The Irreparable Rotator Cuff Tear:
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- Corey Glenn
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1 The Irreparable Rotator Cuff Tear: Trauma 101: Shoulder Session #2 Brian Grawe, MD Assistant Professor Orthopaedics & Sports Medicine 5/10/2018
2 Brian Grawe, MD Assistant Professor Phone Number: I HAVE NO DISCLOSURES or COI
3 Outline Background Definition & Classification Pathomechanics Clinical Presentation Treatment Options Summary
4 20 second TO : What this talk is NOT Comprehensive review of literature for treatment options for the irreparable rotator cuff tear Endorsement of any one treatment strategy Comprehensive review of rotator cuff tear arthropathy
5 Background: Rotator Cuff Disease Epidemiology Millions of Americans have some aspect of rotator cuff disease Full-thickness tear 28% (> 60 yo) 65% (>70 yo) Those with asx tear 50% chance of developing sxs w/in three years 40% chance of tear progression
6 Background Irreparable Rotator Cuff Tear (IRCT) Complex clinical spectrum Lack of consensus (regarding treatment) Progression Fatty infiltration Tendon retraction Inelastic tissue Scar & adhesion formation Repair Unpredictable Highly morbid
7 Definition & Classification Massive tear Irreparable tear Lack of healing potential Not technical feasibility Size (USA) Cofield JBJS 1985 > 5 cm # of Tendons (Europe) Gerber JBJS 2000 Prognosis, function, outcome Consider: amount of humeral head exposed, tear pattern, tissue mobility
8 Pathomechanics Suspension Bridge Force Couple Impoverished biologic environment Attritional Concavity-Compression changes to tendon Attritional Cuff centers changes the to muscle head Relative hypovascularity JBJS 1999 & 2007
9 Clinical Presentation (IRCT Pearls) History Determine CC Pain? Weakness? Was there an acute event? Tear extension Effect early tx Physical Exam Pseudoparalysis Pain? Fulcrum loss? CA arch violation Escape Fossae atrophy Lag signs JBJS Br 1998
10 Clinical Presentation (IRCT Pearls) Radiographs AHI < 5mm CORR 1990 Fatty infiltration JSES 2008 MRI Size Retraction Fatty infiltration Stage 3 & 4 no improvement after repair (AJR 2005) ***U/S cannot determine reparability***
11 Treatment Options Nonoperative vs.who, What, Where, How, Why, and When? Operative TAYLOR THE PLAN: patients goals, symptoms, demands (patient and shoulder) remember the snowflake
12 Treatment Nonoperative Physical therapy Subscap; trapezieus; ANTERIOR DELT Scapular stabilization Corticosteroid injection PT participation Defines true pseudoparalysis v pain Treat people not x-rays JBJS 2008 & 2012
13 Treatment Operative Arthroscopic Reconstruction Superior Capsule Grafts Tendon Transfers Arthroplasty Hemi RSA
14 Treatment: Arthroscopic Rotator cuff debridement Burkhart CORR 1991; Gartsman JBJS 1997 Partial Repair (margin convergence) (HH coverage) Burkhart Arthropscopy 1994; Duralde JSES 2005 Reverse decompression (tuberoplasty) (maintains arch) Fenlin JSES 2002 Biceps tenotomy Walch JSES 2005; Boileau JBJS 2007 Suprascapular nerve release Lafosse Arthroscopy 2007 Eliminate all pain generators!!! Steroid restores elevation or not ready for arthroplasty Bad OA or significant cuff atrophy
15 Treatment: Reconstruction (Salvage?) Superior capsule (NKOTB) Biomechanical sound Mihata AJSM 2016 Clinical results promising Mihata Arthroscopy 2013 Tendon Transfer (<50, weakness, ready for rehab) Lat Dorsi Gerber CORR 1992 Pec Major Elhassan JBJS 2008 Scaffolds (bridge) beyond scope Data is conflicting & conflicted
16 Treatment: Arthroplasty Hemiarthroplasty Balance mechanics - AKA - Preserved coronal plane force couple (intact subscap) Conventional 67% or 63% good results; previous SAD bad Sanchez Sotelo JBJS 2001 Field JBJS 1997 EAS head Copeland J Surg Orthop Adv 2009 Function and cost better with RSA Leung JSES 2012; Leung JSES 2012
17 Treatment: Arthroplasty Reverse Shoulder Replacement (RSA) TSA leads to loosening via rocking horse Franklin & Matsen Arthroplasty 1988 COR moved medially (not too much) and distally Improve fulcrum of deltoid (lengths momement arm and tensions) Prosthesis more constrained; more stable Higher complication rate
18 Treatment: Arthroplasty Reverse Shoulder Replacement (Results) Grammont s modification (invented for CTA) Clinical Success Boileau JSES 2007 Wall JBJS 2007 Frankle JBJS 2010 DO s Elderly; low demand; arthropathy; consider lat tranfer too DON T s Young age; high function preop; neurologic dysfunction Maybe s Revision surgery; no pseudoparalysis; severe concomitant cervical radiculopathy
19 Case 1: LE 47 yo male s/p MVC Poly trauma: flail chest, bilateral shoulder injuries w/ acromial fracture ORIF Underwent attempt at RCR failed Now 8 months from initial injury
20
21 Case 1: LE Summary Chronic subscap, supra, and infra tear Failed previous repair attempt Significant atrophy of supra Plan Pectoralis major transfer SCR
22 Case 1: LE * Pec transfer: under coracoid * ASES: ** ** *Back to work
23 Summary Treat all patients like snowflakes Define expectations early Consider injection to define pseudoparalysis PT should focus on ANTERIOR DELTOID Arthroscopic surgery can help in certain pts RSA should not be take lightly Good pain control Overhead power less reliable Complication rate relative high
24 END Thank you! Questions / Comments
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