Arthroscopic Transosseous(No Implant) Rotator Cuff Repair-Dr. Raghuveer Reddy .K
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Transcript of Arthroscopic Transosseous(No Implant) Rotator Cuff Repair-Dr. Raghuveer Reddy .K
![Page 1: Arthroscopic Transosseous(No Implant) Rotator Cuff Repair-Dr. Raghuveer Reddy .K](https://reader036.fdocuments.in/reader036/viewer/2022081721/55a435a01a28ab04188b4624/html5/thumbnails/1.jpg)
ARTHROSCOPIC TRANSOSSEOUS
(No implant) ROTATOR CUFF REPAIR
Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad
Dr. Raghuveer Reddy. K
IAS 2014
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I am Thankful to Dr. Sumant G. Krishnan
for providing with Biomechanical work
& Clinical outcome statistics of his
study done in U.S.
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History
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Cycle of Rotator Cuff Repair
Open Transosseous
Mini-Open Transosseous
Mini-Open with Anchors
Arthroscopic with Anchors
SR vs DR vsTOE
Arthroscopic Transosseous
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The Perfect RCR
Large Contact Area
High Initial Fixation Strength
Stable Construct
Biology
High Contact Pressure
Low Tension Repair
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Mechanical fixation Biological healing
Suture strength
Multiple sutures
Suture configuration
Suture anchors
Transosseous Equivalent
Transosseous Repair
Prepare bone foot print
? Acromioplasty??
• Collagen coated suture
Growth Factors ( PRP)
Stem Cells
ECM Grafts
Biologic Scaffolds
Graft Jacket
Cuff Healing - Stimulation
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Cyclic Testing
Tunnel: Bone Failure
Anchors: Tendon Failure
Burkhart et al Arthroscopy 1997
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Design Arthrotunneller
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Arthroscopic Transosseous RCRHISTORICAL PERSPECTIVE
Fleega 2002
“Giant Needle”
Krishnan 2002
All-Arthroscopic
Transosseous
Lu 2005
ACL Guide
Beauchamp 2007
Curved passers
Resch 2009
Curved hollow needle
Castagna 2012
Taylor Stitch
Kuroda 2013
Customized drill guide
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ATRCRThe Surgical Technique
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ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR
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ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR
Surgical Technique –
Any suture configuration possible
Simple (medial)
Mattress (ant/post)
Bridges
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ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR
Single Tunnel
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ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR
Two Tunnel
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ATRCRThe Science
BIOMECHANICAL EVALUATION
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Ideal Rotator Cuff Repair
● High initial fixation strength
● Minimal gap formation
● Mechanical stability till tendon bone healing
Gerber JBJS (Br) 1994
Sugaya JBJS 2007
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Arthroscopic Transosseous RCRREVISITING HISTORY
● Burkhart et al. - Arthroscopy, 2000
● Barber et al. - Arthroscopy, 2010
● Jost et al. - JBJS, 2012
“Increasing the number of sutures crossing the repair
site increases the load to failure and decreases gap
formation under cyclic loading”
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ATRCRThe Outcomes of
Our Prospective Clinical Study &
Sumant’s Randomized Study
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My Experience
PROSPECTIVE CLINICAL STUDY
Material 2013 - 14 20 cases
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Our Prospective Clinical Study
Primary 18, Revision 2
Posterior superior tears 14, Superior 6 tears
Single tunnel 11Pts. Simple Suture
Two tunnel 9Pts. Mattress Suture
10 Cases evaluated. 6 - 12 months follow up
Functional evaluation (VAS, ASES)One pt. Had ASES < 70
MRI Evaluation – Sugaya criteria for cuff healing5 pts. Type I Three pts , Type II Two pts
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MRI evaluation using Sugaya
Criteria for Cuff Healing Arthroscopy 2005
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity
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Case 1 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity
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Case 2 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity
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Case 3 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity
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Posterosuperior rotator cuff tear amenableto GT footprint repair without tension (L , Crescent, reverse L)
• No subscapularis tendon involvement
• Grade I, II, III (Goutallier) FI
• One single surgeon
• Prospective Randomized allocation
• MRI evaluation at 1 year postop from 3 independent radiologists using SugayaCriteria for cuff healing
Prospective Randomized Study - Sumant
INCLUSION CRITERIA
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TECHNIQUE AT SUTURE ANCHORS
N cases 28 24
Retear (NH) 4 (14%) 4 (16%)
Grade I 10 (38%) 6 (26%)
Grade II 13 (48%) 8 (34%)
Grade III (PT) 1 (3%) 6 (26%)
OVERALL 86% 84%
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Type I healing Type III healing
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity
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Arthroscopic Transosseous Repair Integrity
Various Centers
LOCATION STRUCTURAL INTEGRITY# OF CASES TO DATE
Krishnan ASES 2010 82% (49/60) MRI 1350
Mozes ISRAEL 2011 96% (48/50) U/S 98
Brassart FRANCE 2011 86% (33/38) U/S 241
Mikek SECEC 2011 95% (56/59) U/S 175
OVERALL 86% (214/239) >2000
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Study Overall Integrity TypeSugaya JBJS 2007 83% ( 71 / 86 ) DR SA
DeBeer JBJS 2007 83% ( 174 / 210 ) DR SA
LaFosse JBJS 2007 89% (93 / 105 ) DR SA
ElAttrache AJSM 2008 88% (22 /25) TOE/Suture bridge
Gartsman ASES 2010 94% (44 / 47) TOE/Suture bridge
Volgt AJSM 2010 71% ( 32 / 45) TOE/Suture bridge
Boileau Nice 2010 72% (28 / 39) TOE/Suture bridge
Sethi JSES 2010 83% (33 / 40) TOE/Suture bridge
Toussaint AJSM 2011 86% (132 / 154) TOE/Suture bridge
Rhee AJSM 2011 67% (58 / 87) TOE/Suture bridge
Kim JBJS 2012 85% (62 / 73) TOE/Suture bridge
OVERALL 82% (749 / 911)
Double Row & TOE Repair Integrity
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Requirement Transosseous
RCR
Suture Anchor
RCR
Contact Area X X
Initial Strength X X
Contact Stability X X
Gap Formation X X
Mechanical Stability X X
Biology X
No Implants in Bone X
Ideal Rotator Cuff Repair
Transosseous repairs10,000+ cases worldwide
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Bone Tunnel Placement
Bone Quality
Overtensioning
Of repair
Number of Tunnels
Arthroscopic Transosseous RCRWHAT ARE THE CONCERNS AND RISK?
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Arthroscopic Transosseous RCRREVISITING HISTORY
Tunnel Augmentation
Warner JP, Piza P
Warren Alpert Medical School 2012
Bone “Tunnel Protection”
Courtesy: Warner JP
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Arthroscopic Transosseous RCRASSESS THE TEAR AND AVOID OVERTENSIONING
Shorter tendon = increased tension if pulled to normal length
Some cuffs cannot be pulled all the
way out to cover the old footprint
Myotendinous Junction Retears
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Tight Cuff Tears
• Covers the footprint as much as possible and
remaining with suture
• Auto adjusts the tension – Spiral Binding
• Less over tensioning when compared to DR/ TOE
Arthroscopic Transosseous RCR
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ComparisonARTHROTUNNELER Vs ANCHORS
Implant ARTHROTUNNELER
No Implant
ANCHORS
Implant Present
Small Tears
Single tunnel
Expensive Cheap
Large Tears
Two or three tunnel
Cheap Expensive
Technique Simple suture - Easy SR - Easy
Mattress suture - Demanding DR - Demanding
TOE - Easy
Biology Bone marrow from tunnel - More Less in vented anchors
Re tear Easy Re -operation Difficult
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● Equivalent to Current Methods
● Repair Integrity
● Biomechanical Strength
● Reliable/Reproducible Technique
● Multiple Sutures
● Bone Tunnel Augmentation
● Assess the lesion
● Anatomic repair and avoid over tensioning
● More easy reoperation in case of Re-tear
● Biology
● Marrow elements from bone tunnels
Arthroscopic Transosseous RCRCONCLUSIONS
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ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad
Dr. Raghuveer Reddy. K
IAS 2014
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06 Hrs
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Recent Advances
Rotator Cuff Repair
ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad
Dr. Raghuveer Reddy. K
OASIS 2014
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TOE ConcernsMyotendinous Junction Retears
Lill, et al. Arthroscopic Supraspinatus Tendon Repair with
Suture Bridging Technique: Functional Outcome
and MRI. - AJSM 2010
Retear rate by MRI at 12 mos: 28.9%
Cho, et al. Retear Patterns After Arthroscopic Cuff Repair:
Single Row vs. Suture Bridge Technique. - AJSM
2010
27 cases of failed suture bridge technique74% failure at myotendinous junction
Gerhardt et
al.
Arthroscopic Single-Row Modified Mason-Allen
Repair vs. Double-Row SutureBridge
Reconstruction for Supraspinatus Tendon Tears -
AJSM Dec. 2012
20 patients/5 retears80% retears at myotendinous junction
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TOE Concerns
Myotendinous Junction Retears
Hayashida et al. Characteristic re-tear pattern after arthroscopic double-row
repair. Arthroscopy, 2012
15% retear rate at myotendinous junction
Conclusion:
“A new repair method, which achieves a wide
footprint, a good initial fixation strength, and
avoids re-tearing around the proximal suture
anchors should be developed to obtain better
cuff integrity and clinical results.”