Rc repair philosophy and technique microhand 2014

www.shoulder.grwww.shoulder.gr

Manos AntonogiannakisHead B’ Orthopaedics Dept

Center for shoulder arthroscopy IASO GENERAL Hospital

Arthroscopic Treatment of Rotator Cuff Tears – Philosophy and Technique

Philosophy of treatment:

restore the 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.

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Back to Basics


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)


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?”


Partial Tears Treatment Options

1. Debride partial tear only2. In-situ Repair3. 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


Partial Tears In situ repair


COMPLETE TEARS

Small 1cm Medium 2-3cm Large 3-5 cm Massive >5cm Cofield et all


Type Description Preoperative MRI 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.


ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD

OF THE REPAIR


Surgical Technique

Steps

1. GH Joint 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


Patient Position

Lateral decubitus my preferred position


Bleeding control


Keys to control bleeding


30º Scope Entrance from posterior portal but change portal and viewing angle of scope ( 30 to 70) as needed


Joint Side Inspection


Bursal Side Inspection-Bursectomy


Problem no 1: Bad quality retracted tendons covered by a thickened bursa

Find and recognize the tendons


Remove the thickened bursa 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


The posterior extent of the tear

Differentiate thickened bursa from the infraspinatus by finding the posterior insertion of the cuff to the tuberosity


Solution Idendify recognizable landmarks

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


Identify: 1. the Anterolateral Corner of the Acromion


Identify: 2. the acromioclavicular joint


Identify: 3. Lateral edge of the greater tuberosity


Identify

4. the keel of the acromion


Recognize the Tear PatternTears 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


Tear Patterns Crescent shaped U-Shaped L-shaped (or reverse L) Massive Contracted Immobile

tears S.S. Burkhart


Crescent Shaped Tear

mobilized easily for tendon to

bone fixation

S.S Burkhart


Crescent-Shaped TearsRepair to bone with increased points of fixation

Double row repair ? Single row triple loadead anchors Mc Stitch configuration

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Double Row FixationRestoration of the footprint

Medial Row - Matress Sutures - 2 anchors

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Lateral Row - Simple Sutures - 2 anchors

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Suture Bridge double row

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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]


Large U-shaped cuff tear extending to glenoid

Margin convergence

The free margin of the cuff is repaired to bone with suture anchors


U-Shaped tear: Margin covergence with side to side sutures


Massive Contracted Immobile Tears No mobility from medial to lateral

or from anterior to posterior Represent 9.6% of massive tears

[S.Burkhart]


Massive Contracted Tears

Anterior Interval Slide

and/or

Posterior Interval Slide

Single and double interval slide


Anterior slide-supraspinatus from coracoid –coracohumeral ligament


Posterior slideInfraspinatus - supraspinatus


Before

After


Biologic enhancement of healing

•Acromioplasty•Tuberoplasty•PRGF injection in the subacromial space


Acromioplasty


Tuberoplasty


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


Using the above techniques Burkhart reported less than

3% irreparable cuff tears


Complete loss of active 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?


Conclusions Acute Crescent Tear 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


Thank you for your attention


Single and double interval slide

Anterior slide through release in the rotator interval (supraspinatus–coracobrachialis)

Posterior slide through release of the interval supraspinatus-infraspinatus


Stay sutures to the cuff


Release of MMP and 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


Conclusions Rot Cuff is 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

Rc repair philosophy and technique microhand 2014

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