Rotator cuff Tear Dr Justin 6/1/24

1. What is rotator cuff (ice breaking questions)

 Function – Dynamic stabiliser by force coupling, allow movement around glenohumeral
joint.
 Macroscopy – SITS muscle.

 Microscopy
- Histologically 5 layers

 Layer 1 – Coracohumeral ligament

 Layer 2- tendon fibre of rotator cuff
 Layer 3 – tendon fibre at 45° in relation to layer 2
 Layer 4- loose connective tissue
 Layer 5- 2mm joint capsule

 Artery supply
- Suprascapular artery
- Subscapular artery
- Anterior circumflex humeral artery

 Nerve supply
- Supraspinatus/infraspinatus- Suprascapular nerve
- Teres Minor- Axillary nerve
- - Subscapularis – Upper/ lower subscapular nerve

2. Critical shoulder angle?

 - Normal angle – 30-35 degree

- It’s an angle formed between plane of glenoid fossa and line drawn from inferior
edge of glenoid to lateral edge of acromion on AP view of shoulder Xray (grashey
view)

- Less than 30° - increased risk of glenohumeral arthritis

- More than 35°- increased risk of rotator cuff Tear

Why is it so? Its because of compressive force/ vector/ force coupling

3. Natural history of RCT? (rule of 50)

- 50% asymptomatic tear will develop symptoms.
- 50% of symptomatic tear will increase in size.

4. Which tear is painful?

- Partial tear due to inflammation

5. Mechanism of rotator cuff tear.

- Extrinsic compression
- Intrinsic degeneration (seen in elderly)

6. Rct failure of healing where occurs?

- Tendon bone interface

7. Even non healing tendon, does not have pain, hence what is the benefit of tendon healing?
- Higher strength
- Improve outcome.
- Higher outcome score

8. Classification of RCT
A. DeOrio and Cofield classification (based on greatest tear diameter in AP or
medial lateral plane)
B. Patte classification (based on degree of retraction)

C. Gouteullier- Fusch classification (based on degree of fat infiltration)

D. Thomazeau Classification (based on degree of muscle atrophy)

Mild 0.6- 1.0%

Moderate 0.4-0.6%
Severe <0.4%
E. Ellman Classification (based on degree of partial thickness tear)

F. Snyder Classification (based on location of tear)

A- Articular
B- Bursal
C- Complete tear

G. Davidson-Burkhart classification (based on shape of tear)

 Additional is V and reverse L.

9. Tangential sign/ line?

- Used to grade atrophy.

- Line drawn from acromion to coracoid on MRI sagittal view at supraspinatus
view.
- If line doesn’t cross supraspinatus muscle, signify muscle atrophy.

10. Dead-man angle?

45° angle that anchor suture should be inserted in footprint during repair to increase
resistance to pullout.

11. Massive Tear definition?

- 2 or more complete rotator cuff complete tear (Garber)

- More than 5cm tear either in AP/ML direction (DeOrio)
- Coronal/sagittal width more than or equals to 2cm (Donaldson)
12. Non repairable tear?

- Massive tear
- Retraction Patte stage 3
- Gouteullier stage 3- 4
- Acromion-humeral index less than 7mm
- Static migration (unable to pull tendon back to original location)

13. Acromiohumeral Index?

- Normal is 8-12mm.
- Shortest distance between 2 Harmonics line from undersurface of acromion
and superior border of humerus.

14. Fatty infiltration reversible?

- It is not reversible.

15. Management goals of rotator cuff repair?

- Reduce pain.
- Restore functional normalcy.
- Improve function.

16. Indication of surgery?

- Persistent pain despite conservative treatment

- Acute traumatic tear
- Bursal sided (less than 25- debride, more than 25 repair)
- Articular sided (less than 50- debride, more than 50- repair)
17. Massive tear can do partial tear?

- Yes can, for restoration of cable for force coupling, not a good repair but good
enough for force transmission.

18. Medialisation of footprint? (when tendon cannot be retracted to its footprint, we can
medialise the tendon for repair, but maximum limitation is as follows)

- Subscapular tendon – 4-7mm

- Suprascapular tendon 10mm

19. How to repair RCT?

A. Single row
B. Double row
C. Trans- osseous equivalent

Double row is better than single row in terms of better tendon healing but does not
translate to clinical superior clinical outcome.

Time to heal and repair rate is same.

20. New case, do you order MRI?

- Acute traumatic tear

- Preop Planning

21. For massive rotator cuff tear, management?

A. Conservative- physiotherapy. Activity modification

B. Surgical

(i) Partial repair

(ii) Superior capsule Recon – static stability
(iii) Tendon transfer – dynamic stability
(iv)Reverse total shoulder arthroplasty
(v) Balloonplasty, Tuberoplasty (cheap but it is just a time buying
procedure. Satisfactory early clinical outcome)

22. Where to harvest graft for superior capsular reconstruction?

 Autograft - 8mm of fascia Lata, biceps tendon, semitendinosus tendon

 Allograft – Achilles tendon, Fascia Lata, semitendinosus, human dermal matrix
  Synthetic- Teflon patch (commonly used)
 Xenograft

23. Name of tendon transfer using latissimus dorsi and teres major?

L’Episcope procedure

-advantage – posterior muscles used hence improve external rotation of shoulder

24. How common tendon transfer done in RCT?

- 92% done repair.

- 5% latissimus dorsi transfer
- 3% pectoralis major transfer

25. How to augment rotator cuff repair?

- Using long head of biceps.

26. Poor prognostic factor for rotator cuff repair?

Patient Factor Surgical factor Injury pattern

Elderly Poor surgical technique Massive tear
Delayed presentation Acromion-humeral index
less than 7mm
DM Retraction Patte stage 3
Smoker Gouteullier stage 3- 4
Poor compliance to post
op rehab

27. Rotator cuff arthropathy management?

- Conservative – injection, physio, lifestyle modification

- Surgery

 Arthroscopic debridement
 Anatomical total shoulder Arthroplasty
 Reverse total shoulder Arthroplasty
 Fusion Arthroplasty

- Reverse total shoulder Arthroplasty

 Pre-requisite is deltoid must be intact.

  Bcs deltoid function as lever
 If deltoid deficiency, and rotator cuff arthropathy, only option is
fusion.

28. In massive tear, what if we do anatomical total shoulder arthroplasty?

- Rocking house phenomenon. The rocking horse phenomenon refers to the

proposed mechanism of prosthesis failure in rotator cuff–deficient patients.
The humeral head rocks superiorly and inferiorly like a rocking horse,
causing premature glenoid loosening. This mechanism also may cause failure
if subscapularis failure or anterior joint instability is present, allowing the
humeral head to rock anteriorly and posteriorly.

29. Reverse total shoulder arthroplasty principle? (Paul Gram)

- Inferior and medialisation of centre of rotation

- Lengthen level arm.
- Restore deltoid tension.