Arthroscopic Rotator Cuff Repair: Mastering the Essentials

Transcription

1 Arthroscopic Rotator Cuff Repair: Mastering the Essentials Dr. Robert Hunter Director, Orthopedic Sports Medicine Center Heart of the Rockies Regional Medical Center Salida, Colorado U of Colorado Sports Medicine Symposium September 30, 2016

2 Conflict of Interest Paid Consultant: Smith & Nephew Biomet Royalties Zimmer/Biomet Institutional Support: Smith & Nephew Biomet DJO BOD: AANA Executive Committee: AANA 1 st VP Member: Arthroscopy Journal Board of Trustees

3 1.What Are the Essentials? 2.How Are They Mastered?

4 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Patience

5 RCT

6 Questions: What Is the First Thing You Do When You Enter the SAS? How Do You Decide What to Clean or Release? What Do You Release? How and When Do You Decide to Do an Acromioplasty?

7 Bursectomy

8 You Can t Fix What You Can t See

9 Questions: How and Where Do You Position the Arthroscope to Get the Best View of the Subacromial Space and the Rotator Cuff?

10 Posterior vs. Posterolateral Portal

11 Understand The Cuff Tear: What s Mobile What s Rigid What Goes Where

12 Questions: How Do You Safely Access the Medial Tuberosity? How Do You Decide to Do A DR vs. SR RCR? How Do You Decide How Many Medial Anchors to Use? How Do You Position Them?

13 Abduction Vs Adduction For Medial Row Anchors

14 Questions: How Do You Decide to Do A DR vs. SR RCR? How Do You Safely Access the Medial Tuberosity? How Do You Decide How Many Medial Anchors to Use? How Do You Position Them?

15 SR vs DR Meta-analysis Level I, II and III Tears < 3cm No Functional Differences No Structural Differences Tears > 3cm DR had Better ASES and UCLA Scores DR had Lower Retear Rate Chen et al 13

16 Clinical and Structural Outcomes: SR vs DR Met-analysis of Level 1Studies 7 Studies No Diff: ASES UCLA Constant Scores Retear Rate SR 25.9% Retear Rate DR 14.2% Increased Risk of Retear for SR (Primarily Partial Thickness) Millett et al 14

17 DRRCR Never Sacrifice A Tension- Free Single Row Repair to Achieve A Stronger Double Row Repair With Added Tension.

18 Rotator Cuff Size Small Medium Large Massive No Real Need DRRCR Likely Of Value Not Enough Tissue

19 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Patience

20 Core Shoulder Arthroscopy Skills Ability to Perform a Diagnostic Intraarticular and Subacromial Exam Ability to perform SAD and Distal Clavicle Resection Ability to Probe and Evaluate a RCT

21 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Patience

22 Knot Tying Learn A Couple/Forget the Rest I Use Two Knots Double Half-Hitch (Non-Sliding) Tennessee Slider (Sliding)

23 Tennessee Slider- Rope

24 Knot Tying Knotless Strategies Can Solve Some Problems But Not All. You Must Know How to Tie a Good Knot.

25 Knot Tying Test Your Knot FAST Knot Tester Will Give You Feedback on How Well and Consistently You Tie Knots. Experts Have Failed

26 AANA FAST Program (Fundamentals of Arthroscopic Surgery Training)

27 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Patience

28 Suture Positioning Store Them Where They Won t Interfere With Passage. Store Them Where You Won t Work Or Look Stay Out of Your Own Way Insert Sutures From Far to Near Tie From Near to Far Don t Work Over Sutures

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30 Suture Passage Punch & Shuttle Pierce & Grab Pass an Instrument Through the Cuff, Grab a Suture and Pull the Suture Back Through the Cuff Pierce & Carry Pass an Instrument/Needle With A Suture Attached Through the Cuff and Retrieve the Suture on the Other Side Pierce & Shuttle Pass an Instrument With a Monofilament or Shuttle Devise Through the Cuff, Attach a Permanent Suture to it and Pull the Monofilament/Shuttle Back Through the Cuff With the Permanent Suture Attached

31 Suture Passage It Is OK to Have a Favorite Way to Pass Sutures But You Need to Know How to Use All Three Methods.

32 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Patience

33 What Are the Essentials? 1. Core Shoulder Arthroscopy Skills 2. Knot Tying Skills 3. Knot Pusher (Puller) Skills 4. Anchor Insertion/Orientation Skills 5. Suture Management Skills 6. A Desire To Convert From Open to An Arthroscopic Technique 7. Plan Patience

34 Lateral Rotator Cuff Repair Acromioplasty, A/C Jt. Room Set Up Anterior Portal Posterior Portal Insertion of Cannulas Intra-Articular Accessory Exam Lateral Portal Accessory Lateral Portal Subacromial Exam Insert Anchor/s Lateral Portal Store Sutures Accessory Lateral Portal Bursectomy (Acromioplasty, A/C Jt) Probe/Evaluation of the Cuff Tear Debridement Store Suturesof the GT Pass Sutures Through the Cuff Tie Knots Start Pass With Sutures a Less Through Demanding the Cuff Case Fall Back to Mini-Open Store Sutures

35 Never Be Afraid to Open Mini-Open Maxi-Arthroscopic

36 Never Be Afraid to Open Mini-Open Maxi-Arthroscopic!!

37 Make Mini-Open Maxi-Arthroscopic Extend the Lateral Portal View Through the Lateral Incision Work Through the Anterior and Posterior Cannulas Continue to Use Arthroscopic Equipment Tie Knots With Arthroscopic Technique and With the Knot Pusher

38 /26/1941 F MRI-UP EXT JW/O-RIGHT COR T2 frfse S FATSAT 5/20/ :15: LOC: THK: 4 SP: 4.4 HFS R L SHLDRPA4 EC: 1 SE FA: 90 TR: TE: Z: 2.17 C: 279 W: 736

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40 Thank You