Massive Rotator Cuff Tears Arthroscopic Treatments

Transcription

1 Massive Rotator Cuff Tears Arthroscopic Treatments Brian D. Busconi, MD Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center

2 Disclosures Consultant Arthrex Mitek I (and/or my co-authors) have something to disclose. Detailed disclosure information is available via: Printed Final Program or AAOS Orthopaedic Disclosure Program on the AAOS website at

3 Disclosure I am a Joint Preservationist!! I Prefer Biologic Options Dr. Mc Millan prefers Metal and Plastic.JPG

4 AOAO Thank You

5 Thank You Jeffrey Murray,DO

6 This is hard. "It's supposed to be hard. If it wasn't hard, everyone would do it. The hard is what makes you great. - Tom Hanks, A League of Their Own

7 Managing Expectations Arthroscopy, 2017 Patient satisfaction is the most important quality outcome metric and will affect physician reimbursement Patient satisfaction directly linked to a patient s pre-operative expectations Less Pain and More Function

8 What do they want? Less Pain More Function AJO, % % 0 Labor Occupation 82.7% 17.3% Non-Labor Class Prefer Strong Shoulder/Mild Pain Prefer Weak Shoulder/No Pain

9 Overview The Problem The Options Patient Paradigm How will you choose?

10 Source of the Problem 62 M fall onto shoulder C/O weakness and pain

11 Massive RCT Options v Non-Surgical v Debride/Repair v Bridge ECM v SCR v SA Balloon v Tendon Transfer v Reverse TSA KSST 2016 Arthroscopy 2013 JBJS 2014 AJSM 2017 AOTS 2017

12 Massive RCT Classification DeOrio: >5cm either M-L or A-P Gerber: At least 2 tendons involved Descriptive: acute vs chronic, retraction, atrophy

13 Physical Exam Supraspinatus: Empty can Infraspinatus: Weakness with ER at 0 deg abduction, ER lag sign* Teres Minor: Hornblower Other Pearls: evaluate for trapezial recruitment, atrophy, winging

14 Imaging My Pearls Acromiohumeral Interval: 8-11mm

15 CORR 1990 Repair /SCR Repair /SCR AHI > 6 mm AHI < 5 mm Acetabulization * Excavated acromion GH JSN Spur along CAL HH Collapse * Concave Acromion

16 Imaging Decreased AHI, with OA REVERSE!

17 Imaging Critical shoulder angle <30 associated with osteoarthritis >35 associated with degenerative rotator cuff tears

18 MRI Based Algorithm Massive Cuff Tear 5 cm² 2 tendons ( Grade 3 Fatty deg.) Repair ± Augmentation ± Bridge Graft Tendon Transfer (Latissimus) (Pectoralis) Reverse Prosthesis ± Latissimus Superior Capsule Reconstruction Mihata T, Arthroscopy 2013

19 MRI Considerations Correlation between fatty atrophy and JSES, Functional Outcome 2. Risk of Anatomic Failure 3. Reparability Flurin et al., Rev Chir Orthop, 2005 Fuchs et al., JBJS 2006

20 Fatty Infiltration = RTSA Arthroscopic repair can provide significant functional improvement (39.3 mo FU) Grade 3 shoulders had better results than grade 4 Overall, 86.4% satisfaction

21 Options for Massive RC Tears Traditional Debridement Biceps tenotomy Partial repair Latissimus dorsi transfer Interposition patch graft / Bridging Reverse arthroplasty Biologic Superior Capsular Reconstruction

22 Debridement +/- biceps procedure Ideal for: pain relief with low functional demand Sick, elderly Pros: quick case, easy rehab, not relying on body to heal anything Cons: limited functional gain, likely continued progression of cuff atrophy and OA Rockwood et al, JBJS 1995 showed 83% satisfaction at 6.5 years post op Mean forward flexion improved from 105 to 140, despite not performing any repair Gartsman et al, JBJS 1997 Sig decrease in pain, increase in ROM and ability to perform ADLs No improvement in strength

23 Partial Repairs Marginal Convergence Restores biomechanical force couples in shoulder Enhances axial compressive force Increases AHI Reduces pain, improves function Persistent abnormal kinematics despite the centering effect Burkhart 1994, Duralde 2005 DiBenedetto et al, Acta Biomed 2017 Good short to medium results with a limit of 6-7 years Cuff et al, JSES 2016 Reasonable outcomes at 5 yrs, 29% failure Shon et al, AJSM 2015 Over half of 31 patients at years, unsatisfied with outcome Kim et al, Arthroscopy 2012 Satisfactory short term outcomes

24 Complete Repair Goal - tension free, anatomic repair of entire tendon Complete healing is the goal, but healing rates may not correlate with clinical outcomes Patient selection is key! 78 y/o diabetic, smoker vs 65 y/o with no PMH Understand their goals for surgery Establish realistic expectations

25 Complete Repair - Surgical Pearls Visualize entire extent of tear - thorough bursectomy, SAD Debride non-viable cuff tissue Margin Convergence stitches Mobilization Subacromial, supraglenoid adhesions Anterior/posterior interval slides Biology - footprint preparation, crimson duvet, biologics

26 Complete Repair - Surgical Options Single row Double row (traditional) Double row - linked/transosseous equivalent Biologic adjuncts? PRP Crimson duvet Patch augmentation

27 Repair is Possible in Some 1 yr Significant Improvements Reversed Pseudoparalysis in 53/56 AJSM, 2015 N=67 Posterior Repair SST 4.6à9.0 Constant 44à73 Restored AHI JSES, yr 91% satisfied DR 5x likelihood of G/E Arthroscopy, 2012 AJSM, 2013 IS Atrophy predicted failure Decreased AHI predicted failure

28 Complete Repair - Outcomes Overall retear rates: Single Row: 68/263 (25.9%)* Double Row: 37/261 (14.2%)* No difference in functional outcomes (ASES, UCLA,Constant)

29 Complete Repair - Outcomes High patient satisfaction All measured outcome scores showed significant improvement MRI documented retear rate, min 1 year: 26% No correlation with functional outcomes Conclusion: arthroscopic RCR is safe and effective in patients > 75 years old

30 Repair of the Massive RCT History 72 yo 10 year h/o R shoulder pain and weakness w repeated non-operative treatment

31 Imaging

32 What was done

33 Latissimus Dorsi Muscle Transfers Namdari et al, Systematic review, JBJS-A studies included Improved shoulder function, ROM, strength, pain relief But not normal shoulder or complete relief Risks of neuropraxia, infection

34 Snyder et al, IJSS 2007 Schlamberg et al, JSES 20 Intercalary Placement Bridging / Spanning Biomechanical studies showing equivalent load-tofailure and mechanical properties, but few articles show success clinically Gupta, Toth et al., AJSM pts interposition repair using human dermal allograft Minimum f/u 29 mos ASES > 88.7 (p=0.0003) Improvements in pain / ROM Ultrasound demonstrated intact repairs in 76%

35 What if it looked like this?

36 Superior Capsular Reconstruction Technique described by Hanada (1993) & Mihata (2007) No option for Reverse TSR Needed option for massive irreparable RCT Re-center the humeral head using fascia lata autograft

37 What is the SCR? Papers Describing Surgical Technique 8 Papers Describing Outcomes 1

38 How Does SCR Work? Lowers center of humeral head rotation Couples functioning rotator cuff to superior capsular checkrein Stabilized glenohumeral joint rotational platform to regain maximal shoulder function and avoids RSA in the younger cuff deficient patients

39 Superior Capsular Folding Intact superior capsule Superior capsule reconstruction Courtesy of Dr. Teruhisa Mi

40 Arthroscopic Superior Capsule Reconstruction Teruhisa Mihata, MD Mihata et al, Arthroscopy, 2013 Methods: 24 shoulders over 2 years Autograft fascia lata used to reconstruct superior capsule Results: A-H distance: 4.6±2.2 mm to 8.7±2.6 mm (p < ) ASES Score: 23.5 to 92.9 points (p < ) Twenty patients (83.3%) had no graft tear or tendon retear Mihata et al, Arthroscopy 2013 Nagasawa, ISAKOS Presentation

41 Mihata et al., Arthroscopy 2016 Graft Size Affects Shoulder Stability after Superior Capsule Reconstruction for Irreparable Rotator Cuff Tear Fascia lata SCR 4 & 8 mm normalized subacromial contact pressures Superior translation differences 4 mm - partially restored 8 mm - fully restored

42 ArthroFlex Human Allograft Dermis Ready to use Hydrated Room temperature storage Sterile (10-6 SAL) 3 year shelf life Biocompatible > 97% DNA removal Excellent suture retention strength Intact framework Variable thickness ( mm) Matracell Process

43 Biomechanical Comparison Fascia Lata, Doubled ArthroFlex, 3.5 mm Failure = 180 N Failure = 550 N Double Surgeon s Knot = 480 N

44 Solid Surgical Game Plan Critical Flow of case Specific instruments & accessories Specific implants and suturing technique to ease graft passage and deployment Measure twice, cut once (dermal graft)

45 Mihata et al., AAOS 2016 Superior Capsule Reconstruction Using Human Dermal Allograft: A Biomechanical Cadaveric Study Fascia Lata Fully restored: Superior humeral head translation Subacromial contact characteristics Superior glenohumeral joint force Stiffer Human Dermal Allograft Partially restored: Superior humeral head translation Fully restored: Subacromial contact characteristics Superior glenohumeral joint force Significantly improved ROM compared to FL

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47 Margin Convergence? Mihata et al, AJSM 2016 Posterior margin convergence necessary to restore biomechanics When using fascia lata, anterior margin convergence does not effect outcome Dermal allograft More elastic than fascia lata Need to consider anterior margin convergence If no rotator interval tissue, then attach graft into or anterior to biceps groove

48 Preparation: Tape off the room Hemostasis Cannulas and flexible Passport (radial cut) Adequate bursectomy Glenoid preparation (consider Neviaser portal) Stab incisions to park sutures Exact measurements at glenoid, greater tuberosity and medial to lateral Streamlined graft passage plan

49 Pearls to Success Span the defect with graft & anchors Decorticate laterally and centrally Glenoid anchors medial to labrum - min 3 Neutral arm position Accurately measure between anchors Punch graft for suture sliding Double pulley technique Ant/Post central knotless 12 mm Passport for graft passage Must incorporate infraspinatus repair Posterior Key Do NOT over-constrain the shoulder But graft must have good tension!!!

50 Option 1 Superior Capsular Reconstruction History 58 yo R Shoulder pain Prior massive RCR and never got better Continued pain and weakness Unresponsive to additional non surgical care FE 140, ER 50, Strength 3/5 SS, IS

51 Imaging

52 Arthroscopy

53 Current Technique

54 Radiographic Outcome 2 months post-op SCR Pre-op Post-op AH Distance = 2.0 mm AH Distance = 8.4 mm

55 Radiologic Outcome 4 months post-op MRI Normal Pre-op Post-op

56 Radiographic Outcome 8 months post-op Ultrasound

57 When it was done

58 Summary Mihata Fascia lata autograft 180 N A-H distance 4.6 mm to 8.7 mm ASES Scores 23.5 to % - No graft or re-tear Busconi ArthroFlex allograft 550 N A-H distance 4.8 mm to 8.7 mm ASES Scores 41.2 to 88.0 Complications (1) Fall / Torn IS n = 24 patients / Follow up mos n = 14 patients / Follow up 6-18 mos

59 Why Not RSA? Subject to overuse Too commonly seen as solution for previously untrestable shouder pathologies Challenging surgical technique Requires extensive training and experience limits availability Wide range of significant complications rates Arthroplasty has limited lifespan- bridge burner

60 Implant Cost* SCR RTSA $6,700 $10,400 *Estimated that total cost for RTSA is 15-22K more than SCR

61 My Indications Inclusion Irreparable supraspinatus and/or infraspinatus tears Failed conservative management Intolerable shoulder pain Subjectively unacceptable dysfunction Exclusion Moderate to severe arthropathy Bone defects Absence of deltoid, latissimus dorsi, or pec function Shoulder stiffness

62 Final Thoughts: Rock, Paper, Scissors Having a biologic force coupler trumps no cuff whatsoever SCR trumps RSA, especially in younger non-arthritic cuff deficient shoulders Four definable steps 1.Bony prep 2.Anchor placement 3.ArthroFlex graft prep 4.Graft deployment Now let s go save some shoulders!!

63 Thank You It s about solving your patient s Problem

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