Repair Methods for Full Thickness Rotator Cuff Tears: Implications for PT

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  • For the single-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.47 ± 0.63, 3.11 ± 1.55, and 2.24 ± 0.94 mm, respectively. For the double-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.25 ± 0.54, 2.29 ± 1.10, and 1.57 ± 0.48 mm, respectively. For gapping averaged over all positions, the double-row repair had significantly less gapping than the single-row repair ( P = .0109); gapping was greatest for internal rotation, followed by external rotation, and least for neutral ( P < .0001).
  • Repair Methods for Full Thickness Rotator Cuff Tears: Implications for PT

    1. 1. Repair methods for full thickness rotator cuff tears: Implications for PT
    2. 2. Goals of repair <ul><li>High initial fixation strength </li></ul><ul><li>Minimize gap formation </li></ul><ul><li>Maintain mechanical stability under cyclic loading </li></ul><ul><li>Optimize the biology of the tendon-bone interface until the cuff heals to the bone </li></ul>
    3. 3. Goals of postoperative rehab <ul><li>High initial fixation strength </li></ul><ul><li>Minimize gap formation </li></ul><ul><li>Maintain mechanical stability under cyclic loading </li></ul><ul><li>Optimize the biology of the tendon-bone interface until the cuff heals to the bone </li></ul>Protect the repair Promote healing Gradually restore passive motion and muscular strength to restore function
    4. 4. Are we currently achieving these goals?
    5. 5. Clinical Problem <ul><li>Incidence of Radiographic RTC Repair Failure: </li></ul>Study Failure Rate Harryman, 1991 20% 1-tendon, 50% massive tear Gazielly, 1994 36% Fuchs, 1994 13% Gleyze, 2000 43% medium tear, 59% with retraction Gerber, 2000 41% Galatz, 2004 94% for massive tears Fealy, 2006 48%
    6. 6. Clinical Problem <ul><li>Do Radiographic Failures Correlate with Clinical Outcomes? </li></ul><ul><ul><li>Dodson, 2010: </li></ul></ul><ul><ul><ul><li>At 8 yr f/u, most patients remained happy with results, but…. </li></ul></ul></ul><ul><ul><ul><ul><li>Tear size increased with time </li></ul></ul></ul></ul><ul><ul><ul><ul><li>FF and ER strength decreased </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Didn ’t compare to patients with intact repairs </li></ul></ul></ul></ul><ul><ul><li>Harryman, 1991: </li></ul></ul><ul><ul><ul><li>Most were happy with results regardless of recurrent tear, but…. </li></ul></ul></ul><ul><ul><ul><li>Intact repairs had better: </li></ul></ul></ul><ul><ul><ul><ul><li>Function during ADL ’s </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Better ROM (129 vs 71 deg) </li></ul></ul></ul></ul>
    7. 7. Clinical Problem <ul><li>Do Radiographic Failures Correlate with Clinical Outcomes? </li></ul><ul><ul><li>Galatz 2004: </li></ul></ul><ul><ul><ul><li>Patients with recurrent tears showed deterioration over time </li></ul></ul></ul><ul><ul><ul><ul><li>ASES from 90 at 12 mos, to 79.9 at 24 mos. </li></ul></ul></ul></ul>
    8. 8. Can we improve outcome with individualized PT?
    9. 9. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><ul><li>Open, Mini-Open, Arthroscopic </li></ul></ul><ul><li>Fixation method </li></ul><ul><ul><li>Single row, double row, transosseous, hybrid </li></ul></ul><ul><li>Tissue quality </li></ul><ul><ul><li>Good, adequate, poor </li></ul></ul><ul><li>Size of the tear </li></ul><ul><ul><li>Small, medium, large, massive </li></ul></ul>
    10. 10. Factors Affecting Rehabilitation Program <ul><li>Location of tear </li></ul><ul><ul><li>Supraspinatus, infraspinatus/t. minor, subscap </li></ul></ul><ul><li>Type of tear </li></ul><ul><ul><li>Crescent, U-shaped, L-shaped, retracted Mechanism of failure </li></ul></ul><ul><li>Timing of surgery </li></ul><ul><ul><li>Immediate vs delayed </li></ul></ul>
    11. 11. Factors Affecting Rehabilitation Program <ul><li>Patient characteristics </li></ul><ul><ul><li>Smoking, DM, age </li></ul></ul><ul><li>Access to care </li></ul><ul><ul><li>Supervised vs independent </li></ul></ul><ul><li>Physician philosophical approach </li></ul><ul><ul><li>Conservative vs aggressive </li></ul></ul>
    12. 12. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><li>Fixation method </li></ul><ul><li>Tissue quality </li></ul><ul><li>Size of the tear </li></ul><ul><li>Location of tear </li></ul><ul><li>Type of tear </li></ul><ul><li>Mechanism of failure </li></ul><ul><li>Timing of surgery </li></ul><ul><li>RC tissue quality adjacent to repair site </li></ul><ul><li>Patient characteristics </li></ul><ul><li>Access to care </li></ul><ul><li>Physician philosophical approach </li></ul>
    13. 13. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><li>Mini-open </li></ul></ul><ul><ul><li>Arthroscopic </li></ul></ul><ul><li>Suture Technique </li></ul><ul><ul><li>Mason-Allen Stitches </li></ul></ul><ul><ul><li>Mattress Stitches </li></ul></ul><ul><li>Fixation method </li></ul><ul><ul><li>Simple Stitches </li></ul></ul><ul><ul><li>Transosseous </li></ul></ul><ul><ul><li>Single row suture anchors </li></ul></ul><ul><ul><li>Double row suture anchors </li></ul></ul><ul><ul><li>Arthroscopic transosseous equivalent </li></ul></ul>How does surgical approach affect PT? How does the Suture Technique and Method of Fixation affect PT?
    14. 14. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><li>Mini-open </li></ul></ul><ul><ul><li>Arthroscopic </li></ul></ul><ul><li>Suture Technique </li></ul><ul><ul><li>Mason-Allen Stitches </li></ul></ul><ul><ul><li>Mattress Stitches </li></ul></ul><ul><li>Fixation method </li></ul><ul><ul><li>Simple Stitches </li></ul></ul><ul><ul><li>Transosseous </li></ul></ul><ul><ul><li>Single row suture anchors </li></ul></ul><ul><ul><li>Double row suture anchors </li></ul></ul><ul><ul><li>Arthroscopic transosseous equivalent </li></ul></ul>
    15. 15. Open RCR <ul><li>First performed by Dr. Codman in 1911 </li></ul><ul><li>Further modifications by Neer in 1972 and Bigliani et al 1992 </li></ul><ul><li>Clinical outcomes: </li></ul><ul><ul><li>Good to excellent functional improvement in 75-95% patients </li></ul></ul><ul><ul><li>Pain relief in 85-100% patients </li></ul></ul>Bigliani, Cordasco JBJS 1992 Ianotti JSES 1996 Rokito JBJS 1999
    16. 16. Surgical technique <ul><li>Deltoid taken off anterior acromion beginning at AC joint </li></ul><ul><li>Deltoid split laterally 3-5 cm </li></ul><ul><li>Deltoid reattachment critical </li></ul><ul><ul><li>Repair both superficial and deep fascial layers to avoid dehiscence during rehabiliation </li></ul></ul><ul><ul><li>Consider drill holes in acromion </li></ul></ul>
    17. 17. Deltoid dehiscence <ul><li>Loss of anterior deltoid devastating complication </li></ul><ul><li>0.5% incidence </li></ul><ul><li>Therapy </li></ul><ul><ul><li>Avoid activities that create tensile loads to area of deltoid reattachment </li></ul></ul><ul><ul><li>No active deltoid contractions for 6-8 weeks </li></ul></ul>Mansat, Cofield Orthop Clin North Am 1997 Mormino Arthroscopy 1996 Yamaguchi Tech Ortho 1997
    18. 18. Mini-open RCR <ul><li>First described by Levy et al in 1990 </li></ul><ul><li>80-88% good/excellent results at 5 year follow-up </li></ul><ul><li>Patients undergoing mini-open RCR returned to previous activity on avg 1 month earlier than open repair* </li></ul>Levy et al Arthroscopy 1990 *Baker AJSM 1995 Posada Arthroscopy 2000
    19. 19. Mini-open surgical technique <ul><li>Arthroscopic-assisted </li></ul><ul><li>Acromioplasty, traction sutures placed arthroscopically </li></ul><ul><li>Lateral portal extended 3-4 cm </li></ul><ul><li>Deltoid fibers split in line, no takedown from acromion </li></ul><ul><li>Repair RC in an open fashion </li></ul>
    20. 20. Post-operative stiffness <ul><ul><li>Incidence </li></ul></ul><ul><ul><ul><li>Open RCR </li></ul></ul></ul><ul><ul><ul><ul><li>4-26% </li></ul></ul></ul></ul><ul><ul><ul><li>Mini-open </li></ul></ul></ul><ul><ul><ul><ul><li>14% </li></ul></ul></ul></ul><ul><ul><ul><li>Arthroscopic </li></ul></ul></ul><ul><ul><ul><ul><li>0% to 5 % </li></ul></ul></ul></ul>Warner Inst Course Lect 1998 Severud et al Arthroscopy 2003 Huberty, Burkhart Arthroscopy 2009
    21. 21. Arthroscopic surgical technique <ul><li>Technical difficulty has become routine procedure </li></ul><ul><li>Lower risk of stiffness, infection, deltoid dehiscence </li></ul><ul><li>Controversy over optimal fixation method </li></ul>
    22. 22. Comparison of RC techniques Open RCR Mini-open All arthroscopic GH joint evaluation No Yes Yes Incision size 4-6 cm 3-4 cm 4-7 mm Deltoid surgical insult Moderate-Severe Small Minimal Early active motion No Variable Variable Early passive motion Yes Yes Variable Post-op pain Moderate-severe Moderate Mild
    23. 23. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><li>Mini-open </li></ul></ul><ul><ul><li>Arthroscopic </li></ul></ul><ul><li>Suture Technique </li></ul><ul><ul><li>Mason-Allen Stitches </li></ul></ul><ul><ul><li>Mattress Stitches </li></ul></ul><ul><li>Fixation method </li></ul><ul><ul><li>Simple Stitches </li></ul></ul><ul><ul><li>Transosseous </li></ul></ul><ul><ul><li>Single row suture anchors </li></ul></ul><ul><ul><li>Double row suture anchors </li></ul></ul><ul><ul><li>Arthroscopic transosseous equivalent </li></ul></ul>
    24. 24. Mason-Allen vs. Simple Stitches Suture Repair of Rotator Cuff Tendons Gerber et al, JBJS Br 1994 <ul><li>Sheep Infraspinatus Tendon </li></ul><ul><li>Ultimate tensile strength </li></ul><ul><ul><li>Simple (2 stitches) 184 N </li></ul></ul><ul><ul><li>Simple (4 stitches) 208 N </li></ul></ul><ul><ul><li>Mod Mason-Allen 359 N </li></ul></ul><ul><ul><li>(2 stitches) </li></ul></ul>
    25. 25. Mason-Allen vs. Mattress Stitches Arthroscopic mod Mason-Allen Schneeberger et al, JBJS 2002 <ul><li>Metal anchor </li></ul><ul><ul><li>Mattress 228 N </li></ul></ul><ul><ul><li>Mod Mason-Allen 210 N </li></ul></ul><ul><li>Bioabsorbable anchor </li></ul><ul><ul><li>Mattress 230 N </li></ul></ul><ul><ul><li>Mod Mason-Allen 168 N </li></ul></ul><ul><li>Majority failed from anchor pullout, or rupture of suture </li></ul>No significant differences
    26. 26. Factors Affecting Rehabilitation Program <ul><li>Surgical approach </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><li>Mini-open </li></ul></ul><ul><ul><li>Arthroscopic </li></ul></ul><ul><li>Suture Technique </li></ul><ul><ul><li>Mason-Allen Stitches </li></ul></ul><ul><ul><li>Mattress Stitches </li></ul></ul><ul><li>Fixation method </li></ul><ul><ul><li>Simple Stitches </li></ul></ul><ul><ul><li>Transosseous </li></ul></ul><ul><ul><li>Single row suture anchors </li></ul></ul><ul><ul><li>Double row suture anchors </li></ul></ul><ul><ul><li>Arthroscopic transosseous equivalent </li></ul></ul>
    27. 27. Fixation method based on ability to restore anatomy of RTC Insertion
    28. 28. Anatomy of RTC <ul><li>Rotator Cuff </li></ul><ul><ul><li>Supraspinatus </li></ul></ul><ul><ul><li>Infraspinatus </li></ul></ul><ul><ul><li>Teres Minor </li></ul></ul><ul><ul><li>Subscapularis </li></ul></ul><ul><ul><li>Motion and dynamic stability </li></ul></ul><ul><ul><li>Originate at scapula </li></ul></ul><ul><ul><li>Terminate as short, flat tendons that fuse with capsule </li></ul></ul>
    29. 29. Subscapularis Infraspinatus 1.76cm2 surface area of insertion Teres Minor Supraspinatus 1.55cm2 surface area of insertion Curtis et al. The Insertional Footprint of the Rotator Cuff: An Anatomic Study. Arthroscopy 2006 Dugas Anatomy and dimensions of rotator cuff insertions. JSES 2002 Supraspinatus 14.7mm med-lat FOOTPRINT ANATOMY-Restoration
    30. 30. Anatomy of RTC Insertion <ul><li>Ruotolo et al, 2004 </li></ul><ul><ul><li>48 Cadavers </li></ul></ul><ul><ul><li>Determine Supraspinatus Insertion </li></ul></ul><ul><ul><ul><li>Medial – Lateral </li></ul></ul></ul><ul><ul><ul><ul><li>11.6mm at RI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>12.1mm at mid-tendon </li></ul></ul></ul></ul><ul><ul><ul><ul><li>12.0mm at post margin </li></ul></ul></ul></ul><ul><ul><ul><li>Confirms Dugas ’ Results </li></ul></ul></ul>
    31. 31. Anatomy of RTC Insertion <ul><li>Mochizuki et al, 2008 </li></ul><ul><ul><li>64 Cadavers </li></ul></ul><ul><ul><li>Supra footprint actually smaller than thought </li></ul></ul><ul><ul><li>Area of GT footprint mostly Infraspinatus </li></ul></ul><ul><ul><ul><li>Medial – Lateral </li></ul></ul></ul><ul><ul><ul><ul><li>Supra: 6.9mm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infra: 10.2mm </li></ul></ul></ul></ul>Traditional New Model
    32. 32. Why is RC footprint important? <ul><li>Initial single row fixation unable to restore footprint </li></ul><ul><li>Supraspinatus footprint </li></ul><ul><ul><li>Single row ~65% normal surface area </li></ul></ul><ul><ul><li>Double row ~100% normal surface area </li></ul></ul><ul><ul><li>Kim AJSM 2006 </li></ul></ul><ul><ul><li>Mazzocca AJSM 2005 </li></ul></ul><ul><li>Biomechanical strength at time zero </li></ul><ul><ul><li>Double row increased ultimate load to failure and less gap formation compared to single row </li></ul></ul><ul><ul><ul><li>Milano Arthroscopy 2008 </li></ul></ul></ul><ul><ul><ul><li>Nelson Arthroscopy 2008 </li></ul></ul></ul>
    33. 33. Rotator Cuff Repair Types
    34. 34. Transosseous Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area . Apreleva, Arthroscopy. 2002 <ul><li>Evaluated 4 different repair to reconstruct footprint </li></ul><ul><ul><li>Trans-osseous simple suture </li></ul></ul><ul><ul><li>Transosseous mattress </li></ul></ul><ul><ul><li>Suture anchor simple </li></ul></ul><ul><ul><li>Suture anchor mattress </li></ul></ul><ul><li>Found the transosseous simple suture (TOS) to recreate the insertional area the best (85%) </li></ul><ul><li>Found others to be between 65-67% </li></ul>
    35. 35. Transosseous Rotator Cuff Repair: A Biomechanical comparison of three techniques Waltrip AJSM 2003 <ul><li>3 types of repair </li></ul><ul><ul><li>Suture anchors with simple sutures </li></ul></ul><ul><ul><li>Transosseous tunnels with mason-allen sutures </li></ul></ul><ul><ul><li>Horizontal mattress anchor and transosseous mason-Allen sutures </li></ul></ul><ul><li>Best repair was suture anchors with transosseous anatomic repair at 3694 cycles </li></ul>
    36. 36. Transosseous Tendon bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques Ahmad AJSM 2005 <ul><li>Assessed tendon motion relative to footprint with in and ext rot </li></ul><ul><ul><ul><li>Intact tendon </li></ul></ul></ul><ul><ul><ul><li>Transosseous </li></ul></ul></ul><ul><ul><ul><li>Two simple suture anchor </li></ul></ul></ul><ul><li>Difference in tendon bone interface motion compared to intact tendon </li></ul><ul><ul><li>RTC tear – 7.14+/-3.72mm </li></ul></ul><ul><ul><li>Anchor – 2.35+/-1.26mm </li></ul></ul><ul><ul><li>Transosseous – 0.02+/-1.18mm </li></ul></ul><ul><li>Transosseous superior to simple anchor technique </li></ul>
    37. 37. Transosseous Tendon-to-Bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques Park AJSM 2005 <ul><li>Three techniques to repair IS </li></ul><ul><ul><li>Simple suture </li></ul></ul><ul><ul><li>Mattress </li></ul></ul><ul><ul><li>Transosseous </li></ul></ul><ul><li>Transosseous had best contact area and mean interface pressure at 67.7mm2 and 0.32MPa respectively </li></ul><ul><li>TOS>SAS>SAM </li></ul>
    38. 38. Double Row Anchor Fixation Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. Kim AJSM 2006 <ul><li>Gap formation was smaller for double row </li></ul><ul><ul><li>1 st cycle: 1.67 vs 3.1mm </li></ul></ul><ul><ul><li>Last: 3.58 vs 7.64mm </li></ul></ul><ul><li>Adding medial row increased the stiffness of the repair by 48% and ultimate failure load by 48% </li></ul>
    39. 39. Double Row Anchor Fixation In vitro analysis of rotator cuff repairs: a comparison of arthroscopically inserted tacks or anchors with open transosseous repairs Chhabra Arthroscopy 2005 <ul><li>25 cadaveric shoulders </li></ul><ul><ul><li>Open transosseous </li></ul></ul><ul><ul><li>Arthroscopic two single loaded </li></ul></ul><ul><ul><li>Arthroscopic two double loaded </li></ul></ul><ul><ul><li>Cuff tacks </li></ul></ul>Arthroscopically double loaded suture repair more stable than transosseous
    40. 40. Double Row Anchor Fixation Arthroscopic single row versus double row suture anchor rotator cuff repair Mazzocca AJSM 2005 <ul><li>20 cadaver shoulders </li></ul><ul><ul><li>3 Single row double loaded </li></ul></ul><ul><ul><li>Diamond (2 lateral and 1 medial anchor all double loaded) </li></ul></ul><ul><ul><li>Mattress double anchor (Millett) </li></ul></ul><ul><ul><li>Modified mattress double anchor (Gaunche) </li></ul></ul>
    41. 41. Double Row Anchor Fixation Arthroscopic single row versus double row suture anchor rotator cuff repair Mazzocca AJSM 2005 ALL Double Row Repairs restored the footprint
    42. 42. Transosseous Equivalent Part I: Footprint contact characteristics for a TOE compared with a DR repair technique Park JSES 2007 <ul><li>6 cadaveric shoulders </li></ul><ul><ul><li>Double row </li></ul></ul><ul><ul><li>Transosseous with single lateral screw (two suture bridges) </li></ul></ul><ul><ul><li>Transosseous with two lateral screws (four suture bridges) </li></ul></ul><ul><li>Pressure contact area measured </li></ul>
    43. 43. Transosseous Equivalent Part I: Footprint contact characteristics for a TOE compared with a DR repair technique Park JSES 2007 <ul><li>Mean interface pressure over footprint greatest for the 4-suture bridge technique (0.27MPa vs 0.19MPa for DR) </li></ul>
    44. 44. Transosseous Equivalent Part II: Biomechanical assessment for TOE compared with a DR repair technique Park JSES 2007 <ul><li>Mean ultimate load to failure greater in TOE (443N vs 299N for DR) </li></ul><ul><li>Gap formation not different </li></ul>
    45. 45. Double Row vs Single Row Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence Wall JSES 2009 <ul><li>5 studies looked at footprint restoration. </li></ul>Double Row better at footprint restoration in all studies Study Repair Outcome Variable Footprint Coverage Brady 2006 SR vs DR M->L coverage SR = 47% DR=100% Mazzocca 2005 SR vs DR Mean area SR=52% DR Diamond=102% DR MDA=81% DR MMDA=89% Meier 2006 SR vs DR (vs TOS) Mean Area SR=46% DR=106% Nelson 2008 SR vs DR Mean Area DR 74% more than SR Tuoheti 2005 SR vs DR (vs TOS) NA DR 60% more than SR
    46. 46. Double Row vs Single Row Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence Wall JSES 2009 <ul><li>9 of 12 studies showed advantage to a DR repair with regards to: </li></ul><ul><ul><li>Biomechanical strength </li></ul></ul><ul><ul><li>Failure </li></ul></ul><ul><ul><li>Gap Formation </li></ul></ul>
    47. 47. Regardless of approach or fixation <ul><li>We are currently unable to hasten biologic healing </li></ul><ul><li>12 weeks required for Sharpey ’s fibers at tendon-bone reattachment site </li></ul><ul><li>15 weeks required for reattachment site maturity </li></ul>Sonnabend et al JBJS Br 2010
    48. 48. Does Footprint Restoration Correlate to Improved Clinical Results?
    49. 49. Double Row vs Single Row Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 <ul><li>Review of 6 papers </li></ul><ul><ul><li>No differences in functional scores in any of the studies </li></ul></ul><ul><ul><li>However, Parks et al found better functional scores with DR in patients with large (>3cm) tears. </li></ul></ul>
    50. 50. Double Row vs Single Row Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 <ul><li>Review of 6 papers </li></ul><ul><ul><li>2 of 4 showed improved radiographic healing </li></ul></ul>
    51. 51. Double Row vs Single Row Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 <ul><li>Review of 6 papers </li></ul><ul><ul><li>2 of 4 showed improved radiographic healing </li></ul></ul>Study Failure Rate Imaging P-value Burks SR DR 10% 10% MRI NR Cherousset SR DR 40% 22.6% CT Arthro 0.03 Franceschi SR DR 46.2% 30.7% MRI >0.05 Sugaya SR DR 25.6% 9.8% MRI <0.01
    52. 52. Summary <ul><li>Supraspinatus footprint is about 14mm wide, from medial to lateral. </li></ul><ul><li>Double row and TOE do a better job of recreating the footprint compared to single row. </li></ul><ul><li>Double row and TOE have greater initial strength compared to single row. </li></ul><ul><li>This has not correlated to better clinical results. </li></ul><ul><ul><li>However, most studies underpowered to adequately detect a statistical difference. </li></ul></ul><ul><li>Nevertheless, there seems to be a trend towards improved healing with double row repairs. </li></ul>
    53. 53. RTC Repair: Should fixation affect post-op PT?
    54. 54. Passive external rotation <ul><li>Suture bridge construct provides better load sharing under rotational forces </li></ul><ul><li>Posterolateral suture anchor has higher vector force in double row configuration </li></ul>Park JSES 2007
    55. 55. Cyclic rotation model <ul><li>Ahmad AJSM 2008 </li></ul><ul><li>Cyclic rotation model=more realistic post-op rehab model </li></ul><ul><li>Single row vs double row with cyclic rotation </li></ul><ul><li>Average gapping significantly greater in single row repair in IR > ER > neutral (p<0.0001) </li></ul>
    56. 56. Effect of abduction and rotation <ul><li>Park AJSM 2009 </li></ul><ul><li>Abduction pillow/abduction rotation exercises common after RCR </li></ul><ul><li>30° or less of abduction and up to 60° of internal rotation optimizes footprint contact </li></ul><ul><li>Dual-row repair maximizes contact when initiating rehab that involves abduction and rotation </li></ul>
    57. 57. Summary <ul><li>Multitude of surgical techniques and fixation methods for RCR </li></ul><ul><li>Rehab challenging for patient, therapist, and surgeon </li></ul><ul><li>Surgery-specific rotator cuff rehabilitation program </li></ul><ul><li>Optimal patient education and outcome through: </li></ul><ul><ul><li>Effective communication </li></ul></ul><ul><ul><li>Coordination of care </li></ul></ul>
    58. 58. Thank You

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