Massive Rotator Cuff Tears. Rafael M. Williams, MD

Massive Rotator Cuff Tears Rafael M. Williams, MD

Rotator Cuff

MRI

Small / Partial Thickness

Medium Tear

Arthroscopic View

Massive Tear Fatty Atrophy

Arthroscopic View

MassiveTears Tear is > 5cm in size Generally retracted Involves more than one tendon

How can a shoulder still function with a massive RTC tear? Force coupling..

Force Coupling

What happens when force coupling doesn t work? Rotator cuff arthropathy

Rotator Cuff Arthropathy

Treatment Options Debride it (address AC joint) Fix it Arthroscopic vs. open Augment it Tendon transfer Pectoralis or latissimus Reverse total shoulder

Cuff Debridement Good prognostic indicators: an intact anterior deltoid and an intact long head of the biceps Poor prognostic indicators: non-functioning anterior deltoid and previous acromioplasty and attempted RTC repair If an acromioplasty is indicated, be conservative and leave the CA ligament intact intact ligament helps prevent superior migration of humeral head Superior migration of head is associated with poor results

Debridement of degenerative, irreparable lesions of the rotator cuff Rockwood CA Jr. Williams GR Jr. Burkhead WZ Jr., Journal of Bone & Joint Surgery - Am., Jun1995, 77(6):857-66. 50 patients (Ave age = 60) were followed for an average of 6.5 years Results were satisfactory in 83% and unsatisfactory in 17% A favorable outcome was observed in shoulders in which both the anterior portion of the deltoid and the long head of the biceps tendon were intact The active forward flexion of the shoulder improved from an average of 105 preop to an average of 140 postop.

Primary Repair May require extensive mobilization and soft tissue releases Rotator interval Superior glenoid Interval between supra and infraspinatus May Require medialization About 1 cm of medialization may be acceptable but 17 mm of supraspinatus medialization will result in a significant reduction in the moment arm (Liu MD et al 1998)

Tear Pattern??Repairable??

Tear Pattern Marginal Convergence

Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy. 2003 Jul-Aug;19(6):564-71. Jones CK, Savoie FH 3rd. Thirty-seven patients had large tears and 13 had massive tears. Follow-up averaged 32 months (range, 12 to 63 months). Based on the University of California Los Angeles shoulder rating, 88% of patients had good or excellent outcomes. 98% of patients were satisfied with the result. CONCLUSIONS: Arthroscopic management of large and massive tears results in good or excellent outcomes in 88% of patients, which is comparable to reported outcomes following open repairs.

Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration. Arthroscopy. 2007 Apr;23(4):347-54. Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M. 22 patients with massive rotator cuff tears and stage 3 or 4 fatty degeneration mean age of 66.5 mean time from surgery to follow-up was 39.3 months increase of mean active forward elevation was 54 gain of mean active ER was 19 degrees In 5 patients with fatty degeneration greater than 75% (advanced stage 4), results were less dramatically improved than in 17 patients with fatty degeneration of 50% to 75%

Tissue Augmentation

Graft Jacket

16 patients with massive, contracted, immobile rotator cuff tears were treated with arthroscopic placement of a GraftJacket allograft by a single surgeon. Followed up for 1 to 2 years. Magnetic resonance imaging was performed postoperatively at 3 months and 1 year At a mean follow-up of 26.8 months (range, 12 to 38 months), 15 of 16 patients were satisfied with the procedure Statistically significant improvements were seen in pain, forward flexion, and external rotation strength. Thirteen patients had full incorporation of the graft into the native tissue as documented on magnetic resonance imaging.

Latissimus Transfer Latissimus (rerouted) Teres Major Pec Major

Latissimus Transfer

Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff, Gerber-C. Clin-Orthop., Feb.1992 (275),152-60. 16pts with an average follow-up of 33 months No neurovascular complications or infections Pain relief was satisfactory in 94% of the shoulders at rest and in 81% on exertion. Flexion was 83 degrees preoperatively and 135 degrees postoperatively. If the subscapularis was torn and irrepairable, latissimus dorsi transfer was of no value. In cases with good subscapularis function but irreparable defects in the external rotator tendons, restoration of approximately 80% of normal shoulder function was obtained.

Reverse Total Shoulder

Indications for a Reverse RTC Athropathy Chronic irrepairable RTC tear Failed total shoulder?acute fractures? (+/- dislocation)

RTC Tear After TSA

4 Part Proximal Humerus Fxs

Fractures Soft bone in elderly pt Likelihood of tuberosity absorption Poor cuff function / recovery Delayed rehab with poor outcome Accepted in the elbow

Between May 1995 and June 2003, 240 consecutive reverse total shoulder arthroplasties were performed in 232 patients with an average age of 72.7 years. 186 pts with 191 retained reverse total shoulder arthroplasty prostheses were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 pts before surgery to 60 pts at follow-up 173 of the 186 patients were satisfied or very satisfied with the result.

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