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Rc repair philosophy and technique microhand 2014

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Rc repair philosophy and technique microhand 2014

  1. 1. www.shoulder.grwww.shoulder.gr Manos Antonogiannakis Head B’ Orthopaedics Dept Center for shoulder arthroscopy IASO GENERAL Hospital Arthroscopic Treatment of Rotator Cuff Tears – Philosophy and Technique
  2. 2. Philosophy of treatment: restore the equilibrium between the functional demands of the patient and the capacity of the rotator cuff  Lower the functional demands of the patient.  Increase the functional capacity of the remaining intact cuff  repair the cuff. www.shoulder.gr
  3. 3. www.shoulder.grwww.shoulder.gr Back to Basics
  4. 4. www.shoulder.grwww.shoulder.gr 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)
  5. 5. www.shoulder.grwww.shoulder.gr Partial Tears Treatment  By far the most common partial tears are Articular- side, vascular or age related Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”
  6. 6. www.shoulder.grwww.shoulder.gr Partial Tears Treatment Options 1. Debride partial tear only 2. In-situ Repair 3. Convert to full thickness, Debride, Repair Etiology drives 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 partial tear causes significant pain then debridement alone [Yamaguch K, 2006 Nice Shoulder Course] r
  7. 7. www.shoulder.grwww.shoulder.gr Partial Tears In situ repair
  8. 8. www.shoulder.grwww.shoulder.gr COMPLETE TEARS  Small 1cm  Medium 2-3cm  Large 3-5 cm  Massive >5cm Cofield et all
  9. 9. www.shoulder.grwww.shoulder.gr 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 Arthroplast y Fair to good.
  10. 10. www.shoulder.grwww.shoulder.gr ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR
  11. 11. www.shoulder.grwww.shoulder.gr Surgical Technique Steps 1. GH Joint and Subacromial Joint Inspection 2. Bursal debridement 3. Acromioplasty (+/-) 4. Cuff mobilization 5. Strong mechanical repair without tension(side to side, tendon to bone) 6. Biologic enhancement of the repair
  12. 12. www.shoulder.grwww.shoulder.gr Patient Position Lateral decubitus my preferred position
  13. 13. www.shoulder.grwww.shoulder.gr Bleeding control
  14. 14. www.shoulder.grwww.shoulder.gr Keys to control bleeding
  15. 15. www.shoulder.grwww.shoulder.gr 30º Scope Entrance from posterior portal but change portal and viewing angle of scope ( 30 to 70) as needed
  16. 16. www.shoulder.grwww.shoulder.gr Joint Side Inspection
  17. 17. www.shoulder.grwww.shoulder.gr Bursal Side Inspection-Bursectomy
  18. 18. www.shoulder.grwww.shoulder.gr Problem no 1: Bad quality retracted tendons covered by a thickened bursa  Find and recognize the tendons
  19. 19. www.shoulder.grwww.shoulder.gr 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
  20. 20. www.shoulder.grwww.shoulder.gr The posterior extent of the tear  Differentiate thickened bursa from the infraspinatus by finding the posterior insertion of the cuff to the tuberosity
  21. 21. www.shoulder.grwww.shoulder.gr Solution  Idendify recognizable landmarks 1. the undersurface of the acromion and the underolateral corner 2.the acromioclavicular joint 3.the spine of the scapula 4.the lateral border of the tuberosity And remove the bursa
  22. 22. www.shoulder.grwww.shoulder.gr Identify: 1. the Anterolateral Corner of the Acromion
  23. 23. www.shoulder.grwww.shoulder.gr Identify: 2. the acromioclavicular joint
  24. 24. www.shoulder.grwww.shoulder.gr Identify: 3. Lateral edge of the greater tuberosity
  25. 25. www.shoulder.grwww.shoulder.gr Identify 4. the keel of the acromion
  26. 26. www.shoulder.grwww.shoulder.gr Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain The muscle-tendon junction must be 2-3 mm medial of the edge of the cartilage at the tuberosity after the repair
  27. 27. www.shoulder.grwww.shoulder.gr Tear Patterns  Crescent shaped  U-Shaped  L-shaped (or reverse L)  Massive Contracted Immobile tears S.S. Burkhart
  28. 28. www.shoulder.grwww.shoulder.gr Crescent Shaped Tear mobilized easily for tendon to bone fixation S.S Burkhart
  29. 29. www.shoulder.grwww.shoulder.gr Crescent-Shaped Tears Repair to bone with increased points of fixation  Double row repair ?  Single row triple loadead anchors  Mc Stitch configuration
  30. 30. www.shoulder.grwww.shoulder.gr
  31. 31. www.shoulder.gr
  32. 32. www.shoulder.grwww.shoulder.gr Double Row Fixation Restoration of the footprint
  33. 33. Medial Row - Matress Sutures - 2 anchors www.shoulder.gr
  34. 34. Lateral Row - Simple Sutures - 2 anchors www.shoulder.gr
  35. 35. www.shoulder.grwww.shoulder.gr Suture Bridge double row
  36. 36. www.shoulder.gr
  37. 37. www.shoulder.grwww.shoulder.gr L-Shaped & U-Shaped Tears  Side to side sutures from medial to lateral  Progressively converge the margin of the tear lateral to the bone bed  Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [S. S .Burkhart]
  38. 38. www.shoulder.grwww.shoulder.gr  Large U-shaped cuff tear extending to glenoid  Margin convergence  The free margin of the cuff is repaired to bone with suture anchors
  39. 39. www.shoulder.grwww.shoulder.gr U-Shaped tear: Margin covergence with side to side sutures
  40. 40. www.shoulder.grwww.shoulder.gr Massive Contracted Immobile Tears  No mobility from medial to lateral or from anterior to posterior  Represent 9.6% of massive tears [S.Burkhart]
  41. 41. www.shoulder.grwww.shoulder.gr Massive Contracted Tears  Anterior Interval Slide and/or  Posterior Interval Slide Single and double interval slide
  42. 42. www.shoulder.grwww.shoulder.gr Anterior slide- supraspinatus from coracoid –coracohumeral ligament
  43. 43. www.shoulder.grwww.shoulder.gr Posterior slide Infraspinatus - supraspinatus
  44. 44. www.shoulder.grwww.shoulder.gr Before After
  45. 45. www.shoulder.grwww.shoulder.gr Biologic enhancement of healing •Acromioplasty •Tuberoplasty •PRGF injection in the subacromial space
  46. 46. www.shoulder.grwww.shoulder.gr Acromioplasty
  47. 47. www.shoulder.grwww.shoulder.gr Tuberoplasty
  48. 48. www.shoulder.grwww.shoulder.gr Arthroscopic repair yields  90-95% excellent in small and medium size tears at 4 to 10 years F.Up. • Burkhart SS, Danaceau SM, Pearce CM Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique—Margin convergence versus direct tendon to bone repair. Arthroscopy 2001;17:905-912. • Wolf EM, Pennington WT, Agrawal V. Arthroscopic rotator cuff repair: 4- to 10-year results. Arthroscopy 2004;20:5-12. • Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011: pp xxx  Good to excellent results in massive tears with less than 75% fatty infiltration of the infraspinatus, even at 10 years F.Up • Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M., Arthroscopic repair of massive rotator cuff rears with stage 3 and 4 fatty degeneration. Arthroscopy 2007;23:347-354. • Jones CK, Savoie FH III. Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy 2003;19:564- 571. • Dodson CC, Kitay A, Verma NN, et al. The long-term outcome of recurrent defects after rotator cuff repair. Am J Sports Med 2010;38:35-39. • Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011: pp xxx
  49. 49. www.shoulder.grwww.shoulder.gr Using the above techniques Burkhart reported less than 3% irreparable cuff tears
  50. 50. www.shoulder.grwww.shoulder.gr Complete loss of active external rotation (external rotation lag ) is a bad prognostic factor Superior migration of the humeral head in contact with the acromion – repair attempt is going to be a failure Rotator Cuff Arthropathy What are the limits?
  51. 51. www.shoulder.grwww.shoulder.gr Conclusions  Acute Crescent Tear Standard Techniques for tendon to bone fixation  U- or L- shaped Tears  Side to side margin convergence  Partially mobile tears  Anterior / Posterior Slide  Medialized Repair  Incomplete repair  Irreparable Tears  debridement  Tendon transfers  Reverse – Extended head arthroplasty
  52. 52. www.shoulder.grwww.shoulder.gr Thank you for your attention
  53. 53. www.shoulder.grwww.shoulder.gr Single and double interval slide Anterior slide through release in the rotator interval (supraspinatus– coracobrachialis) Posterior slide through release of the interval supraspinatus-infraspinatus
  54. 54. www.shoulder.grwww.shoulder.gr Stay sutures to the cuff
  55. 55. www.shoulder.grwww.shoulder.gr Release of MMP and GF after acromioplasty  Platelet-derived growth factor-AB (PDGF-AB), basic fibroblast growth factor basic (bFGF) and transforming growth factor beta 1 (TGF-b1) are released after acromioplasty in the subacromial space.  Knee Surg Sports Traumatol Arthrosc (2009) 17:98–101 Release of growth factors after arthroscopic acromioplasty . Pietro Randelli Ζ Fabrizio Margheritini Ζ Paolo Cabitza Ζ Giada Dogliotti Ζ Massimiliano M. Corsi  MMP-2 does not increase but MMP-9 increases after acromioplasty and their mesurment can be a useful tool to be monitored in parallel with growth factors level and other bone turnover markers in order to evaluate the bone remodelling and tissue healing.  E. Galliera , P. Randelli, G. Dogliotti, E. Dozio, A. Colombini, G. Lombardi, P. Cabitza, M. Corsi. Matrix metalloproteases MMP-2 and MMP-9: Are they early biomarkers of bone remodelling and healing after arthroscopic acromioplasty? Injury, Int. J. Care Injured 41 (2010) 1204–1207
  56. 56. www.shoulder.grwww.shoulder.gr Conclusions  Rot Cuff is extremely significant for the normal function of the shoulder  Rot Cuff tears can be asymptomatic  Symptoms Produced by a tear depend on:  Size  Location  Functional demands of the patient

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