case presentations for rotator cuff: indications ... · case presentations for rotator cuff:...

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Case Presentations for Rotator Cuff: Indications, Techniques, Outcomes

William N. Levine, MD

Frank E. Stinchfield Professor and ChairmanNYP/Columbia University Irving Medical CenterDepartment of Orthopedic SurgeryNew York, NY

SKS MeetingFebruary 22, 2018 – Snowbird, UT

Disclosure

1. Basic Science Supporta. NIH

2. Consultant – Zimmer Design Team3. Royalties – None4. Editor in Chief – JAAOS5. 1st Vice President – ASES

SKS 2018 – Cuff Cases

The Experts


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Case 1

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

• No lag signs

• + impingement signs

• Normal xrays

• MRI? Ultrasound?


Case 1 – What Would You Do?

1. PT/NSAIDs

2. PT/injection

3. Arthroscopic RCR

4. Mini-open/Open RCR


Case 1 – Outcome

• Serial MRI/clinical exam

• 3 years: no tear progression

• How long do we need to follow?

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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


Case 2 – Small RCT What Would You Do?

1. Single row

2. Double row

3. DR transosseous

4. Open

5. Mini-open


Case 2 – Small RCT Questions

1. # of anchors

2. # of sutures

3. Transosseous equivalent

4. Vented anchors

5. Biologic augmentation

6. Age of patient

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Arthroscopic Single Row RCR


Case 2 – Your Choice?

• Same

• Different

• Rationale?


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

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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


Case 2 – Massive Recurrent RCT

• Now what do you do?

• Revision RCR

– Augmentation?

– Double row

– Refer to junior partner?


Case 2 – Revision RCR

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Case 2 – Biologic Augmentation


Case 2

• 9 months post-op

• Doing well (so far…)


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

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Case 3

• 57 y.o RHD male

• Fell 4 months ago

• Pain, weakness

• Rx

– PT

– Cortisone x 1

– NSAIDs


Case 3 – MRI


Case 3 – MRI

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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


Case 3 – Patient Positioning

Head

Torso


Case 3 – EUA

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Case 3 – Portals

P

AASL


Case 3 – Subscap Mobilization


Case 3 – Lateral Anchor

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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


Case 4

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Case 4 – What Do You Do?

• Shut him down + …??

– Injection

– NSAIDs

– PRP

– Other?


Case 4 – Now What?

• Shut him down x 3mo.

• Cortisone injection

• PRPx2

• NSAIDs

• Rest

• And no better…

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Case 4 – Scope



1. Debridement

2. Repair

3. Scaffold



1. Debridement

2. Repair

3. Scaffold

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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


• 55 y.o RHD male with LEFT shoulder RCR

Case 5


• Tenotomy

• Tenodesis

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Case 5


1. PITT

2. Suprapec

3. Low suprapec

4. Open subpec

Case 5


1. PITT

2. Suprapec

3. Low suprapec

4. Open subpec

Case 5 - Questions


• Consent?

– All patients

– Tenotomy vs tenodesis

• Does it really matter where you do the tenodesis?

• Percentage of cases you do tenotomy vs tenodesis?

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Case 6


• 51 y.o RHD female

• Arth DR-SB 8/23/09

• 2cm crescent supra tear

• Doing “great”

• No trauma – presents with pain 2 yrspost-op

• FE 120°; ER 40°

Case 6


Case 6


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Case 6


Case 6


Case 6


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Case 6


Case 6


Case 6


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Case 6


Case 6


Case 6


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Case 6


Case 6


Case 6


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Case 6


Re-Tears


• Type 2

– Medial to healed footprint

– More prevalent in classic double row suture bridge with medial knots

– “over tension” Kim ’14



1. Arth revision RCR

2. Open revision RCR


– Dermal allograft

– Acellular bovine

4. Non-op

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1. Arth revision RCR

2. Open revision RCR


– Dermal allograft

– Acellular bovine

4. Non-op

Case 7 – AC Joint


• How do you decide?

• When do you do it?

• Technical pearls

Case 7 – AC Joint


• How do you decide?

• When do you do it?

• Technical pearls

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Case 8


• 58 y.o RHD female

• 1 yr RIGHT shoulder pain

• Treatment

– Cortisone x 3 (complete relief)

– PT

– Rest

– NSAIDs

– Activity modification

Case 8


Case 8


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Case 8




1. Debridement alone

2. ASD

3. In situ repair

4. Conversion to Full tear

Thank You!

[email protected]

case presentations for rotator cuff: indications ... · case presentations for rotator cuff:...

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