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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
  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
  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
  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
  5. 5. • In 1972 Neer defined the concept of subacromial impingement • Open Surgery • Mini Open Surgery • In the 90s’ the arthroscope changed the treatment 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]
  7. 7. How frequent are RC Tears? • Rotator Cuff Frequency: 30% of population • Significant correlation with age [Sher JS, Arthroscopy 1995]
  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?
  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
  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]
  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
  12. 12. RC Treatment Patient Profile Size & Location Symptoms Tissue Quality Other Lesions MAKE YOURMAKE YOUR DECISIONDECISION
  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
  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]]
  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]
  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
  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 Operative Treatment
  18. 18. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration
  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
  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
  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
  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
  23. 23. Early failure of arthroscopic rot cuff repair 1. Failure of tendon-suture interface 2. Suture-anchor failure 3. Suture failure
  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
  26. 26. Side to Side Repair Cuff repair
  27. 27. Side to Side Repair
  28. 28. Cuff repair Tendon to bone repair
  29. 29. Double Row Fixation Restoration of the footprint
  30. 30. Steps Of Double Row Repair
  31. 31. Joint Side Inspection
  32. 32. Bursal Side View - Bursectomy
  33. 33. Busral view before acromioplasty
  34. 34. Acromioplasty
  35. 35. Full thickness Tear
  36. 36. Tendon debridement- Tear morphology recognition
  37. 37. Mobility Check
  38. 38. Tuberoplasty
  39. 39. 1st Anchor Insertion – Medial Row
  40. 40. 1st suture passage- Medial row - mattress
  41. 41. 2nd Anchor Insertion – Medial Row
  42. 42. suture passage- Medial row – post. anchor
  43. 43. Suture inspection – medial row - mattress
  44. 44. Lateral Row 1st Anchor Insertion
  45. 45. Lateral Row Suture Passage
  46. 46. Lateral Row 2nd Anchor Insertion
  47. 47. Inspection of Suture Position
  48. 48. Knot Tying Lateral Row
  49. 49. Knot Tying Mattress Medial Row
  50. 50. Final Repair Double rowDouble row Stronger repair but Time consuming and of raised difficulty
  51. 51. New ideas Knotless double row repair
  52. 52. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Medial Row Lateral Row Contact area
  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
  54. 54. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock 2 medial anchors tied, …. Do NOT cut the sutures Load separate sutures through PushLock
  55. 55. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Disengage driver from anchor 6 counterclockwise rotations, cut suture Placement second PushLock ….. Done !
  56. 56. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock
  57. 57. A Knotless Rotator Cuff Repair
  58. 58.
  59. 59. Double Row RepairDouble Row Repair Single Row RepairSingle Row Repair
  60. 60. Double row with push-lock
  61. 61. Double row with push-lock
  62. 62. Double row with push-lock
  63. 63. Double row with push-lock
  64. 64. Suture Bridge
  65. 65. 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
  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
  69. 69. Double Row Disadvantages • Time consuming • Technical demanding • Higher cost
  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
  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
  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
  73. 73. 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
  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
  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
  77. 77. Case Presentation
  78. 78. 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]