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![www.shoulder.grwww.shoulder.gr
Partial Tears Treatment Options
1. Debride partial tear only
2. In-situ Repair
3. Convert to full thickness, Debride, Repair
Etiology drives the decision!!!
Because most tears are degenerative, option 3 should be the
best for most cases
Trauma or young athletes are candidates for in-situ repair
If partial tear causes significant pain then debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]
r](https://image.slidesharecdn.com/xehajezurdox1bft3h3a-signature-69d9f1a3cb3f2649714837b93c1c3b7b41f9a67bbef005eecf911e10fcb33758-poli-170927100657/75/Rc-repair-philosophy-and-technique-microhand-2014-7-2048.jpg)
![www.shoulder.grwww.shoulder.gr
L-Shaped & U-Shaped Tears
Side to side sutures from medial to
lateral
Progressively converge the margin of the
tear lateral to the bone bed
Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by a
factor of 6
[S. S .Burkhart]](https://image.slidesharecdn.com/xehajezurdox1bft3h3a-signature-69d9f1a3cb3f2649714837b93c1c3b7b41f9a67bbef005eecf911e10fcb33758-poli-170927100657/75/Rc-repair-philosophy-and-technique-microhand-2014-38-2048.jpg)
![www.shoulder.grwww.shoulder.gr
Massive Contracted Immobile Tears
No mobility from medial to lateral
or from anterior to posterior
Represent 9.6% of massive tears
[S.Burkhart]](https://image.slidesharecdn.com/xehajezurdox1bft3h3a-signature-69d9f1a3cb3f2649714837b93c1c3b7b41f9a67bbef005eecf911e10fcb33758-poli-170927100657/75/Rc-repair-philosophy-and-technique-microhand-2014-41-2048.jpg)
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Rc repair philosophy and technique microhand 2014
- 1. www.shoulder.grwww.shoulder.gr Manos Antonogiannakis Head B’Orthopaedics Dept Center for shoulder arthroscopy IASO GENERAL Hospital Arthroscopic Treatment of Rotator Cuff Tears – Philosophy and Technique
- 2. Philosophy of treatment: restorethe equilibrium between the functional demands of the patient and the capacity of the rotator cuff Lower the functional demands of the patient. Increase the functional capacity of the remaining intact cuff repair the cuff. www.shoulder.gr
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- 5. www.shoulder.grwww.shoulder.gr Partial Thickness Tear Bursal side tears Articular side tears Intratendinus tears Partial tear classification by Ellman Grade I <3mm deep Grade II 3-6mm deep Grade III>6mm deep (i.e. >50% thickness)
- 6. www.shoulder.grwww.shoulder.gr Partial Tears Treatment By far the most common partial tears are Articular- side, vascular or age related Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”
- 7. www.shoulder.grwww.shoulder.gr Partial Tears TreatmentOptions 1. Debride partial tear only 2. In-situ Repair 3. Convert to full thickness, Debride, Repair Etiology drives the decision!!! Because most tears are degenerative, option 3 should be the best for most cases Trauma or young athletes are candidates for in-situ repair If partial tear causes significant pain then debridement alone [Yamaguch K, 2006 Nice Shoulder Course] r
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- 9. www.shoulder.grwww.shoulder.gr COMPLETE TEARS Small1cm Medium 2-3cm Large 3-5 cm Massive >5cm Cofield et all
- 10. www.shoulder.grwww.shoulder.gr Type Description PreoperativeMRI Findings Treatment Prognosis 1 Crescent Short and wide tear End-to- bone repair Good to excellent 2 Longitudinal (L or U) Long and narrow tear Margin convergence Good to excellent 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good 4 Cuff tear arthropathy Cuff tear arthropathy Arthroplast y Fair to good.
- 11. www.shoulder.grwww.shoulder.gr ANY TYPE OFRECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR
- 12. www.shoulder.grwww.shoulder.gr Surgical Technique Steps 1. GHJoint and Subacromial Joint Inspection 2. Bursal debridement 3. Acromioplasty (+/-) 4. Cuff mobilization 5. Strong mechanical repair without tension(side to side, tendon to bone) 6. Biologic enhancement of the repair
- 13. www.shoulder.grwww.shoulder.gr Patient Position Lateral decubitusmy preferred position
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- 16. www.shoulder.grwww.shoulder.gr 30º Scope Entrancefrom posterior portal but change portal and viewing angle of scope ( 30 to 70) as needed
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- 19. www.shoulder.grwww.shoulder.gr Problem no 1:Bad quality retracted tendons covered by a thickened bursa Find and recognize the tendons
- 20. www.shoulder.grwww.shoulder.gr Remove the thickenedbursa till to see the posterior edge of the cuff ending to the greater tuberosity. Everything that goes around the tuberosity to the deltoid is bursa Don’t suture the bursa instead of the cuff. It doesn’t work
- 21. www.shoulder.grwww.shoulder.gr The posterior extentof the tear Differentiate thickened bursa from the infraspinatus by finding the posterior insertion of the cuff to the tuberosity
- 22. www.shoulder.grwww.shoulder.gr Solution Idendify recognizablelandmarks 1. the undersurface of the acromion and the underolateral corner 2.the acromioclavicular joint 3.the spine of the scapula 4.the lateral border of the tuberosity And remove the bursa
- 23. www.shoulder.grwww.shoulder.gr Identify: 1. the AnterolateralCorner of the Acromion
- 24.
- 25. www.shoulder.grwww.shoulder.gr Identify: 3. Lateral edgeof the greater tuberosity
- 26. www.shoulder.grwww.shoulder.gr Identify 4. the keelof the acromion
- 27. www.shoulder.grwww.shoulder.gr Recognize the TearPattern Tears must be repaired in the direction of greatest mobility -> minimal strain The muscle-tendon junction must be 2-3 mm medial of the edge of the cartilage at the tuberosity after the repair
- 28. www.shoulder.grwww.shoulder.gr Tear Patterns Crescentshaped U-Shaped L-shaped (or reverse L) Massive Contracted Immobile tears S.S. Burkhart
- 29. www.shoulder.grwww.shoulder.gr Crescent Shaped Tear mobilized easily for tendonto bone fixation S.S Burkhart
- 30. www.shoulder.grwww.shoulder.gr Crescent-Shaped Tears Repair tobone with increased points of fixation Double row repair ? Single row triple loadead anchors Mc Stitch configuration
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- 33. www.shoulder.grwww.shoulder.gr Double Row Fixation Restorationof the footprint
- 34. Medial Row -Matress Sutures - 2 anchors www.shoulder.gr
- 35. Lateral Row -Simple Sutures - 2 anchors www.shoulder.gr
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- 38. www.shoulder.grwww.shoulder.gr L-Shaped & U-ShapedTears Side to side sutures from medial to lateral Progressively converge the margin of the tear lateral to the bone bed Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [S. S .Burkhart]
- 39. www.shoulder.grwww.shoulder.gr Large U-shapedcuff tear extending to glenoid Margin convergence The free margin of the cuff is repaired to bone with suture anchors
- 40. www.shoulder.grwww.shoulder.gr U-Shaped tear: Margincovergence with side to side sutures
- 41. www.shoulder.grwww.shoulder.gr Massive Contracted ImmobileTears No mobility from medial to lateral or from anterior to posterior Represent 9.6% of massive tears [S.Burkhart]
- 42. www.shoulder.grwww.shoulder.gr Massive Contracted Tears Anterior Interval Slide and/or Posterior Interval Slide Single and double interval slide
- 43. www.shoulder.grwww.shoulder.gr Anterior slide- supraspinatus from coracoid–coracohumeral ligament
- 44.
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- 46. www.shoulder.grwww.shoulder.gr Biologic enhancement of healing •Acromioplasty •Tuberoplasty •PRGFinjection in the subacromial space
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- 49. www.shoulder.grwww.shoulder.gr Arthroscopic repair yields 90-95% excellent in small and medium size tears at 4 to 10 years F.Up. • Burkhart SS, Danaceau SM, Pearce CM Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique—Margin convergence versus direct tendon to bone repair. Arthroscopy 2001;17:905-912. • Wolf EM, Pennington WT, Agrawal V. Arthroscopic rotator cuff repair: 4- to 10-year results. Arthroscopy 2004;20:5-12. • Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011: pp xxx Good to excellent results in massive tears with less than 75% fatty infiltration of the infraspinatus, even at 10 years F.Up • Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M., Arthroscopic repair of massive rotator cuff rears with stage 3 and 4 fatty degeneration. Arthroscopy 2007;23:347-354. • Jones CK, Savoie FH III. Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy 2003;19:564- 571. • Dodson CC, Kitay A, Verma NN, et al. The long-term outcome of recurrent defects after rotator cuff repair. Am J Sports Med 2010;38:35-39. • Luis G. Marrero, M.D., Kyle R. Nelman, M.D., and Wesley M. Nottage, M.D., Long-Term Follow-Up of Arthroscopic Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol xx, No x (Month), 2011: pp xxx
- 50. www.shoulder.grwww.shoulder.gr Using the abovetechniques Burkhart reported less than 3% irreparable cuff tears
- 51. www.shoulder.grwww.shoulder.gr Complete loss ofactive external rotation (external rotation lag ) is a bad prognostic factor Superior migration of the humeral head in contact with the acromion – repair attempt is going to be a failure Rotator Cuff Arthropathy What are the limits?
- 52. www.shoulder.grwww.shoulder.gr Conclusions Acute CrescentTear Standard Techniques for tendon to bone fixation U- or L- shaped Tears Side to side margin convergence Partially mobile tears Anterior / Posterior Slide Medialized Repair Incomplete repair Irreparable Tears debridement Tendon transfers Reverse – Extended head arthroplasty
- 53. www.shoulder.grwww.shoulder.gr Thank you foryour attention
- 54. www.shoulder.grwww.shoulder.gr Single and doubleinterval slide Anterior slide through release in the rotator interval (supraspinatus– coracobrachialis) Posterior slide through release of the interval supraspinatus-infraspinatus
- 55.
- 56. www.shoulder.grwww.shoulder.gr Release of MMPand GF after acromioplasty Platelet-derived growth factor-AB (PDGF-AB), basic fibroblast growth factor basic (bFGF) and transforming growth factor beta 1 (TGF-b1) are released after acromioplasty in the subacromial space. Knee Surg Sports Traumatol Arthrosc (2009) 17:98–101 Release of growth factors after arthroscopic acromioplasty . Pietro Randelli Ζ Fabrizio Margheritini Ζ Paolo Cabitza Ζ Giada Dogliotti Ζ Massimiliano M. Corsi MMP-2 does not increase but MMP-9 increases after acromioplasty and their mesurment can be a useful tool to be monitored in parallel with growth factors level and other bone turnover markers in order to evaluate the bone remodelling and tissue healing. E. Galliera , P. Randelli, G. Dogliotti, E. Dozio, A. Colombini, G. Lombardi, P. Cabitza, M. Corsi. Matrix metalloproteases MMP-2 and MMP-9: Are they early biomarkers of bone remodelling and healing after arthroscopic acromioplasty? Injury, Int. J. Care Injured 41 (2010) 1204–1207
- 57. www.shoulder.grwww.shoulder.gr Conclusions Rot Cuffis extremely significant for the normal function of the shoulder Rot Cuff tears can be asymptomatic Symptoms Produced by a tear depend on: Size Location Functional demands of the patient