The Current State of Rotator Cuff Repairs

Transcription

1 Conflict of Interest Slide The Current State of Rotator Cuff Repairs Gerald R. Williams, Jr, MD John M. Fenlin, Jr, MD Professor of Shoulder and Elbow Surgery Royalties Depuy: shoulder arthroplasty DJO: shoulder arthroplasty Walters Kluwer: shoulder texts IMDS/Cleveland Clinic: arthroplasty Research: Tornier, Depuy, Synthasome Stock Ownership: In vivo therapeutics, CrossCurrent Business Analytics, LLC, OBERD, LLC, Force Therapeutics Agenda 1) Anatomy/Physiology/Pathogenesis 2) Rotator cuff repair prognostic factors 3) Surgical techniques 4) Rehabilitation 5) Results 6) Augmentation techniques 7) Irreparable cuff tear A. Partial repair B. Superior capsular reconstruction C. Transfers lower trapezius, latissimus dorsi Rotator cuff Supraspinatus outlet Anterior acromion CA ligament AC joint Anatomy Anatomy Physiology Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90: Kato A, Nimura A, Yamaguchi K, Mochizuki T, Sugaya H, Akita K. An anatomical study of the transverse part of the infraspinatus muscle that is closely related with the supraspinatus muscle. Surg Radiol Anat 2012;34:

2 Physiology Pathogenesis Rotator Cuff Tears Age Arm Impingement Trauma Rotator Cuff and CA Arch Deltoid Most cuff tears are the result of a combination of 3 factors Pathogenesis Age Pathogenesis Impingement Critical Shoulder Angle Sher, et.al., JBJS 77A, 1995 Increasing cuff tears Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. [Relationship of acromial architecture and diseases of the rotator cuff]. Orthopade 1991;20: Gerber C, et al. Orthop Traumatol Surg Res 2014;100: Cuff Repair Prognostic Factors Prognostic Factors Size, Chronicity Patient age (> 70) Cuff tear size Chronicity Tendon quality Smoking Patient compliance/rehabilitation protocol Lag signs/proximal migration Workers compensation/litigation Poor prognosic factor (Fenlin, Goutallier, Gerber, others) 2

3 Prognostic Factors Chronicity Surgical Techniques Repair Tension (N) Gimbel, J. A., S. Mehta, Williams, G, et al. (2004). Open vs. Arthroscopic Single vs. double row Mobilization techniques (repair tension management) Anchorless repairs Time from Injury (weeks) Cuff Repair Principles (Neer 1972) Open superior approach Subperiosteal anterior deltoid take down Coracoacromial ligament excision Anterior acromioplasty Cuff mobilization Cuff repair to bone through tunnels Early (immediate) passive motion 3

4 Open vs. Arthroscopic Repair Pot. Arthro. Adv. Pot. Arthro. Disadv. Less deltoid morbidity Less post operative pain Less subacromial scarring Better cuff mobilization/visualization Better patient acceptance Simple sutures Anchors vs. tunnels Cuff repair footprint Surface area available for healing Double row may help Technically demanding may be volume dependent Repair Techniques Systematic Review Suture Bridge or Double row (1 cm) Transosseo us or single anchor (1 cm) Suture Bridge or Double row (5 cm) Transosseo us or single anchor (5 cm) Re-tear rate 7% 17% 41% 69% 1252 repairs, 23 studies No difference between arthroscopic, open, or miniopen techniques Duquin, T. R.; Buyea, C.; and Bisson, L. J.:. Am J Sports Med, 38(4): , Arthroscopic Repair Techniques Single vs. Double Row Suture Bridge George J. Trappey, MD and Gary M. Gartsman, MD Journal of Shoulder and Elbow Surgery Volume 20, Issue 2, Pages S14 S19 (March 2011) DOI: /j.jse Double Row Single Row Copyright 2011 Journal of Shoulder and Elbow Surgery Board of Trustees Single vs. Double Row Systematic Review Mobilization Techniques Repair tension management Burkhart, S. S., et al Arthroscopy, 12(3): 335-8, Copyright 2011 Journal of Shoulder and Elbow Surgery Board of Trustees George J. Trappey, MD and Gary M. Gartsman, MD, Journal of Shoulder and Elbow Surgery, Volume 20, Issue 2, Pages S14 S19 (March 2011)DOI: /j.jse Margin Convergence 4

5 Traditional Mobilization Arthroscopic Interval Slides Large U shaped Tear Lo, I. K., and Burkhart, S. S.: Arthroscopy, 20(1): 22-33, Tauro, J. C.: Arthroscopy, 15(5): , Anchorless Repair Rehabilitation Neer (1972) immediate, full, passive range of motion Reported high failure rates have lead to delayed rehab Must be individualized Pre op stiffness Concommittent pathology Tear size and chronicity Rehabilitation Immobilization vs. Activity (rat model) Thomopoulos, S., G. R. Williams, et al. JOR (2003). Rehabilitation Immobilization vs. Loss of motion Injury and repair caused loss of motion Addition of immobilization transiently increased loss of motion Cross Sectional Area Structural Properties Material Properties Organization Sarver, J. J., C. D. Peltz, Williams G, et al. JSES(2008). 5

6 ROM (% of pre- injury) Rehabilitation Passive Motion may be detrimental ROM 2 weeks * *, CA IM PM Sarver, J. J., C. D. Peltz, Williams G, et al. *=sig from JSES(2008). CA, =sig from IM CA = cage activity IM = immobilization PM = passive motion Post-op FE FE and ER at 1 year F/U Post-op ER Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. J Shoulder Elbow Surg 2010;19: week ROM Stiff Non Stiff Repair Integrity at 1 yr (MRI) Overall 44% rate of intact repair at 1 year 6 wk ROM Intact Cuff Retear Stiff % intact Good % intact p=0.10 Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. J Shoulder Elbow Surg 2010;19:

7 Cuff Repair Results Repair Integrity 105 shoulders, avg 5 year f/u Supraspinatus 20% recurrence Two tendons 45% recurrence Three tendons 65% recurrence Most patients satisfied even with recurrent defect Function and satisfaction correlated with integrity Mean ASES Score: 91 vs 69 Younger age, Work Comp, Lower Education Harryman, et.al., JBJS 73A, 1991 Successful outcome in 54% Labor intensive occupation Distribution RCR + dermal patch Reinforced fascia lata patch greater ultimate load at Time 0 than nonaugmented repairs 2 tendon tears 44 patients Mean 2 year followup (minimum 1 year) 85% healed with augmentation, 40% healed without augmentation 7

8 Irreparable Tears Deciding on Treatment Treatment options depend on level of function and presence or absence of arthritic change Choices Partial repair Superior capsular reconstruction Transfers Reverse arthroplasty Weakness Pain Active Motion Loss Age Activity level Work demands Expectations Nonoperative Superior Capsule Reconstruction Tendon Transfer Biceps Tenotomy, Tuberoplasty Partial Repair Reverse Arthroplasty Superior Capsule Reconstruction Tendon Transfers Specific Indications Pectoralis Major Transfer Latissimus or lower trapezius Transfer Reverse Rotator Cuff Repair Conclusions Rotator cuff tears multifactorial Age (senescence) Trauma Impingement? Cuff repair techniques should aim to improve healing rates Biologics will probably have a role Early repair of retracted tears desirable especially in young patients Slow early rehab Management of irreparable tears difficult, especially in young patients Thank You 8