Rotator cuff tear is a very common orthopedic condition, which causes shoulder pain and stiffness. The slides are on rotator cuff tears and its management by open repair, mini open repair & by arthroscopy

1. Rotator cuff tear: Basic
understanding and treatment
options
Dr Rohan Vakta
M.S.Ortho
AASH Arthroscopy Center
Ahmedabad,India

2. They Fuse together with the articular capsule
into a common insertion on the tuberosities of
the humerus, which is known as the footprint
of the rotator cuff.

3. Action of rotator cuff
Rotator cuff acts as a
mechanical couple in
conjunction with Deltoid
in shoulder rotation &
elevation

4. Important functions:
• Counterbalance the upward pull of the deltoid on the
humerus.
• Hold the head of the humerus secure in the glenoid.
• Externally rotate the shoulder which is important
during arm elevation.

5. Etiology
Traumatic
Non-Traumatic
(Age >40 years)
high velocity trauma
( partial- or full-thickness tears)
Repetitive microtrauma (overuse,
athletic)
(Age <40 years)

6. Non-Traumatic
•Degenerative (Work related: Painters,electrician)
•Subacromial Impingement syndrome
•Developmental Factors :
Os acromiale , Type 2 or 3 acromion

7. Non-Traumatic
• Others:
o Shoulder Instability
o Inflammatory dz : Calcific tendinitis/RA/Crystal
induced arthropathy
o Scapulohumeral neuromuscular dysfunction:
o Entrapment syndromes

8. p

9. Crescent
Trapezoidal
Reverse ‘L’
Full Thickness Tear
‘L’ Shaped
Massive tear

10. Pathophysiology
Torn Rotator Cuff
Can not Counterbalance the upward
pull of the deltoid on the humerus
Not able to Hold the head of the
humerus secure in the glenoid
AHD <6mm

11. Leads to abutement of humeral
head against acromion
Acetabulization: Concave deformity of
under surface of Acromion

12. Narrowing & Arthritis
of Gleno-Humeral Joint
Last stage of Cuff tear
arthropathy with collapse of
humerus head

13. Hamada and Fukuda Stages of
Cuff Arthropathy

14. History
•
•
•
•
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•
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Pain around shoulder
Sleep disturbed by pain
Weakness during activities of daily living
Previous trauma
Time lag before presentation
Occupation
Predominant hand

15. Physical Examination
• Passive and Active ROM
• Strength of motions
• Supraspinatus :
Resisted elevation
of arm kept in
"empty can" position

16. • Subscapularis
“ Lift-off test”
•Infraspinatus : Resisted
External Rotation
•Teres minor:Resisted external
rotation with arm abducted
more than 45°.

17. Impingement Test
• Hawkin-kennedy test
• Injection test:Very effective test
for diagnosis
• Approx 7-10 ml of Xylocaine
injected in subacromial bursa
• Wait for 2-3 minutes
• Pain in ROM will be minimal
• D/D between impingement &
RC tear

18. Ultrasonography
•Dynamic
•Non-invasive
•Inexpensive
•Helpful as a
screening tool
•USG guided
Injection

19. MRI
T2 images -Presence of fluid in the subacromial
space
T1 images- loss of the subacromial fat plane, and
proliferative spur formation of the acromion and/or
acromioclavicular joint.
Discontinuity of the tendon.
Size of tear , retraction of tendon

20. Treatment of Rotator Cuff Tears
o Conservative :
Physical Therapy ± Injection
treatment
Indication:
• Medical Cormodities
• Relatively Inactive lifestyle
• Patients not willing for post-op
rehab.

21. Surgical Management
Open
Mini-Open
Arthroscopic
(not recommended)
four major objectives:
(1) closure of the cuff defect.
(2) eliminating impingement.
(3) preserving the origin of the deltoid muscle.
(4) preventing adhesions postoperatively without
disturbing the repair by a careful exercise program

22. Mini open repair
Cl.
• Midway between open &
arthroscopic repair
• Less than 5 cms. incision in the line from
centre of acromion
• Axillary N. should be protected, 5 cm. below
acromial line
• Deltoid splitting approach, not erased
Acr.

23. Mini open RC repair
• Identify bursa
• Mimics rotator cuff
• Bursectomy
• Tear evaluation
• Preparing foot print
• Freshning of tear
• Transosseus sutures or
suture anchor cuff repair
• Meticulous Deltoid repair
Torn cuff

24. Arthroscopic rotator cuff
repair
• Lateral or Beach chair
position
• Hypotensive anaesthesia
• Pressure pump- Very useful
• Skin marking of landmarks
• GH arthroscopy- frayed
intra- articular RC debrided

25. Arthroscopic rotator cuff
repair
• Scope moved to sub
acromial area
• Bursectomy & SAD for
impingement
• LAP ( Lateral acromial
portal)– main viewing portal
• Ant. & post. Working portals
• SOS-Mini or complete distal
clavicle resection

26. Arthroscopic rotator cuff
repair
• Bone at insertion site &
Gr. tuberosity- lightly burred
• Torn edges of cuff debrided
• Tear pattern assessed- Y or V
• Repaired with suture
anchors & side to side
sutures
• Preserve CA lig. in massive
tear
• Repair checked- No tension
repair

27. Arthroscopic rotator cuff repair

28. Arthroscopic SAD
Removal of inferior part of anterolateral acromion
Open SAD
Arthroscopic
• No morbidity
• Genuine benefit

29. Arthroscopic rotator cuff
repair
Post. Op. regimen
• Shoulder immobilizer for 6 weeks
• Post. op physiotherapy is as
important as good surgery
• Recovery time 12 to 16 weeks
• Total time 1 year

30. Arthroscopic cuff repair
• Tears of all sizes can be done
arthroscopically- 95% tears can be
repaired by an experienced surgeon
• Minimal damage to Deltoid musclepotential source of post-op morbidity
in open repairs
• Greater versatility for
characterization, assessment,
mobilization as well as fixation
• Complete evaluation of Shoulder
joint anatomy- PASTA, SLAP, Arthritis
etc.
•Day care surgery
•Early & Easier postop rehabilitation
Deltoid
detachm
ent

31. Arthroscopic cuff repair
Despite these advantages, arthroscopic
rotator cuff repair is technically
demanding procedure that needs
prerequisite skills as diagnostic shoulder
arthroscopy, arthroscopic subacromial
decompression, and arthroscopic knot
tying in order for a surgeon to obtain
proficiency in this procedure.

32. RC repairContraindications
• Severe OA of Glenohumeral jt.
• Medically unfit patient
• Low activity level individual who can live with
deficient shoulder
• Adhesive capsulitis
• Failed prior RC surgery
• Fatty infiltration in muscles

33. Rotator cuff injury
If not addressed in time…
• Young active individuals- torn cuff cannot heal to
bone- late cuff arthropathy
- continuous pain & weakness
• Muscles undergo atrophy & fatty degeneration
• Waiting too long- repairable cuff
becomes irreparable with poor tissue
& poor prognosis
• At >1 year of f’up, a’scopic and
mini-open rotator cuff repairs produces
Fatty degeneration
similar results with equivalent
patient satisfaction rates

34. Thank You