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Rotator Cuff Disease. Current Surgical Management. Chris Pullen. Historical Aspects. Codman in 1934 Impingement syndrome Arthroscopic SAD. Shoulder Arthroscopy. Rotator Cuff Disease. Tendinopathy/Impingement Rotator Cuff Tear Cuff Tear Arthropathy. - PowerPoint PPT Presentation

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Rotator Cuff Tear

Rotator Cuff DiseaseCurrent Surgical Management

Chris PullenJon, Ladies and Gentlemen,

Thank you for inviting me to give this presentation on the current surgical management of RCD

1Historical AspectsCodman in 1934Impingement syndromeArthroscopic SADRCD was first described by Codman in 1934Neer in 1972 described Impingement syndrome as a mechanism for rotator cuff diseaseArthroscopic SAD (Ellman) 1985

Stress that NONOPERATIVE TREATMENT is successful in a number of cases2Shoulder Arthroscopy

Early part of this presentation will focus on arthroscopic techniquesCurrent treatment for a number of shoulder problems including those related to the rotator cuffin particular impingement, cuff repair and debridement (preferred technique)Increasingly importantAdvantagesSmaller skin incisionsGleno-humeral joint inspectionTreat intra-articular lesions Deltoid detachment avoidedLess soft tissue dissectionLess painMore rapid rehabilitation

3Rotator Cuff DiseaseTendinopathy/Impingement

Rotator Cuff Tear

Cuff Tear Arthropathy

SpectrumStarts with Tendinopathy which may be secondary toExtrinsic mechanismsImpingement - SA spur, ACJ osteophytesIntrinsic mechanismsTendon failure secondary to aging, wear and tearCombo Tendinopathy is usually treated non-operatively

So I will move on to cuff tears and specifically PTT4PARTIAL THICKNESS TEARS(IMPINGEMENT/TENDINOPATHY)

No consensus in regards treatment>50% Thickness (9-12mm) needs repair80% progress to FTT 40 patients at 2 year follow-up, 10% heal, 10% increase size

5PTT SurgeryOpen Mini openArthroscopic*

OpenMini-openArthroscopicDebridementSub Acromial DecompressionExcision of degenerate tendon and Repair

6PTT - ArthroscopyAdvantagesVisualisationTreatment articular tears

AdvantagesVisualise articular & bursal surface of tendonAbility to treat especially articular tearsDebrideSADRCR

7PTT - ArthroscopyBursal surface tearSADArticular surface tearDebridement onlyRepair>50% Thickness tearActive patients

Bursal surface tearAcromioplastySADArticular surface tearDebrideNo SADTear >50% Thickness repairedConsider repair in active patientsIdeal repair candidate is active individual with normal bone anatomy and a tear >50%Inactive patient with bone impingement and tear 50 % thicknessSevere degeneration92% success rate with repair of partial tears (Fukuda)

9FULL THICKNESS TEARS

10FTT - Surgical ApproachesArthroscopic*Arthroscopic assisted/mini-open*Open

Arthroscopic surgery has revolutionised the repair of the rotator cuff11FTT - Arthroscopic RCRGleno-humeral JointPTTLabral tearsLigament injuries Cartilage tears

Significant lesions in 12.5%

Gleno-humeral joint is not viewed with traditional open surgeryThis may lead to Untreated intra-articular lesions and consequently poorer resultsAdvantage of arthroscopy is the ability to view the gleno-humeral jointGleno-humeral JointPTTLabral tearsLigament injuries Cartilage tearsRecent studies have shown treatment of intra-articular lesions does have a positive effect on outcomecomparison of UCLA shoulder scores US studyNormal 30 V Intra-articular treated 29 V Untreated 11

12FTT Arthroscopic RCRRepair Site PreparationRemoval of ragged or degenerate tissueDecortication of bone

Repair Site Preparationsimple decortication of the bone at the repair siteanterior to posterior margins of the tearimmediately lateral to the articular surface of the humerus to the lateral most margin of the greater tuberosity13FTT Arthroscopic RCRSuture Placement

Suture Placementsutures placed 1-2 cm from the torn edge of the tendonArthrex cross-over 14FTT Arthroscopic RCRAnchor PlacementFoot printDouble row technique

Anchor Placement1 to 4 anchors usually usedDouble row techniqueX1 row anchors just lateral to the articular surfaceX1 row on the lateral margin of the greater tuberosityRestore the cuff footprint on the tuberositySingle V Double rowin a single layer repair on the most outside (lateral) aspect of the tendon, the more you lift thearm away from your body, the more you reduce the contact of the rotator cuff tendons, to itsfootprint on the bone15FTT Arthroscopic RCROther Tendon LesionsInfraspinatusTeres minorSubscapularisBiceps

Other Tendon LesionsInfraspinatus, Teres minor may be repairedSubscapularis if involves upper repaired arthroscopically but larger tears require open surgeryBICEPS

16FTT Arthroscopic RCRBiceps DebridementTenotomyTenodesis

Bicepsspontaneous rupture often leads to pain reliefbiceps does not play a major role as a humeral head depressoran unstable biceps may cause paradoxical upward thrust of humeral headDebridement partial tears 50% tendon thickness Tenotomy elderly patientsWalsh et al biceps tenotomy on 86 patients at 4 year follow-up 9% excellent, 43% satisfactory

17FTT Arthroscopic RCRPost operative TreatmentSlingCryotherapy PROMAROMStrengthening

Post operative TreatmentSling/ Abduction splintCryotherapy PROM elevation & ER 1-6 weeksAROM 6 weeksStrengthening 12 weeks ( deltoid, infra, supra, scapular rotators, biceps)

Rehabilitation takes 1 year

18FTT Arthroscopic RCRResults90% satisfaction78% pain reliefAROM

Results equivalent to open RCR90% satisfaction (good to excellent)78% good to excellent pain reliefBETTER SLEEPAROM Constant score 27.2/40 to 37.9/40 19MASSIVE TEARS

Rotator cuff tears are classified according to size:small tears 5 cm

More commonly progress to arthropathyfunctional demand / disability determines treatment

20Massive Tears SurgeryDebridementOpenArthroscopic*Rotator Cuff Repair*Tendon transfer*Synthetic interpositionArthrodesisArthroplasty50-85% patients with massive tear improved with non surgical treatment Bokor et al(1993)

21Massive Tears - DebridementDebridement alone Low demand patientsResults tend to deteriorate over timeArthroscopic debridement easier more rapid rehabilitation

Debridement alone may be adequate to manage massive cuff tears - Gartsman (1997), Rockwood et al (1995)Best suited to low demand patients unwilling or unable to perform prolonged rehabilitation.Results tend to deteriorate over time so active people are probably better served with attempted repair - Zvijac et al (1994) 3 and 6 year follow-up

Ideal candidate is relatively inactive with shoulder pain but good elevation strength and can elevate arm actively overhead and externally rotate.

Arthroscopic approach for subacromial debridement is easier and has a more rapid rehabilitation than the open approach because the deltoid origin is preserved - Gartsman (199722Massive Tears - Debridement Limited acromioplastycoracoacromial arch is maintainedBiceps tenotomy / tenodesis subluxation, dislocation, or partial tearingenhance the ability to alleviate shoulder painLimited acromioplasty involves removal of undersurface spurring and rough excrescences along with smoothing of the greater tuberosity The coracoacromial arch should be maintained byavoiding excessive acromioplasty and preserving the coracoacromial ligament, which helps prevent loss of the restraint to superior humeral head subluxation.Biceps tenotomy or tenodesis been recommended as an adjunct to arthroscopic debridement of chronic massive rotator cuff tears. subluxation, dislocation, or partial tearing of the tendon of the long head of the biceps, tenotomy or tenodesis may enhance the ability to alleviate shoulder pain.23Massive Tears - RCRGood function & pain relief 80-90%Goal of surgery is to repair the cuff without disrupting the coraco-acromial arch

good function and pain relief in 80% to 90% of cases. Bassett (1983), Biglani et al (1992)The goal of rotator cuff surgery is to repair the rotator cuff tendons to the proximal humerus and to decompressthe subacromial space without disrupting the coracoacromial arch.More recently, arthroscopy has been used to repair larger chronic rotator cuff tearsColman et al (1996) demonstrated that removal of 5.4mm of the undersurface of the anterior acromion reduces the contact pressure of the acromion on the supraspinatus tendon.

24Massive Tears - RCRRehabilitationSling / Abduction splintPROMAAROMStrengthening

Overall recovery may take >12 months

Postoperative recovery and rehabilitation is lengthy. The repair is protected with an arm sling or abduction immobilizer for 6 to 8 weeks. Abduction positioning is used to relieve tension on repairs done with the arm at the side.Passive stretching exercises to regain shoulder motion are begun the day after surgery. - passive IR and horizontal adduction are avoided for the first 6 weeks to protect the infraspinatus repair. Light active use and active-assisted range-of-motion movement are initiated after 6 weeks. Formal strengthening is delayed until 12 weeks after surgery. Overall recovery can take more than 12 months. Overly aggressive early rehabilitation has been implicated as a cause of failure

25Massive Tears - RCRResultsInferiorBetter within 6 weeks (Bassett & Cofield 1983)Shoulder dislocation >4085-90% good to excellent ( Bigliani 1992)In general, outcomes for repair of larger tears are inferior to those for smaller ones Harryman et al (1991)

Bjrkenheim et al (1988) reported that the results of repair of large and massive rotator cuff tears were markedly inferior to the results of repair of smaller tears

Bassett and Cofield (1983) found better results when tears were repaired within 6 weeks of injury. In the case of acute massive rotator cuff tears, early repair is technically easier and probably more likely to restore shoulderstrengthBigliani et al(1992) reported 85% good and excellent long-term results.

26Massive Tears Ten

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