Post on 28-May-2020
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ISAKOS PrecourseRotator Cuff
Pre-operative Evaluation: How to plan a Successful Repair.
Guillermo Arce, MD. Buenos Aires, Argentina
§ Lectures, paid Consultant: üArthrex.üZimmer.
§ Education: ConMed.
§ Journals: JISAKOS
§BODs:ü ISAKOS, Second Vice President.üSLARD, Past -President.
Financial Disclosure
What do we need to get good results ? My Goals: Steps for Succesful Outcomes
§Diagnosis:oPatient history: Pain, Sports, Trauma. oPhysical Exam: Motion and Strength.oPre-operative ScoresoMRI / Ultrasound interpretation
§Patient Positioning and Anesthesia.
§ Equipment: Pump, Anchors, Grafts, Patches.
Peter Drucker: Father of Management
”If you can’t measure it, you can’t manage it.
If you can’t manage it, you can’t improve it “
Take at least 2 Scores before any treatment.ASEShttp://orthotoolkit.com/ases/
ü Work, Sports/Leisure, pain killers ( type ).
ü VAS Scale 1/10 average.
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Constant & Murleyhttp://orthotoolkit.com/constant-shoulder/
MCID: 10,4
• Pain: 15
• Activities of daily living:20
• Motion: 40
• Strength: 25
4 Domains: 100 points
Disease Specific
WORC
• 21 Questions: 100 mm lines
• 5 Domains: 21 Questions= 2100
1. Physical Symptoms: 600
2. Sports and Recreations:400
3. Work:400
4. Social Function:400
5. Emotions:300
MCID: 245
Short WORC
7 Questions
http://www.orthopaedicscore.com/http://orthotoolkit.com/
Socrates Orthopaedic Outcomes Software:
SOS. Surgical Outcomes System.
Softwares to track Outcomes
For printing
Digital Storage
Data analysis / follow up
Websites for Shoulder ScoresAutomated Cumulative Sum Formula
•ROM
• Impingement/Neer• Jobe: Empty and Full can. SSP
•Strength: Subs, ISP.
•Lift off: Subs.•Speed / O’Brien: LHBT
•OFP: Biceps and ACJ
Physical Exam
1.Magee, David J; Sueki, Derrick (2011). Orthopedic Physical Assessment Atlas and Video: Selected Special Tests and Movements. St. Louis, Missouri: Saunders. pp. 122.2.Konin, Jeff G; Wiksten, Denise L; Isear, Jerome A; Brader, Holly (2006). Special Tests for Orthopedic Examination (3rd ed.). Thorofare, New Jersey: SLACK incorporated. p. 24..3.Loudon, Janice; Marcie, Swift; Bell, Stephania (2008). The Clinical Orthopedic Assessment Guide. Lower Mitcham, South Australia: Human Kinetics. p. 148. .
•AHD: Acromion Humeral Distance: > 7 mm.
•CSA: Critical Shoulder Angle: 34 0
•AS: Acromion Slope. Bigliani I, II, III.
X rays: Are they needed ?
Jun-Han Kim, Young-Kyoung Min, et al. JSES March 2019Gerber C, Catanazaro R, et al. Artrhroscopy, March 2018Degen R. Arthroscopy. October 2018.
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X Rays
Sagital Plane:• Acromion Shape• Acromion Slope
Coronal Plane:• Critical Shoulder Angle 330
• Lateral Acromion Angle.• Acromion Index. GA/GH =0.73
GH
GA
Nyffeler R, Meyer D. EFORT Open Rev. May 2017
CSA
Jun-Han Kim, Young-Kyoung Min, et al. JSES March 2019Gerber C, Catanazaro R, et al. Artrhroscopy, March 2018Degen R. Arthroscopy. October 2018.
Massive Cuff: Cables: Subs and Teres Minor. Teres Minor
ISP
TMISP
TM
Massive Cuff: Subs and Teres Minor.
Not everything is lost !
JAAOS 2018
Teres Minor: PE & T 1 Sagital Oblique.
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Diagnosis: Lidocaine InjectionsLHBT or ACJ
BicepsDynamic Ultrasound: A growing tool
MRI: What should be look for ??References Lines
• Coronal T 2 FS: LHBT, SSP/ISP Tears
• Sagital Oblique T 1: Fat Infiltration.
• Axial: LHBT, Subs, OA.
•What does he/she has ?
•Why he/she needs surgery ?
•What are the realistic expectations ?
•How good are the reported outcomes ?
•Retear rate ?
Informed Consent
Inter-scalene BlockNIRSBrain Spectometry
Anesthesia / Blood Pressure / Pump
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NIRS: Cerebral Oximetry.
Customized pump pressure
Anesthesia / Blood Pressure / Pump
Tip # 4
Fa Large, Massive or Revision
Fascia Lata Graft
Mesh
Take Home Messages•ARCR is a quite
demanding operation.
•You need to plan ahead.
•Right diagnosis: PE and MRI.
•Allways be prepared for worst but hope the best.
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Plan Ahead. Be prepared.
Thank you.Guillermo Arce, MD.
Buenos Aires, Argentina
Tip # 8 The Biceps is a Winner !!
• Develop your surgical skills for different biceps tenodesis.
• The weak link is the Tendon.
Surgical Workflow.
Always keep in mind:ü The LHBT is a winner.
ü Adequate Releases.
ü Tear shape and pattern
and reduction.
ü Forget the SSP: Recover the Cables.
Tip # 9 The SUBS is always needed.
Reduction with a proximal anchor and grab the coma ..
RC Disease ISAKOS Consensus Meeting
Munich 2018