Case Presentations for Rotator Cuff: Indications ... · Case Presentations for Rotator Cuff:...
Transcript of Case Presentations for Rotator Cuff: Indications ... · Case Presentations for Rotator Cuff:...
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Case Presentations for Rotator Cuff: Indications, Techniques, Outcomes
William N. Levine, MD
Frank E. Stinchfield Professor and ChairmanNYP/Columbia University Irving Medical CenterDepartment of Orthopedic SurgeryNew York, NY
SKS MeetingFebruary 22, 2018 – Snowbird, UT
Disclosure
1. Basic Science Supporta. NIH
2. Consultant – Zimmer Design Team3. Royalties – None4. Editor in Chief – JAAOS5. 1st Vice President – ASES
SKS 2018 – Cuff Cases
The Experts
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Case 1
• 45 y.o RHD male with atraumatic R shoulder pain x 6 months
• No lag signs
• + impingement signs
• Normal xrays
• MRI? Ultrasound?
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Case 1 – What Would You Do?
1. PT/NSAIDs
2. PT/injection
3. Arthroscopic RCR
4. Mini-open/Open RCR
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Case 1 – Outcome
• Serial MRI/clinical exam
• 3 years: no tear progression
• How long do we need to follow?
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Case 2
• 47 y.o RHD male police officer
• 6’6”, 410 pounds
• 9 mo. pain – failed non-op Rx
• Pre-op MRI – small supra FTRCT
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Case 2 – Small RCT What Would You Do?
1. Single row
2. Double row
3. DR transosseous
4. Open
5. Mini-open
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Case 2 – Small RCT Questions
1. # of anchors
2. # of sutures
3. Transosseous equivalent
4. Vented anchors
5. Biologic augmentation
6. Age of patient
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Arthroscopic Single Row RCR
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Case 2 – Your Choice?
• Same
• Different
• Rationale?
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Case 2
• No PT x 4 weeks (worried about his girth)
• Gentle PT at 4 wks
• Comes in 3 months post-op telling me he has been “heavy lifting” to get in shape
• Has pain/weakness
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Case 2
• No PT x 4 weeks (worried about his girth)
• Gentle PT at 4 wks
• Comes in 3 months post-op telling me he has been “heavy lifting” to get in shape
• Has pain/weakness
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Case 2 – Massive Recurrent RCT
• Now what do you do?
• Revision RCR
– Augmentation?
– Double row
– Refer to junior partner?
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Case 2 – Revision RCR
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Case 2 – Biologic Augmentation
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Case 2
• 9 months post-op
• Doing well (so far…)
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Acellular Bovine Collagen Scaffold
• Animal studies
– Promising Arnoczky et al
• Humans Schlegel JSES ‘17
– PTRCT (33 pts)
8 healed
23 decreased in size
1 stable
1 progressed to full tear
Bokor ‘16
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Case 3
• 57 y.o RHD male
• Fell 4 months ago
• Pain, weakness
• Rx
– PT
– Cortisone x 1
– NSAIDs
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Case 3 – MRI
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Case 3 – MRI
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Case 3 – What Do You Do?
1. Arth single row repair
2. Arth double row repair
3. Open repair
4. With Biceps tenotomy
5. With biceps tenodesis
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Case 3 – Patient Positioning
Head
Torso
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Case 3 – EUA
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Case 3 – Portals
P
AASL
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Case 3 – Subscap Mobilization
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Case 3 – Lateral Anchor
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Case 4
• 20 y.o RHD male collegiate pitcher• Pain with pitching– Most pain in follow-through
• Loses velocity and control• Exam– + active compression– No apprehension, relocation, ant
release– No Biceps signs– Equivocal posterior stress
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Case 4
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Case 4 – What Do You Do?
• Shut him down + …??
– Injection
– NSAIDs
– PRP
– Other?
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Case 4 – Now What?
• Shut him down x 3mo.
• Cortisone injection
• PRPx2
• NSAIDs
• Rest
• And no better…
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Case 4 – Scope
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Case 4 – Now What?
1. Debridement
2. Repair
3. Scaffold
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Case 4 – Now What?
1. Debridement
2. Repair
3. Scaffold
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Case 4 – Follow-up
• Sling x 2 weeks
• ROM, light strengthening early
• Throwing program
• Return to pitching at 4 months
• No pain
• Completed 2 seasons since surgery
Case 5
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• 55 y.o RHD male with LEFT shoulder RCR
Case 5
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• Tenotomy
• Tenodesis
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Case 5
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1. PITT
2. Suprapec
3. Low suprapec
4. Open subpec
Case 5
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1. PITT
2. Suprapec
3. Low suprapec
4. Open subpec
Case 5 - Questions
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• Consent?
– All patients
– Tenotomy vs tenodesis
• Does it really matter where you do the tenodesis?
• Percentage of cases you do tenotomy vs tenodesis?
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Case 6
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• 51 y.o RHD female
• Arth DR-SB 8/23/09
• 2cm crescent supra tear
• Doing “great”
• No trauma – presents with pain 2 yrspost-op
• FE 120°; ER 40°
Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Case 6
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Re-Tears
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• Type 2
– Medial to healed footprint
– More prevalent in classic double row suture bridge with medial knots
– “over tension” Kim ’14
Case 6 – What Would You Do?
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1. Arth revision RCR
2. Open revision RCR
3. Biologic augmentation
– Dermal allograft
– Acellular bovine
4. Non-op
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Case 6 – What Would You Do?
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1. Arth revision RCR
2. Open revision RCR
3. Biologic augmentation
– Dermal allograft
– Acellular bovine
4. Non-op
Case 7 – AC Joint
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• How do you decide?
• When do you do it?
• Technical pearls
Case 7 – AC Joint
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• How do you decide?
• When do you do it?
• Technical pearls
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Case 8
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• 58 y.o RHD female
• 1 yr RIGHT shoulder pain
• Treatment
– Cortisone x 3 (complete relief)
– PT
– Rest
– NSAIDs
– Activity modification
Case 8
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Case 8
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Case 8
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Case 8 – What Would You Do?
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1. Debridement alone
2. ASD
3. In situ repair
4. Conversion to Full tear
Thank You!