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ISAKOS PrecourseRotator Cuff

Pre-operative Evaluation: How to plan a Successful Repair.

Guillermo Arce, MD. Buenos Aires, Argentina

§ Lectures, paid Consultant: üArthrex.üZimmer.

§ Education: ConMed.

§ Journals: JISAKOS

§BODs:ü ISAKOS, Second Vice President.üSLARD, Past -President.

Financial Disclosure

What do we need to get good results ? My Goals: Steps for Succesful Outcomes

§Diagnosis:oPatient history: Pain, Sports, Trauma. oPhysical Exam: Motion and Strength.oPre-operative ScoresoMRI / Ultrasound interpretation

§Patient Positioning and Anesthesia.

§ Equipment: Pump, Anchors, Grafts, Patches.

Peter Drucker: Father of Management

”If you can’t measure it, you can’t manage it.

If you can’t manage it, you can’t improve it “

Take at least 2 Scores before any treatment.ASEShttp://orthotoolkit.com/ases/

ü Work, Sports/Leisure, pain killers ( type ).

ü VAS Scale 1/10 average.

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Constant & Murleyhttp://orthotoolkit.com/constant-shoulder/

MCID: 10,4

• Pain: 15

• Activities of daily living:20

• Motion: 40

• Strength: 25

4 Domains: 100 points

Disease Specific

WORC

• 21 Questions: 100 mm lines

• 5 Domains: 21 Questions= 2100

1. Physical Symptoms: 600

2. Sports and Recreations:400

3. Work:400

4. Social Function:400

5. Emotions:300

MCID: 245

Short WORC

7 Questions

http://www.orthopaedicscore.com/http://orthotoolkit.com/

Socrates Orthopaedic Outcomes Software:

SOS. Surgical Outcomes System.

Softwares to track Outcomes

For printing

Digital Storage

Data analysis / follow up

Websites for Shoulder ScoresAutomated Cumulative Sum Formula

•ROM

• Impingement/Neer• Jobe: Empty and Full can. SSP

•Strength: Subs, ISP.

•Lift off: Subs.•Speed / O’Brien: LHBT

•OFP: Biceps and ACJ

Physical Exam

1.Magee, David J; Sueki, Derrick (2011). Orthopedic Physical Assessment Atlas and Video: Selected Special Tests and Movements. St. Louis, Missouri: Saunders. pp. 122.2.Konin, Jeff G; Wiksten, Denise L; Isear, Jerome A; Brader, Holly (2006). Special Tests for Orthopedic Examination (3rd ed.). Thorofare, New Jersey: SLACK incorporated. p. 24..3.Loudon, Janice; Marcie, Swift; Bell, Stephania (2008). The Clinical Orthopedic Assessment Guide. Lower Mitcham, South Australia: Human Kinetics. p. 148. .

•AHD: Acromion Humeral Distance: > 7 mm.

•CSA: Critical Shoulder Angle: 34 0

•AS: Acromion Slope. Bigliani I, II, III.

X rays: Are they needed ?

Jun-Han Kim, Young-Kyoung Min, et al. JSES March 2019Gerber C, Catanazaro R, et al. Artrhroscopy, March 2018Degen R. Arthroscopy. October 2018.

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X Rays

Sagital Plane:• Acromion Shape• Acromion Slope

Coronal Plane:• Critical Shoulder Angle 330

• Lateral Acromion Angle.• Acromion Index. GA/GH =0.73

GH

GA

Nyffeler R, Meyer D. EFORT Open Rev. May 2017

CSA

Jun-Han Kim, Young-Kyoung Min, et al. JSES March 2019Gerber C, Catanazaro R, et al. Artrhroscopy, March 2018Degen R. Arthroscopy. October 2018.

Massive Cuff: Cables: Subs and Teres Minor. Teres Minor

ISP

TMISP

TM

Massive Cuff: Subs and Teres Minor.

Not everything is lost !

JAAOS 2018

Teres Minor: PE & T 1 Sagital Oblique.

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Diagnosis: Lidocaine InjectionsLHBT or ACJ

BicepsDynamic Ultrasound: A growing tool

MRI: What should be look for ??References Lines

• Coronal T 2 FS: LHBT, SSP/ISP Tears

• Sagital Oblique T 1: Fat Infiltration.

• Axial: LHBT, Subs, OA.

•What does he/she has ?

•Why he/she needs surgery ?

•What are the realistic expectations ?

•How good are the reported outcomes ?

•Retear rate ?

Informed Consent

Inter-scalene BlockNIRSBrain Spectometry

Anesthesia / Blood Pressure / Pump

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NIRS: Cerebral Oximetry.

Customized pump pressure

Anesthesia / Blood Pressure / Pump

Tip # 4

Fa Large, Massive or Revision

Fascia Lata Graft

Mesh

Take Home Messages•ARCR is a quite

demanding operation.

•You need to plan ahead.

•Right diagnosis: PE and MRI.

•Allways be prepared for worst but hope the best.

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Plan Ahead. Be prepared.

Thank you.Guillermo Arce, MD.

Buenos Aires, Argentina

Tip # 8 The Biceps is a Winner !!

• Develop your surgical skills for different biceps tenodesis.

• The weak link is the Tendon.

Surgical Workflow.

Always keep in mind:ü The LHBT is a winner.

ü Adequate Releases.

ü Tear shape and pattern

and reduction.

ü Forget the SSP: Recover the Cables.

Tip # 9 The SUBS is always needed.

Reduction with a proximal anchor and grab the coma ..

RC Disease ISAKOS Consensus Meeting

Munich 2018