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Arthroscopic Rotator Cuff Repair

- Rotator cuff tears can be caused by extrinsic factors like repetitive use or impingement, or intrinsic factors like changes in tendon vascularity or degenerative changes. - Physical examination involves inspection, palpation, range of motion testing and muscle strength testing. Investigations include ultrasound and MRI. - Symptomatic rotator cuff tears tend to increase in size over time if left untreated, especially in younger patients under 60 years old. - Surgery is indicated for failed conservative treatment, significant weakness, or acute tears in young active patients. - Arthroscopic repair has advantages over open repair like less pain and blood loss, but requires special instruments and equipment. -

Health & Medicine◦
Prof. Bijayendra Singh Consultant Trauma & Orthopaedic Surgeon Medway NHS Foundation Trust Visiting Professor, Canterbury Christ Church University Cuff Repair
What is Rotator cuff ?
Extrinsic Factors • Repetitive use • Glenohumeral instability • Internal impingement • Impingement • Acromial spurs • Coracoacromial ligament • AC joint osteophytes • Coracoid process • Posterior superior glenoid Acute Trauma
Intrinsic Factors • Vascular supply (? significance) • Distal 1cm of supraspinatus tendon (early studies) • Hypervascularity with tendonitis • Codman (1934) described critical zone • Rathburn (1970) position related to blood supply • Lohr (1990) bursal side better blood supply : Increased incidence of articular surface tears? • Degenerative changes • Age related • Change in proteoglycan and collagen content in symptomatic tendons
Physical Examination • Inspection: Atrophy, symmetry • Palpation: AC joint, cuff tenderness • Range of motion: Active, passive • Muscle strength • Special tests
Investigations
• Ultrasound: • High Accuracy for Full Thickness Tear • Poor info on other pathologies • Static images for dynamic investigation • Operator Dependent • MRI: • Gold Standard • Easier to explain to patient • Other Shoulder Pathologies • Muscle Atrophy • Expensive/Cumbersome • May find pathologies of no clinical relevnace..
Natural History • Asymptomatic: 5 - 40% • Increases with age
• Sher et al, J Bone Joint Surg Am. 1995 Jan;77(1):10-5: Abnormal MRI Findings in asymptomatic shoulders • 96 asymptomatic shoulders MRI • 14 FT & 19 PT • > 60: 28% FT, 26% PT (54%) • 40 - 60: 4% FT, 24% PT (28%) • < 40: no FT, 4% PT
Pain and/or fatigue of cuff Rotator Cuff dysfunction Impingement with motion
Indications for Surgery • Failed conservative management • Significant or progressive weakness • Young, active • Acute tear • Early repair if age<50 years and full-thickness tear
• Do we need to repair Open vs Arthroscopic
Do we need to Repair Cuffs?
Natural History of Non operatively Treated Symptomatic Rotator Cuff Tears in <60 yrs. (5mm or more) Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714 • F/U: 25 - 39 months • Ultrasonography by same sonographer • 51/61 evaluated –30 (49%) tears increased in size –26 (41%) no change –5 (8%) reduced –10(25%) found to have new tears • No correlation between change in tear size, –patient age –prior trauma –size of tear at index • Co-relation between considerable pain & increase in tear size
Open Vs Arthroscopic
Open Repair • Advantages: • Easy • No special equipment required • Direct visualization of cuff repair and acromioplasty • Good long term follow-up. Several studies with >10 year follow-up show generally stable results with time • UKCUFF Trial
Disadvantages • Deltoid detachment required • Increased perioperative morbidity • Unrepairable tear will be opened • Significant intraarticular pathology can be missed • Increased blood loss • Increased rehabilitation time • Large scar
Arthroscopic Cuff Repair • Deltoid preservation • Diagnosis and treatment of any concomitant shoulder pathology • Decreased postoperative pain • Decreased blood loss • Small surgical scar • Shorter hospital stay • Earlier rehabilitation • Decreased postoperative stiffness
Disadvantages • Special Instruments • Cannula • Suture Passer • Suture manipulator • Appropriate Anchors • Suture Cutter • Suture Management Learning Curve
Principles of Repair • Neer JBJS-A 1972 • Adequate subacromial decompression • Repair tendon to bone • Secure fixation of tendon to tuberosity • Mobilization of muscle-tendon units • Closely supervised rehabilitation
Single Row vs Double Row
Biomechanics • Single Row - 220 N • Double Row - 320 N • Suture Bridge - 20 - 50% higher • Almost all biomechanical studies show lower re-tear rates for double row / Suture Bridge
Clinical Outcomes • Franceschi et al: • 30 in each group, UCLA 32.9 vs 33.3 post op • MRI retear = 12/16 single, 8/26 • Burks et al: • 20 in each group, No difference in UCLA, ASES, Constant • Retear 2 in each on MRI • Grasso et al • 40 in each group • No significant difference in DASH, Constant & Muscle Strength • No post op imaging Level 1 studies
Rehabilitation • Four Phases • Inflammatory: 7 days • Proliferative: 2 - 3weeks • Healing Phase: 3 - 12 weeks • Maturation: 12 - 26 weeks
Ross et al: Rehabilitaiton Following Arthroscopic Rotator Cuff Repair - Review of Current Literature. JAAOS, 2014, 22(1), 1 - 9 • ROM: • Some studies have shown better elevation in early stages • Preop ROM important factor • NO difference at one year • Pain: • No significant difference in early vs late mobilisation • Muscle Strength: • No difference, significantly lower than other side • Re Tear Rates: • 0 - 94% • Variable results on radiological re-tears • No functional difference
Enhancement • Biology of patient & tendon (can’t be altered) • Techniques: • Microfracture of healing bed • Use of vented anchors • Doxycycline (reduces effects of MMP) • PRP • Mesenchymal stem cells • No definite evidence at present
Conclusion • Keys to success: • Pick a winner • Good anaesthesia • Tension-free reduction • Thorough bursectomy for visualisation • Work to a system • Variety of equipment invaluable My choice • Small Tears = Single Row - Mattress Repair • Large > 3 cm = Double Row - Suture-bridge technique
Thank You