Massive rotator cuff tears present unique challenges for repair. The document discusses techniques for arthroscopic repair based on tear pattern, including releases to improve mobility. For crescent tears, a double row fixation is recommended. L-shaped and U-shaped tears are repaired with side-to-side sutures converging the margin. Massive contracted immobile tears may require interval slides. Outcomes are generally good, though strength deficits can remain. Proper patient selection considering fatty degeneration and mobility is important for success.
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Massive rot cuf
1. M. AntonogiannakisM. Antonogiannakis
DirectorDirector
Center for Shoulder arthroscopyCenter for Shoulder arthroscopy
IASO Gen. HospitalIASO Gen. Hospital
Athens GreeceAthens Greece
Arthroscopic repair ofArthroscopic repair of
massive rot cuff tearsmassive rot cuff tears
2. Rotator cuff disease is a spectrum
of clinical conditions, which range from
asymptomatic partial thickness tears to
symptomatic rotator cuff arthropathy
3. Massive Rot Cuff TearsMassive Rot Cuff Tears
Definition:Definition:
Involving 2 or more Tendon TearsInvolving 2 or more Tendon Tears (Gerber)(Gerber)
>5cm Tear>5cm Tear (Cofield)(Cofield)
4. The problemThe problem
Poor tendon qualityPoor tendon quality
Muscle tendon retractionMuscle tendon retraction
Muscular atrophy fatty infiltrationMuscular atrophy fatty infiltration
The three central issuesThe three central issues
Passive range of motionPassive range of motion
Tendon retractionTendon retraction
Muscle viabilityMuscle viability
Failure of healingFailure of healing
5. Techniques of releasesTechniques of releases
The techniques adapted from openThe techniques adapted from open
surgery as described by Codmann,surgery as described by Codmann,
Rockwood, NeerRockwood, Neer
Refined and modernized by Esch, Snyder,Refined and modernized by Esch, Snyder,
Gartsman, Burkhart and othersGartsman, Burkhart and others
6. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAIROF THE REPAIR
7. The solutionThe solution
Improve the mechanical strength of theImprove the mechanical strength of the
repairrepair
Enhance the biological responseEnhance the biological response
Abandon and replace-muscle transferAbandon and replace-muscle transfer
Rot cuff arthropathy-reverse or extendedRot cuff arthropathy-reverse or extended
head arthroplastyhead arthroplasty
8. Recognize the TearRecognize the Tear
PatternPattern
Tears must be repaired in theTears must be repaired in the
direction of greatest mobility ->direction of greatest mobility ->
minimal strainminimal strain
25. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Greater mobility from anterior toGreater mobility from anterior to
posterior than medial to lateralposterior than medial to lateral
26. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Side to side sutures from medial to lateralSide to side sutures from medial to lateral
Progressively converge the margin of theProgressively converge the margin of the
tear lateral to bone bedtear lateral to bone bed
Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by areduces strain at converge margin by a
factor of 6factor of 6
[[S. S .Burkhart]S. S .Burkhart]
27. Closing an L-shaped or U-shaped tear is much like closing a tent flap
Closure of an U-shaped tear involves first side-to-side closure
of the vertical limb of the tear, then tendon-to-bone closure of the
transverse limb
L or U -shaped tear
S. S .BurkhartS. S .Burkhart
28. Large U-shaped cuff tear
extending to glenoid
Margin convergence
The free margin of the cuff is
repaired to bone with suture
anchors
32. Massive Contracted ImmobileMassive Contracted Immobile
TearsTears
No mobility from medial to lateral or fromNo mobility from medial to lateral or from
anterior to posterioranterior to posterior
Subcategories:Subcategories:
Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears
Massive Contracted Crescent TearsMassive Contracted Crescent Tears
Represent 9.6% of massive tearsRepresent 9.6% of massive tears
[[S.Burkhart]S.Burkhart]
33. Massive Contractite TearsMassive Contractite Tears
Anterior Interval SlideAnterior Interval Slide
and/orand/or
Posterior Interval SlidePosterior Interval Slide
Single and double interval slideSingle and double interval slide
35. Single and double intervalSingle and double interval
slideslide
Anterior slide through release in theAnterior slide through release in the
rotator interval (supraspinatus–rotator interval (supraspinatus–
coracobrachialis)coracobrachialis)
Posterior slide through release of thePosterior slide through release of the
interval supraspinatus-infraspinatusinterval supraspinatus-infraspinatus
42. Massive TearsMassive Tears
associated withassociated with
Subscapularis TearsSubscapularis Tears
Subscapularis must be mobilized andSubscapularis must be mobilized and
repaired prior to the rest of the cuffrepaired prior to the rest of the cuff
Interval slide in continuityInterval slide in continuity
47. Massive TearsMassive Tears
May beMay be
Eassily repairableEassily repairable
Retracted very difficult to repair (anterior &Retracted very difficult to repair (anterior &
posterior Slides)posterior Slides)
Medially RepairedMedially Repaired
Impossible to repairImpossible to repair
Incomplete RepairIncomplete Repair
Graft JacketsGraft Jackets
Tendon trasfersTendon trasfers
Reverse, extended head arthroplastyReverse, extended head arthroplasty
48. Arthroscopic cuff repairArthroscopic cuff repair
Wolf, Snyder, Gartsman, Esch,
Burkhart, Tauro and others reported
84%-94% excellent and good results
49. Results for massive tearsResults for massive tears
95% Good to Excellent Results95% Good to Excellent Results
independent to tear sizeindependent to tear size [Burkhart, 2001][Burkhart, 2001]
With interval slideWith interval slide
Improve UCLA score (10->28.3)Improve UCLA score (10->28.3)
Improve Active ROM, StrengthImprove Active ROM, Strength
[Burkhart, 2004][Burkhart, 2004]
Graft Jacket RepairGraft Jacket Repair
Improve UCLA score (18->32Improve UCLA score (18->32))
[Snyder, 2008][Snyder, 2008]
50. ConclusionsConclusions
Acute Crescent TearAcute Crescent Tear
Standard Techniques for tendon to bone fisxationStandard Techniques for tendon to bone fisxation
U- or L- shaped TearsU- or L- shaped Tears
Side to side margin convergenceSide to side margin convergence
Partial mobile tearsPartial mobile tears
Anterior / Posterior SlideAnterior / Posterior Slide
Medialized RepairMedialized Repair
Irreparable TearsIrreparable Tears
Partial RepairPartial Repair
GraftsGrafts
Tendon trasfersTendon trasfers
51. What to do???What to do???
Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
DO NOTDO NOT improve with rot cuff repairimprove with rot cuff repair
[Goutallier][Goutallier]
Vs.Vs.
Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
improved significant at 86% of cases afterimproved significant at 86% of cases after
arthroscopic repairarthroscopic repair
[Burkhart][Burkhart]
52. In our experienceIn our experience
Patients withPatients with massivemassive rot cuff tearsrot cuff tears
benefitbenefit from surgeryfrom surgery
but they tend to recover slowlybut they tend to recover slowly
they succeed very good pain reliefthey succeed very good pain relief
but strength deficits remainbut strength deficits remain
53. In our experienceIn our experience
Patients with upward migration of thePatients with upward migration of the
femoral head in contact with the acromionfemoral head in contact with the acromion
do not benefit from arthroscopydo not benefit from arthroscopy
Patients with painless external rotation lagPatients with painless external rotation lag
and inability to keep the arm in externaland inability to keep the arm in external
rotation do not benefit from arthoscopyrotation do not benefit from arthoscopy
With raised experience more previousWith raised experience more previous
irreparable cuff tears can be repairedirreparable cuff tears can be repaired
69. Arthroscopic repairs do not heal faster
Knowledge of biomechanical principles is
mandatory in choosing repair type
Cuff repair is feasible but technically demanding
70. Indications of arthroscopic cuffIndications of arthroscopic cuff
repairrepair
Every repairable cuff tear can be repairedEvery repairable cuff tear can be repaired
arthroscopic or a cuff that can be repairedarthroscopic or a cuff that can be repaired
open can be repaired and arthroscopicopen can be repaired and arthroscopic
The decision to repair a cuff tear open orThe decision to repair a cuff tear open or
arhtroscopic depends in the expertise of thearhtroscopic depends in the expertise of the
surgeonsurgeon
In the long run there is no discernibleIn the long run there is no discernible
difference between mini-open anddifference between mini-open and
arthroscopic cuff repairsarthroscopic cuff repairs
71. Advantages of Arthroscopic Cuff Repair
• Atraumatic
• Deltoid sparing
• Tissue mobilization
• Cosmetic incisions
• Secure repair
• Address accompanying pathology
• No iatrogenic injury to healthy tissues
• Cost-effective on an outpatient basis
72. Disadvantages of Arthroscopic Cuff Repair
• Technically demanding
• Equipment dependent
• Steep learning curve
Know when to keep dealing
or when to pack the cards
in and go home
73. Bennett WF. Arthroscopic repair of massive rotator cuff tears: aBennett WF. Arthroscopic repair of massive rotator cuff tears: a
prospective cohort with 2- to 4-year follow-up.prospective cohort with 2- to 4-year follow-up. Arthroscopy.Arthroscopy.
20032003
Boileau P., Brassart N., Watkinson D.J., Carles M., HatzidakisBoileau P., Brassart N., Watkinson D.J., Carles M., Hatzidakis
A.M., Krishnan S.G. Arthroscopic repair of full-thickness tears ofA.M., Krishnan S.G. Arthroscopic repair of full-thickness tears of
the supraspinatus: does the tendon really heal? J Bone Jointthe supraspinatus: does the tendon really heal? J Bone Joint
Surg Am. 2005Surg Am. 2005
Buess E., Steuber K.U., Waibl B. Open versus arthroscopicBuess E., Steuber K.U., Waibl B. Open versus arthroscopic
rotator cuff repair: a comparative view of 96 cases.rotator cuff repair: a comparative view of 96 cases.
Arthroscopy. 2005Arthroscopy. 2005
Gartsman G.M., Khan M., Hammerman S.M. ArthroscopicGartsman G.M., Khan M., Hammerman S.M. Arthroscopic
repair of full-thickness tears of the rotator cuff.repair of full-thickness tears of the rotator cuff. J Bone JointJ Bone Joint
Surg. 1998 Surg. 1998
Rebuzzi E, Coletti N, Schiavetti S, Giusto F. ArthroscopicRebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic
rotator cuff repair in patients older than 60 years.rotator cuff repair in patients older than 60 years.
Arthroscopy. 2005Arthroscopy. 2005
Tauro JC. Arthroscopic rotator cuff repair: analysis of techniqueTauro JC. Arthroscopic rotator cuff repair: analysis of technique
and results at 2- and 3-year follow-up. Arthroscopy 1998and results at 2- and 3-year follow-up. Arthroscopy 1998
Warner JJ, Tetreault P, Lehtinen J, Zurakowski D. ArthroscopicWarner JJ, Tetreault P, Lehtinen J, Zurakowski D. Arthroscopic
versus mini-open rotator cuff repair: a cohort comparisonversus mini-open rotator cuff repair: a cohort comparison
Results of atrhroscopic rc repair
74. When to ReleaseWhen to Release
andand
When NOT to ReleaseWhen NOT to Release
According to Tear Pattern andAccording to Tear Pattern and
MobilityMobility
Test mobility with grasperTest mobility with grasper
75. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Medial Row
Lateral Row
Contact area
89. Double Row RotatorCuff Repair
SutureBridge technique
Bio-Corkscrew FT & PushLock
2 X 5.5 mm. Bio-Corkscrew FT Medial row
2 X 3.5 mm. PushLock Lateral Row
90. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Check mobility of the tear Punch, creating Pilot hole
91. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Placement of 2 X Bio-Corkscrews FT Scorpion suture passing
92. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
2 medial anchors tied, ….
Do NOT cut the sutures
Load separate sutures through
PushLock
93. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Tensioning the sutures, will reduce
the tendon into position
Impaction of PushLock, until
Laser-line is “flush” with cortex
94. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Disengage driver from anchor
6 counterclockwise rotations, cut
suture
Placement second PushLock
….. Done !
100. Access the mobility of the tear using a KingFisher
suture Retriever / Tissue Grasper
Place both 5.5 mm. Diameter Bio-Corkscrew FT
suture anchors ( These Bio-Corkscrews come
Preloaded with FiberChain, AR-1927BFC )
AR-1927BFC
101. Retrieve the sutrure leader from one of the
FiberChain strands through the lateral portal and
Load it on the Scorpion
Retrieve both FiberChain suture ends through the
Lateral portal and tension them, ….. Decide where to
Make the 2 sockets for the lateral row SwiveLock anchors
102. Introduce the SwiveLock through the percutanious
Superolateral portal and capture the third link from
the free marginnof the Rotator Cuff
Advance the driver in the bone socket and push
The FiberChain toward the bottom of the socket
103. Advance the screw by holding the thumb pad as
the inserter handle is turned clockwise
Repeat step 5 through 7 for the second SwiveLock
To obtain the final construct
104. Double row is simplifiedDouble row is simplified
butbut
it has to pass the test of timeit has to pass the test of time