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Repair methods for full thickness rotator cuff tears: Implications for PT
Goals of repair ,[object Object],[object Object],[object Object],[object Object]
Goals of postoperative rehab ,[object Object],[object Object],[object Object],[object Object],Protect the repair Promote healing Gradually restore passive motion and muscular strength to restore function
Are we currently achieving these goals?
Clinical Problem ,[object Object],Study Failure Rate Harryman, 1991 20% 1-tendon, 50% massive tear Gazielly, 1994 36% Fuchs, 1994 13% Gleyze, 2000 43% medium tear, 59% with retraction Gerber, 2000 41% Galatz, 2004 94% for massive tears Fealy, 2006 48%
Clinical Problem ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Problem ,[object Object],[object Object],[object Object],[object Object]
Can we improve outcome with individualized PT?
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],How does surgical approach affect PT? How does the Suture  Technique and Method of  Fixation affect PT?
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Open RCR ,[object Object],[object Object],[object Object],[object Object],[object Object],Bigliani, Cordasco JBJS 1992 Ianotti JSES 1996 Rokito JBJS 1999
Surgical technique ,[object Object],[object Object],[object Object],[object Object],[object Object]
Deltoid dehiscence ,[object Object],[object Object],[object Object],[object Object],[object Object],Mansat, Cofield Orthop Clin North Am 1997 Mormino Arthroscopy 1996  Yamaguchi Tech Ortho 1997
Mini-open RCR ,[object Object],[object Object],[object Object],Levy et al Arthroscopy 1990 *Baker AJSM 1995 Posada Arthroscopy 2000
Mini-open surgical technique ,[object Object],[object Object],[object Object],[object Object],[object Object]
Post-operative stiffness ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Warner Inst Course Lect 1998 Severud et al Arthroscopy 2003 Huberty, Burkhart Arthroscopy 2009
Arthroscopic surgical technique ,[object Object],[object Object],[object Object]
Comparison of RC techniques Open RCR Mini-open All arthroscopic GH joint evaluation No Yes Yes Incision size 4-6 cm 3-4 cm 4-7 mm Deltoid surgical insult Moderate-Severe Small Minimal Early active motion No Variable Variable Early passive motion Yes Yes Variable Post-op pain Moderate-severe Moderate Mild
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mason-Allen vs. Simple Stitches  Suture Repair of Rotator Cuff Tendons Gerber et al, JBJS Br 1994 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mason-Allen vs. Mattress Stitches  Arthroscopic mod Mason-Allen Schneeberger et al, JBJS 2002 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],No significant differences
Factors Affecting Rehabilitation Program ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fixation method based on ability to restore anatomy of RTC Insertion
Anatomy of RTC  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Subscapularis Infraspinatus 1.76cm2 surface area of insertion Teres Minor Supraspinatus 1.55cm2 surface area of insertion Curtis et al. The Insertional Footprint of the Rotator Cuff: An Anatomic Study. Arthroscopy 2006 Dugas  Anatomy and dimensions of rotator cuff insertions. JSES 2002 Supraspinatus 14.7mm med-lat FOOTPRINT ANATOMY-Restoration
Anatomy of RTC Insertion  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Anatomy of RTC Insertion  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Traditional New Model
Why is RC footprint important? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rotator Cuff Repair Types
Transosseous  Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area .   Apreleva, Arthroscopy. 2002 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Transosseous  Rotator Cuff Repair: A Biomechanical comparison of three techniques Waltrip AJSM 2003 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Transosseous  Tendon bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques Ahmad AJSM 2005 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Transosseous  Tendon-to-Bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques Park AJSM 2005 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Double Row Anchor Fixation  Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. Kim AJSM 2006 ,[object Object],[object Object],[object Object],[object Object]
Double Row Anchor Fixation  In vitro analysis of rotator cuff repairs: a comparison of arthroscopically inserted tacks or anchors with open transosseous repairs Chhabra Arthroscopy 2005 ,[object Object],[object Object],[object Object],[object Object],[object Object],Arthroscopically double loaded suture repair more stable than transosseous
Double Row Anchor Fixation  Arthroscopic single row versus double row suture anchor rotator cuff repair Mazzocca AJSM 2005 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Double Row Anchor Fixation  Arthroscopic single row versus double row suture anchor rotator cuff repair Mazzocca AJSM 2005 ALL Double Row Repairs restored the footprint
Transosseous Equivalent  Part I: Footprint contact characteristics for a TOE compared with a DR repair technique Park JSES 2007 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Transosseous Equivalent  Part I: Footprint contact characteristics for a TOE compared with a DR repair technique Park JSES 2007 ,[object Object]
Transosseous Equivalent  Part II: Biomechanical assessment for TOE compared with a DR repair technique Park JSES 2007 ,[object Object],[object Object]
Double Row vs Single Row  Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence Wall JSES 2009 ,[object Object],Double Row better at footprint restoration in all studies Study Repair Outcome Variable Footprint Coverage Brady 2006 SR vs DR M->L coverage SR = 47% DR=100% Mazzocca 2005 SR vs DR Mean area SR=52% DR Diamond=102% DR MDA=81% DR MMDA=89% Meier 2006 SR vs DR (vs TOS) Mean Area SR=46% DR=106% Nelson 2008 SR vs DR Mean Area DR 74% more than SR Tuoheti 2005 SR vs DR (vs TOS) NA DR 60% more than SR
Double Row vs Single Row  Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence Wall JSES 2009 ,[object Object],[object Object],[object Object],[object Object]
Regardless of approach or fixation ,[object Object],[object Object],[object Object],Sonnabend et al JBJS Br 2010
Does Footprint Restoration Correlate to Improved Clinical Results?
Double Row vs Single Row  Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 ,[object Object],[object Object],[object Object]
Double Row vs Single Row  Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 ,[object Object],[object Object]
Double Row vs Single Row  Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review Saridakis JBJS-Am 2010 ,[object Object],[object Object],Study Failure Rate Imaging P-value Burks SR DR 10% 10% MRI NR Cherousset  SR DR 40% 22.6% CT Arthro 0.03 Franceschi SR DR 46.2% 30.7% MRI >0.05 Sugaya SR DR 25.6% 9.8% MRI <0.01
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RTC Repair: Should fixation affect post-op PT?
Passive external rotation ,[object Object],[object Object],Park JSES 2007
Cyclic rotation model ,[object Object],[object Object],[object Object],[object Object]
Effect of abduction and rotation ,[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Repair Methods for Full Thickness Rotator Cuff Tears: Implications for PT

  • 1. Repair methods for full thickness rotator cuff tears: Implications for PT
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  • 4. Are we currently achieving these goals?
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  • 8. Can we improve outcome with individualized PT?
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  • 22. Comparison of RC techniques Open RCR Mini-open All arthroscopic GH joint evaluation No Yes Yes Incision size 4-6 cm 3-4 cm 4-7 mm Deltoid surgical insult Moderate-Severe Small Minimal Early active motion No Variable Variable Early passive motion Yes Yes Variable Post-op pain Moderate-severe Moderate Mild
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  • 27. Fixation method based on ability to restore anatomy of RTC Insertion
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  • 29. Subscapularis Infraspinatus 1.76cm2 surface area of insertion Teres Minor Supraspinatus 1.55cm2 surface area of insertion Curtis et al. The Insertional Footprint of the Rotator Cuff: An Anatomic Study. Arthroscopy 2006 Dugas Anatomy and dimensions of rotator cuff insertions. JSES 2002 Supraspinatus 14.7mm med-lat FOOTPRINT ANATOMY-Restoration
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  • 41. Double Row Anchor Fixation Arthroscopic single row versus double row suture anchor rotator cuff repair Mazzocca AJSM 2005 ALL Double Row Repairs restored the footprint
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  • 48. Does Footprint Restoration Correlate to Improved Clinical Results?
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  • 53. RTC Repair: Should fixation affect post-op PT?
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Editor's Notes

  1. For the single-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.47 ± 0.63, 3.11 ± 1.55, and 2.24 ± 0.94 mm, respectively. For the double-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.25 ± 0.54, 2.29 ± 1.10, and 1.57 ± 0.48 mm, respectively. For gapping averaged over all positions, the double-row repair had significantly less gapping than the single-row repair ( P = .0109); gapping was greatest for internal rotation, followed by external rotation, and least for neutral ( P &lt; .0001).