0:00

70 year old with shoulder pain,

0:02

decreased range of motion after a fall two months ago.

0:07

So here, this is just a nice case of, uh,

0:10

a massive rotator cuff tendon tear. And, uh,

0:14

a few definitions for a massive rotator cuff tendon tear, depending on,

0:18

and again, depending on who you read, um, but, uh, the,

0:22

probably the two or three major def definitions, uh, proposed. Uh,

0:27

the big ones are gonna be, um, uh,

0:31

two or more rotator cuff tendon, uh, tears. Okay.

0:36

Or, uh,

0:37

a tear of the rotator cuff cuff tendons measuring five

0:42

centimeters or more in either the AP or medial lateral

0:47

direction. Now, Burkhart also gives another, um, definition or classification.

0:52

I, unfortunately, I, I have forgotten, so I apologize.

0:55

But most people will use those two major definitions. Two, that is,

1:00

uh, two or more tendons are torn, or a,

1:03

a tear of the rotator cuff tendons measuring more than five centimeters in,

1:07

in a plane. So, as we can see here, okay, with the, uh,

1:12

the full thickness, uh, essentially full thickness tears of the, uh,

1:16

supraspinatus, and here to a lesser extent,

1:19

the in infraspinatus with a few remaining posterior fibers of the

1:24

infraspinatus remaining intact. You know, this is compatible with the rotator,

1:28

uh, massive rotator cuff tendon tear.

1:30

What we also have here is some partial and high grade tearing

1:35

of the subscapularis tendon. And also here, uh, there's,

1:40

here's another nice example of, uh,

1:43

some differential retraction of the torn, uh,

1:47

articular cited infraspinatus and subscapularis tendon,

1:51

such that there's a little bit of deamination as well here as, uh,

1:55

as you can see here with the in infraspinatus. So, another nice case, uh,

2:00

of, uh, delamination, uh,

2:03

and intrasubstance tearing of some tendons, but also, uh, the, uh,

2:07

massive rotator cuff tendon tear. Um,

2:10

so I'll pause for a moment on this case. Um, but, oh, and,

2:14

and the other thing too, as the, uh, rotator cuff tendon tears,

2:18

we lose that vector. Okay. Keeping, um,

2:22

we lose the rotator cuff tendons keeping the, the, uh,

2:26

the vector or the downward force and the medial lies force of the, uh,

2:31

humeral head in contact, close contact with the glenoid.

2:35

So that's why we start to get this, uh,

2:38

superior migration of the humeral head relative to the glenoid.

2:41

And obviously we have this narrowing of the acromial humeral distance,

2:44

which we could, uh, definitely or, or certainly see with radiographs.

2:49

And also suggest, uh, uh,

2:50

rotator cuff tendon tearing if we are presented with such a radiograph. So,

2:55

uh, massive rotator cuff tendon tear with, uh,

2:58

narrowing of the acromial humeral distance and some synovitis. And, uh, and, uh,

3:03

those are probably the main points, uh, for this case. Any, uh,

3:08

questions, comments, concerns for, uh, this case?

3:12

Yeah, uh, Eddie,

3:13

there's a mention that there's a description of the tear shape as a

3:18

centri u-shaped or l-shaped. How, how do you describe

3:21

Those? So, so, uh, good question. Uh, and I think that was Hari,

3:26

was it? Um, great question. So, so, um, I,

3:31

I just kind of describe and be,

3:32

try to be specific as possible and give measurements. Okay. Um, when,

3:37

when you say CREs, when people say crescentic, usually they're,

3:42

they're gonna give, um, a,

3:46

an axial image, and that has to do typically with the, uh,

3:50

crescent and rotator cable. And if you go back,

3:54

if you remember back to the, uh,

3:56

first case where I was talking about the five layers, okay?

4:00

When the, when the cortical humeral ligament okay. Blends with, uh,

4:05

those five layers, okay. About, uh,

4:10

depending on who you read about 1.4 or

4:14

1.5 centimeters from, uh,

4:19

the footprint okay. Of the greater tuberosity.

4:23

So usually around right here, there's gonna be a thickening,

4:27

and that's where you, the fibers okay,

4:30

of the cortical humeral ligament are cutting across perpendicular,

4:36

okay? With a layer, one of the five layers that I mentioned earlier.

4:41

And that's what gives rise to the rotator cable, okay?

4:45

And that's the perpendicular fibers. And if you have that cable, okay,

4:50

that can, the theory is that prevents full, more,

4:54

more medial retraction of a tendon tear, okay?

4:59

Specifically the, the supraspinatus. Okay?

5:01

When we talk about now the fibers more laterally,

5:06

that's the, so-called cress crescentic fibers, okay?

5:10

And if those tear, what happens is you get,

5:14

let me see if I can do it here. What you get is,

5:20

is retraction and a,

5:26

I'll try to do it here, assuming we have like a cable right here. Let's say,

5:30

let's say the cable is right here, right? Okay. And I'll, and I'll use two,

5:36

assume that there's a cable right here centered about, again,

5:39

1.4 to 1.5 centimeters from the footprint.

5:44

If you have the more distal fibers torn and

5:49

retracted to the cable, that's what's called a crescentic tear, okay? As, as,

5:54

as I understand the, the, the recent, the most recent literature. Okay?

5:59

So that's what's, that's what it,

6:01

that's what I understand to be a crescentic tear. Now. Now with that being said,

6:06

I, I maybe, you know,

6:09

I I would describe this as a massive rotator cuff tear with just retraction,

6:14

you know, to the, you know, uh,

6:17

to the superior medial aspect of the humeral head, or to be more precisely,

6:21

I would just say, you know,

6:22

with approximately 34 millimeters retraction of the torn tendon fibers that

6:27

way, um, just my surgeons like me to be more specific.

6:32

Um, but if you like to use, you know, u-shaped tear,

6:36

crescentic tear L-shaped tears, that's totally fine.

6:41

Um, and it's just more of a, a descriptor for, uh,

6:45

some surgeons that they like to use, but my surgeons like to, uh, like me to be,

6:50

uh, a little bit more specific. They liked for me to give, um,

6:54

percentages of the thickness tear in the cranial coddle

6:59

dimension, um, but also in the medial lateral, uh, uh,

7:04

width as well. So, so you can use those terms.

7:08

So hopefully I answered that question.

7:12

So, uh, so it seems to be those descriptive type, the saying it's Chris centric,

7:16

or U-shaped L-shape is only for major tears, it would seem,

7:20

Yeah, it, it remember the, it's, it's just a descriptor, right? So, you know,

7:25

you can have U-shaped tears. It, it's, it's just the way it looks on our,

7:30

on our study. And some, some of our surgeons use that,

7:33

some of my surgeons don't. But, you know, you could have l-shape,

7:37

you could have, you know, l-shaped with, uh, with the apex sort of, uh,

7:41

of the L or the, um, the, I guess the, the crux, uh,

7:46

I, I, sorry, I don't know the proper term, but maybe, um, uh, where the,

7:51

where the l meets, so that can point sort of anteriorly or posteriorly.

7:55

So I'll just, I'll describe it that way. Um, sometimes, but again,

8:00

it just depends on, on the ordering clinician. Um, yeah,

8:05

so thanks,

8:05

Thanks, Eddie.

8:06

Yeah. But, but I think the more important thing here is,

8:09

is to say comfortably that, you know, this, this is,

8:13

this is a tear involving three tendons of the rotator cuff.

8:18

Um, so that, that would qualify as a massive rotator cuff tendon tear,

8:23

so that they go in and they're ready.

8:24

And obviously the other thing would be to mention if there's atrophy or not.

8:29

Um, but, but mind you here too, um, you know,

8:33

be careful because when you have, uh, large rotator cuff tendon tears,

8:38

um, and this has been mentioned in the literature,

8:40

sometimes the muscle bellies can retract.

8:43

So not only look at your sagittals, the far medial sagittals,

8:47

but also sometimes look at your coronals because the muscle can retract

8:51

medially. And, you know, that can give a false appearance of fatty atrophy.

8:56

So that's something to be aware of too.

8:59

And certainly there was some description on the literature, uh,

9:02

describing muscle atrophy and the ratios that you have to,

9:07

uh, take into account. Um,

9:10

is it just eyeballing or do you really have to

9:13

Use Yeah, for me, I eyeball it for, for me,

9:18

I eyeball it, and I, and I give a qualitative measurement. I, I say mild,

9:22

moderate, or severe or normal, and, but, uh,

9:26

some people will use ratios. Some people have measured, uh,

9:30

the amount of fat using, uh, you know, Dixon and, and, and,

9:35

and other sequences. Um, some people, uh, use, but the,

9:40

but the classic, uh, article that everyone refers to is, is,

9:44

and sorry if I'm butchering their last name, but the guttier, um,

9:48

article and, and classification. But I, and I've seen some people use too,

9:53

that, you know, they just like draw a line from the, uh, the um,

9:57

uh, sort of the corticoid process to the, uh, subscapular spine. And,

10:02

you know, they measure ratios that way too,

10:04

or the amount of fatty infiltration that way too. Um, but I, I do qualitative,

10:09

uh, mild, moderate, severe, but I also have the luxury of,

10:13

of my surgeons, they, they also look at their scans. So, um,

10:18

and if there's a discrepancy, you know, I'll, I'll get a phone call and, and,

10:22

you know, I'll be asked to add, to add an addendum or, or something like that.

10:25

But for the most part, our, our surgeons are pretty good about, um, you know,

10:30

looking at that qualitative muscle bulk. Because again, too, if,

10:33

if you have a massive rotator cuff tear, um, you know, and if,

10:38

and if the next option's gonna be, uh, uh, you know, and if,

10:41

and if there's degeneration and they're working towards a total shoulder,

10:45

you know, my surgeons wanna know if they're gonna be putting in a,

10:48

a conventional total shoulder or a reverse total shoulder. So,

10:52

and that goes back to, again, talking about the muscle bulk,

10:56

not only of the rotator cuff tendons, but also the deltoid muscle as well.

11:01

And I guess when you describe the rotator cable,

11:04

it is the confidence of three tendons. It's the supra, the subscap,

11:09

and the infra, isn't it?

11:11

My, my understanding, my understanding that the cable is, is, is, uh,

11:16

mostly along the supra though. Okay. Okay. But, but,

11:19

and there's a lot of great literature and, and I would highly recommend,

11:22

and it's complex, uh, especially that cortical humeral ligament.

11:27

It sends the, the more I read, and the more I study the anatomic literature,

11:31

the more I'm convinced everything sort of bl all the fascia,

11:34

we sort of just bl they all sort of blend together. And,

11:38

and the cortical humeral ligament is,

11:42

is is pretty robust and pretty amazing, uh, ligament. It,

11:47

it, uh, it surrounds, you know, as we, as we know,

11:51

the longhead of the biceps tendon forming the pulley, it covers, you know,

11:55

the first, the superficial layer of the rotator cuff. Now, you know,

12:00

now it sends a, a layer to communicate with the deep layer,

12:04

with the capsule through the five layers.

12:08

It is a pretty interesting ligament. This is a nice, I think this Kim article,

12:13

they talk, here we go. Yeah. First of all, they,

12:15

they review the four or five layers, the five layers,

12:19

as I was mentioning, of the, uh, cuff. But here also,

12:24

and let me blow this up,

12:25

we can see just some of the contributions of the cortical humeral ligament see

12:30

here, and you know, this, this, this thickening,

12:35

and you can see here,

12:36

it sort of runs parallels to the supra and infra,

12:40

but this is where you're gonna see that, that thickening,

12:43

and that's what helps to form that rotator cuff cable. Okay.

12:46

And then everything sort of more, uh, distal, as I mentioned to that cable,

12:51

that's gonna be the quote, crescentic fibers. Okay.

12:55

So if anything, uh, let's see here, here's some delamination.

13:03

Um, I mean, here,

13:07

maybe there's like a little cable right here. Maybe that's that right there.

13:14

But you can imagine if you don't have a cable, how you know, it,

13:19

it almost acts like a,

13:21

like a little surface fibrosis of the elbow or even, uh,

13:25

you know, the biceps femoris with the, uh, sacral tubes, ligaments, uh,

13:30

at the hip. Um, if you don't have that cable or, or such ligaments it's,

13:35

or, or a neurosis at those joints, you know, if you have a tendon tear,

13:40

those tendons are,

13:41

are gonna retract more further than if you would have

13:46

those ligaments, if that makes sense. Any other questions on this one?

13:51

Well, a surgical perspective to, uh, describe this in detail,

13:55

it would be of, uh, uh,

13:56

real significance to an athlete rather than older patient. Uh,

14:01

would there be any significance in, uh,

14:04

going into much detail in describing the injuries?

14:07

What injuries? Do you mean? Like the rotator cuff

14:09

To the rotator cuff, to the rotator cable, uh, based on those articles,

14:13

it looks pretty complex and details.

14:16

Yeah, I, I mean, you could, I, I think, I think in the end, my, my,

14:20

our surgeons are aware of it. Um, you know, but, uh, again, i, I am just,

14:25

I just be, I just try to be as specific as possible with, uh,

14:30

as accurate of measurements as possible, knowing or,

14:34

or understanding the, the anatomic literature, you know, that know, you know,

14:39

knowing that each layer, again, is about, you know,

14:42

one millimeter to about three millimeters thick with the second and third layers

14:47

being the most robust. The first,

14:50

fourth and fifth layers are gonna be about a millimeter or so each. Okay.

14:54

And then you kind of add, you know, so,

14:57

so you're looking at a maximum of like 1, 2, 3,

15:01

and then throw in another six. So you're looking at about, you know,

15:04

10 millimeters ish for the whole thickness of, of a rotator cuff tendon.

15:09

So just knowing all that, and, and, you know, knowing some of this anatomy, I,

15:14

I just try to be specific. You know, for instance, um, like in this case,

15:18

you know, I, I, I would be saying, you know, there is, uh,

15:23

supraspinatus tendinosis with full essentially, uh,

15:27

full thickness and full width, uh,

15:29

tear of the supraspinatus tendon with a few wispy fibers

15:33

remaining at the, uh, footprint. And,

15:37

and the torn tendon fibers are,

15:39

are retracted medially by approximately 34 millimeters. Uh,

15:43

then I would go on to say, in this case, you know, this,

15:47

this tendon extends posteriorly to involve the anterior fibers of the

15:51

infraspinatus tendon, and there's additional, uh,

15:55

delaminating type chair of the more posterior fibers of the infraspinatus

15:59

tendon, something like that, so that my surgeon's ready, uh,

16:04

and prepared and to have that talk with the, uh, the patient and also,

16:09

you know, has their appropriate tools in the, uh, in the arthro, uh,

16:13

arthroscopic tray

16:16

And, uh, with those footprint, uh, uh, subcortical cyst, uh,

16:20

that occur, uh, those, um, a vaginal injuries in a sense. And,

16:25

and there's just

16:26

So, so, so, yeah, so great question. And I don't know what those cysts are.

16:31

Uh, some people will call them enthesopathy cysts.

16:34

Some people call them inis ganglion cyst. Some people think there's,

16:38

it's just some synovial fluid finding the, uh, least path, the resistance. Um,

16:44

some people I and I challenged, uh, some of those authors and, and, and readers,

16:49

um, why couldn't it be, why couldn't it be like prior calc hydroxide?

16:53

And as I mentioned before with, uh,

16:55

in previous weeks where we had a prior case of, uh, calcific tendinosis,

17:00

you know, as we know,

17:01

there's calcium hydrox appetite that can extend into bone and muscle, right?

17:05

And mimic, you know, infection and tumor, right?

17:09

So I think some of those can be,

17:10

some of those cases can also be residua of subcortical and intra extension

17:15

of had. So the way I do it now is, you know,

17:20

I just say a, a minimal or small amount of, uh,

17:23

subconscious cystic change at the greater tuberosity or, you know,

17:26

humeral head posteriorly or posterior laterally, non-specific. However,

17:31

if it's, if it's a large cyst, you know, and, and it,

17:35

or it really catches my eye if it's like, you know, a centimeter,

17:38

two centimeter,

17:39

if it starts to get to really replace the greater tuberosity where it's gonna

17:44

affect, um, my surgeon going in, you know, with, uh,

17:48

you know, bone graft or a larger screw, or being prepared,

17:52

I will mention that and bring it down to my impression so that they are aware so

17:56

that, you know,

17:57

they know to bring in perhaps a larger screw or some bone graft material,

18:01

or they're just prepared to deal with that cyst because, you know,

18:04

that's essentially gonna be, you know, humeral head bone stock loss, right?

18:09

So that would, that would be, uh,

18:11

potentially a problem I've been told by my surgeons,

18:14

and I've been asked by my surgeons to mention that,

18:16

because that could be a potential problem when they go in to try to, uh,

18:19

reconstruct and, and repair the, uh, torn rotator cuff. So, great question. I.