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Rcd osteo

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Rcd osteo

  1. 1. Rotator Cuff Disease<br />Current Surgical Management<br />Chris Pullen<br />
  2. 2. Historical Aspects<br />Codman in 1934<br />Impingement syndrome<br />Arthroscopic SAD<br />
  3. 3. Shoulder Arthroscopy<br />
  4. 4. Rotator Cuff Disease<br />Tendinopathy/Impingement<br />Rotator Cuff Tear<br />Cuff Tear Arthropathy<br />
  5. 5. PARTIAL THICKNESS TEARS(IMPINGEMENT/TENDINOPATHY) <br />
  6. 6. PTT –Surgery<br />Open <br />Mini – open<br />Arthroscopic*<br />
  7. 7. PTT - Arthroscopy<br />Advantages<br />Visualisation<br />Treatment <br />articular tears<br />
  8. 8. PTT - Arthroscopy<br />Bursal surface tear<br />SAD<br />Articular surface tear<br />Debridement only<br />Repair<br />>50% Thickness tear<br />Active patients<br />
  9. 9. PTT - Arthroscopy<br />Results<br />Debridement +/- SAD<br />Repair <br />
  10. 10. FULL THICKNESS TEARS<br />
  11. 11. FTT - Surgical Approaches<br />Arthroscopic*<br />Arthroscopic assisted/mini-open*<br />Open<br />
  12. 12. FTT - Arthroscopic RCR<br />Gleno-humeral Joint<br />PTT<br />Labral tears<br />Ligament injuries <br />Cartilage tears<br />Significant lesions in 12.5%<br />
  13. 13. FTT – Arthroscopic RCR<br />Repair Site Preparation<br />Removal of ragged or degenerate tissue<br />Decortication of bone<br />
  14. 14. FTT – Arthroscopic RCR<br />Suture Placement<br />
  15. 15. FTT – Arthroscopic RCR<br />Anchor Placement<br />Foot print<br />Double row technique<br />
  16. 16. FTT – Arthroscopic RCR<br />Other Tendon Lesions<br />Infraspinatus<br />Teres minor<br />Subscapularis<br />Biceps<br />
  17. 17. FTT – Arthroscopic RCR<br />Biceps <br />Debridement<br />Tenotomy<br />Tenodesis<br />
  18. 18. FTT – Arthroscopic RCR<br />Post – operative Treatment<br />Sling<br />Cryotherapy <br />PROM<br />AROM<br />Strengthening<br />
  19. 19. FTT – Arthroscopic RCR<br />Results<br />90% satisfaction<br />78% pain relief<br />AROM<br />
  20. 20. MASSIVE TEARS<br />
  21. 21. Massive Tears – Surgery<br />Debridement<br />Open<br />Arthroscopic*<br />Rotator Cuff Repair*<br />Tendon transfer*<br />Synthetic interposition<br />Arthrodesis<br />Arthroplasty<br />
  22. 22. Massive Tears - Debridement<br />Debridement alone <br />Low demand patients<br />Results tend to deteriorate over time<br />Arthroscopic debridement <br />easier <br />more rapid rehabilitation <br />
  23. 23. Massive Tears - Debridement <br />Limited acromioplasty<br />coracoacromial arch is maintained<br /> <br />Biceps tenotomy / tenodesis <br />subluxation, dislocation, or partial tearing<br />enhance the ability to alleviate shoulder pain<br />
  24. 24. Massive Tears - RCR<br />Good function & pain relief 80-90%<br />Goal of surgery is to repair the cuff without disrupting the coraco-acromial arch <br />
  25. 25. Massive Tears - RCR<br />Rehabilitation<br />Sling / Abduction splint<br />PROM<br />AAROM<br />Strengthening<br />Overall recovery may take >12 months<br />
  26. 26. Massive Tears - RCR<br />Results<br />Inferior<br />Better within 6 weeks (Bassett & Cofield 1983)<br />Shoulder dislocation >40<br />85-90% good to excellent ( Bigliani 1992)<br />
  27. 27. Massive Tears – Tendon transfer<br />Latissimus Dorsi*<br />Pectoralis Major*<br />Teres Minor<br />Subscapularis<br />Deltoid muscle flap<br />Trapezius<br />
  28. 28. Massive Tears – Latissimus Dorsi<br />Supraspinatus/Infraspinatus loss<br />Restore ER & head depression forces<br />
  29. 29. Massive Tears – Latissimus Dorsi<br />Results <br />82% satisfactory (Miniaci & MacLeod 1999)<br />Intact subscapularis <br />Little or no restoration of strength in overhead activity<br />
  30. 30. Massive Tears – Pectoralis Major<br />Subscapularis tears<br />
  31. 31. Massive Tears - Reconstruction<br />Tissue implants<br />Autologous<br />Autogenous<br />Freeze-dried cadaveric tissue<br />
  32. 32. CUFF TEAR ARTHROPATHY<br />
  33. 33. CTA - Surgery<br /> Arthroscopic debridement*<br /> Humeral tuberoplasty<br /> Shoulder arthrodesis<br /> Total Shoulder Replacement<br /> Hemiarthroplasty*<br /> Reverse Shoulder Arthroplasty*<br />
  34. 34. CTA - Hemiarthroplasty<br />Indications<br /><70 years<br />Active elevation >90°<br />CTA Head<br />Variation of the hemiarthroplasty<br />
  35. 35. CTA - Hemiarthroplasty<br />Results <br />Functional results limited, pain relief is excellent (Williams & Rockwood 1996)<br />Zuckerman et al (2000) decreased pain, increased FF86 & ER 30. <br />Sanchez-Sotelo et al (2001) 67% successful at 5 year follow-up<br />
  36. 36. CTA - Hemiarthroplasty<br />Results<br />intact coracoacromial arch essential<br />
  37. 37. CTA- Reverse Shoulder Arthroplasty<br />Semiconstrained reverse ball and socket <br />Grammont 1985<br />
  38. 38. CTA - RSA<br /> Biomechanics (Boileau et al 2005)<br />Large glenosphere<br />Medialisation of the centre of rotation <br />Lowers humeral head<br />
  39. 39. CTA - RSA<br />Indications<br />> 70 years or no active elevation<br />Low demand<br />
  40. 40. CTA - RSA<br />Results (Boileau et al 2005, De Buttet et al 1997, Rittmeister et al 2001)<br />Excellent pain reduction <br />Improved active abduction<br />
  41. 41. CTA - RSA<br />Complications<br />High<br />Rate revision is high (4.2-13%)<br />Not for the occasional operator<br />
  42. 42. REHABILITATION<br />
  43. 43. Rehabilitation -Biomechanics<br />Rotator Cuff <br />Stabilises gleno-humeral joint<br />Depresses the humeral head<br />Protective overlap <br />Subscapularis<br />Scapulo-thoracic dyskinesia<br />Compensatory impairment leads to winging<br />Alter orientation of the acromial arch <br />
  44. 44. Rehabilitation – Tendon Healing<br />Spontaneous healing ??<br />Phases <br />Inflammatory<br />Proliferative<br />Maturation<br />Maximal load to failure 12-26 weeks<br />
  45. 45. Rehabilitation - Immobilisation<br />Early ROM<br />Abduction splint<br />Shoulder immobilisation with an abduction-type splint for 4-6 weeks<br />
  46. 46. Rehabilitation - Cryotherapy <br />Speer et al 1996<br />Less pain 1st 24 post-operative hours<br />Better sleep<br />Lesser analgesic requirement<br />Less swelling<br />Better able to tolerate rehabilitation <br />
  47. 47. Rehabilitation - PTT<br />Goals <br />Full ROM<br />Reducing impingement<br />Physical therapy plus exercise program better than exercise alone<br />
  48. 48. Rehabilitation - RCR<br />Goals<br />Mobilise the joint early<br />Load the repaired tendons safely<br />Strengthen the rotator cuff progressively<br />
  49. 49. Rehabilitation - RCR<br />Phases<br />Immediate post-operative period (week 0-6)<br />Protection & active ROM (week 6-12)<br />Early strengthening (week 10-16)<br />Advanced strengthening (week 16-22)<br />
  50. 50. Rehabilitation – Phase 1<br />Goals<br />Maintain / Protect repair integrity<br />Gradual increase PROM<br />Diminish pain & inflamation<br />Prevent muscle inhibition<br />Exercises<br />Sling/abduction splint 6 weeks<br />Immediate PROM (depends on repair tension)<br />Pendular exercises<br />Cryotherapy<br />Hydrotherapy<br />
  51. 51. Rehabilitation – Phase 2<br />Goals <br />Allow healing of soft tissue<br />Do not overstress healing tissue<br />Gradually restore full PROM<br />Exercises<br />Continue PROM<br />Introduce AAROM<br />ADL permitted<br />Hydrotherapy<br />Pulleys<br />
  52. 52. Rehabilitation – Phase 3<br />Goals<br />Maintain Full PROM<br />Full AROM<br />Dynamic shoulder stability<br />Restore shoulder strength & endurance<br />Gradual return to functional activities<br />Exercises<br />Continue PROM & Stretching<br />Progressive strengthening<br />Proprioceptive activities<br />
  53. 53. Rehabilitation – Phase 4<br />Goals<br />Maintain full AROM<br />Advanced muscle strengthening exercises<br />Gradual return to full functional activities<br />Exercises<br />Continue stretching<br />Continue progression of strengthening<br />Light sports (golf chip/putt, tennis ground strokes)<br />
  54. 54. THE END<br />1. Yes 2. Size 3. Latissimus Dorsi 4. 12-26 weeks 5. 6 weeks <br />

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