Massive cuff tears - Decision Making 2018
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The extent to which beliefs are based on evidence is very much less than believers suppose - Bertrand Russel
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Massive cuff tears - Decision Making 2018
- 1. Lennard Funk
- 2. “The extent to which beliefs are based on evidence is very much less than believers suppose” Bertrand Russell The Skeptical Essays, 1928
- 3. • Boutonniere • Loss of suspension bridge (force couple) • LHB subluxes • Subscap tears • muscles atrophy • fixed instability • bone softens Massive Cuff Tear (>5cm)
- 5. PREDICTORS FOR FAILURE OF REPAIR (METANALYSIS, 2014) Age Tear Size Fatty Infiltration Smoking Chronicity Obesity Comorbidities Jack Turnbull, 4th Year Medical Student, 2014.
- 6. EFFECT OF AGE & TEAR SIZE ON HEALING SMALL MEDIUM LARGE MASSIVE 50YRS OLD 74% 78% 63% 43% 60 YRS OLD 65% 70% 52% 33% 70YRS OLD 54% 60% 41% 24% 80YRS OLD 43% 49% 31% 17% MS Rashid et al. Acta Orthop 88 (6), 606-611. 2017 Sep 07.
- 7. IRREPARABLE CUFF TEARS Loss of Teres Minor - Postero-inferior Cuff: 1. +ve Hornblower’s Sign 2. MRI 3. Arthroscopy Walch, JBJS, 1998
- 8. TREATMENT OPTIONS 1. Deltoid Rehabilitation 2. Suprascapular Nerve Ablation 3. Partial Repair 4. Debridement - Humeroplasty, ASD, Biceps Tenotomy 5. Tendon Transfers 6. Synthetic Patches 7. Reverse Arthroplasty 8. Superior Capsular Reconstruction 9. InSpace Balloon
- 9. DECISION MAKING Daniel Kahneman, Amos Tversky (2000). Choice, Values, Frames. Cambridge University Press. ISBN 0-521-62172-0. Normative CognitivePsychological 70% 15% 15%
- 10. DELTOID REHAB Levy et al, JSES, 2008 Minimal Pain Elderly (mean age 80) Significant improvement (9m): ROM (40 - 160 deg) Constant Score (26 - 60) Strength
- 11. SUPRASCAPULAR NERVE ABLATION 70% shoulder joint supplied by SSN Significant improvement inVAS, CS & OS Tapers off at 3-6m ? Long Term Medically Unfit Kane et al. JSES, 2008
- 12. ARTHROSCOPIC DEBRIDEMENT Improvement in pain Reduction in strength ? Long term (Historical) Gartsmann, JBJS, 1997
- 13. LHB TENOTOMY/TENODESIS Isolated LHB Tenotomy 80% satisfied Pain relief significant No improvement in function if: Pseudoparalysis Teres Minor absent Boileau et al, JBJS, 2007
- 15. SYNTHETIC INTERPOSITION BRIDGING GRAFT Significant Improvement in: VAS (7 to 1) Oxford Score 14 (23%) ongoing pain: 12/14 (86%) intact 1 Infection (1.6%) Modi et al, S&E, 2013
- 16. ARTHROSCOPIC TECHNIQUE Click image for Presentation Funk et al. 2004
- 17. LAT DORSI TRANSFER Gerber: 1988, 1992, 2006
- 18. LAT DORSI TRANSFER - ARTHROSCOPIC Gervasi,Arthroscopy J, 2007 Casticini et al., JBJS, 2014 Grimberg et al, Arthroscopy J, 2015 Postero-Superior Tears Significant Improvement in: VAS Constant Score;ASES Ext Rotation (29 to 45deg) Strength (1.4 to 4.8kg)
- 21. SUPERIOR CAPSULAR RECONSTRUCTION Denard et al.Arthroscopy, 2017 Tokish, 2017;Adams, 2017 Funk & Snow, 2016Superior Tears Significant Improvement in: VAS Constant Score;ASES Elevation (29 to 45deg) Strength Intact graft = better outcomes
- 22. INSPACE BALLOON
- 23. HISTORY First case series intended as a safety & efficacy study - Massive Irreparable Cuff Tears Very low complication rate Good Results = debridement, biceps tenotomy, etc. = Partial cuff repair series But not as good as results of Reverse Arthroplasty • Jost, Pfirrmann, Gerber. JBJS. 2000 • Green A. JAAOS. 2003 • Dines DM, Moynihan DP, Dines JS, McCann P. JBJS. 2006 • Neri BR, Chan KW, Kwon YK. JSES. 2009 • Bedi A, Dines J, Warren RF, Dines DM. JBJS. 2010
- 24. @thearmclinic RCT: InSpace vs Repair for MRCT ClinicalTrials.gov: NCT02208440; REC ref: 13/NW/0754; Protocol: IS-CL-02-UK; IRAS: 122315
- 28. SUPRASCAPULAR N. ABLATION PAIN FUNCTION AGE SMOKING COMORBID STIFFNESS HORN- BLOWER EXAM RETRAC- TION FATTY ATROPHY MRI
- 29. DEBRIDEMENT & TENOTOMY PAIN FUNCTION AGE SMOKING COMORBID STIFFNESS HORN- BLOWER EXAM RETRAC- TION FATTY ATROPHY MRI
- 31. LAT DORSI TRANSFER PAIN FUNCTION AGE SMOKING COMORBID STIFFNESS HORN- BLOWER EXAM RETRAC- TION FATTY ATROPHY MRI
- 32. SCR PAIN FUNCTION AGE SMOKING COMORBID STIFFNESS HORN- BLOWER EXAM RETRAC- TION FATTY ATROPHY MRI
- 35. TAKEAWAY MESSAGE Normative Cognitive Psychological When making any decision, ask yourself WHY you are making that decision. What are your driving factors?
- 36. “Gandhi spoke often of how, at important moments, his “inner voice” would pipe up, with its decisive counsel. His strategy was to make that inner voice “hold its breath” for awhile, to give him time to study the facts.” U-Turn by Grierson
- 37. THANKYOU LENFUNK@SHOULDERDOC.CO.UK “The extent to which beliefs are based on evidence is very much less than believers suppose” Bertrand Russell