Rotator Cuff Repair, Arthroscopy, Techniques, Shoulder, Sports Injury
•Als PPTX, PDF herunterladen•
2 gefällt mir•153 views
- Rotator cuff tears can be caused by extrinsic factors like repetitive use or impingement, or intrinsic factors like changes in tendon vascularity or degenerative changes. - Physical examination involves inspection, palpation, range of motion testing and muscle strength testing. Investigations include ultrasound and MRI. - Symptomatic rotator cuff tears tend to increase in size over time if left untreated, though some may remain stable or decrease. - Surgery is generally indicated for failed conservative care, weakness, or acute tears in younger patients. - Arthroscopic repair has benefits over open repair like less pain and faster recovery, though open provides direct visualization and long-term studies.
Empfohlen
Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Ähnlich wie Rotator Cuff Repair, Arthroscopy, Techniques, Shoulder, Sports Injury
Ähnlich wie Rotator Cuff Repair, Arthroscopy, Techniques, Shoulder, Sports Injury (20)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Rotator Cuff Repair, Arthroscopy, Techniques, Shoulder, Sports Injury
- 1. Prof. Bijayendra Singh Consultant Trauma & Orthopaedic Surgeon Medway NHS Foundation Trust Visiting Professor, Canterbury Christ Church University Cuff Repair
- 2. What is Rotator cuff ?
- 3. Extrinsic Factors • Repetitive use • Glenohumeral instability • Internal impingement • Impingement • Acromial spurs • Coracoacromial ligament • AC joint osteophytes • Coracoid process • Posterior superior glenoid Acute Trauma
- 4. Intrinsic Factors • Vascular supply (? significance) • Distal 1cm of supraspinatus tendon (early studies) • Hypervascularity with tendonitis • Codman (1934) described critical zone • Rathburn (1970) position related to blood supply • Lohr (1990) bursal side better blood supply : Increased incidence of articular surface tears? • Degenerative changes • Age related • Change in proteoglycan and collagen content in symptomatic tendons
- 5. Physical Examination • Inspection: Atrophy, symmetry • Palpation: AC joint, cuff tenderness • Range of motion: Active, passive • Muscle strength • Special tests
- 7. • Ultrasound: • High Accuracy for Full Thickness Tear • Poor info on other pathologies • Static images for dynamic investigation • Operator Dependent • MRI: • Gold Standard • Easier to explain to patient • Other Shoulder Pathologies • Muscle Atrophy • Expensive/Cumbersome • May find pathologies of no clinical relevnace..
- 8. Natural History • Asymptomatic: 5 - 40% • Increases with age
- 9. • Sher et al, J Bone Joint Surg Am. 1995 Jan;77(1):10-5: Abnormal MRI Findings in asymptomatic shoulders • 96 asymptomatic shoulders MRI • 14 FT & 19 PT • > 60: 28% FT, 26% PT (54%) • 40 - 60: 4% FT, 24% PT (28%) • < 40: no FT, 4% PT
- 10. Pain and/or fatigue of cuff Rotator Cuff dysfunction Impingement with motion
- 11. Indications for Surgery • Failed conservative management • Significant or progressive weakness • Young, active • Acute tear • Early repair if age<50 years and full-thickness tear
- 12. • Do we need to repair Open vs Arthroscopic
- 13. Do we need to Repair Cuffs?
- 14. Natural History of Non operatively Treated Symptomatic Rotator Cuff Tears in <60 yrs. (5mm or more) Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714 • F/U: 25 - 39 months • Ultrasonography by same sonographer • 51/61 evaluated –30 (49%) tears increased in size –26 (41%) no change –5 (8%) reduced –10(25%) found to have new tears • No correlation between change in tear size, –patient age –prior trauma –size of tear at index • Co-relation between considerable pain & increase in tear size
- 16. Open Repair • Advantages: • Easy • No special equipment required • Direct visualization of cuff repair and acromioplasty • Good long term follow-up. Several studies with >10 year follow-up show generally stable results with time • UKCUFF Trial
- 17. Disadvantages • Deltoid detachment required • Increased perioperative morbidity • Unrepairable tear will be opened • Significant intraarticular pathology can be missed • Increased blood loss • Increased rehabilitation time • Large scar
- 18. Arthroscopic Cuff Repair • Deltoid preservation • Diagnosis and treatment of any concomitant shoulder pathology • Decreased postoperative pain • Decreased blood loss • Small surgical scar • Shorter hospital stay • Earlier rehabilitation • Decreased postoperative stiffness
- 19. Disadvantages • Special Instruments • Cannula • Suture Passer • Suture manipulator • Appropriate Anchors • Suture Cutter • Suture Management Learning Curve
- 21. Principles of Repair • Neer JBJS-A 1972 • Adequate subacromial decompression • Repair tendon to bone • Secure fixation of tendon to tuberosity • Mobilization of muscle-tendon units • Closely supervised rehabilitation
- 22. Single Row vs Double Row
- 26. Biomechanics • Single Row - 220 N • Double Row - 320 N • Suture Bridge - 20 - 50% higher • Almost all biomechanical studies show lower re-tear rates for double row / Suture Bridge
- 27. Clinical Outcomes • Franceschi et al: • 30 in each group, UCLA 32.9 vs 33.3 post op • MRI retear = 12/16 single, 8/26 • Burks et al: • 20 in each group, No difference in UCLA, ASES, Constant • Retear 2 in each on MRI • Grasso et al • 40 in each group • No significant difference in DASH, Constant & Muscle Strength • No post op imaging Level 1 studies
- 28. Rehabilitation • Four Phases • Inflammatory: 7 days • Proliferative: 2 - 3weeks • Healing Phase: 3 - 12 weeks • Maturation: 12 - 26 weeks
- 32. Ross et al: Rehabilitaiton Following Arthroscopic Rotator Cuff Repair - Review of Current Literature. JAAOS, 2014, 22(1), 1 - 9 • ROM: • Some studies have shown better elevation in early stages • Preop ROM important factor • NO difference at one year • Pain: • No significant difference in early vs late mobilisation • Muscle Strength: • No difference, significantly lower than other side • Re Tear Rates: • 0 - 94% • Variable results on radiological re-tears • No functional difference
- 33. Enhancement • Biology of patient & tendon (can’t be altered) • Techniques: • Microfracture of healing bed • Use of vented anchors • Doxycycline (reduces effects of MMP) • PRP • Mesenchymal stem cells • No definite evidence at present
- 34. Conclusion • 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 • Small Tears = Single Row - Mattress Repair • Large > 3 cm = Double Row - Suture-bridge technique
- 35. Thank You
Hinweis der Redaktion
- Thank you for asking me to deliver the Dr. S.K.Lokhare Oration at the 33rd Annual Congress of MOA. Its indeed a great honour and privilege to be able to deliver this lecture. My heartfelt gratitude to the organising committee and the executive at MOA. A special thanks to Ajis & Shiva.
- Fine-tuning” muscles Keep the humeral head centered on the Generally work to depress the humeral head while powerful deltoid contracts
- Failed conservative management 3 to 12 month course of NSAIDs, physio, corticosteroid injections, activity modification Significant or progressive weakness, esp. acute Early repair if <50 y.o. and full-thickness tear Differential diagnosis confirms weakness is from rotator cuff tear (i.e. MRI findings correlate with exam, rule out other causes)