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Reparacion Artroscopica Vs Miniopen de manguito rotador
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Reparación Artroscopica de Manguito Rotador
Dr. Jorge Parra L.
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HISTORIA• Codman: reparacion
abierta 1990.• Burman: 1931, Wantanabe
1935: describieron artroscopia.
• Wiley y Older (1980): la popularizaron.
• Desarrollada paralelamente con artroscopia de rodilla (70 - 80
Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.
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• Ellman (1987): descompresion subacromial y lesiones del labrum.
• Gartsman, Snyder, Wolf y Bayliss (1988 - 1998): reparacion artroscopica grapas metalicas.
Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.
HISTORIA
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INDICACIONES PARA REPARACION ARTROSCOPICA DE MANGUITO
ROTADOR
• Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.• Gartsman GM, Tavema E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997• Tauro JC: Arthroscopic rotator cuff repair: Analysis of Technique and results at 2- and 3-year follow-up. Arthroscopy 1445-51, 1998
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INDICACIONES
Hombro doloroso.
Limitacion funcional.
Deportistas.
Falla tratamiento conservador en 6 meses
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INDICACIONES
Pequenas y medianas lesiones.
Lesiones que permiten colocar el manguito a 10 mm de la inserccion anatomica.
Lesiones que luego de la movilizacion presentan moderada tension.
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CLASIFICACION DE PATTE 1990
• Pequeñas <1 cm• Medianas 1-3 cm• Grandes 3-5 cm• Masivas > 5 cm
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DECISION ARTROSCOPIA – MINI OPEN
REAPARACION ABIERTA
• Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.
• Gartsman GM, Tavema E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997
• Gartsman GM, Khan M, Hammerman SM Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 80:832-840, 1998
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VENTAJAS ENTRE ARTROSCOPIA, MINI-OPEN VS. REPARACION
ABIERTA Mejor aspecto cosmetico.
No acromioplastia
Mantiene el origen del deltoides.
Estadia corta
Menor daño de tejidos blandos.
Menor tiempo de rehabilitación.
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• Helen Razmjou,MSc, PT, PhD(CEvaluating Equivalency of Treatment Effectiveness:The Example of Arthroscopic and Mini-Open Rotator Cuff Repairs, 2009.•Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.•Kim SH, Ha KI, Park JH, et al. Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years’ follow-up. Arthroscopy 2003;19(7):746–54.• Severud EL, Ruotolo C, Abbott DD, et al. All-arthroscopic versus mini-open rotator cuff repair: along-term retrospective outcome comparison.Arthroscopy 2003;19(3):234–8.
DECISION ARTROSCOPIA VS. MINI-OPEN
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DECISION ARTROSCOPIA VS. MINI-OPEN
Experiencia cirujano
• Habilidad, movilización, evitar lesión tendinosa.• 25 anual.
Tamano y orientacion de lesion
Cosmetica.
• Portales accesorios.
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VENTAJAS DE LA ARTROSCOPIA
• Gartsman GM, Tavema E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997• Gartsman GM, Khan M, Hammerman SM Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 80:832-840, 1998• Warner JJ, Tetreault P, Lehtinen J, et al. Arthroscopic versus mini-open rotator cuff repair: a cohort comparison study. Arthroscopy 2005;21(3):328–32• Youm T, Murray DH, Kubiak EN, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcomes and patient satisfaction. J Shoulder Elbow Surg 2005;14(5):455–9•Sauerbrey AM, Getz CL, Piancastelli M, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. Arthroscopy 2005; 21(12):1415–20.
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VENTAJAS
• Cosmetica• Menor afectación de musculatura deltoidea y
subdeltoidea• Menor índice de infección• Menor tiempo rehabilitacion 12.5%– Menor rigidez
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VENTAJAS ARTROSCOPIA
• Permite la valoracion de articulacion glenohumeral.
• Myler y Savoie 74% lesiones asociadas• Gartsman y Taverna 60.5% lesiones
asociadas.• Paulus y Kody encontraron 37% de lesiones
asocidas, necesitan reparacion.
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Lesiones Asociadas
• Patologia labral• Lesion del biceps• Sinovitis• Alteracion superficie articular.
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Técnica Artroscopica
• Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.
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Técnica Artroscopica
• Evaluacion del supraespinoso
• France (1989) Tornillos y grapas no recomendadas vs anclas y suturas
Recorrido •liberacion de capsula y tejidos blandos coracohumerales.
Tension
Calidad tendon
Calidad del hueso
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TUNELES OSEOS VS. ANCLAS
• Hecker 1993, no diferencia estadisticamente significativa.
• Reed 1996, anclas soportan 261 N y tuneles 194 N.
• Burkhart 1996, suturas con anclas mas fuerte fijacion.– Colocar 90 grados el ancla con 30 grados abduccion.– Angulo pullout y angulo de reduccion de la tension = 45
grados.
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Manejo Post - Operatorio
• Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.• Osti L, Papalia R, Paganelli M, Denaro E, Maffulli N. (2010) Artrscopic vs mini-open rotator cuff reapair: A quality of life impairement study.
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REHABILITACION POSTOPERATORIA
• Individualizada• Primer dia postoperatorio.– Ejercicios pendulares.– Movimientos activos de flexion y extension del codo.
• Cabestrillo vs Abductor (30 grados) por tres semanas.
• Rehabilitacion en agua desde tercera semana.
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REHABILITACION POSTOPERATORIA
• Movimientos activos asistidos tercera a cuarta semana.
• Ejercicios activos sin asistencia sexta semana.• Ejercicios para manguito rotador – Baja resistencia, fortalecimento deltoides 12 – 16
semanas.– Ejercicios de alta resistencia del sexto al decimo mes.
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Resultados de reparación Artroscopica de manguito rotador
•Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1.• Osti L, Papalia R, Paganelli M, Denaro E, Maffulli N. (2010) Artrscopic vs mini-open rotator cuff reapair: A quality of life impairement study.
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RESULTADOS ARTROSCOPIA
• Buen resultado 87%.• Valorado con escala Constant a los dos años
de seguimiento.• Gartsman dos anos de seguimiento con 11
lesiones pequenas, 45 lesiones medianas, 11 lesiones mayores, 6 lesiones masivas.
• 90% de satisfaccion.
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Comparacion de los resultados de la calidad de vida, en pacientes con reparacion artroscopia vs. tecnica mini-open en
rupturas < 3 cm.
• 64 pacientes Septiembre 2003-2005.
• 32 mini open (31 meses)• 32 tecnica artroscopica
(30.6 meses).• Hipotesis: no existe
diferencia significativa entre MOR y FAR, para la reparacion del manguito rotador en lesiones <3cm.
• Inclusión– Lesion por RM o
durante la cirugia de lesion < 3cm.
– No evidencia radiologica de fractura.
– No patologia de inestabilidad o lesiones asociadas.
– No comorbilidades – No cirugia previa
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EVALUACION
• Preoperatoria un dia antes de la cirugia• A los 6 meses.• Al final 31 meses MOR y 30.6 AR.• Se evaluo rangos de moilidad ROM (flexion,
rotacion interna y rotacion externa), escala modificada de UCLA y el cuestionario SF- 36. (0-100)
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HALLAZGOS CLINICOS
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HALLAZGOS CLINICOS
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LIMITACIONES
• Estudio retrospectivo• Sesgo de seleccion de pacientes.• No abordaje o sesgo por las lesiones del
tendon del biceps, tanto en pacientes con tenotomia o tenodesis.
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CONCLUSION
• No existe diferencia estadisticamente significativa tanto objetiva como subjetiva con las dos tecnicas.
• El cirujano debe elegir la tecnica con la que este mas familiarizado.
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Hand Clin 25 (2009) 67–70 doi:10.1016/j.hcl.2008.10.0020749-0712/08/$ – see front matterª2009 Elsevier Inc. All rights reserved.
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EVIDENCIA ACTUAL
• No existen RCT o estudios de cohorte comparativos prospectivos en ruptura del manguito rotador.
• Se limita a estudios de cohorte retrospectivos.
Helen Razmjou,MSc, PT, PhD(CEvaluating Equivalency of Treatment Effectiveness:The Example of Arthroscopic and Mini-Open Rotator Cuff Repairs, 2009.
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LIMITACIONES DE EVIDENCIA PARA LA COMPARACION DE TECNICA ARTROSCOPICA VS
MINI-OPEN
• Estudios retrospectivos.• Existen muestras pequenas y diferentes.• Falta de hipotesis clara.• No existe conclusion definitiva, entre cual es
mejor.
Helen Razmjou,MSc, PT, PhD(CEvaluating Equivalency of Treatment Effectiveness:The Example of Arthroscopic and Mini-Open Rotator Cuff Repairs, 2009.
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EVIDENCIA ACTUAL
• Las dos tecnicas mejoran sintomas y presentan bajas tasas de complicaciones.– Incremento ligero mini open.– No diferencia significativa entre las dos tecnicas.
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Helen Razmjou,MSc, PT, PhD(CEvaluating Equivalency of Treatment Effectiveness:The Example of Arthroscopic and Mini-Open Rotator Cuff Repairs, 2009.
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Bibliografía
• Frank B. Nrberg, MD, Larry D. Field, MD, and Felix H. Savoie II , MD. (2000). Repair of Rotator Cuff. Missisipi: Clinics in Spots Medicine Vol 19, Number 1
• Gartsman GM, Tavema E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997
• Tauro JC: Arthroscopic rotator cuff repair: Analysis of Technique and results at 2- and 3-year follow-up. Arthroscopy 1445-51, 1998
![Page 37: Reparacion Artroscopica Vs Miniopen de manguito rotador](https://reader030.fdocuments.us/reader030/viewer/2022032617/55b1bfb6bb61ebbe208b469b/html5/thumbnails/37.jpg)
Bibliografía
• Helen Razmjou,MSc, PT, PhD(CEvaluating Equivalency of Treatment Effectiveness:The Example of Arthroscopic and Mini-Open Rotator Cuff Repairs, 2009.•Kim SH, Ha KI, Park JH, et al. Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years’ follow-up. Arthroscopy 2003;19(7):746–54.• Severud EL, Ruotolo C, Abbott DD, et al. All-arthroscopic versus mini-open rotator cuff repair: along-term retrospective outcome comparison.Arthroscopy 2003;19(3):234–8.
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Bibliografía
•Osti L, Papalia R, Paganelli M, Denaro E, Maffulli N. (2010) Artrscopic vs mini-open rotator cuff reapair: A quality of life impairement study.• Warner JJ, Tetreault P, Lehtinen J, et al. Arthroscopic
versus mini-open rotator cuff repair: a cohort comparison study. Arthroscopy 2005;21(3):328–32
• Youm T, Murray DH, Kubiak EN, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcomes and patient satisfaction. J Shoulder Elbow Surg 2005;14(5):455–9
![Page 39: Reparacion Artroscopica Vs Miniopen de manguito rotador](https://reader030.fdocuments.us/reader030/viewer/2022032617/55b1bfb6bb61ebbe208b469b/html5/thumbnails/39.jpg)
• Sauerbrey AM, Getz CL, Piancastelli M, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. Arthroscopy 2005; 21(12):1415–20.