Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Massive rot cuf

45 views

Published on

-

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Massive rot cuf

  1. 1. M. AntonogiannakisM. Antonogiannakis DirectorDirector Center for Shoulder arthroscopyCenter for Shoulder arthroscopy IASO Gen. HospitalIASO Gen. Hospital Athens GreeceAthens Greece Arthroscopic repair ofArthroscopic repair of massive rot cuff tearsmassive rot cuff tears
  2. 2. Rotator cuff disease is a spectrum of clinical conditions, which range from asymptomatic partial thickness tears to symptomatic rotator cuff arthropathy
  3. 3. 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)
  4. 4. 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
  5. 5. 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
  6. 6. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD OF THE REPAIROF THE REPAIR
  7. 7. 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
  8. 8. Recognize the TearRecognize the Tear PatternPattern  Tears must be repaired in theTears must be repaired in the direction of greatest mobility ->direction of greatest mobility -> minimal strainminimal strain
  9. 9. Mobility Check
  10. 10. Tendon debridement- Tear morphology recognition
  11. 11. 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
  12. 12. Crescent Shaped Tear S.S Burkhart
  13. 13. Crescent-Shaped TearCrescent-Shaped Tear  Double row repair,Double row repair,
  14. 14. Double Row Fixation Restoration of the footprint www.shoulder.gr
  15. 15. Tuberoplasty
  16. 16. 1st Anchor Insertion – Medial Row
  17. 17. 1st suture passage- Medial row - mattress
  18. 18. suture passage- Medial row – post. anchor
  19. 19. Suture inspection – medial row - mattress
  20. 20. Lateral Row 1st Anchor Insertion
  21. 21. Lateral Row 2nd Anchor Insertion
  22. 22. Inspection of Suture Position
  23. 23. Knot Tying Lateral Row
  24. 24. Final Repair Double rowDouble row Probably stronger repair but Time consuming and of raised difficulty
  25. 25. 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
  26. 26. 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]
  27. 27. 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
  28. 28.  Large U-shaped cuff tear extending to glenoid  Margin convergence  The free margin of the cuff is repaired to bone with suture anchors
  29. 29. Side to Side Repair Cuff repair www.shoulder.gr
  30. 30. Side to Side Repair
  31. 31. Cuff repairCuff repair Tendon to bone repairTendon to bone repair www.shoulder.gr
  32. 32. Massive Contracted ImmobileMassive Contracted Immobile TearsTears  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]
  33. 33. 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
  34. 34. Subacromial viewSubacromial view
  35. 35. Single and double intervalSingle and double interval slideslide  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
  36. 36. Free sutures to the cuffFree sutures to the cuff
  37. 37. Anterior slide- supraspinatus from coracoid – coracohumeral ligament
  38. 38. Posterior slide Infraspinatus-supraspinatus
  39. 39. Posterior slide
  40. 40. Side to side sutures
  41. 41. Final Subacromial viewFinal Subacromial view
  42. 42. 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
  43. 43. Subscapularis Repair Recognition
  44. 44. Subscapularis Repair Recognition
  45. 45. Subscapularis RepairSubscapularis Repair
  46. 46. Bicepts tenodesisBicepts tenodesis
  47. 47. 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
  48. 48. Arthroscopic cuff repairArthroscopic cuff repair Wolf, Snyder, Gartsman, Esch, Burkhart, Tauro and others reported 84%-94% excellent and good results
  49. 49. 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]
  50. 50. 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
  51. 51. 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]
  52. 52. 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
  53. 53. 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
  54. 54. Lateral Row Suture Passage
  55. 55. Knot Tying Mattress Medial Row
  56. 56. 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)
  57. 57. Patient position Lateral decubitus Traction3-4 kgr Abduction 20 degrees
  58. 58. Portals Outside in technique
  59. 59. Bleeding control
  60. 60. Bleeding control
  61. 61. Joint Side Inspection
  62. 62. Bursal Side Inspection-Bursectomy
  63. 63. Tendon debridement- Tear morphology recognition
  64. 64. Acromioplasty
  65. 65. Side to Side Repair Cuff repair
  66. 66. Cuff repairCuff repair Tendon to bone repairTendon to bone repair
  67. 67. Double Row Fixation Restoration of the footprint
  68. 68. Arthroscopic repairs do not heal faster Knowledge of biomechanical principles is mandatory in choosing repair type Cuff repair is feasible but technically demanding
  69. 69. Indications of arthroscopic cuffIndications of arthroscopic cuff repairrepair  Every repairable cuff tear can be repairedEvery repairable cuff tear can be repaired arthroscopic or a cuff that can be repairedarthroscopic or a cuff that can be repaired open can be repaired and arthroscopicopen can be repaired and arthroscopic  The decision to repair a cuff tear open orThe decision to repair a cuff tear open or arhtroscopic depends in the expertise of thearhtroscopic depends in the expertise of the surgeonsurgeon  In the long run there is no discernibleIn the long run there is no discernible difference between mini-open anddifference between mini-open and arthroscopic cuff repairsarthroscopic cuff repairs
  70. 70. Advantages of Arthroscopic Cuff Repair • Atraumatic • Deltoid sparing • Tissue mobilization • Cosmetic incisions • Secure repair • Address accompanying pathology • No iatrogenic injury to healthy tissues • Cost-effective on an outpatient basis
  71. 71. Disadvantages of Arthroscopic Cuff Repair • Technically demanding • Equipment dependent • Steep learning curve Know when to keep dealing or when to pack the cards in and go home
  72. 72.  Bennett WF. Arthroscopic repair of massive rotator cuff tears: aBennett WF. Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up.prospective cohort with 2- to 4-year follow-up. Arthroscopy.Arthroscopy. 20032003  Boileau P., Brassart N., Watkinson D.J., Carles M., HatzidakisBoileau P., Brassart N., Watkinson D.J., Carles M., Hatzidakis A.M., Krishnan S.G. Arthroscopic repair of full-thickness tears ofA.M., Krishnan S.G. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Jointthe supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005Surg Am. 2005  Buess E., Steuber K.U., Waibl B. Open versus arthroscopicBuess E., Steuber K.U., Waibl B. Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases.rotator cuff repair: a comparative view of 96 cases. Arthroscopy. 2005Arthroscopy. 2005  Gartsman G.M., Khan M., Hammerman S.M. ArthroscopicGartsman G.M., Khan M., Hammerman S.M. Arthroscopic repair of full-thickness tears of the rotator cuff.repair of full-thickness tears of the rotator cuff. J Bone JointJ Bone Joint Surg. 1998 Surg. 1998   Rebuzzi E, Coletti N, Schiavetti S, Giusto F. ArthroscopicRebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic rotator cuff repair in patients older than 60 years.rotator cuff repair in patients older than 60 years. Arthroscopy. 2005Arthroscopy. 2005  Tauro JC. Arthroscopic rotator cuff repair: analysis of techniqueTauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 1998and results at 2- and 3-year follow-up. Arthroscopy 1998  Warner JJ, Tetreault P, Lehtinen J, Zurakowski D. ArthroscopicWarner JJ, Tetreault P, Lehtinen J, Zurakowski D. Arthroscopic versus mini-open rotator cuff repair: a cohort comparisonversus mini-open rotator cuff repair: a cohort comparison Results of atrhroscopic rc repair
  73. 73. When to ReleaseWhen to Release andand When NOT to ReleaseWhen NOT to Release  According to Tear Pattern andAccording to Tear Pattern and MobilityMobility  Test mobility with grasperTest mobility with grasper
  74. 74. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Medial Row Lateral Row Contact area
  75. 75. Lateral Row Suture Passage
  76. 76. Inspection from the Glenohumeral Joint
  77. 77. Mobilization of the Articular Part of the Rotator Cuff
  78. 78. 2nd suture passage- Medial row - mattress
  79. 79. Knot Tying Lateral Row
  80. 80. Knot Tying Lateral Row
  81. 81. Knot Tying Mattress Medial Row
  82. 82. Knot Tying Mattress Medial Row
  83. 83. 4rd suture passage- Medial row - mattress
  84. 84. suture passage- Medial row – post. anchor
  85. 85. Lateral Row Suture Passage
  86. 86. Final Inspection
  87. 87. New ideasNew ideas Knotless double row repairKnotless double row repair
  88. 88. 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
  89. 89. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Check mobility of the tear Punch, creating Pilot hole
  90. 90. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Placement of 2 X Bio-Corkscrews FT Scorpion suture passing
  91. 91. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock 2 medial anchors tied, …. Do NOT cut the sutures Load separate sutures through PushLock
  92. 92. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Tensioning the sutures, will reduce the tendon into position Impaction of PushLock, until Laser-line is “flush” with cortex
  93. 93. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock Disengage driver from anchor 6 counterclockwise rotations, cut suture Placement second PushLock ….. Done !
  94. 94. Double Row RotatorCuff Repair Bio-Corkscrew FT & PushLock
  95. 95. A Knotless Rotator Cuff Repair
  96. 96. Double Row RepairDouble Row Repair Single Row RepairSingle Row Repair
  97. 97. SwiveLock AR-2323BSL FiberChain AR-7270 Thumb Pad #0 Tip Retention Suture Forked Tip Anchor Body 5.5mm x 15mm Terminal Link Free End (Suture Leader) #2 FiberWire w/ten 7 mm long loops
  98. 98. Access the mobility of the tear using a KingFisher suture Retriever / Tissue Grasper Place both 5.5 mm. Diameter Bio-Corkscrew FT suture anchors ( These Bio-Corkscrews come Preloaded with FiberChain, AR-1927BFC ) AR-1927BFC
  99. 99. Retrieve the sutrure leader from one of the FiberChain strands through the lateral portal and Load it on the Scorpion Retrieve both FiberChain suture ends through the Lateral portal and tension them, ….. Decide where to Make the 2 sockets for the lateral row SwiveLock anchors
  100. 100. Introduce the SwiveLock through the percutanious Superolateral portal and capture the third link from the free marginnof the Rotator Cuff Advance the driver in the bone socket and push The FiberChain toward the bottom of the socket
  101. 101. Advance the screw by holding the thumb pad as the inserter handle is turned clockwise Repeat step 5 through 7 for the second SwiveLock To obtain the final construct
  102. 102. Double row is simplifiedDouble row is simplified butbut it has to pass the test of timeit has to pass the test of time
  103. 103. Stable fulcrum(SS-part IS) Unstable fulcrum(SS-IS) Transform an unstable fulcrum to a stable one
  104. 104. 2nd Anchor Insertion – Medial Row

×