34-Year-Old with a Labral Tear and a Small Full-Thickness Rotator - - PowerPoint PPT Presentation

34-Year-Old with a Labral Tear and a Small Full-Thickness Rotator Cuff Tear: What Do I Do? My Algorithm

Theodore F. Schlegel, MD

UC Health / Steadman Hawkins Clinic – Denver

Orthopaedic Summit Las Vegas, Nevada December 9, 2017

Neither I, Theodore Schlegel, or a family member have relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows:

• Available in the course book and on the AAOS website

Disclosures

Who came up with this title?

This combination rarely occurs

Case to Consider

34 year old RHD professional kiteboarder who presents following an acute traumatic traction injury to his RUE Did this combination occur as a result of a traumatic instability incident?

small full thickness cuff tear Labral Tear

Plus

Define the Condition

1) Is it is a rotator cuff tear w/o instability and labral tear (SLAP) 2) Is it a rotator cuff tear with instability and labral tear (Bankart Lesion)

• r is it

So say we really do see one of these patients, then we need to figure out if:

Breakdown the Problem

1) Scenario #1: How do I treat an isolated cuff tear in a young patient? 2) Scenario #2: How do I treat a cuff tear with a labral tear (SLAP Lesion)? 1) Scenario #1: How do I treat an isolated cuff tear in a young patient? 2) Scenario #2: How do I treat a cuff tear with a labral tear (SLAP Lesion)? 3) Scenario #3 How do I treat a cuff tear with a labral tear (Bankart Lesion)?

Scenario #1: How do I treat a small cuff tear in a young patient?

Non-operative vs. Operative

1) Full thickness tears do not heal spontaneously in humans

Natural History of Untreated Rotator Cuff Tears

Mall, et al, JBJS 2010 Yamaguchi , et al, JSES 2001 Moosmayer, et al, JBJS 2013

Level of Evidence - 3

2) Full thickness tears have a risk of increasing in size

Natural History of Untreated Rotator Cuff Tears

Keener et al JBJS 2015 Kukkonen, et al, JBJS 2015 Mall, et al, JBJS 2010 Maman, et al, JBJS 2009 Safran, et al, AJSM 2011 Yamamoto et AJSM 2017

2008 2010

Level of Evidence - 3

3) Full thickness tears that increase in size have decreased strength

Natural History of Untreated Rotator Cuff Tears

Moosmayer, et al, JBJS Br. 2009 Tempelhof, et al, JSES 1999

Level of Evidence - 4

4) Unrepaired cuff tears have progressive fatty infiltration which is irreversible

Natural History of Untreated Rotator Cuff Tears

Goutallier, et al, Rev Chir Ortho 1999 Kim, et al, JBJS 2010 Maman, et al, JBJS 2009 Meyer, et al, J Orthop Res 2004 Normal Chronic Tear

Cohort Study – Level 3

5) Chronic Tears Result in Tendon Shortening

Meyer, et al, AJSM 2012

Natural History of Untreated Rotator Cuff Tears

• In chronic tendon tears the residual

tendon stump has been shown to have decreased length of the original tendon

• May be difficult to repair secondary to

shortening.

Cross-Sectional Study – Level 3

Evidence Suggests

Timing of Repair Matters

• Delayed Repair = Worse Results

1) > 3 weeks

Bassett and Cofield, Clin Orthop Related Res 1983 Lahteenmaki, et al, JSES 2006

2) > 4 months

Petersen and Murphy, JSES 2011

Retrospective Case Control – Level 3

Fix small cuff tears, “early”, in young patients

What do I want to do?

Scenario #2:

How do I treat a cuff tear with a labral tear (SLAP Lesion)?

• Considerations same as Scenario #1 regarding

the management of the rotator cuff tear

Cuff Tears without Instability

Thoughts on SLAP Tears

• Do they really hurt?
• Is this an incidental finding?
• What is the true pain generator?

is it the labrum?

• r

is it the biceps?

Treatment Options

What are options for managing a SLAP Tear?

• Fix the SLAP
• Debridement of SLAP
• Release the biceps and tenodesis
• Simple release (tenotomy)

Outcome of SLAP Repairs

• Decreased ROM compared to Pre-Op
• Return to previous level of participation -

37%

• High rate of revision surgery -28%
• Relative Risk for Failure (3.45) – patients
• ver 36 y.o.

Case-control study – Level 3

AJSM, 2013

Unpredictable …..

My Experience with fixing SLAP Tears

• Real risk of tightening the

shoulder (dramatically seen in the middle-aged SLAP repair)

• High percentage will have
• ngoing biceps pain

Fix the cuff early and release the biceps (tenodesis or tenotomy)

What do I want to do?

You don’t need your biceps to be active!!

Scenario #3:

How do I treat a cuff tear with a labral tear (Bankart Lesion)?

• Considerations same as Scenario #1 regarding

the management of the rotator cuff tear

Cuff Tears with Instability

History and PE are Critical with this Scenario

• Document the history of an anterior

dislocation

• Confirm positive apprehension with

stability testing (symptomatic instability)

Treatment Options

Considerations same as #1 for managing the rotator cuff How to manage the Bankart Lesion

• Ignore
• Open vs arthroscopic repair
• Staged repair

Treatment of Combined Lesions: Open Repairs

Simultaneous Open Repair of the Cuff and Labrum

• 4 of 7 : Acceptable outcome

Hawkins et al, CORR 1986

Open cuff repair with staged labral repair

6 Elite Rugby Players 26 y.o. (23 – 29 y.o.)

• Returned to Sports : 100%
• Recurrent Instability: 0%

Goldberg et al, Br. J Sports Med, 2003

• Retrospective Review
• 16 Cuff + Bankart
• Average age 47y.o (36-61 y.o.)

Good or Excellent Results : 90% Recurrent Instability: 0%

AJSM 2007

Scenario # 3: Combined Injury from Traumatic Shoulder Instability

My Treatment Algorithm

Cuff tear and Labral Tear WITHOUT Instability

IGNORE THE LABRAL TEAR

• Fix the Cuff
• If symptomatic biceps
• Most will do well with a tenotomy
• Tenodesis for aggressive overhead athlete (climber)
• r body builder

My Treatment Algorithm

Cuff tear and Labral Tear WITH Instability

ADDRESS THE LABRAL TEAR

• Fix the Cuff
• If symptomatic instability
• simultaneous arthroscopic cuff and inferior labral

repair