Arthroscopic cuff repair

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Arthroscopic cuff repair

  1. 1. Arthroscopic RotatorCuff RepairBijayendra SinghFRCS (T&O), FRCS, MS, DNB (Ortho)Consultant Orthopaedic SurgeonMedway NHS Foundation TrustHonorary Tutor Royal College of Surgeons EdinburghHonorary Treasurer Indian Orthopaedic Society
  2. 2. 2• Anatomy• Classification• Methods of repair• Techniques of Repair2
  3. 3. Anatomy• Footprint of Supraspinatus = 25x 11-22 mm (Nottage 2003)• Supraspinatus and Infraspinatusis 8 cmƒU (Bassett 1990)• Infraspinatus is partly coveringthe supraspinatus.• Supraspinatus: hardly barebone between the cartilage ofthe head and insertion of thetendon (Nottage 2003)• Infraspinatus: bare area
  4. 4. 7Etiology• Age related degeneration• Compromised microvascular supply– Codman (1934) described critical zone– Rathburn (1970) position related to bloodsupply– Lohr (1990) bursal side better blood supply• Increased incidence of articular surface tears?• Outlet impingement7
  5. 5. Incidence5-40%Increases with ageYoung:Repetitive useThrowing sportsImpingementOlder:FallOther traumaMurrell et al: The Lancet,Volume 357, Issue 9258, 10 March 2001, Pages 769–770
  6. 6. 7Indication• Symptomatic Cuff Tear– Age no barrier• When– Early• if bony avulsion• pseudo - paralysis• No difference in outcome in delayed repair
  7. 7. 8Biomechanical Factors• Suture tendon interface– Suture material– Suture method• Tendon-bone interface– Suture anchor/ bone tunnel fixation strength– Tendon-bone contact area– Tendon-bone interface motion– Tendon-bone footprint pressurization8
  8. 8. 9Maximising healing potential• Restoration of footprint contact area• Uniform footprint contact pressurization• Minimization of footprint tendon-bone interfacemotion9
  9. 9. 10Tendon-to-Bone Pressure Distributionsat a Repaired Rotator Cuff Footprint UsingTransosseous Suture And Suture Anchor FixationTechniquesMaxwell C Park, Edwin R Cadet, William N Levine, Louis U Bigliani, Christopher SAhmad.The American Journal of Sports Medicine. Aug 2005.Vol.33, Iss. 8; pg. 1154• Hypothesis: Suture anchor fixation forrotator cuff repair has greater interfacemotion between tendon and bone thandoes transosseous suture fixation10
  10. 10. 11Transosseous (TOS)68mm2Mattress Sutureanchor (SAM)26mm2suture anchorsuture anchorsimple (SAS)simple (SAS)34.1 mm34.1 mm22
  11. 11. 12Contact Area, Contact Pressure, and Pressure Patterns ofthe Tendon-Bone Interface After Rotator Cuff RepairYilihamu Tuoheti, Eiji Itoi, Nobuyuki Yamamoto, Nobutoshi Seki, etal.The American Journal of Sports Medicine.Dec 2005.Vol.33, Iss. 12; pg. 1869Contact Area Contact Pressure
  12. 12. Codman (1934)• Full thickness tears (FTRCT)• Partial thickness tears (PTRCT)– bursal side– articular side (rim rent)– Intratendinous– vertical, with connection from joint to bursa,not involving the whole breadth (width?) of thetendon
  13. 13. Full Thickness• DeOrio and Cofield (1984)• Small: < 2 cm in diameter (from stump to cartilage)• Medium: 1-3 cm diameter• Large: 3-5 cm diameter• Massive: more than 5 cm diameter(nearly always with involvement of Infraspinatus)This classification only refers to frontal measurement, can be usedfor arthroscopy and is most frequently used.
  14. 14. MRI / CT Arthro• Stage 1: stump at level at footprint• Stage 2: stump at level of humeral head• Stage 3: stump at level of glenoid
  15. 15. 1616
  16. 16. Fatty Infiltration (Goutallier1994)• Stage 0: absence of fat• Stage 1: several fine fat lines• Stage 2: fat less than muscle• Stage 3: fat equivalent to muscle• Stage 4: fat greater than muscle
  17. 17. 18Literature
  18. 18. 24Arthroscopic vs Transosseous
  19. 19. 25Bisson LJ & Manohar LM - Biomechanical comparison oftransosseous suture anchor & suture bridge rotator cuff,Am J Sports Med, 2009, Oct: 37, 1991 - 5• Eight paired cadaveric shoulder specimens (16 specimens)• Cycled from 10 to 180 N for 200 cycles,• Testing to failure at 33 mm/s• No significant difference between transosseous-suture anchor repairs andsuture bridge repairs for elongation or stiffness• The most common mode of failure with each method was suture cuttingthrough tendon.25
  20. 20. 26Chhabra et al: In vitro analysis of rotator cuff repairs -comparison of tacks, anchors & open transosseous repairs:Arthroscopy 2005, 21 (3), 323 - 7• Full-thickness 3 cm rotator cuff defects, 25 fresh-frozen cadaveric shoulders• Randomized to 1 of 4 repair groups:– (1) open repair with transosseous sutures– (2) arthroscopic repair with 2 singly loaded suture anchors,– (3) arthroscopic repair with 2 doubly loaded suture anchors,– (4) arthroscopic repair with cuff tacks.• Testing:– Cyclically & Gap Formation• Results (cycles to 100% failure)– Significantly higher for the arthroscopic doubly loaded suture anchor repairs when comparedwith the (1) open transosseous suture repair (P = .009), (2) arthroscopic cuff tack repair (P = .003), and (3) arthroscopic singly loaded suture anchor repair (P = .02).– Number of cycles to 50% failure was significantly higher for all anchors versus open or tackrepair (P = .03 for both).26
  21. 21. 27Duquin et al: Which method of rotator cuff repair leads tohighest rate of structural healing? A systematic review,Am J Sports Med, 2010, Apr, 38 835 - 41• Hypothesis– rotator cuff repair method will not affect retear rate– surgical approach will not affect the retear rate for a given repair method.• transosseous (TO), single-row(SA), double-row (DA), and suture bridge (SB)• Open (O), miniopen (MO), and arthroscopic (A) approaches.• Results:– Retear rates were significantly lower for double-row repairs when compared with TO or SAfor all tears greater than 1 cm– Double Row Repair - 7% for tears less than 1 cm to 41% for tears greater than 5 cm– single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than5 cm, respectively.– There was no significant difference in retear rates between TO and SA repair methods orbetween arthroscopic and nonarthroscopic approaches for any tear size– double-row repair methods lead to significantly lower re-tear rates when compared withsingle-row methods for tears greater than 1 cm.– Surgical approach has no significant effect on retear rate.27
  22. 22. 23Salata et al: Biomechanical Evaluation of TransosseousRCR -Do anchors Really Matter?Am J Sports Med - 41, 2, 2013, p 283• Purpose:– Compare biomechanical performancebetween TOE with anchors, TO, SimpleAnchor & X box• Methods:– 28 human cadavers– Dissected to create isolated supra-spinatustear– Initial preload, Cyclic testing & Pull to failure23
  23. 23. 24Results & Conclusion• Mechanical testing– TOE - 558+/-122.9– TO - 325.3 +/- 79.9– AT - 291.7 +/- 57.9– ATX - 388.5 +/- 92.6TOE TO AT ATXTendon Failure 4 0 2 7Suture Failure 0 6 1 0Bone Failure 3 1 3 0
  24. 24. 25Wu et al - Intraoperative determinants of Rotator CuffRepair Integrity: Analysis of 500 casesAJSM, 2012, 40, 2771• 500 consecutive cases at St George Hospital,Sydney• Single Surgeon• Retear rate - 19% at 6 months• Predictors:– Tear size - Correlatio coeff: 0.33• < 2cm - 10%, 2-4 cm 16%, 4-6 cm 31%, 6-8 cm50%– Repair quality, Tendon Mobility & Quality• Formula: 25
  25. 25. 26Intraop ScoringFair (1 pt) Good(2 pts)Very Good(3 pts)Excellent(4 pts)Quality ofTendonThin, Friable,Does nothold suturePatchythickness,holds sutureNormalthickness,holds suturewellThick &Robust,holds suturewellTendonMobilityImmobile &RetractedPoor mobility,barely pulledto footprintMobile,easily pulledto foot printMobile,easily pulledto foot printRepairQualityVery WeakRepairRepair notoptimalRelativelyStrongRepairVery StrongRepair
  26. 26. Cuff Repairs• Tear patterns and how to treat them• Margin convergence• Single row repairs• Double row repairs• Instrumentation review• Anchor type options
  27. 27. 19Tear Patterns(Davidson & Burkhart)• Type 1– Crescent-shaped tears– Repaired end to bone - good to excellent prognosis• Type 2– longitudinal (L- or U-shaped) tears– Margin convergence - good to excellent• Type 3– Massive contracted tears– interval slides or partial repair; fair to good prognosis• Type 4– Rotator cuff arthropathy– Irreparable; and require arthroplasty if surgery isconsidered.19
  28. 28. 20Margin Convergence ‘Crescent’20
  29. 29. 21‘L’ Shape21
  30. 30. 31Arthroscopic Repair
  31. 31. Arthroscopic repair• Cannula• Suture Passer• Suture manipulator• Appropriate Anchors• Knotless• Knot tying• Suture CutterLearning Curve
  32. 32. 35Which Anchor
  33. 33. 36Schneeberger et al: Mechanical Strength of ArthroscopicRotator Cuff Repair Techniques. JBJS, 84A, 2152 - 2160• Five Bone Anchors– Revo Screw– Mitek Rotator CUff– 5 mm Statak– Panalok– 5mm Bio-Statak• Two types of sutures– Arthroscopic Mattress– Mason-Allen36
  34. 34. Pull out StrengthTendon Stitch Failure Load (N)Revo – Mattress 228 ± 26 (200-250)Revo – Modified Mason-Allen 210 ± 22 (200-250)BioStatak – Mattress 230 ± 57 (150-300)BioStatak – Modified Mason-Allen 168 ± 46 (140-250)38
  35. 35. 36Standard Knotless Repair31
  36. 36. Positioning
  37. 37. 3838Text
  38. 38. 4141
  39. 39. 4242
  40. 40. 4332
  41. 41. 4433
  42. 42. 45
  43. 43. 29Single Row vs Double Row
  44. 44. 47Nho et al: Does the support double-row suture anchorfixation for arthroscopic rotator cuff repair? A systematicreview comparign DR vs SR, Arthroscopy 2009, Nov,25(11), 1319 - 28• Clinical outcome of single-row (SR) and double-row (DR) suture anchorfixation in arthroscopic rotator cuff repair* January 1966 to December 2008* Inclusion criteria+ Cohort studies (Levels I to III) that compared SR and DR suture anchor+ Arthroscopic treatment of full-thickness rotator cuff tears* 5 studies that met the criteriaNo clinical differences between the SR and DR sutureanchor repair techniques for arthroscopic rotator cuffrepairs.47
  45. 45. 48Saridakis et al: Outcomes of Single Row & DoubleRow - Systematic Review, JBJS 92(A), 732 - 42* Systematic Review of English Language Literature* Difference between SR & DR fixation - clinical outcomes &radiographic healing* Six studies included– no significant difference between the single-row and double-row groups• One study– Two groups with < 3 cm & those with > or = 3 cm– patients with large to massive tears who had DR, better ASES & Constant Score• Two studies demonstrated a significant difference with structural healing with DR• Conclusion:• Better structural healing with DR compared with SR• Little evidence to support functional difference between the two techniques48
  46. 46. 49De Haan et al: Does Double Row Repair ImproveFunctional Outcome compared to Single Row.AJSM, 40(5), 1176• Systematic Review - Level I & II studies• Seven StudiesSingle Row Double RowPatients 226 220Mean Age 59 57.7Dominant 76 75Male 43 52Mean Tear Size 3.1 3.2Small Tear 50.8 43.4Large Tear 49.2 56.6
  47. 47. 50Functional ScorePre OpSinglePre OpDoublePost OpSinglePost opDoublePost OpDifferenceASES 40.4 38.9 91.3 92.5 1.2(-0.2 to 2.8)Constant 50.2 50.6 80.4 80.9 0.5(-1.4 to2.6)UCLA 14 13.7 31.4 31.9 0.5(-0.7 to 1.8)
  48. 48. 51Complications• No intraop complications• 6 in single row & 4 in double row– 5 adhesive capsulitis (3 vs 2)– 2 anchor failure ( 1 each)– 2 infection (1 each)• 56 / 186 complications in single row• 35/180 complications in double row51
  49. 49. 52RetearFTSingle RowFTDoubleRowFT & PTSingle RowFT & PTDoubleRow22(19%)16(14%)50(43%)21(27%)
  50. 50. 5353
  51. 51. 54
  52. 52. 56Kluger et al - Long termSurvivorship using ultrasound &MRI• 107 consecutive patients• 95 patients followed up• 7 - 11 years, Median - 96 months• Age: 37 - 77 yrs (60 +/- 9)56
  53. 53. 57Results• 33% failure rate (35)– 74% within 3 months– 11% 3 - 6 months– 15% 2-5 years: usually additional trauma /sports– 3 had further repair, 6 had debridement• Others:– 4 stiffness (1 arthrolysis)– 4 impingement (3 decompression)– Second arthroscopy in 13 57
  54. 54. 58• At 84 months:– Size• 86% with cuff tear < 500 mm2 - intact• 48% with cuff tear >500 mm2 - intact– Age• < 65 = 31% rerupture• >65 = 38% rerupture58
  55. 55. 59Thank You
  56. 56. 60www.youtube.com/bijayendrasinghwww.finger2shouldersurgery.com

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