Surgical Options From Tennis Elbow to Cuff15 minforms.acsm.org/2014ATPC/PDFs/4 Kelly.pdfSurgical...
Transcript of Surgical Options From Tennis Elbow to Cuff15 minforms.acsm.org/2014ATPC/PDFs/4 Kelly.pdfSurgical...
Surgical Options From Tennis Elbow to Cuff
John D. Kelly IV
Director Shoulder Sports Med
Univ. of Penn
Tendinopathy
• Part of aging process
• Vascular issue
• Association with Hyperlidemia, Hypertension
• Associated with Eccentric Overload
Common Tendinopathies
• Medial Epicondylitis
• Lateral Epicondylitis
• Rotator Cuff
Medial Epicondylitis (least common)
• Golfer’s Elbow
• Worsened with hitting
‘fat shots’
Golfer’s Elbow
• Usually responds to eccentric rx
• PRP
• Braces
• Stubborn cases (rare) debridement
Debridement
• Small Medial Incision
• Surgically debride
devitalized tissue
Lateral Epicondylitis
• Tennis elbow
• Tendinosis, degeneration of ECRB
• Age related
• Eccentric stress induced
Path
• ECRB > 95%
• EDC superior 10-20% up to 1/3 cases
• Angiofibroblastic tendinosis ECRB
• Synovitis approx, 25%
Angiofibroblastic Tendinosis
• increased cellularity, vascularity
• cell morphology changes
• myxoid changes in the matrix
• increased glycosaminoglycan
• occasionally calcification and
lipid deposition
Nirschl
Anatomy
• ECRB origin: Deep to muscular ECRL
• ECRB Tendon Conjoined w/ EDC
• LUCL: posterior to ECRB
Diagnosis
• Pain with Handshake, lifting ‘milk carton’
• Pronated more painful than supinated
• Wrist extension pain
• Tenderness ant to LE
• Diff Dx: OA, radial tunnel, LUCL, triceps, discogenic, synovitis, plica
Imaging?????
• Radiographs: usually normal
• MRI: ?indications, able to demonstrate partial tears, other pathology, LUCL
• CT: helpful for OA
• Ultrasound: evolving
• Bone scan
MAN SCAN
Non Op Rx
• Pt Education:
• Activity modification
• Supinated lifting
• Braces, splints
• Cortisone injection….
• ECSWT: Buchbinder, 2005
• Prolotherapy • PRP…some evidence • Accupuncture • Botox ?
• Eccentric strength training
Surgery
• Rarely needed!
• If your surgeon doing ‘100’ releases a year, beware
• Sometimes truly necessary
Indications Surgery
• Failure At least 4-6 mo non op rx (prp etc.)
• Severe sx
• <8% patients (at most!!!)
• (?MRI indications)
• (Response w/injection)
Surgical Options
• Open
• Scope
• Percutaneous
Which to choose?
• Surgeon preference • Data not clear • Goal: Excise all the bad stuff !! • • Studies generally show no difference • Prob earlier RTW & pain relief w/
arthroscopy
Percutaneous Release
• Quick
• Office based
• Less morbidity
• ‘Blind’
• Does not address anatomic lesion
• Potential LCL damage
Open Release
• Release origin extensors
• ‘full release’ with predictable decompression of tension tendons
• ‘overkill’?
• Release not targeted at
distinct pathology
• Weakness extensors?
Open Debridement
• ‘Nirschl’ procedure
• Degeneration ECRB excised, bone drilled, repair tendon
• Addresses ‘lesion’
Open debridement
• Pain
• Morbidity
• Does not address intra articular injury
• Pathology is deep…….. surgery starts superficially
Open
• Identify ECRL/EDC interval
• Incise 2-3 mm..Retract ECRL, undermine EDC
• Define ECRB…resect proximal to distal
• Arthrotomy not necessary…
• Key: excision of all pathological tissue
Open
• Reattach ECRB (Hannafin, AJSM)
• Meticulous Closure of EDC/ECRL interval
• Lightly debride lat. epicondyle…? drilling
Scope Release
• Release deep ECRB
• Precise attention to lesion
• Less pain
• Joint evaluation
• Plica, synovitis
The posterolateral plica: A cause of refractory lateral elbow pain
Ruch et al 2006
Beware of the Plica
Technique
• Lateral decub
• Two portals
• Sometimes distractor portal
• Stay above mid portion capitellum
• Identify, release, debride
• Resect above the capitellum until ECRL seen
• Debride to the EDC ridge and fibrous origin….
Scope Technique
• Identify ECRB
• Shave away capsule
• Release tendon off origin
• Burr or shave bone for healing response
• Explore radiocapitellar joint
• Explore remainder of joint
Greco
Capsular Rent
Greco
Exposure Tendon
Greco
Tendon Release
Greco
Steinmann
Post Op
• Early ROM
• Same for scope or open
• Avoid pronated lifting
• Slow for first 6-8 weeks
• Eccentric exercise
• Sports and heavy labor 3-4 mos
Results
• Nirschl open 85% returned to full activity
• Walenkamp open release 89% good/exc
• Baker scope 37/39 ‘better or much better’
• Grundberg percutaneous release 29/32 good/exc
• Dunkow open vs percutaneous: perc group better results!
Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment
Szabo et al
• Open, scope, percutaneous
• 109 patients
• Min 2 year follow up
• No difference in
Andrews/Carson score
Failure
• Inadequate resection (Nirschl)
• Excessive resection
• LUCL, EDC injury
• Improper diagnosis: PLRI, PIN, Biceps, etc.
• Patient motivation
• Stiffness, arthrofibrosis, smokers
Iatrogenic LCL Injury
• Posterolateral instability secondary to LCL resection
• Pain with supination
• ‘rising from a chair’
Bottom Line
• Surgery RARELY indicated
• Literature implies edge to scope since earlier return to activity.
• JDK favors scope:
less pain
precise release
concomitant treatment associated path.
Rotator Cuff Tears
• Not all tears need surgery
• BUT…if active and require strong arm or……more than one tendon tear surgery best option
Supraspinatus – ‘It starts here’
• Tears propagate anteriorly >> Subscap
• Posterior propagation >>Infraspinatus, Teres minor
Tear Propagation Anterior or Posterior
Burkhart et al
Postero Inferior Supra + Infra
Antero Superior Subscap + Supra
Massive Cuff Tears
• Involve more than one tendon
• Generally over 5cm in width
• Fatty infiltration common
Do ‘MAN SCAN’ to see what is TORN
• Chao, Kelly et al
• EMG Study
• Best Test Upper Subscap?
Bear Hug at 45 Degrees
forward flexion
Massive Cuff Tears – Why Bother to Fix?
• Arthropathy may be delayed
• Reverse prosthesis is no picnic!
• Burns no bridges
• Pain relief predictable
Treatment GOALS
• Restore force couple
• ‘Reduce tear’
• Debride joint, release inferior capsule
• Mumford
• ‘Delicate’ acromioplasty, tuberosplasty
• Treat biceps
Force Couple: Opposing Moments rotation without translation
• Provide fulcrum
• Neutralize deltoid
• *Subscap
• *Infraspinatus
Inferior Half Infraspinatus and Upper Subscap:
Resists Upward Pull Deltoid
Rotator Cable: ‘Spans’ the Humeral Head
GO for the CABLE
Subscap/CHL: Key part of Cable
My Approach
• Thorough mobilization cuff
release CHL – only if subscap intact
release inferior capsule
excavate cuff from acromion
• Margin convergence
• Medialize repair
McLaughlin 1945 Recognized Tear Patterns
• Reduce the Tear
Tear Patterns
• Crescent tear – symmetric retraction
• L shaped – mobile limb anterior
• *Reverse L – mobile limb posterior
• (U shaped – anterior and posterior limbs equally mobile)
Pre Op Planning MRI
Davidson
Mobile Limb Indicates Pattern of Tear Extension
‘Reverse L’ (most common) Posterior Limb Mobile
Ant. Post.
Note Suture Pattern is Oblique
Margin Convergence
• Shifts tissue > defect
• Shortens medial – lateral dimensions
• Free margin “converges” to tuberosity
• Decreases strain cuff edge
Job1: Restore Force Couple
• *Do your best to repair upper subscap
• Do your best to repair lower half of infraspinatus
• Partial repair is better than no repair!
• DON’T SWEAT SUPRASPINATUS
‘Comma Sign’ >> Edge of Subscap
• Affords Infra Repair
Examples: Antero Superior Tear
Sew Posterior Cuff to CHL
Completed repair
Enhance Repair
• Avoid tension!!!
• Increase number of sutures
• MEDIALIZE!
• ‘Rip stop sutures’
• ‘Marrow stimulation’
Burkhart
‘Double Row Hysteria’
• Forgotten the art of ‘tear reduction’
• Margin convergence replaced by ‘more rows’
• ‘Dog Ear’ = NOT REDUCED
• Tension, ischemia?
‘Type 2 Failure’ Result of Tension Double Row
Wang et al Arthroscopy 2012
• 5x increase tension double-row vs single row
• Tears >2 cm require significantly more tension to reapproximate to articular margin and lateral tuberosity.
Respect Anatomy!!
• This!!!! Use anchor to converge margin!
NOT THIS!!!!
Avoid Tension Medialize if Neccessary
Punch Holes Tuberosity ‘crimson duvet’, Stem Cells
• Snyder
Graft Augmentation
• Promising
• Scope vs Mini Open
• JDK seeing early ‘encouraging’ results
Oh AJSM 2011
• Large tears with ‘pseudoparalysis’
• Repaired arthroscopically or mini open
• 76% had psuedoparalysis resolve
Iagulli AOSSM 2011
• Partial repair of massive tears yielded results similar to complete repair
• Avg. pre op tear size 35.20cm2
Bottom Line – Cuff Repair
• You will help many!
• Most patients are satisfied, despite residual weakness!!
• May arrest progression to arthropathy
• Subscap may hold the key
THANK YOU