Defini&ons. PH Collin CHP Saint Grégoire Rennes France

Transcription

1 Defini&ons PH Collin CHP Saint Grégoire Rennes France

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4 SURVEY 16 surgeons among the faculty

5 Large 2 tendons( 4) 3 to 5 cms (3) More than one but less than 2 (3) Complete tear of SSN and SSC (2) Retrac&on to the glenoid (2) Less retrac&on massive tendon reducibility to the bone without tension (2)

6 The term massive tear has been widely used to iden&fy very large tears that are par&cularly difficult to repair and therefore are associated with an uncertain prognosis. Unfortunately, there is no universal agreement on the defini&on of a massive rotator cuff tear. In North America, Cofield s defini&on of a massive tear was a tear of greater than five cen&meters in diameter. Because of varia&ons in the sizes of pa&ents and the techniques of measurement, we believe that it is more appropriate to define the size of a tear in terms of the amount of tendon that has been detached from the tuberosi&es. In the current study, rotator cuff tears were defined as massive if they involved the detachment of at least two en&re tendons.

7 Massive 3 4

8 Massive 3 tendons (4) 2 tendons (4) One and a half complete tendons usually with retrac&on beyond the apex of the humeral head. ( 2) More than 5 cms (2) 3-5 cm, less than 2 en&re tendons (1) From ISN to SSC( SSC must be involved)(1) large mul&ple tendon tear that will give me an hard &me to completely repair(1) MRCT that cannot be repaired back to the footprint or that will almost certainly be associated with structural failure has to be considered as irreparable (1)

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11 TYPE 1

12 TYPE 2 TYPE 3

13 Lafosse

14 Irreparable tear Before surgery (11) Head migra&on (1) 3 tendons and FI>3 ( 4) Faay infiltra&on >2 Tendon length less than 15 mm Faay infiltra&on > 3 with retrac&on to the glenoid margin (2) minus er and one that in any posi&on if the arm is externally rotated then it drops back in to internal rota&on, especially in adduc&on ( with elbow at side) It is a tear which has a probability to structurally heal of less than 95%. During surgery: 4

15 Pseudo paraly&c Shoulder All passive ROM ( 7)and Less than 45 Less than 60 Less than 90 (5) Less than 90 and no ER Less than 90 ager 6 months of rehab Drop arm sign from 30degrees abduc&on Inability to raise the arm to the horizontal or if raised, it cannot be maintained against gravity above the horizontal Arm in 90 abduc&on/90 ER and pa&ent told to resist TM is involved

16 «If you want to discuss we need to agree on words» Voltaire

17 2 tendons or more Massive Necessity to localise Rela>onship between massive chronic rotator cuff tear pagern and loss of ac>ve shoulder range of mo>on. Collin P, Matsumura N, Lädermann A, Denard PJ, Walch G. J Shoulder Elbow Surg. 2014

18 Massive rotator cuff tears in patients younger than 65 years. Epidemiology and characteristics. Berhouet J, Collin P, Benkalfate T, Le Du C, Duparc F, Courage O, Favard L; Société d'orthopédie de l'ouest. Orthop Traumatol Surg Res. 2009

19 Group A/B/C/D D C B A NS

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21 Subscapularis minor an analogue of the Teres Minor? Collin P, Lädermann A, Le Bourg M, Walch G. Orthop Traumatol Surg Res. 2013

22 JSES 2014

23 Compartments of the rotator cuff we divided the rotator cuff as 5 compartments infraspinatus (ISP) supraspinatus (SSP) superior subscapularis (SSC sup.) teres minor (TM) inferior subscapularis (SSC MINOR)

24 Active forward elevation p<0.001 p<0.008 Range of motion SSP SSC sup. SSP SSC sup. SSC inf. SSP SSC sup. ISP SSP ISP SSP ISP TM

25 Pseudo- paralysis 80% of type B (SSP + entire SSC) 50% of type C (SSP + ISP + SSC sup.) 33% of type E (SSP + ISP + TM)

26 Massive rotator cuff tear superior inferior subscapularis «Subscapularis minor»

27 The subscapularis The subscapularis is the largest muscle in the rotator cuff (Keating JF, et al. JBJS Br 1993) - larger muscle volume - larger force-generating capacity (Keating JF, et al. JBJS Br 1993)

28 The subscapularis Anatomical difference between superior & inferior inser&ons (Klapper RC, et al. AJSM 1992) (Cleeman E, et al. JSES 2003) superior 2/3 coalesce into a tendon to the lesser tuberosity inferior 1/3 remains muscular in its inser&on (Cleeman E, et al. JSES 2003)

29 The subscapularis The independent upper & lower subscapular (Kasper JC, et al. JSES 2008)

30 Large - Seems to be more related to retrac&on ( 3 to 5)?

31 Pseudo- paraly>c All passive ROM Forward eleva&on less than 90

32 Irreperable «It is a tear which has a probability to structurally heal of less than 95%»

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35 Au Total SUPRA EPINEUX ISOLE SOUS SCAPULAIRE ISOLE COIFFE MASSIVE A B C D E RETRACTION : PATTE LE MUSCLE +++