d8b42ac71e8b4c1c/html5/thumbnails/34.jpg)
Thank You