Massive RTC tear
synonyms: massive rotator cuff tear, massive RTC tear, massive RC tear, RTC rupture
Massive RTC Tear ICD-9
- non-traumatic complete rupture of rotator cuff),
- 726.10 (disorder shoulder tendon cuff)
- 840.3 (disorder infraspinatus tendon)
Massive RTC Tear Etiology / Epidemiology / Natural History
- Definition: RTC tear with: maximum diameter >5cm or disinsertion into the tuberosites of at least two complete tendons
- Posterior rotator interval(interval between supraspinatus and infraspinatus) is found by identifying scapular spine.
- Linked to calcium phosphate and calcium hydroxyapatiite crystals
- Generally 6th-8th
- MUST ENSURE CORACOACROMIAL ARCH IS PRESERVED
Massive RTC Tear Anatomy
- Rotator cable-rotator crescent complex: an arching, cable-like thickening surrounding a thinner crescent of tissue that inserts into the greater tuberosity of the humerus seen when the RTC is viewed intra-articularly. The rotator cable is 2.59 times the thickness of the rotator crescent that it surrounds and functions to stress-shield the rotator crescent. (Burkhart SS, Arthroscopy 1993; 9: 611-616)
- Scapular spine: resembles the keel of a boat when viewed arthroscopically after excision of its surrounding subacromial fibroadipose tissue, and serves as a marker between the supraspinatus and infraspinatus
- Suprascapular nerve: At risk during the posterior interval slide. Curves tightly around the base of the scapular spine at its junction with the posterior glenoid neck, enveloped within a fat pad. The average distance from the origin of the long tendon of the biceps to the motor branches of the supraspinatus is 2 cm. The average distance from the posterior rim of the glenoid to the motor branches of the infraspinatus muscle is 2cm. (Warner JJP,JBJS 1992; 74Am: 36-45)
- Coracoacromial Ligament: Must not be disrupted in patients with RTC tears.
- Long head of Biceps Tendon:
- See also Shoulder anatomy.
Massive RTC Tear Clinical Evaluation
- Supraspinatus and infraspinatus atrophy. Patients may have associated suprascapular neuropathy (Mallon WJ, JSES 2006;15:395).
- Passive and active ROM discrepancy.
- Lag sign: tests posteriosuperior RTC. Arm is placed in maximal ER. Pts with a massive RTC tear will be unable to maintain the arm in the position and the arm will swing toward neutral rotation.
- Hornblower's Sign: patient is unable to ER the arm to 90 degrees with the arm in abduction. Indicates massive tear usually including the teres minor.
- Subscapularis is tested with lift-off test and abdominal compresison test.
Massive RTC Tear Xray / Diagnositc Tests
- AP, scapular lateral and axillary views. . Evaluate for acromial spur, greater tuberosity sclerosis/cysts, loss of acromiohumeral interval.
- Supraspinatus "outlet" view lateral radiographic view of the scapula and acromion, with a 20-degree caudal tilt. Intended to identify any bone projecting downward into the supraspinatus outlet.
- Acromiohumeral interval measured on true AP view in neutral rotation <7mm = superior subluxation of humeral head. Indicates chronic long standing massive tear and is associated with failures of direct repair.
- Note proximal migration of humeral head, sclerosis of the undersurface of the acromion and superior humeral head, acetabularization of the undersurface of the acromion, degenerative changes of the GH joint.
- Evaluate for subacromial arthritis
- Goutallier Classification of Muscle Atrophy (Goutallier D, CORR 1994;304:78).
-Stage 0=completely normal muscle.
-Stage 1=muscle contains some fatty streaks.
-Stage 2=fatty infiltration is important, but there is still more muscle than fat.
-Stage 3=there is as much fat as muscle.
-Stage 4=more fat than muscle is present.
-Degeneration is grade at the tip of the coracoid process and at the inferior margin of the glenoid and the values are averaged to determine the stage.
- GFDI(global fatty degeneration index) = mean fatty infiltration score of subscap, supraspinatus and infraspinatus. <0.5 = retear rate <25%. GFDI>2 = 100% retear rate.
- Hamada Classification of Arthritis in chronic rotator cuff tears (Hamada K, CORR 1990;254:92).
Stage 1: Acromiohumeral interval greater than 6 mm.
Stage 2: Acromiohumeral interval less than 7 mm.
Stage 3: Acromiohumeral interval less than 7 mm with acetabulization of acromion.
Stage 4a: Acromiohumeral interval less than 7 mm with glenohumeral arthritis without acetabulization.
Stage 4b: Acromiohumeral interval less than 7 mm with acetabulization and glenohumeral arthritis.
Stage 5: Acromiohumeral interval less than 7 mm with osteonecrosis of humeral head.
Massive RTC Tear Classification / Treatment
- Low functional demands, asymptomatic. If patient has a tolerable pain level and is able to do ADL’s non-operative treatment with below elbow level physical therapy as needed is indicated
- Low functional demands, severe pain: subacromial injection > scope with biceps tenotomy, acromial smoothing, debridement. 83% patient satisfaction. Be sure to preserve acromion and CA arch. Goals of surgery are pain relief not functional recovery. (Walch G, JSES 2005;14:238).
- High functional demands, acromial-humeral interval >7mm: RTC repair.
- High functional demands, acromial-humeral interval <7mm: consider partial repair +/- tendon transfers vs fusion vs hemiarthroplasty vs reverse TSA. Goals of surgery are pain relief not functional recovery.
- Latissmus dorsi transfer results only good if subacapularis intact (Aoki JBJS 1996;78Br:761-766)
- Consider Biceps tenotomy if tendon is degenerated and especially if subluxated into joint.
- Hemiarthroplasty (Field, JSES 1997;6:18-23)
- Scope, decompression (Gartsman JBJS 1997;79A:715-721)
- Consider concomittent biceps tenotomy.
Massive RTC Tear Muscle Transfers
- Anterosuperior tears(involve subscapularis and supraspinatus): treated with pectoralis major transfer. (Resch H, JBJS 2000;82A:372), (Jost B, JBJS 2003;85A:1944). Biomechanically pec transfer under the conjoined tendon perform better (Konrad GG, JBJS 2007;89A:2477)
- Posterosuperior tears(involve infraspinatus and supraspinatur): treated with latissmus dorsi and or teres major transfer. (Gerber C, CORR 1988;232:51) (Warner JJ, JSES 2001;10:514)
- See Latissmus dorsi transfer technique.
Massive RTC Tear Associated Injuries / Differential Diagnosis
Massive RTC Tear Complications
- Recurrent tear: high failure rate for repair of tears with Acromiohumeral interval <5mm, marked muscle atrophy and fatty degeneration.
- Hardware failure / Anchor pull-out
- Acromion fx
- Infections
- Stiffness
- CRPS
- Nerve injury: Axillary nerve, Brachial plexus
- Fluid Extravasation:
- Chondrolysis: though to be related to heat from electo cautery or radiofrequency probes used during capsular release or capsular shrinkage.
- Hematoma
- Chondral Injury / arthritis
- Instrument failure
- Deltoid dehiscence (open repair)
- Anterior-superior instability / migration: Do not disrupt acromiohumeral ligament
- Suprascapular neuropathy (Mallon WJ, JSES 2006;15:395)
Massive RTC Tear Follow-up Care
- abduction splint for 6weeks. Abduction of 30 degrees has been shown to substantially reduce tensions on a supraspinatus repair.
Massive RTC Tear Review References
- Burkhart SS, A Cowboy's Guide to Advanced Shoulder Arthroscopy, 2006
- Rockwood and Green's Fractures in Adults 6th ed, 2006
- OKU - Shoulder and Elbow 2nd ed, 2002
- Williams GR, Rockwood CA Jr, Bigliani LU, Iannotti JP, Stanwood W, Rotator Cuff Tears: Why do we repair them? JBJS 2004:86A:2764)
- Warner JP, JBJS 2000:82:878
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