cuff repair chris roberts

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Mr Chris RobertsMr Chris RobertsConsultant Orthopaedic Consultant Orthopaedic

SurgeonSurgeonIpswich HospitalIpswich Hospital

22ndnd Indian Watanabe Indian Watanabe meeting, Chennaimeeting, Chennai

Rotator cuff repair

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Cuff repairsCuff repairs

Which cuff tears Which cuff tears need surgery and need surgery and when?when?

Does patient age Does patient age matter?matter?

Which tears will Which tears will progress?progress?

Pick winners.Pick winners. How to repair a How to repair a

tear.tear.

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Age does matterAge does matter

Average age patients who heal 55Average age patients who heal 55 Average age patients who do not heal Average age patients who do not heal

6565 Only 43% supraspinatus tears healed Only 43% supraspinatus tears healed

in patients older than 65 c/w 85% in patients older than 65 c/w 85% under 65(Boileau)under 65(Boileau)

65 is correct cut off for aggressive vs 65 is correct cut off for aggressive vs conservative management cuff tears conservative management cuff tears (Yamaguchi ICSES 2010)(Yamaguchi ICSES 2010)

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Which tears progressWhich tears progress

MamanMaman More than 1 tendonMore than 1 tendon Tear location - ant SSTTear location - ant SST Duration of symptomsDuration of symptoms

MoosmayerMoosmayer >3cm>3cm

YamaguchiYamaguchi Full > partial thicknessFull > partial thickness 21% asymp symp over 2 years21% asymp symp over 2 years

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Factors affecting healingFactors affecting healing

Tear size and retractionTear size and retraction Patient agePatient age Fatty infiltration (Goutallier grade)Fatty infiltration (Goutallier grade) Tangent sign (Thomazeau)Tangent sign (Thomazeau) SmokingSmoking MarcaineMarcaine Failure to load (Botox)Failure to load (Botox)

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Tears under 65Tears under 65

Advise surgeryAdvise surgery New or sudden pain (= ? tear New or sudden pain (= ? tear

progression)progression) >1.5cm>1.5cm Anterior column supraspinatus involvedAnterior column supraspinatus involved

Else patient choiceElse patient choice Conservative vs operativeConservative vs operative Injection reasonable but not >4 Injection reasonable but not >4

(Burkhead)(Burkhead)

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Tears over 65Tears over 65

Conservative initiallyConservative initially PhysiotherapyPhysiotherapy Activity modificationActivity modification AnalgesiaAnalgesia InjectionsInjections

Surgery if still symptomatic at 6 Surgery if still symptomatic at 6 monthsmonths

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Spectrum of pathology

Impingement Partial thickness tears Full thickness tears Biceps lesions ACJ degeneration Cuff tear arthropathy

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Variables in cuff repair

Biological: Extent and shape of tear Degree of retraction Quality of tendon Quality of muscle Quality of bone Mobility of tendon Healing of tendon to bone

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Steps in cuff repair

GHJ arthroscopy Bursectomy/soft tissue clearance Tear

inspection/type/reduction/mobilisation Cuff and bed preparation Anchor placement Suture passage Knot tying Acromioplasty?

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Work to a system

Most tears can be repaired using a standardised system so familiarise yourself with one

Techniques needed: Knot tying

Sliding and non-sliding Suture passage

Antegrade and retrograde Repair type

Footprint: single or double row Side to side

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Set-up Beach chair/lateral

decubitus Traction Hypotensive anaesthesia Shavers/burrs/

radiofrequency device Fluid management

system Arthroscopic

instruments Anchors/sutures Cannulae

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PortalsPortals

AP

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GH Joint: Assessment of tear GH Joint: Assessment of tear mobilitymobility

Medial-lateral reductionMedial-lateral reduction

QuickTime™ and a decompressor

are needed to see this picture.

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Bursal View: Assessment of Bursal View: Assessment of tear mobilitytear mobility

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Crescent-shaped Tears

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U-shaped Tears

Firstly close side to side Then medial to lateral

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Margin Convergence

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L-Shaped Tears: (L-Shaped or Reverse-L)

Reducing The Cuff Tear:- Reducing The Cuff Tear:- L-Shaped Tears L-Shaped Tears

Greater TuberosityGreater Tuberosity Greater TuberosityGreater Tuberosity

S/SpinatusS/Spinatus

Reverse-L Tear

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L – Shaped Tears

Side-to-side

Fix tobone

L-shape

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Assessment of tear pattern

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are needed to see this picture.

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NB!! Bursectomy (? SAD first)NB!! Bursectomy (? SAD first)

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are needed to see this picture.

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Prepare footprint

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Anchor InsertionAnchor Insertion Anchor fixation to bone

(Mahar,Arthroscopy 2006, 22) ‘Dead man’s angle of anchor insertion

(Burkhart, Arthroscopy, 95, 11)

< 40 < 40 DegDeg

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Anchor Insertion:Anchor Insertion: ‘Dead man Angle’ ‘Dead man Angle’ (Burkhart, (Burkhart,

1995) 1995)

< 40 Deg< 40 Deg

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Medial anchor insertion

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Lateral row

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Suture retrieval - retrograde

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are needed to see this picture.

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Suture Passing - Suture Passing - retrograderetrograde

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are needed to see this picture.

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Suture Passing - Suture Passing - antegradeantegrade

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are needed to see this picture.

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Suture Passing - shuttlingSuture Passing - shuttling

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are needed to see this picture.

QuickTime™ and a decompressor

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Current Preferred Technique: Current Preferred Technique: ‘Suture-Bridge’ ‘Suture-Bridge’ ((Footprint Anchor for Lateral Row)Footprint Anchor for Lateral Row)•Medial anchor: pass sutures through cuff medially and tie knots (increases tissue cut-out resistance) Suture limbs inserted into 1 or 2 lateral footprint anchors

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Footprint AnchorFootprint Anchor•Standard medial row anchor(s) and deep mattress sutures•Don’t cut the sutures after tying knots!!

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ConclusionConclusion

Keys to success: Pick a winner Good anaesthesia Tension-free reduction Thorough bursectomy for

visualisation Work to a system Variety of equipment invaluable

My choice is Suture-bridge Suture-bridge technique: technique: some evidence of improved biomechanical strength