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Double row athlitiatriko 2008

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Double row athlitiatriko 2008

  1. 1. Double Row Arthroscopic Rotator Cuff Repair Manos Antonogiannakis Director Center for Shoulder Arthroscopy IASO General Hospital www.shoulder.gr
  2. 2. Rotator Cuff Function 1. Dynamic stabilizer of the shoulder 2. Contributes strength to the arm (50% of the abduction strength is generated by supraspinatus) 3. Couple forces stabilize and regulate the motion of the shoulder www.shoulder.gr
  3. 3. Rotator Cuff disease Rotator cuff disease is a wide spectrum of clinical conditions, which range from asymptomatic partial thickness tears to symptomatic rotator cuff arthropathy www.shoulder.gr
  4. 4. First Successful RC Repair Codman EA. Rupture of the supraspinatus tendon Boston Medical & Surgical Journal 1911 Vol clxiv (2) 708-10 McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder: the exposure and repair of tears with retraction. J Bone Joint Surg 1944;26:31-51. First Description of RC tears Smith JG. London. Med Gaz, 1834,14:280 Pathological appearances of seven cases of injury of the shoulder joint, with remarks. EA Codman HL McLaughlin The History of Rotator Cuff Repair www.shoulder.gr
  5. 5. • In 1972 Neer defined the concept of subacromial impingement • Open Surgery • Mini Open Surgery • In the 90s’ the arthroscope changed the treatment www.shoulder.gr The History of Rotator Cuff Repair
  6. 6. Tears’ Definitions • Partial Thickness Tears = absence of communication between the glenohumeral joint and the subacromial bursa. • Full Thickness Tears = communication between the glenohumeral joint and the subacromial bursa. • Massive Tear = Involving 2 or 3 tendons [Gerbers] or bigger than 5cm [Cofield] www.shoulder.gr
  7. 7. How frequent are RC Tears? • Rotator Cuff Frequency: 30% of population • Significant correlation with age [Sher JS, Arthroscopy 1995] www.shoulder.gr
  8. 8. Full Thickness Tear Age Frequency 40-60 4-13% 60-70 20% 70-80 50% >80 80% Partial Thickness Tear Age Frequency <40 4% >60 25% [Tempelhof S, JSES, 1999] How Frequent are RC Tears? www.shoulder.gr
  9. 9. Rot cuff disease etiology and pathogenesis 1. Tendon degeneration 2. Vascular factors 3. Impingement • Type of acromion as identified by Bigliani • Acromial angle devised by Toivonen . • Type I. Angle 0-12 • Type II. Angle 13-27 • Type III. Angle > 27 Popularized by Neer 4. Secondary impingement popularized by Jobe 5. Instability overload of the cuff - secondary superior migration 6. Trauma 7. Glenohumeral instability 8. Scapulothoracic dysfunction www.shoulder.gr
  10. 10. Natural History of a Tear • Tears DO NOT HEAL. Some but NOT ALL of them will progress • Rot cuff arthropathy is the end stage (4%) • 50% of newly symptomatic tears will progress in size • 20% of asymptomatic tears will progress. • No Tear seem to decrease in size. • 80% of partial tears progress in size or become full thickness at 2 years [Yamaguchi K., 2006, Nice Shoulder Course] www.shoulder.gr
  11. 11. Current Knowledge • RC tears DO NOT behave the same in different patients • Patients PROFILE plays the most important role • Size and Location of the tear DOES MATTER www.shoulder.gr
  12. 12. RC Treatment Patient Profile Size & Location Symptoms Tissue Quality Other Lesions MAKE YOURMAKE YOUR DECISIONDECISION www.shoulder.gr
  13. 13.  Stable RC repair  Restoration of tensile strength  Creation of an environment that facilitates healing mediated by the bursa  Prevention of bone/tendon gap formation Example of applied basic science in surgery The Goal of Operative Treatment www.shoulder.gr
  14. 14. What kind of Repair is NECESSARY? • An anatomically deficient RC could be a biomechanically intact rotator cuff [Burkhart] • Conservative treatment of chronic painful rot cuff tears will result in a successful outcome in about 50% of patients [Cofield] • Cuff tear arthropathy will develop in 4% of patients with complete rot cuff tears [Neer]] www.shoulder.gr
  15. 15. What can we Repair? • UP to 50% of cuff repairs had a postoperative defect • This didn’t affected patient satisfaction or pain relief • But it did affected shoulder strength [Harryman et all J. B.J.S 1991] www.shoulder.gr
  16. 16. Factors that affect RC Healing • Age • Sex • Activity • Size • Location • Tissue quality and elasticity • Muscle fat degeneration • Chronicity of the tear • Concomitant lesions • Smoking • Family history • Rehabilitation Protocol • NSAID • Surgical Technique www.shoulder.gr
  17. 17. Risk to Benefit Ratio • Rot cuff tears DO NOT heal spontaneously • Tear repairability • Think of Size, Elasticity and Chronicity • Fatty infiltration is not fully reversible www.shoulder.gr Operative Treatment
  18. 18. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration www.shoulder.gr
  19. 19. RC Arthroscopic Repair 1. Recognition, of the type of the tear 2. Retraction and releases 3. Repair Options: Anchors: metallic or absorbable Type of stitch: Mason-Allen, Mc Stitch, Mattress sutures, Horizontal mattress, Simple sutures Restoration of footprint: Double row or Single row www.shoulder.gr
  20. 20. The quality of Functional results depends on: 1. The size of the persistent defect 2. Associated atrophy of the muscles 3. Integrity of the deltoid and the coracoacromial arch 4. Functional demands of the patient www.shoulder.gr
  21. 21. How to convert a Symptomatic tear to an Asymptomatic re-tear • Subacromial decompression and debridmeut • Biseps tenotomy • Partial repair and healing of the rot cuff • Adequate post-op rehabilitation www.shoulder.gr
  22. 22. Factors affecting Recurrence of tear 1. Advanced age 2. Tear size 3. Fatty degeneration 4. Chronicity and atrophy 5. Poor tendon quality 6. Inappropriate rehabilitation 7. Smoking 8. Steroid injections 9. Diabetes www.shoulder.gr
  23. 23. Early failure of arthroscopic rot cuff repair 1. Failure of tendon-suture interface 2. Suture-anchor failure 3. Suture failure www.shoulder.gr
  24. 24. RC Repair Results • The rate of structural failure after open repair varies from 20% to more 50%, while it is greater for arthroscopic repairs • First report of DOUBLE ROW repair: Fealy S, Kingham TP, Altchek DW, Arthoscopy July 2002 Mini-open Rot cuff repair using a two row fixation technique www.shoulder.gr
  25. 25. ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR www.shoulder.gr
  26. 26. Side to Side Repair Cuff repair www.shoulder.gr
  27. 27. Side to Side Repair www.shoulder.gr
  28. 28. Cuff repair Tendon to bone repair www.shoulder.gr
  29. 29. Double Row Fixation Restoration of the footprint www.shoulder.gr
  30. 30. Steps Of Double Row Repair www.shoulder.gr
  31. 31. Joint Side Inspection www.shoulder.gr
  32. 32. Bursal Side View - Bursectomy www.shoulder.gr
  33. 33. Busral view before acromioplasty www.shoulder.gr
  34. 34. Acromioplasty www.shoulder.gr
  35. 35. Full thickness Tear www.shoulder.gr
  36. 36. Tendon debridement- Tear morphology recognition www.shoulder.gr
  37. 37. Mobility Check www.shoulder.gr
  38. 38. Tuberoplasty www.shoulder.gr
  39. 39. 1st Anchor Insertion – Medial Row www.shoulder.gr
  40. 40. 1st suture passage- Medial row - mattress www.shoulder.gr
  41. 41. 2nd Anchor Insertion – Medial Row www.shoulder.gr
  42. 42. suture passage- Medial row – post. anchor www.shoulder.gr
  43. 43. Suture inspection – medial row - mattress www.shoulder.gr
  44. 44. Lateral Row 1st Anchor Insertion www.shoulder.gr
  45. 45. Lateral Row Suture Passage www.shoulder.gr
  46. 46. Lateral Row 2nd Anchor Insertion www.shoulder.gr
  47. 47. Inspection of Suture Position www.shoulder.gr
  48. 48. Knot Tying Lateral Row www.shoulder.gr
  49. 49. Knot Tying Mattress Medial Row www.shoulder.gr
  50. 50. Final Repair Double rowDouble row Stronger repair but Time consuming and of raised difficulty www.shoulder.gr
  51. 51. New ideas Knotless double row repair www.shoulder.gr
  52. 52. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Medial Row Lateral Row Contact area www.shoulder.gr
  53. 53. Double Row RotatorCuff Repair SutureBridge technique Bio-Corkscrew FT & PushLock 2 X 5.5 mm. Bio-Corkscrew FT Medial row 2 X 3.5 mm. PushLock Lateral Row www.shoulder.gr
  54. 54. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock 2 medial anchors tied, …. Do NOT cut the sutures Load separate sutures through PushLock www.shoulder.gr
  55. 55. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Disengage driver from anchor 6 counterclockwise rotations, cut suture Placement second PushLock ….. Done ! www.shoulder.gr
  56. 56. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock www.shoulder.gr
  57. 57. A Knotless Rotator Cuff Repair www.shoulder.gr
  58. 58. www.shoulder.gr
  59. 59. Double Row RepairDouble Row Repair Single Row RepairSingle Row Repair www.shoulder.gr
  60. 60. Double row with push-lock
  61. 61. Double row with push-lock www.shoulder.gr
  62. 62. Double row with push-lock www.shoulder.gr
  63. 63. Double row with push-lock
  64. 64. www.shoulder.gr Suture Bridge
  65. 65. www.shoulder.gr Final double row reconstruction
  66. 66. • Harryman et all J. B.J.S 1991 found that UP to 50% of cuff repairs had a postoperative defect. This didn’t affected patient satisfaction or pain relief but it did affected shoulder strength • Klepps reported open repair of 32 medium and large rot cuff tears. The retear rate by MRI at I year was 31%. And patients with failed repairs hod lower UCLA scores and worse pain scores • Open or arthroscopic repairs are expected to improve pain and function in 90% of patients
  67. 67. Arthroscopic repairs do not heal faster Knowledge of biomechanical principles is mandatory in choosing repair type Cuff repair is feasible but technically demanding www.shoulder.gr
  68. 68. Double Row Advantages • BETTER restoration of the footprint • Wider bone to tendon contact • Stronger repair • More points of fixation to share the loads • Biomechanically superior to single row • No clinical difference with single row www.shoulder.gr
  69. 69. Double Row Disadvantages • Time consuming • Technical demanding • Higher cost www.shoulder.gr
  70. 70. Conclusions • Rot Cuf is extremely significant for the normal function of the shoulder • Rot Cuf tears can be asymptomatic • Symptoms Produced by a tear depend on: – Size – Location – Functional demands of the patient www.shoulder.gr
  71. 71. Conclusions • An anatomically deficient but biomechanical intact cuff is possible • Biomechanical intact cuff is the cuff that restores the equilibrium of the force couples • A cuff tear does not heal conservative • A cuff tear after operative repair may yet not heal • Partial healing may restore sufficient power to the cuff to equilibrate the force couples www.shoulder.gr
  72. 72. Conclusions • Non-operative treatment strives to optimize the function of the remaining cuff • Rehabilitation after surgery strives to optimize the function of the partially or completely healed cuff www.shoulder.gr
  73. 73. ..so when we treat a RC tear… We must try to: • Optimize the anatomic integrity of the cuff by a repair with minimal morbidity to the healthy tissues (mainly deltoid) and maximum strength THEN • Rehabilitate vigorously the patient, to optimize the total function of the shoulder THEN We can expect a majority of satisfied patients www.shoulder.gr
  74. 74. Conclusions • Double row provides maximum strength of initial fixation • Restores the footprint of the rot cuff • Although technically demanding probably is more suitable for young overhead athletes that stress vigorously the rot cuf
  75. 75. Thank you for your attention www.shoulder.gr
  76. 76. • Older patients • Chronic symptoms • Minimal loss of function (strength-mobility) • Less active Non-Operative Treatment for: •Older patients •Massive tear •Superior migration of the humeral head •Fatty infiltration of the muscles •Retraction of the tendons Trial of Non-Operative Treatment www.shoulder.gr
  77. 77. www.shoulder.gr Case Presentation
  78. 78. www.shoulder.gr Case Presentation
  79. 79. What to do??? • Patients with grade 3 or 4 fatty degeneration DO NOT improve with rot cuff repair [Goutallier] Vs. • Patients with grade 3 or 4 fatty degeneration improved significant at 86% of cases after arthroscopic repair [Burkhart] www.shoulder.gr

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