Rotator Cuff Tears Flashcards
prevalence
age >60: 28% have a full thickness tear, Age>70: 65% have a full thickness tear
risk factors for rotator cuff tear
age, smoking, HLD, family history
age you worry about cuff tears with dislocation
> 40 years
what is internal impingement
Due to posterior capsular contracture, leading to partial thicknes articular sided tear of the roattor cuff do to wind up (wrong - its the deceleration phase)
fucntion of the rotator cuff
balances the force couples in the shoulder: subscap vs. infra/teres and subscap/infra/teres vs. the deltoid. Supraspinatus is the primary initiator of abduction
function of supraspinatus
Initiates and assists deltoid in abduction of arm and acts with other rotator cuff muscles
rotator cuff footprint
supraspinatus 12.7 mm in wdith mediolateral, a a tear of 6-7 mm is a 50% tear
where does tear start
15 mm posterior ot biceps tendon at junction of supraspinatus and ifnraspinatus, in degenerative tears
AP dimensino of infra/supra
20 mm
layers to the rotator cuff
5 layers, strong is layer 2 (3-5 mm thickness)
contents of rotator interval
CHL, SGHL, biceps tendon, and capsule
bursal or aritcular is more vascular
bursal is more vascular, articular side is more commonly involved in degen tears
what is the rotator crescent
rotator cuff tendon extending from the cable medially to the footprint, it is thin and is comprised of the infra and supra
what is rotator cable
it is a thickening of the tendon which is formed by the coracohumeral ligament, it is towards the end of the infra/supraspinatus tendons, it has been likened to a suspension bridge in terms of it’s function.
sizes of rotator cuff tears
small is 0-1 cm, medium is 1-3 cm, large is 3-5 cm, massive is >5 cm (invovles 2 or more tendons)
Classification for rotator cuff tears,
Cofield or Ellman, depeneding on the typeFu
Full thickness tear classification
Cofield 1982, cuff tear sizes small 0-1, medium 1-3, large 3-5, massive >5 cm (2 or more tendons).
partial thickness tear classification
Ellman, Grade 1 <3 mm, 2 is 3-6 mm, III is >6 mm (>50%) of supra tear. A is articular, B is bursal, C intratendinous
SLAP lesion cuases
overuse injury in overhead atheletes or traumatic falls in older patients. Deep shoulder pain and biceps tendonitis.
slap mechanism in throwers
tight PIGHL, shifts contact point of GHJ posterosuperiorly increasing the shear force on the superior labrum
function of the biceps tendon during throwing
contributes to torsional and horizontal stability during late-cocking phase of throwing
slap tear biceps tenderness?
yes can have biceps groove tenderness
Tests for biceps
Speed’s test, Yergason’s and Kim biceps load test
how to perform speed’s test
FF 90 degrees, supinated, resist downward pressure. Or initialy descrived as starting with arm at side and FF with supinated 0-60
how to perform yergasons
pronated with arm at side, try to supinate, thumb on groove to feel for subluxation
how to perform kim biceps load test
abduct shouler 120 degrees, elbow bent 90, have them bend elbow against resistance
obriens test also known as
Active compression test
Crank test description
abduct to 160 degrees supine patient, axial load and internally/exteronally rotate tyring to pinch the SLAp tear
dynamic labral shear test
place in ABER position, push anteriorly on huemral head, then raise up to 90-160 degrees if pain or click
kibler anterior slide test
place hands onhips, thumb pointing posteriorly, examiner axially pushes up on the elbow and pain should be felt anteriorly
use of apprehension in SLAP tears
positive in 85% of patients
treatment for slap tears by age
tenotomy/tenodesis for those over 40 years of age
what is peel back
SLAP tear, go into ABER position should see labrum peel back
most common complication SLAP repair
stiffness, 78% of patients
SLAP repair in older patients with ARCR patients risk
stiffness
Other NV risks with SLAP repair
overdrilling glenoid leading to Suprascapular nerve injury
subacromial impingement due to what
impingenet of the cuff against acromion, CA ligament, AC joint
acromial types
TYpe 1 flat, 2 curved, 3 hooked. Bigliani
Yocum test
hand on contraltaeral extremity and raise the elbow up, sensitive but not specific.
internal impingemnt test
positive if pain with ABER
GIRD associated with
SLAP lesion
normal acromiohumeral interval
7-14 mm
findings of rotator cuff dsiease on xray
traction osteophytes, subchondral cysts at greater tuberosity, CA ligamen tcalficiation, typ3. hooked acormion
Subacromial bursa histology
high levels of metalloprotesaes and other inflammatory cytokines
prp for impingemnt
insufficient evidence to support use with a recent meta analysis
Internal impingement symptoms
Diagnosis is may clinically with worsening posterior shoulder pain during maximal abduction and external rotation (position of late cocking) associated with decreased internal rotation and supplemented with MRI showing posterior rotator cuff and posterior labral pathology.
GIRD findings
smaller arc of motion and elevated ER
GIRD mechanism of pain
ABER in late cocking and early acceleration leads to pel back by the biceps. Supraspinatus undersurface impinges on posteroupseiro rglenoid
bennet lesion
hypertrophy and scarring of posterior capsule glenoid. exostosis of posteroinferior glenoid on xray
GIRD etiology
PIGHL tightness, anterior microinstaiblity
apprehension test and internal impingement
positive for pain
gird translates humeral head
anterosuperior, opposite of tight strecutures in flexion, however in ABER ledas to posteropusruperior translation
slap and gird
throws with gird are 25% more likely to have a slap lesion
GIRD number of IR degrees
> 20-25 degrees decrease and smaller arc
gird treatment
sleeper stretch, cross body adduction stretch, pec minor stretching
gird surgery
posteiror capsule release and anterior stablization
Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears
A Multicenter, Randomized Controlled Trial
MacDonald, Peter MD, FRCSC1; McRae, Sheila MSc1; Leiter, Jeffrey MSc, PhD1; Mascarenhas, Randy MD1; Lapner, Peter MD, FRCSC2
Author Information
The Journal of Bone & Joint Surgery 93(21):p 1953-1960, November 2, 2011.
WORC and ASES scores improved significantly in each group over time (p < 0.001). There were no differences in WORC or ASES scores between the groups that had arthroscopic cuff repair with or without acromioplasty at any time point. There were no differences in scores on the basis of acromion type, nor were any interaction effects identified between group and acromion type. Four participants (9%) in the group that had arthroscopic cuff repair alone, one with a Type-2 and three with a Type-3 acromion, required additional surgery by the twenty-four-month time point. The number of patients who required additional surgery was greater (p = 0.05) in the group that had arthroscopic cuff repair alone than in the group that had arthroscopic cuff repair and acromioplasty.
Conclusions:
Our findings are consistent with previous research reports in which there was no difference in functional and quality-of-life indices for patients who had rotator cuff repair with or without acromioplasty. The higher reoperation rate was found in the group without acromioplasty. Further study that includes follow-up imaging and patient-reported outcomes over a greater follow-up period is needed.
Risk factors for lack of repair healing
Factors influencing the risk of failure in tendon healing after primary
rotator cuff repair1:
■ AP tear size
■ Grade of infraspinatus
fatty infiltration
■ Bone mineral density
■ Tear retraction
■ Increasing age >70 years
■ Level of work activity
Forsythe B, Agarwalla A, Puzzitiello RN, Mascarenhas R, Werner BC. Rates and Risk Factors for Revision Open and Arthroscopic Proximal Biceps Tenodesis. Orthopaedic Journal of Sports Medicine. 2019;7(2).
Results:
There were 15,257 patients who underwent biceps tenodesis. Of these, 9274 patients (60.8%) underwent arthroscopic biceps tenodesis, while 5983 (39.2%) underwent open biceps tenodesis. A total of 171 patients (1.8%) and 111 patients (1.9%) required revision biceps tenodesis after arthroscopic and open biceps tenodesis, respectively (P = .5). Male sex (OR, 1.38 [95% CI, 1.04-1.85]; P = .02) was the only independent risk factor for revision biceps tenodesis after the index open biceps tenodesis. After arthroscopic biceps tenodesis, age >45 years (OR, 0.58 [95% CI, 0.39-0.89]; P = .01) and concomitant rotator cuff tear (OR, 0.58 [95% CI, 0.47-0.71]; P < .001) were independent protective factors for revision biceps tenodesis. The total cost of revision biceps tenodesis after open and arthroscopic biceps tenodesis was US$3427.95 and US$2174.33 per patient, respectively.
Conclusion:
There was no significant difference in the revision rate between arthroscopic and open biceps tenodesis. Risk factors for revision surgery included male sex for open biceps tenodesis, while age >45 years and rotator cuff tears were protective factors for arthroscopic biceps tenodesis.
Journal of Shoulder and Elbow Surgery
Volume 21, Issue 1, January 2012, Pages 66-71
Journal of Shoulder and Elbow Surgery
Shoulder
Clinical success of biceps tenodesis with and without release of the transverse humeral ligament
Author links open overlay panelBrett Sanders MD a, Kyle P. Lavery BA b, Scott Pennington MD c, Jon J.P. Warner MD b
When all techniques that released the biceps sheath (6.8%, 4/59) were compared to those that did not release the biceps sheath (20.6%, 14/68), a statistically significant difference was found, P = .026 (chi-square). Proximal arthroscopic techniques were revised at a significantly higher rate than distal tenodesis techniques (P = .005).
Conclusion
Biceps tenodesis techniques which do not release the biceps sheath or remove the tendon from the sheath have increased revision rates, compared to techniques that do. This may be supportive evidence for the theory that residual pain generating elements in the biceps groove is a cause of failure of proximal tenodesis methods.
