. Mr Lee Van Rensburg 2014. . . J Bone Joint Surg Am. 2014;96:265.
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Transcript of . Mr Lee Van Rensburg 2014. . . J Bone Joint Surg Am. 2014;96:265.
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Mr Lee Van Rensburg
2014
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J Bone Joint Surg Am. 2014;96:265
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Farmer Falls from tractor
Pain and weakness in shoulder
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Diffuse pain in upper arm, following fall X rays show some arthritis Weakness and pain
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See’s physio - 2 weeks later Pain slightly better Affecting sleep Still struggling with elevation 90°
? Rotator cuff tear
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Why ? tear Jobe’s
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- Apley's Scratch Test - Jobes Supraspinatus test - Dawburn's sign- Sherry Party sign- Codman's Sign (Drop Arm Sign)- Rent Test- Zero Degree Abduction Test - Burkhead's Thumbs down & Burkhead's Thumbs up
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J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
175175
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Image
Inject
Start rehab?
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? Tear in tendon Special scan Stop using it tear get worse……
Keep it moving !
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Full thickness tear Supraspinatus Infraspinatus
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60-69 =30% FTRCT
70-79 = 50% FTRCT
80-89 = 80% FTRCT
Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299
1953 - 61
1930 - 84
1936 - 78
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Surgery Rehabilitation
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Agency for healthcare research and qualityUSA July 2010
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1 study
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J BJS - Br January 2010 vol. 92-B no. 1 83-91
Age 59 (44-75) Age 61 (46-75)
Symptoms 10 - 12 months
+- 50:50 traumatic and atraumatic
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J BJS - Br January 2010 vol. 92-B no. 1 83-91
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J BJS - Br January 2010 vol. 92-B no. 1 83-91
Constant score
SatisfactionPhysiotherapy 7.2 (1-10)Surgery 9 (1-10)
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J BJS - Br January 2010 vol. 92-B no. 1 83-91
Secondary surgery group
Delay in surgery 5 monthsFinal outcome 7.5 points less constant score
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J BJS - Br January 2010 vol. 92-B no. 1 83-91
42 Happy not surgery
9 no surgery constant score 7.5 less
Surgery did better
BUT
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Clin Orthop 1983;175:18-24.
N = 37 Group 1 – Operated within 3 weeks (n=12) Group 2 – Operated within 3 to 6 weeks (n=6) Group 3 – Operated within 6-12 weeks (n=19)
F/U ave. 7.0 years (range, 1 - 21 years) Abduction
Group 1 = 168° Group 2 = 126° Group 3 = 129°
Pain relief good for all Repair best within 3 weeks
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J Shoulder Elbow Surg (2011) 20, 62-68
N= 36 3 groups
Group 1 - 0-8 weeks Group 2 - 8-16 weeks Group 3 - > 16 weeks
All improved Pain 7 down to 1Elevation 55 to 133
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Surgery Rehabilitation
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Anaesthetic Infection Stiffness Incomplete resolution Recurrence Re tear Rehab
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Day case overnight stay 60-80% better Drive 6-8 weeks (2 weeks)
Desk top 4-6 weeks Manual work 3 months
Healed 6 weeks 60% 3 months 80%
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Sling till arm awake Stay out of kitchen Most wear off 8 Hours
Pre emptive analgesia
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Many different types of procedures Single row Vs double row Multiple anchor variations
Knotless anchors Metal vs PEEK Vs Absorbable Biological, vented
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- “footprint” (Smith & Nephew)
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Double-row have Significantly lower re-tear rate Higher ASES score Greater range of motion of internal rotation
Particularly in tears >30 mm
J Shoulder Elbow Surg (2014) 23, 182-188
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Single row resulted in significantly higher re-tear rates compared with double-row repairs
No detectable differences in improvement in outcomes scores between single-row and double-row repairs
Shoulder Elbow Surg (2014) 23, 586-597
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Sling 3 weeks all time
except when doing physio/ bath or shower 6 Weeks or social protection
Assisted range of movement “Nothing heavier than a cup of tea 6 weeks” No strengthening 6 weeks
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J Shoulder Elbow Surg (2014) 23, 1631-1639
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Mepore Dressings
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Pad
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J Shoulder Elbow Surg (2011) 20, 326-332
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J Shoulder Elbow Surg (2012) 21, 61-65
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Non operative Relative rest NSAID Physio Steroid injection (controversial) Supra scapular nerve block
Operative
JSES - 2008;17:863-870
3 months
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Non operative Operative
Arthroscopic Debridement Reverse decompression Biceps tenotomy Suprascapular nerve ablation
Open Reverse shoulder replacement
JSES - 2008;17:863-870
3 months