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Massive rct salonica 2106

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Massive rct salonica 2106

  1. 1. | Emmanouil Antonogiannakis | Director | 3rd Orthopaedic Department | Centre of Shoulder Arthroscopy and Open Surgery | Hygeia General Hospital Massive Rotator Cuff Tears 7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery Thessaloniki 2016 .
  2. 2. Massive Rotator Cuff Tears Rotator Cuff disease from a functional point of view Tears of the rot cuff lower the functional reserves of the shoulder When the functional demands of the patient exceeds the reserves of the remaining intact rot cuff clinical symptoms are produced www.shoulder.gr
  3. 3. Massive Rotator Cuff Tears Philosophy of treatment: Restore the equilibrium between the functional demands and the capacity of the cuff  Lower the functional demands of the patient (persuation)  Increase the functional capacity of the remaining intact cuff physiotherapy , InSpace balloon, reconstruction of the superior capsule  Repair the cuff  Tendon transfers  By-pass the rot cuff – Reverse shoulder arthroplasty www.shoulder.gr
  4. 4. Massive Rotator Cuff Tears Ideally Repair the cuff But when this is not possible what to do ? www.shoulder.gr
  5. 5. Massive Rotator Cuff Tears When to suspect irreparability? Age of the patient Chronicity of tear (duration of symptoms) Fatty infiltration more than stage 3-4 according to Goutallier classification (more fat than muscle) Patte tendon retraction stage 3 (tendons to the glenoid) Acromiohumeral distance <2mm Rot cuff arthropathy www.shoulder.gr
  6. 6. Massive Rotator Cuff Tears Goutallier classification Stage 0: normal muscle Stage 1: some fatty streaks Stage 2: <50 % fatty muscle atrophy Stage 3: 50 % fatty muscle atrophy Stage 4: >50 % fatty muscle atrophy www.shoulder.gr
  7. 7. Massive Rotator Cuff Tears Patte classification of tendon retraction in the frontal plane Stage 1: proximal stump near the bony insertion Stage 2: proximal stump at level of the humeral head Stage 3: proximal stump at level of glenoid www.shoulder.gr
  8. 8. Massive Rotator Cuff Tears Posterosuperior and anterosuperior are two most common tear types seen. The prevalence of massive tears reported in the literature has ranged from 10 to 40%of all RCT tears www.shoulder.gr
  9. 9. Massive Rotator Cuff Tears Type Description Preoperative MRI Findings Treatment Prognosis 1 Crescent Short and wide tear End-to-bone repair Good to excellent 2 Longitudinal (L or U) Long and narrow tear Margin convergence Good to excellent 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good 4 Cuff tear arthropathy Cuff tear arthropathy Arthroplasty Fair to good. www.shoulder.gr
  10. 10. Massive Rotator Cuff Tears What to do ? Type 1 and 2 repair Type 3 we will consider Type 4 reverse arthroplasty www.shoulder.gr
  11. 11. Massive Rotator Cuff Tears Repair the cuff the first option  Balanced force couples  Stability of the edges  Strong fixation  Repair without tension www.shoulder.gr
  12. 12. Massive Rotator Cuff Tears How to perform a repair When to consider a tear as irreparable or When to stop the repairing effort We must be able to:  Recognize the tendons  Release the tendons completely  Fix the tendons without tension www.shoulder.gr
  13. 13. Massive Rotator Cuff Tears How to perform a repair Find and recognize the tendons Identify recognizable landmarks  the undersurface of the acromion and  the anterolateral corner  the acromio-clavicular joint  the spine of the scapula  the lateral border of the tuberosity www.shoulder.gr
  14. 14. Massive Rotator Cuff Tears Tips and tricks Remove the thickened bursa till to see the posterior edge of the cuff ending to the greater tuberosity. Everything that goes around the tuberosity to the deltoid is bursa www.shoulder.gr
  15. 15. Massive Rotator Cuff Tears Tips and tricks Remove the thickened bursa till to see the posterior edge of the cuff ending to the greater tuberosity. Everything that goes around the tuberosity to the deltoid is bursa Don’t suture the bursa instead of the cuff It doesn’t work www.shoulder.gr
  16. 16. Massive Rotator Cuff Tears Tips and tricks  Recognize the tendons  Release the tendons completely  Fix the tendons www.shoulder.gr
  17. 17. Massive Rotator Cuff Tears Tips and tricks  Recognize the tendons  Release the tendons completely  Fix the tendons You can’t consider repairability before a complete release www.shoulder.gr
  18. 18. Massive Rotator Cuff Tears Release the tendons from:  The coracoid  The acromion  The glenoid www.shoulder.gr
  19. 19. Massive Rotator Cuff Tears www.shoulder.gr Release from the interval
  20. 20. Massive Rotator Cuff Tears Release from the coracoid www.shoulder.gr
  21. 21. Massive Rotator Cuff Tears Release from the glenoid P o s t e r i o r l y S u p e r i o r l y A n t e r i o r l y www.shoulder.gr
  22. 22. Massive Rotator Cuff Tears Release from the glenoid P o s t e r i o r l y I n f e r i o r l y A n t e r i o r l y www.shoulder.gr
  23. 23. Massive Rotator Cuff Tears All around thylacotomy P o s t e r i o r l y S u p e r i o r l y A n t e r i o r l y www.shoulder.gr
  24. 24. Massive Rotator Cuff Tears Release from the interval and thylacotomy www.shoulder.gr
  25. 25. Massive Rotator Cuff Tears Release the tendons from the acromion P o s t e r i o r l yA n t e r i o r l y www.shoulder.gr
  26. 26. Massive Rotator Cuff Tears Pre-operatively Post-operatively www.shoulder.gr
  27. 27. Massive Rotator Cuff Tears Decisions after complete release  Complete repair  Medialized repair  Partial repair  Debridement, biceps tenotomy www.shoulder.gr
  28. 28. Massive Rotator Cuff Tears www.shoulder.gr Repair without Tension
  29. 29. Massive Rotator Cuff Tears Rotator Cuff Grafts www.shoulder.gr Our Experience is limited
  30. 30. Massive Rotator Cuff Tears TENDON TRANSFERS www.shoulder.gr Latissimus dorsi transfer for posterosuperior tears
  31. 31. Massive Rotator Cuff Tears Latissimus Dorsi Transfer www.shoulder.gr The goal is not to cover the humeral head but to establish a balanced force couple centering the head Subscapularis Lat. Dorsi
  32. 32. Massive Rotator Cuff Tears Latissimus Dorsi Transfer www.shoulder.gr Indications  Intact Subscapularis  Intact Deltoid  No Stiffness
  33. 33. Massive Rotator Cuff Tears Latissimus Dorsi Transfer www.shoulder.gr
  34. 34. Massive Rotator Cuff Tears Results (6 months post-op) www.shoulder.gr
  35. 35. Massive Rotator Cuff Tears Passive spacers www.shoulder.gr Superior capsule reconstraction
  36. 36. Massive Rotator Cuff Tears Subacromial Spacer (InSpace Balloon) www.shoulder.gr
  37. 37. 11 cases with irreparable cuff tears treated by balloon implantation only 11 cases treated with partial repair augmented by balloon implantation 1 case treated with complete repair augmented by balloon implantation 1 revision balloon case due to balloon failure treated by revision balloon implantation Our experience 24 cases no psheudoparalytic shoulder Massive Rotator Cuff Tears www.shoulder.gr
  38. 38. Our experience 24 cases During the rehabilitation: No pain or very slight pain Very satisfied patients Most regained good active ROM They declare that their life quality has changed Massive Rotator Cuff Tears www.shoulder.gr
  39. 39. Our experience 24 cases Average VAS Rest Motion Night 1.5 5.4 7.4 0.0 0.4 0.0 Parameter Pre-op Post-op Average follow-up: 3.9 months Massive Rotator Cuff Tears www.shoulder.gr
  40. 40. Our experience 24 cases Parameter Pre-op Post-op ROM FF ER side ER 90 abd IR 119.4 48.8 48.2 L1 148.5 61.8 50.8 Th11 Average follow-up: 3.9 months Massive Rotator Cuff Tears www.shoulder.gr
  41. 41. Our experience 24 cases Parameter Pre-op Post-op Function Constant ASES Oxford 44.2 50.8 28.6 55.6 80.2 41.4 Average follow-up: 3.9 months Massive Rotator Cuff Tears www.shoulder.gr
  42. 42. Our experience 24 cases All patients had: Significant pain relief Increased ROM Less pain during rehabilitation Massive Rotator Cuff Tears www.shoulder.gr
  43. 43. Massive Rotator Cuff Tears Take home message In every massive cuff tear follow the steps  Recognize the tendons  Release the tendons completely  Fix the tendons without tension if possible  Use alternative methods www.shoulder.gr
  44. 44. | Emmanouil Antonogiannakis | Director | 3rd Orthopaedic Department | Centre of Shoulder Arthroscopy and Open Surgery | Hygeia General Hospital 7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery Thessaloniki 2016 . Thank you …for your attention
  45. 45. Massive Rotator Cuff Tears Release the anterior capsule www.shoulder.gr
  46. 46. Massive Rotator Cuff Tears Release from the posterior capsule www.shoulder.gr

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