The Current State of Rotator Cuff Repairs LLC, OBERD,...
Transcript of The Current State of Rotator Cuff Repairs LLC, OBERD,...
2/7/2018
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The Current State of Rotator Cuff Repairs
Gerald R. Williams, Jr, MD
John M. Fenlin, Jr, MD Professor of Shoulder and Elbow Surgery
Conflict of Interest Slide
•Royalties• Depuy: shoulder arthroplasty
• DJO: shoulder arthroplasty
• Walters Kluwer: shoulder texts
• IMDS/Cleveland Clinic: arthroplasty
•Research: Tornier, Depuy, Synthasome
•Stock Ownership: In‐vivo therapeutics, CrossCurrent Business Analytics, LLC, OBERD, LLC, Force Therapeutics
1) Anatomy/Physiology/Pathogenesis
2) Rotator cuff repair‐ prognostic factors
3) Surgical techniques
4) Rehabilitation
5) Results
6) Augmentation techniques
7) Irreparable cuff tearA. Partial repairB. Superior capsular reconstructionC. Transfers– lower trapezius, latissimus dorsi
Agenda Anatomy
• Rotator cuff
• Supraspinatus outlet• Anterior acromion
• CA ligament
• AC joint
Anatomy
Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90:962‐9.
Kato A, Nimura A, Yamaguchi K, Mochizuki T, SugayaH, Akita K. An anatomical study of the transverse part of the infraspinatus muscle that is closely related with the supraspinatus muscle. Surg RadiolAnat 2012;34:257‐65.
Physiology
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Rotator Cuff and CA Arch
Arm
Deltoid
Physiology PathogenesisRotator Cuff Tears
Age
Impingement Trauma
Most cuff tears are the result of a combination of 3 factors
Pathogenesis‐‐ Age
Sher, et.al., JBJS 77A, 1995
Increasing cuff tears
Pathogenesis‐‐Impingement
Critical Shoulder Angle
Gerber C, et al. OrthopTraumatol Surg Res 2014;100:489‐94.
Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. [Relationship of acromial architecture and diseases of the rotator cuff]. Orthopade1991;20:302‐9.
Cuff Repair– Prognostic Factors
• Patient age (> 70)
• Cuff tear size
• Chronicity
• Tendon quality
• Smoking
• Patient compliance/rehabilitation protocol
• Lag signs/proximal migration
• Workers compensation/litigation
Prognostic Factors– Size, Chronicity
• Poor prognosic factor (Fenlin, Goutallier, Gerber, others)
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Prognostic Factors‐‐ Chronicity
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Time from Injury (weeks)
Rep
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Gimbel, J. A., S. Mehta, Williams, G, et al. (2004).
Surgical Techniques
• Open vs. Arthroscopic
• Single vs. double row
• Mobilization techniques (repair tension management)
• Anchorless repairs
Cuff Repair Principles
(Neer 1972)
• Open superior approach
• Subperiosteal anterior deltoid take‐down
• Coracoacromial ligament excision
• Anterior acromioplasty
• Cuff mobilization
• Cuff repair to bone through tunnels
• Early (immediate) passive motion
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Open vs. Arthroscopic Repair
• Less deltoid morbidity
• Less post‐operative pain
• Less subacromial scarring
• Better cuff mobilization/visualization
• Better patient acceptance
• Simple sutures
• Anchors vs. tunnels
• Cuff repair footprint• Surface area available for healing
• Double row may help
• Technically demanding‐‐may be volume dependent
Pot. Arthro. Adv. Pot. Arthro. Disadv.
Repair Techniques
Systematic ReviewSuture Bridge or Double row
(1 cm)
Transosseous or single anchor (1 cm)
Suture Bridge or Double row (5 cm)
Transosseous or single anchor
(5 cm)
Re-tear rate
7% 17% 41% 69%
•1252 repairs, 23 studies•No difference between arthroscopic, open, or mini‐open techniques
Duquin, T. R.; Buyea, C.; and Bisson, L. J.:. Am J Sports Med, 38(4): 835-41, 2010.
Arthroscopic Repair Techniques– Single vs. Double Row
Suture Bridge
Double Row
Single Row
Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees
George J. Trappey, MD and Gary M. Gartsman, MD
Journal of Shoulder and Elbow SurgeryVolume 20, Issue 2, Pages S14‐S19(March 2011)DOI: 10.1016/j.jse.2010.12.001
Single vs. Double Row
Systematic Review
George J. Trappey, MD and Gary M. Gartsman, MD, Journal of Shoulder and Elbow Surgery, Volume 20, Issue 2, Pages S14‐S19 (March 2011)DOI: 10.1016/j.jse.2010.12.001
Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees
Mobilization Techniques– Repair tension management
Burkhart, S. S., et al Arthroscopy, 12(3): 335-8, 1996.
Margin Convergence
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Traditional MobilizationArthroscopic Interval Slides
Lo, I. K., and Burkhart, S. S.: Arthroscopy, 20(1): 22-33, 2004. Tauro, J. C.: Arthroscopy, 15(5): 527-30, 1999.
Large U‐shaped Tear
Anchorless Repair Rehabilitation
• Neer (1972)– immediate, full, passive range of motion
• Reported high failure rates have lead to delayed rehab
• Must be individualized• Pre‐op stiffness
• Concommittent pathology
• Tear size and chronicity
Rehabilitation
Cross Sectional Area
Thomopoulos, S., G. R. Williams, et al. JOR (2003).
Organization
Material Properties
Structural Properties
Immobilization vs. Activity (rat model)
Rehabilitation
Immobilization vs. Loss of motion
• Injury and repair caused loss of motion
• Addition of immobilization transiently increased loss of motion
Sarver, J. J., C. D. Peltz, Williams G, et al. JSES(2008).
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Rehabilitation
Passive Motion may be detrimental
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CA IM PM
RO
M (
% o
f p
re-
inju
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CA IM PM
RO
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CA IM PM
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ROM 2 weeks
*=sig from CA, †=sig from IM
• CA = cage activity
•IM = immobilization
•PM = passive motion
Sarver, J. J., C. D. Peltz, Williams G, et al. JSES(2008).
FE and ER at 1 year F/U
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Post-op FE Post-op ER
StiffNon Stiff
6 week ROM
Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. J Shoulder Elbow Surg2010;19:1034‐9.
Repair Integrity at 1 yr (MRI)
6 wk ROM Intact Cuff Retear
Stiff 7 3 70% intact
Good 12 21 36% intact
p=0.10
Overall 44% rate of intact repair at 1 year
Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. J Shoulder Elbow Surg
2010;19:1034‐9.
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Cuff Repair ResultsRepair Integrity
• 105 shoulders, avg 5 year f/u
• Supraspinatus‐‐ 20% recurrence
• Two tendons‐‐ 45% recurrence
• Three tendons‐‐ 65% recurrence
• Most patients satisfied‐‐ even with recurrent defect
• Function and satisfaction correlated with integrity
Harryman, et.al., JBJS 73A, 1991 Successful outcome in 54%
Labor‐intensive occupation
Mean ASES Score: 91 vs 69
Younger age, Work Comp, Lower Education
Distribution RCR + dermal patch
• Reinforced fascia lata patch
• greater ultimate load at Time 0 than nonaugmented repairs
• 2‐tendon tears
• 44 patients
• Mean 2 –year followup(minimum 1‐year)
• 85% healed with augmentation, 40% healed without augmentation
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Irreparable Tears
• Treatment options depend on level of function and presence or absence of arthritic change
• Choices• Partial repair
• Superior capsular reconstruction
• Transfers
• Reverse arthroplasty
Deciding on Treatment
Pain
Active Motion Loss
Weakness
Tendon TransferBiceps Tenotomy, Tuberoplasty
ReverseArthroplasty
• Age• Activity level• Work demands• Expectations
Superior Capsule Reconstruction
Partial Repair
Nonoperative
Superior Capsule Reconstruction
$
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Tendon TransfersSpecific Indications
Pectoralis Major Transfer
Latissimus or lower trapezius Transfer
Reverse
Rotator Cuff Repair
Conclusions• Rotator cuff tears multifactorial
• Age (senescence)
• Trauma
• Impingement?
• Cuff repair techniques should aim to improve healing rates
• Biologics will probably have a role
• Early repair of retracted tears desirable– especially in young patients
• Slow early rehab
• Management of irreparable tears difficult, especially in young patients
Thank You