cuff repair chris roberts
TRANSCRIPT
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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
QuickTime™ and a decompressor
are needed to see this picture.
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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
QuickTime™ and a decompressor
are needed to see this picture.
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NB!! Bursectomy (? SAD first)NB!! Bursectomy (? SAD first)
QuickTime™ and a decompressor
are needed to see this picture.
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Prepare footprint
QuickTime™ and a decompressor
are needed to see this picture.
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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
QuickTime™ and a decompressor
are needed to see this picture.
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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
QuickTime™ and a decompressor
are needed to see this picture.
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Lateral row
QuickTime™ and a decompressor
are needed to see this picture.
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Suture retrieval - retrograde
QuickTime™ and a decompressor
are needed to see this picture.
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Suture Passing - Suture Passing - retrograderetrograde
QuickTime™ and a decompressor
are needed to see this picture.
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Suture Passing - Suture Passing - antegradeantegrade
QuickTime™ and a decompressor
are needed to see this picture.
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Suture Passing - shuttlingSuture Passing - shuttling
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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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