Massive Rotator Cuff Tears Pathophysiology and Treatment Options. Mike Walton Consultant Shoulder Surgeon Wrightington Hospital
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1 Massive Rotator Cuff Tears Pathophysiology and Treatment Options Mike Walton Consultant Shoulder Surgeon Wrightington Hospital
2 Tendon Structure Tendons are mechanically responsible for the transmission of muscle forces to bone Enthesis has four distinct zones; tendon, fibrocartillage, mineralised fibrocartillage (Sharpey s fibres) and bone. Enthesis is subjected to tensile, compressive and shear forces, which may be four times the force of that at the muscle mid-substance
3 Tendon Injury
4 Tendon Injury
5 Tendon Overuse Small repetitive strains lead to microinjuries Prostaglandins and Leukotrienes released PGE2 induces profound degenerative change when injected into tendon mid-substance LTB4 induces tendon oedema
6 Tendinopathy Lack of inflammtory cells in Chronic Tendinopathy
7 Tendinopathy Inflammation occurs in the early stages of tendinopathy Disappears once the degenerative process has begun? Explanation for frequent lack of pain
8 Tendinopathy Mechanotransduction Molecular and genetic level Complex cascade of extracellular matrix gene expression and protein synthesis
9 Tendinopathy Careful balance of these pathways appropriate positive change in tendon as a result of physical training negative degenerative changes
10 Normal Tendon
11 Tendinopathy Angiofibroblastic Hyperplasia (Nirchl, 1979) (i) increased cellular numbers (ii) neovascularisation (iii) increased neurochemicals (iv) disordered collagen matrix Tenocyte Apoptosis (programmed cell death)
12 Tendinopathy
13 Rotator Cuff Tears A Brief History Codman - Rim Rent of Supraspinatus Critical area of Hypovascularity Neer - External Impingement
14 Cuff EndoSkeleton SubS SupSp InfSp LHB
15 Cuff EndoSkeleton SubS SupSp InfSp LHB
16 Cuff EndoSkeleton SubS SupSp InfSp LHB
17 Cresent Tear SubS LHB SupSp InfSp
18 Tear Progression SubS SupSp InfSp LHB
19 Tear Progression SubS SupSp InfSp LHB
20 Massive Tear SubS LHB SupSp InfSp
21 Cuff Dysfunction ($)*'&+ Acromion!"#$%&'% Humeral Head Glenoid,'*-*'%./"0
22 Cuff Dysfunction ($)*'&+ Acromion!"#$%&'% Humeral Head Glenoid,'*-*'%./"0
23 Cuff Dysfunction ($)*'&+ Acromion Humeral Head!"#$%&'% Glenoid,'*-*'%./"0
24 Cuff Tear Arthropathy
25 Management Goals Reduce Pain Maintain Function
26 Management Options Restore Anatomy Rehabilitate Replace Remove Pain Generators
27 Treatment Options Restore Anatomy Rotator Cuff Repair Quality / Mobility - tendon and muscle
28
29 Treatment Options Restore Anatomy Rotator Cuff Repair Biology Viable tenocytes in massive cuff tears = 0 (Carr et al) Quality / Mobility - tendon and muscle Partial vs Complete repairs
30 Massive Tear SubS LHB SupSp InfSp
31 Treatment Options Restore Anatomy Tendon Transfers Latisimus Dorsi +/- Teres Major for Posterior Cuff Pec Major for Anterior Cuff
32 Treatment Options Remove Pain Generators (non-surgical) Analgesia Injections Nerve Blocks Suprascapular Lateral Pectoral
33 Treatment Options Remove Pain Generators (Surgical) Debridement / Decompression / Bursectomy / Tuberoplasty Retain CoracoAcromial Arch LHB Tenotomy / Tenodesis Suprascapular Neurectomy
34 Treatment Options Rehabilitation Painfree Passive ROM Anterior Deltoid Strengthening
35 Treatment Options Replace Hemiarthroplasty Reverse Geometry Shoulder
36 Thank You Any Questions?
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