8/8/2017. Partial Rotator Cuff Tears. Disclosures. Prevalence. Geoffrey S. Van Thiel, MD/MBA OrthoIllinois

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1 Partial Rotator Cuff Tears Geoffrey S. Van Thiel, MD/MBA OrthoIllinois Associate Professor Rush University Medical Center Associate Professor University of Illinois Team Physician US National Soccer Team Team Physician Chicago Blackhawks Medical Network Ice Hogs : VanThielMD@orthoillinois.com Disclosures Please visit the AAOS website for a complete list of disclosures Prevalence Milgrom et al. - full or partial thickness rotator cuff tears of 5% 11% in subjects aged but 80% in those aged 70 years or older. Throwing athlete - Connor et al. MRI asymptomatic elite athletes. Rotator cuff tears in 40% in the dominant throwing shoulder. Importantly, at a 5-year follow-up, none of the athletes developed shoulder symptoms. 1

Why? Intrinsic factors Age-related (hypocellularity, fascicular thinning, and granulation tissue) and decreased

degenerative tearing and change in intratendinous strain Extrinsic factors Subacromial impingement Glenohumeral

The rotator cable (Burkhart) surrounds a thinner area (the crescent region) and mechanically protects avascular crescent

2 Why? Intrinsic factors Age-related (hypocellularity, fascicular thinning, and granulation tissue) and decreased vascularity of the tissues. degenerative tearing and change in intratendinous strain Extrinsic factors Subacromial impingement Glenohumeral instability Internal impingement Where? The rotator cable (Burkhart) surrounds a thinner area (the crescent region) and mechanically protects avascular crescent region Cable: At margin of the avascular zone Function similar to suspension bridge Crescent: Zone of hypovascularity just lateral to the rotator cable, located at the insertion of the rotator cuff Where Internal Impingement Contact between the articular side of the rotator cuff an the posterior-superior glenoid Jobe 92 2

intact tendons and articular surface PTRCTs involving

Diagnosis Painful arc of motion Crepitus Weakness

3 Where? Intra-Tendinous Shearing of Cuff - Fukuda Why Painful? Mazzocca et al. found an increase in rotator cuff strain between intact tendons and articular surface PTRCTs involving > 50% of the tendon thickness. Diagnosis Painful arc of motion Crepitus Weakness Positive impingement signs Difficulties with overhead activities or overhead sports are common. Due to the high prevalence of asymptomatic PTRCTs correlate with imaging 3

Classification Classification system does not take into account an analysis of tissue quality The area of tearing The etiology of the tear itself.

4 Classification Classification system does not take into account an analysis of tissue quality The area of tearing The etiology of the tear itself. Treatment Initial treatment of PTRCTs is non-operative. Optimal treatment of PTRCTs is multifactorial Patient s age Symptoms Functional deficit, Size of the tear Tear location (bursal versus articular), Nature of onset (degenerative versus traumatic) Do They Heal? Hypo-vascularity in the critical zone of the tear site The effect of subacromial impingement Spontaneous healing with non-operative treatment has rarely been reported Furthermore, the progression of symptomatic PTRCTs to full- thickness RCTs has been reported in up to 50% of cases - Yamaguchi K et al 4

of 96 cases Hyvönen, JBJS-Br 1998 Treatment Failure of Conservative Management Extent of tear (<50% vs.

5 Do They Heal? Serial arthrography illustrated a 28% progression rate & a 53% enlargement rate in a study of 40 pts Yamanaka, CORR 1994 Tears have been shown to progress despite subacromial decompression in a study of 96 cases Hyvönen, JBJS-Br 1998 Treatment Failure of Conservative Management Extent of tear (<50% vs. >50% of the tendon thickness) Location (articular, bursal, intratendinous) Define associated pathology What to Do? Debridement Good results, but most studies have associated procedures Debridement does not appear to invoke an active healing response & histologic sections of partial cuff tears show no signs of ongoing repair Fukuda, JSES 2000 Repair Weber et al PTRCTs involving >50% of the tendon thickness. Superior outcomes in patients following rotator cuff repair versus debridement 5

6 What to Do? Repair Technique Articular Side Repair if greater than 50% or 5 mm tear Leave bursal cuff intact If less than 50% debride and treat associated pathology Bursal Side Take down standard cuff repair Intratendinous Treat like articular sided Repair Technique Articular Sided and Intratendinous Repair Technique Articular Sided 6

Repair Technique Bursal Side Results The repair

arthroscopic debridement of bursal-sided compared to

7 Repair Technique Bursal Side Results The repair technique did not significantly affect the outcomes for arthroscopic repair of PTRCTs >50%. Inferior outcomes and higher failure rates after arthroscopic debridement of bursal-sided compared to articular-sided PTRCTs Biologic Augments No Evidence However, kind of cool.. 7

8 Thank You Geoffrey S. Van Thiel, MD/MBA 8

ROTATOR CUFF DISORDERS/IMPINGEMENT

ROTATOR CUFF DISORDERS/IMPINGEMENT Dr.KN Subramanian M.Ch Orth., FRCS (Tr & Orth), CCT Orth(UK) Consultant Orthopaedic Surgeon, Special interest: Orthopaedic Sports Injury, Shoulder and Knee Surgery, SPARSH