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  • 3/9/2018

    1

    Case Presentations for Rotator Cuff: Indications, Techniques, Outcomes

    William N. Levine, MD Frank E. Stinchfield Professor and Chairman NYP/Columbia University Irving Medical Center Department of Orthopedic Surgery New York, NY

    SKS Meeting February 22, 2018 – Snowbird, UT

    Disclosure 1. Basic Science Support

    a. NIH 2. Consultant – Zimmer Design Team 3. Royalties – None 4. Editor in Chief – JAAOS 5. 1st Vice President – ASES

    SKS 2018 – Cuff Cases

    The Experts SKS 2018 – Cuff Cases

  • 3/9/2018

    2

    SKS 2018 – Cuff Cases

    Case 1

    • 45 y.o RHD male with atraumatic R shoulder pain x 6 months

    • No lag signs • + impingement signs • Normal xrays • MRI? Ultrasound?

    SKS 2018 – Cuff Cases

    Case 1 – What Would You Do?

    1. PT/NSAIDs 2. PT/injection 3. Arthroscopic RCR 4. Mini-open/Open RCR

    SKS 2018 – Cuff Cases

    Case 1 – Outcome

    • Serial MRI/clinical exam • 3 years: no tear progression • How long do we need to follow?

  • 3/9/2018

    3

    SKS 2018 – Cuff Cases

    Case 2

    • 47 y.o RHD male police officer

    • 6’6”, 410 pounds • 9 mo. pain – failed

    non-op Rx • Pre-op MRI – small

    supra FTRCT

    SKS 2018 – Cuff Cases

    Case 2 – Small RCT What Would You Do?

    1. Single row 2. Double row 3. DR transosseous 4. Open 5. Mini-open

    SKS 2018 – Cuff Cases

    Case 2 – Small RCT Questions

    1. # of anchors 2. # of sutures 3. Transosseous equivalent 4. Vented anchors 5. Biologic augmentation 6. Age of patient

  • 3/9/2018

    4

    SKS 2018 – Cuff Cases

    Arthroscopic Single Row RCR

    SKS 2018 – Cuff Cases

    Case 2 – Your Choice?

    • Same • Different • Rationale?

    SKS 2018 – Cuff Cases

    Case 2

    • No PT x 4 weeks (worried about his girth)

    • Gentle PT at 4 wks • Comes in 3 months

    post-op telling me he has been “heavy lifting” to get in shape

    • Has pain/weakness

  • 3/9/2018

    5

    SKS 2018 – Cuff Cases

    Case 2

    • No PT x 4 weeks (worried about his girth)

    • Gentle PT at 4 wks • Comes in 3 months

    post-op telling me he has been “heavy lifting” to get in shape

    • Has pain/weakness

    SKS 2018 – Cuff Cases

    Case 2 – Massive Recurrent RCT

    • Now what do you do? • Revision RCR – Augmentation? – Double row – Refer to junior partner?

    SKS 2018 – Cuff Cases

    Case 2 – Revision RCR

  • 3/9/2018

    6

    SKS 2018 – Cuff Cases

    Case 2 – Biologic Augmentation

    SKS 2018 – Cuff Cases

    Case 2

    • 9 months post-op • Doing well (so far…)

    SKS 2018 – Cuff Cases

    Acellular Bovine Collagen Scaffold

    • Animal studies – Promising Arnoczky et al

    • Humans Schlegel JSES ‘17 – PTRCT (33 pts)  8 healed  23 decreased in size  1 stable  1 progressed to full tear

    Bokor ‘16

  • 3/9/2018

    7

    SKS 2018 – Cuff Cases

    Case 3

    • 57 y.o RHD male • Fell 4 months ago • Pain, weakness • Rx – PT – Cortisone x 1 – NSAIDs

    SKS 2018 – Cuff Cases

    Case 3 – MRI

    SKS 2018 – Cuff Cases

    Case 3 – MRI

  • 3/9/2018

    8

    SKS 2018 – Cuff Cases

    Case 3 – What Do You Do?

    1. Arth single row repair 2. Arth double row repair 3. Open repair 4. With Biceps tenotomy 5. With biceps tenodesis

    SKS 2018 – Cuff Cases

    Case 3 – Patient Positioning

    Head

    Torso

    SKS 2018 – Cuff Cases

    Case 3 – EUA

  • 3/9/2018

    9

    SKS 2018 – Cuff Cases

    Case 3 – Portals

    P

    A ASL

    SKS 2018 – Cuff Cases

    Case 3 – Subscap Mobilization

    SKS 2018 – Cuff Cases

    Case 3 – Lateral Anchor

  • 3/9/2018

    10

    SKS 2018 – Cuff Cases

    Case 4 • 20 y.o RHD male collegiate pitcher • Pain with pitching – Most pain in follow-through

    • Loses velocity and control • Exam – + active compression – No apprehension, relocation, ant

    release – No Biceps signs – Equivocal posterior stress

    SKS 2018 – Cuff Cases

    Case 4

  • 3/9/2018

    11

    SKS 2018 – Cuff Cases

    Case 4 – What Do You Do?

    • Shut him down + …?? – Injection – NSAIDs – PRP – Other?

    SKS 2018 – Cuff Cases

    Case 4 – Now What?

    • Shut him down x 3mo. • Cortisone injection • PRPx2 • NSAIDs • Rest • And no better…

  • 3/9/2018

    12

    SKS 2018 – Cuff Cases

    Case 4 – Scope

    SKS 2018 – Cuff Cases

    Case 4 – Now What?

    1. Debridement 2. Repair 3. Scaffold

    SKS 2018 – Cuff Cases

    Case 4 – Now What?

    1. Debridement 2. Repair 3. Scaffold

  • 3/9/2018

    13

    SKS 2018 – Cuff Cases

    Case 4 – Follow-up

    • Sling x 2 weeks • ROM, light strengthening early • Throwing program • Return to pitching at 4 months • No pain • Completed 2 seasons since surgery

    Case 5 SKS 2018 – Cuff Cases

    • 55 y.o RHD male with LEFT shoulder RCR

    Case 5 SKS 2018 – Cuff Cases

    • Tenotomy • Tenodesis

  • 3/9/2018

    14

    Case 5 SKS 2018 – Cuff Cases

    1. PITT 2. Suprapec 3. Low suprapec 4. Open subpec

    Case 5 SKS 2018 – Cuff Cases

    1. PITT 2. Suprapec 3. Low suprapec 4. Open subpec

    Case 5 - Questions SKS 2018 – Cuff Cases

    • Consent? – All patients – Tenotomy vs tenodesis

    • Does it really matter where you do the tenodesis?

    • Percentage of cases you do tenotomy vs tenodesis?

  • 3/9/2018

    15

    Case 6 SKS 2018 – Cuff Cases

    • 51 y.o RHD female • Arth DR-SB 8/23/09 • 2cm crescent supra tear • Doing “great” • No trauma – presents with  pain 2 yrs

    post-op • FE 120°; ER 40°

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

  • 3/9/2018

    16

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

  • 3/9/2018

    17

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

  • 3/9/2018

    18

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

  • 3/9/2018

    19

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

    Case 6 SKS 2018 – Cuff Cases

  • 3/9/2018

    20

    Case 6 SKS 2018 – Cuff Cases

    Re-Tears SKS 2018 – Cuff Cases

    • Type 2 – Medial to healed footprint – More prevalent in classic double row

    suture bridge with medial knots – “over tension” Kim ’14

    Case 6 – What Would You Do? SKS 2018 – Cuff Cases

    1. Arth revision RCR 2. Open revision RCR 3. Biologic augmentation – Dermal allograft – Acellular bovine

    4. Non-op

  • 3/9/2018

    21

    Case 6 – What Would You Do? SKS 2018 – Cuff Cases

    1. Arth revision RCR 2. Open revision RCR 3. Biologic augmentation – Dermal allograft – Acellular bovine

    4. Non-op

    Case 7 – AC Joint SKS 2018 – Cuff Cases

    • How do you decide? • When do you do it? • Technical pearls

    Case 7 – AC Joint SKS 2018 – Cuff Cases

    • How do you decide? • When do you do it? • Technical pearls

  • 3/9/2018

    22

    Case 8 SKS 2018 – Cuff Cases

    • 58 y.o RHD female • 1 yr RIGHT shoulder pain • Treatment – Cortisone x 3 (complete relief) – PT – Rest – NSAIDs – Activity modification

    Case 8 SKS 2018 – Cuff Cases

    Case 8 SKS 2018 – Cuff Cases

  • 3/9/2018

    23

    Case 8 SKS 2018 – Cuff Cases

    Case 8 – What Would You Do? SKS 2018 – Cuff Cases

    1. Debridement alone 2. ASD 3. In situ repair 4. Conversion to Full tear

    Thank You!

    wnl1@Columbia.edu