cuff disorder

Question 1

Rotator cuff
* sections
* function
* classification

Answer 1

sections:
* superior - supraspinatous
* anterior - subscapularis
* inferior - infraspinatous, teres minor and subscap
* posterior - infraspinatous and teres minor

function:
- dynamic stabiliser
- balances force couples - transverse and coronal
- fixed - fulcrum

blood supply:
- suprascapular
- subscapular
- ant and post circumflex humeral
- thoracoacromial

Pathogenesis
Cuff fails due to repeatative tensile load exceeding the ability to heal.

Classification
- TEAR SIZE
- MORPHOLOGY
- DEPTH
- RETRACTION
- LOCATION
- FATTY INFILTRATION

Tear size
Partial thickness - based on depth- Ellman
1. <3mm
2. 3-5mm - <50% tendon depth
3. >5mm >50% tendon depth
Full thickness - codfield
small <1cm
moderate 1-3cm
large 3-5cm
massive >5cm

Goutallier - fatty infiltration
originally CT modified for MRI
0 - normal
1 - fatty streaks
2 <50% fatty infiltration
3 - 50% fatty infiltration
4- >50% fatty infiltration

Question 2

Rotator cuff tear management

Answer 2

Treatment goals
- treat pain
- restore fixed-fulcrum

Determined by:
* Patient factors
* Tear factors

Tear factors:
* age
* size
* retraction
* fatty infiltration

Patient factors
* age
* activity level
* dominance
* function
* motivation

Non-operative management
- physiotherapy
- injection
- steroid - no good evidence but may help pain/ physio

Operative
- mini open
- arthroscopic

Principles of surgery
- approach
- assessment of cuff
- release of capsular contractures
- reintroduce healing biology - debride degenerate cuff and subacromial decompression
- bone bed preparation
- reduction and fixation to anatomical footprint- intraosseous sutures and anchors
- type of repair - single vs double
- protect repair until heals
- regain movement with physiotherapy

Size of Partial thickness tear:
<50% debride +/- acromioplasty
> 50% completion of tear and repair of cuff and acromioplasty

morphology:
determines if side to side repair needed first

Question 3

Management irrepairable rotator cuff tendon tears

Answer 3

Salvage procedures

Treatment goals:
- treat pain
- restore fixed-fulcrum

Treat pain
- analgesia
- physiotherapy
- injections
- suprascapular nerve block

Restore fixed-fulcrum
* Tendon transfers
* Graft augment
* Superior capsule reconstruction
* Reverse tsr

Tendon transfers
* pec major transfer - subscap tears
* lattissimus dorsi transfer - supra and infraspinatous tears - risk of radial nerve tear

LANCET - InSpace Balloon interposition + debridement vs debridement alone - Metcalfe et all - higher oxford shoulder scores - stat sign difference