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Fixation techniques in rot cuff repair

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Fixation techniques in rot cuff repair

  1. 1. Fixation techniques in rotator cuff repair Manos Antonogiannakis Director Center for shoulder arthroscopy IASO General Hospital Athens, Greece
  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. 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 [Gerber] or bigger than 5cm [Cofield]
  5. 5. Partial Thickness Tear • Bursal side tears • Articular side tears • Intratendinus tears Partial tear classification by Ellman • Grade I <3mm deep • Grade II 3-6mm deep • Grade III >6mm deep (i.e. >50% thickness)
  6. 6. How frequent are RC Tears? • Rotator Cuff Frequency: 30% of population • Significant correlation with age [Sher JS, Arthroscopy 1995]
  7. 7. Natural History of a Tear • Tears DO NOT HEAL. Some but NOT ALL of them will progress • Rot cuff arthropathy is the end stage (4-20%) • 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]
  8. 8. Partial Tears Treatment • By far the most common partial tears are Articular-side, vascular or age relateted Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”
  9. 9. Partial Tears Treatment Options 1. Debride partial tear only 2. In-situ Repair 3. Convert to full thickness, Debride, Repair Etiology makes the decision!!! • Because most tears are degenerative, option 3 should be the best for most cases • Trauma or young athletes are candidates for in-situ repair • If minimal partial tears cause significant pain then debridement alone [Yamaguch K, 2006 Nice Shoulder Course]
  10. 10. RC Tear Classification Acute, Chronic, Acute on chronic Tear Age Tissue Quality 1. Partial <40 Good 2. Complete <40 Good 3. Complete 40-65 Good 4. Complete 40-65 Bad 5. Complete >65 Good 6. Complete >65 Bad
  11. 11. Full thickness Tear
  12. 12. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration
  13. 13. Busral view after acromioplasty
  14. 14. Checking Tissue Quality
  15. 15. Today’s Knowledge • Rot cuff has some degree of reserve that affords functional use of the arm in cases of limited tendon deficiency. • Location rather that size of a tear maybe more important in the development of symptoms. • Type of activities plays an important factor in the development of symptoms
  16. 16. Goutallier fatty degeneration of muscles • Stage 0 Normal muscle – no fatty streaming • Stage 1 Occasional fatty streaming • Stage 2 Fat<50% of cross sectioned area Fat < Muscle • Stage 3 Fat=50% of cross sectioned area Fat = Muscle • Stage 4 Fat>50% of cross sectioned area Fat > Muscle
  17. 17. 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]
  18. 18. 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
  19. 19. Early failure of arthroscopic rot cuff repair 1. Failure of tendon-suture interface 2. Suture-anchor failure 3. Suture failure
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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) THEN • Rehabilitate vigorously the patient, to optimize the total function of the shoulder THEN We can expect a majority of satisfied patients
  25. 25. Our Results • 41 pts single row repair • Small 3 (7.31%) • Medium 26 (63.41%) • Large 5 (12.18%) • Massive 7 (17.7%) • Mean age 58.8 years • Mean FU 14 months • UCLA score Excellent 10 (24.39%) Good 20 (48.78%) Fair 9 (21.95%) Poor 2 (4.87%) 92% Substantial Improvement in Pain [Acta Orthopedica Hellenica, 2007]
  26. 26. Case Presentation
  27. 27. Case Presentation
  28. 28. FIRST: Have Good Friends around !
  29. 29. Light General Anesthesia with Laryngeal Mask
  30. 30. Plus Local Anesthesia Scalene Block
  31. 31. Positioning the patient Lateral decubitus My preferred position
  32. 32. Patient Positioning Padding bony prominences Beware of the neck
  33. 33. Room Set up Lateral decubitus allows easy access to the anterior and posterior part of the joint
  34. 34. Keep the operating room cold to avoid fogging but Keep the patient warm
  35. 35. Beach Chair position Equally suitable but ask those who use it for tips and secrets tomorrow !!!
  36. 36. Basic Arthroscopic Tools Have them all ready from the beginning
  37. 37. Draping
  38. 38. Traction: NOT more than 4 Kgrs
  39. 39. Instruments in side pocket – easily available
  40. 40. Is everything ready BEFORE starting ?
  41. 41. The arthroscopic tower opposite the surgeon
  42. 42. Commonly used tools arranged by the scrub nurse
  43. 43. Skin Marking
  44. 44. Before Entering with the Scope Saline Backflow Saline in
  45. 45. Starting with the scope portal
  46. 46. 30º Scope inserted into the joint
  47. 47. Anterior Superior Portal
  48. 48. Working Team
  49. 49. Thank you
  50. 50. Massive Rot Cuff TearsMassive Rot Cuff Tears Definition:Definition: • Involving 2 or more Tendon TearsInvolving 2 or more Tendon Tears (Gerber)(Gerber) • >5cm Tear>5cm Tear (Cofield)(Cofield)
  51. 51. The problemThe problem • Poor tendon qualityPoor tendon quality • Muscle tendon retractionMuscle tendon retraction • Muscular atrophy fatty infiltrationMuscular atrophy fatty infiltration The three central issuesThe three central issues • Passive range of motionPassive range of motion • Tendon retractionTendon retraction • Muscle viabilityMuscle viability • Failure of healingFailure of healing
  52. 52. Techniques of releasesTechniques of releases • The techniques adapted from openThe techniques adapted from open surgery as described by Codmann,surgery as described by Codmann, Rockwood, NeerRockwood, Neer • Refined and modernized by Esch, Snyder,Refined and modernized by Esch, Snyder, Gartsman, Burkhart and othersGartsman, Burkhart and others
  54. 54. The solutionThe solution • Improve the mechanical strength of theImprove the mechanical strength of the repairrepair • Enhance the biological responseEnhance the biological response • Abandon and replace-muscle transferAbandon and replace-muscle transfer • Rot cuff arthropathy-reverse or extendedRot cuff arthropathy-reverse or extended head arthroplastyhead arthroplasty
  55. 55. Recognize the Tear PatternRecognize the Tear Pattern • Tears must be repaired in theTears must be repaired in the direction of greatest mobility ->direction of greatest mobility -> minimal strainminimal strain
  56. 56. Mobility Check
  57. 57. Tendon debridement- Tear morphology recognition
  58. 58. Tear PatternsTear Patterns • Crescent shapedCrescent shaped • L-shaped (or reverse L)L-shaped (or reverse L) • U-ShapedU-Shaped • Massive Contracted Immobile tearsMassive Contracted Immobile tears S.S. BurkhartS.S. Burkhart
  59. 59. Crescent Shaped Tear S.S Burkhart
  60. 60. Crescent-Shaped TearCrescent-Shaped Tear • Double row repair,Double row repair,
  61. 61. Double Row Fixation Restoration of the footprint
  62. 62. Tuberoplasty
  63. 63. 1st Anchor Insertion – Medial Row
  64. 64. 1st suture passage- Medial row - mattress
  65. 65. suture passage- Medial row – post. anchor
  66. 66. Suture inspection – medial row - mattress
  67. 67. Lateral Row 1st Anchor Insertion
  68. 68. Lateral Row 2nd Anchor Insertion
  69. 69. Inspection of Suture Position
  70. 70. Knot Tying Lateral Row
  71. 71. Final Repair Double rowDouble row Probably stronger repair but Time consuming and of raised difficulty
  72. 72. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears Greater mobility from anterior toGreater mobility from anterior to posterior than medial to lateralposterior than medial to lateral
  73. 73. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears • Side to side sutures from medial to lateralSide to side sutures from medial to lateral • Progressively converge the margin of theProgressively converge the margin of the tear lateral to bone bedtear lateral to bone bed • Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear -> reduces strain at converge margin by areduces strain at converge margin by a factor of 6factor of 6 [[S. S .Burkhart]S. S .Burkhart]
  74. 74. Closing an L-shaped or U-shaped tear is much like closing a tent flap Closure of an U-shaped tear involves first side-to-side closure of the vertical limb of the tear, then tendon-to-bone closure of the transverse limb L or U -shaped tear S. S .BurkhartS. S .Burkhart
  75. 75.  Large U-shaped cuff tear extending to glenoid  Margin convergence  The free margin of the cuff is repaired to bone with suture anchors
  76. 76. Side to Side Repair Cuff repair
  77. 77. Side to Side Repair
  78. 78. Cuff repairCuff repair Tendon to bone repairTendon to bone repair
  79. 79. Massive Contracted Immobile TearsMassive Contracted Immobile Tears • No mobility from medial to lateral or fromNo mobility from medial to lateral or from anterior to posterioranterior to posterior • Subcategories:Subcategories: – Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears – Massive Contracted Crescent TearsMassive Contracted Crescent Tears • Represent 9.6% of massive tearsRepresent 9.6% of massive tears [[S.Burkhart]S.Burkhart]
  80. 80. Massive Contractite TearsMassive Contractite Tears • Anterior Interval SlideAnterior Interval Slide and/orand/or • Posterior Interval SlidePosterior Interval Slide Single and double interval slideSingle and double interval slide
  81. 81. Subacromial viewSubacromial view
  82. 82. Single and double interval slideSingle and double interval slide • Anterior slide through release in theAnterior slide through release in the rotator interval (supraspinatus–rotator interval (supraspinatus– coracobrachialis)coracobrachialis) • Posterior slide through release of thePosterior slide through release of the interval supraspinatus-infraspinatusinterval supraspinatus-infraspinatus
  83. 83. Free sutures to the cuffFree sutures to the cuff
  84. 84. Anterior slide- supraspinatus from coracoid – coracohumeral ligament
  85. 85. Posterior slide Infraspinatus-supraspinatus
  86. 86. Posterior slide
  87. 87. Side to side sutures
  88. 88. Final Subacromial viewFinal Subacromial view
  89. 89. Massive TearsMassive Tears associated withassociated with Subscapularis TearsSubscapularis Tears • Subscapularis must be mobilized andSubscapularis must be mobilized and repaired prior to the rest of the cuffrepaired prior to the rest of the cuff • Interval slide in continuityInterval slide in continuity
  90. 90. Subscapularis Repair Recognition
  91. 91. Subscapularis Repair Recognition
  92. 92. Subscapularis RepairSubscapularis Repair
  93. 93. Bicepts tenodesisBicepts tenodesis
  94. 94. Massive TearsMassive Tears May beMay be • Eassily repairableEassily repairable • Retracted very difficult to repair (anterior &Retracted very difficult to repair (anterior & posterior Slides)posterior Slides) • Medially RepairedMedially Repaired • Impossible to repairImpossible to repair • Incomplete RepairIncomplete Repair • Graft JacketsGraft Jackets • Tendon trasfersTendon trasfers • Reverse, extended head arthroplastyReverse, extended head arthroplasty
  95. 95. Arthroscopic cuff repairArthroscopic cuff repair Wolf, Snyder, Gartsman, Esch, Burkhart, Tauro and others reported 84%-94% excellent and good results
  96. 96. Results for massive tearsResults for massive tears • 95% Good to Excellent Results95% Good to Excellent Results independent to tear sizeindependent to tear size [Burkhart, 2001][Burkhart, 2001] • With interval slideWith interval slide • Improve UCLA score (10->28.3)Improve UCLA score (10->28.3) • Improve Active ROM, StrengthImprove Active ROM, Strength [Burkhart, 2004][Burkhart, 2004] • Graft Jacket RepairGraft Jacket Repair • Improve UCLA score (18->32Improve UCLA score (18->32)) [Snyder, 2008][Snyder, 2008]
  97. 97. ConclusionsConclusions • Acute Crescent TearAcute Crescent Tear Standard Techniques for tendon to bone fisxationStandard Techniques for tendon to bone fisxation • U- or L- shaped TearsU- or L- shaped Tears • Side to side margin convergenceSide to side margin convergence • Partial mobile tearsPartial mobile tears • Anterior / Posterior SlideAnterior / Posterior Slide • Medialized RepairMedialized Repair • Irreparable TearsIrreparable Tears • Partial RepairPartial Repair • GraftsGrafts • Tendon trasfersTendon trasfers
  98. 98. What to do???What to do??? • Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration DO NOTDO NOT improve with rot cuff repairimprove with rot cuff repair [Goutallier][Goutallier] Vs.Vs. • Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration improved significant at 86% of cases afterimproved significant at 86% of cases after arthroscopic repairarthroscopic repair [Burkhart][Burkhart]
  99. 99. In our experienceIn our experience Patients withPatients with massivemassive rot cuff tearsrot cuff tears benefitbenefit from surgeryfrom surgery but they tend to recover slowlybut they tend to recover slowly they succeed very good pain reliefthey succeed very good pain relief but strength deficits remainbut strength deficits remain
  100. 100. In our experienceIn our experience • Patients with upward migration of thePatients with upward migration of the femoral head in contact with the acromionfemoral head in contact with the acromion do not benefit from arthroscopydo not benefit from arthroscopy • Patients with painless external rotation lagPatients with painless external rotation lag and inability to keep the arm in externaland inability to keep the arm in external rotation do not benefit from arthoscopyrotation do not benefit from arthoscopy • With raised experience more previousWith raised experience more previous irreparable cuff tears can be repairedirreparable cuff tears can be repaired
  101. 101. Surgical Technique 1. GH Joint and Subacromial Joint Inspection 2. Bursal debridement 3. Acromioplasty 4. Cuff mobilization 5. Repair (side to side, tendon to bone)
  102. 102. Portals Outside in technique
  103. 103. Bleeding control
  104. 104. Bleeding control
  105. 105. Joint Side Inspection
  106. 106. Bursal Side Inspection-Bursectomy
  107. 107. Tendon debridement- Tear morphology recognition
  108. 108. Acromioplasty
  109. 109. Double Row Fixation Restoration of the footprint
  110. 110. Lateral Row Suture Passage
  111. 111. Inspection from the Glenohumeral Joint
  112. 112. Mobilization of the Articular Part of the Rotator Cuff
  113. 113. 2nd suture passage- Medial row - mattress
  114. 114. Knot Tying Lateral Row
  115. 115. Knot Tying Lateral Row
  116. 116. Knot Tying Mattress Medial Row
  117. 117. Knot Tying Mattress Medial Row
  118. 118. 4rd suture passage- Medial row - mattress
  119. 119. suture passage- Medial row – post. anchor
  120. 120. Lateral Row Suture Passage
  121. 121. Final Inspection