Rotator Cuff Disease - all you need to know. Part 3
My name is Gavin Jennings. I’m an orthopaedic surgeon specialising in problems of the shoulder.
This presentation is the third of three parts giving an in-depth overview of rotator cuff disease and will deal with the role of surgery in the treatment of rotator cuff problems.
Surgery may be considered if the patient has had insufficient improvement from good quality non-operative treatment. Symptomatic cuff tears, including traumatic tears may be considered for surgical intervention. If there is a major mechanical problem, such as with this spur, surgical intervention may be considered sooner rather than later. A more controversial indication for surgery would be in the patient with a mildly symptomatic cuff tear in order to reduce the risk of progression of the tearing.
Surgery on the rotator cuff is almost invariably preceded by imaging. Ultrasound and MRI are the favoured modalities, but both are used for surgical planning primarily and are not usually necessary for diagnosis of a rotator cuff problem. Ultrasound scans allow for dynamic scanning, but MRI provides additional information which can be very useful in terms of surgical decision making.
For an impingement type problem, a suitable patient would usually undergo an arthroscopic subacromial decompression. In the presence of calcific tendonitis, the decompression is supplemented with removal of the calcium
Considering rotator cuff tears now. The difference between a partial thickness and full thickness tear is demonstrated here. There are numerous classifications of full thickness tears, but these are beyond the scope of this talk.
One of the roles of surgery, as alluded to previously, may be to try and prevent progression as well as treating the current symptoms. Tears most commonly start at the anterior portion of the supraspinatus tendon and progress posteriorly. The theory as to why this occurs relates to the attachment to the bone, or the ‘footprint’ It is narrowest at the front of the tendon thus the traction forces may be more concentrated at this part. As a tear progresses, the forces on the remaining footprint attachment will increase, explaining the tendency of cuff tears to progress over time.
Small to large tears such as the example shown on this MRI image, are usually amenable to direct arthroscopic repair. Some chronic massive tears may still be reparable but are more likely to need an augmented repair. The use of acellular human dermal (skin) matrix such as the Graft Jacket has gained significant popularity in recent years. Using the same type of graft, superior capsular reconstruction procedures are currently gaining interest.
The use of implants such as the graft jacket in rotator cuff repair has a good deal of literature to support it.
The sort of imaging features which raise concern about the reparability of a rotator cuff tear are superior head migration, significant retraction beyond the glenoid rim and advanced fatty atrophy of the involved muscle.
If deemed to be an irreparable tear, there are some established and other emerging surgical treatment options.Traditionally a debridement procedure might be performed. The essential elements of this are a rotator interval release to try to improve stiffness, a biceps tenotomy or occasionally tenodesis and a limited subacromial decompression trying to preserve the coracoacromial ligament if intact. (This is to try and reduce the risk of anterosuperior escape). This procedure is combined with an anterior deltoid strengthening programme postoperatively and proves to be worthwhile in about 70% of cases
Another option which has now been around for sometime is the use of an InSpace balloon. This biodegradable device is inserted into the subacromial space arthroscopically. It starts to reabsorb over a few months, but during that time it reproduces the depressor effect of the torn rotator cuff, restoring balance to the shoulder, thereby facilitating rehabilitation with an anterior deltoid programme. The designers’ preliminary study and one other in Eastern Europe suggested this technique achieved its aims in about 70% of cases. A couple of larger studies are getting underway in this U.K. presently.
So how does the presence of rotator cuff disease affect the options for arthroplasty as a treatment of shoulder arthritis?
Well, it is now very well established that total shoulder replacement outperforms hemiarthroplasty in terms of both the range of movement and pain relief achieved. This also applies in the replacement of the shoulder with inflammatory arthropathy. However we know that in a rotator cuff deficient shoulder, rapid glenoid component loosening is a genuine problem and thus hemiarthroplasties have often been used in the arthritic cuff deficient shoulder. Studies have, however, shown that in the presence of a cuff tear, the outcomes following a total shoulder replacement combined with rotator cuff repair are still be better than those following a hemiarthroplasty,
In the older patient age group, say over 75’s, it is well established that the operation of choice for the cuff deficient and arthritic shoulder is a reverse total shoulder replacement (RSR). This aims to medialise the centre of rotation of the glenohumeral joint. This results in an increase of the lever arm of the deltoid making it more efficient at lifting the arm. This operation is thus particularly useful in the shoulder with poor active range of movement as both pain and range can be significantly improved.
Many thanks for listening to “An overview of rotator cuff disease”. If you have any questions or would like further information, please do not hesitate to contact me at shoulderspecialists.co.uk.