The Repair and Rehab of the Rotator Cuff. Toby B. Husserl, MD ABOS, AAOS, ABIME Orthopedic Surgeon
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1 The Repair and Rehab of the Rotator Cuff Toby B. Husserl, MD ABOS, AAOS, ABIME Orthopedic Surgeon
2 Introduction The Rotator Cuff The natural history of the Cuff -
3 Rotator Cuff Shoulder DESIGN: Is a joint that has most degrees of motion. Is primarily non weight bearing. Requires stability and strength for function.
4 Rotator Cuff Skeletally unstable Sub acromial space- is the rotator passageway
5 Rotator CuffFOUR covering converging tendons attaching to the Greater Tuberosity of Humeral Head. SUPRASPINATUS INFRASPINATUS X XXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXX IIIIIIIIIIIIIII IIIIIIII XXXXXXXXXXXXXXXX XXXXXXXX XXXXXXXXXXXXXX TERES MINOR SUBSCAPULARIS xxxxxxxxxxxxxxx
6 The Repair and Rehab of the Rotator Cuff DESIGN: As (we) Age... AND True of all tissue - there is a progressive and?? natural reduction of Blood Supply accompanied by nutritional, and thus our ability to repair... Attrition ( Attrition by design??...)
7 attrition Rotator Cuff pathology
8 Rotator Cuff PLUS/plus... DIABETES
9 (RC passageway) Supraspinatus xxxxxxxxxxxxxxxxx
10 Rotator Cuff The fulcrum of the shoulder requires a intact Rotator Cuff to centrally Stabilize the Humeral glenoid forces-- in order to allow ALL muscles to Concentrically elevate the arm
11 Rotator Cuff DESIGN Function: Concentric Compression of Humeral xxxxxxxxxxxxxxxxx Head to Glenoid.(keep socket snug) Elevation is Secondary-(deltoid, trapezius) Pulling head into socket primary function
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13 Supraspinatus xxxxxxxxxxxxxxxx
14 TEAR of RC Rotator tendon to muscle
15 Rotator Cuff In the begining... x X X x Rotator tendons X X Humeralx head biceps
16 supraspinatus Humeral head biceps
17 Rotator Cuff Subacromial spacethe top side of the cuff surface
18 Rotator Cuff Subacromial space RC with coverage of head of humerus and and Greater Tuberosity
19 Rotator Cuff In the begining... Rotator tendons Humeral head biceps
20 Cuff- partial tears hh glenoid/labrum
21 Rotator Cuff Partial tears HH
22 Rotator Cuff In the begining... Rotator tendons Humeral head biceps
23 RC hh??
24 HH biceps
25 Tear of cuff Supra- Infraspinatus margin
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27 biceps HH Delaminating tear
28 Rotator Cuff Subacromial space- the top side of the cuff surface
29 Rotator Cuff Subacromial space RC with coverage of head of humerus and and Greater Tuberosity
30 Cuff edge Tuberosity of Humeral head
31 The footprint"humeral surface Edge of cuff
32 Subacromial space Blunted, avascular cuff leading edge of cuff adhesions HH
33 Biceps tendon Remnant cuff on tuberosity
34 The Repair and Rehab of the Rotator Cuff Principles of repair: ~ Recreate a recipient footprint ~ Repair with no / minimal tension, it s a cable. ~ Watertight, sealed closure. ~ Address surrounding pathology; biceps, labrum, outlet.
35 The footprint"humeral surface Edge of cuff
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37 The Repair and Rehab of the Rotator Cuff
38 The Repair and Rehab of the Rotator Cuff
39 Retracted cuff footprint
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42 The Repair and Rehab of the Rotator Cuff Devices used in repair : FDA sanctioned bioabsorbable high strength medical device Anchors - small screw systems with contained and deployable multiply sutures. $$$$$ Molly bolts
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51 The Repair of the Rotator Cuff The End
52 Rehab of a Repaired Rotator Cuff What is rehab? Prehab? Is it necessary? Is it proven? Is it guaranteed to work?
53 Rehab of the Rotator Cuff Doc, how long is this gonna take????
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55 Rehab of the Rotator Cuff Clinical Orthopedic Literature: Early cyclical motion helps align and trigger chemotactic tendon repair processes which may improve overall tissue strength, and facilitate healing.
56 Rehab of the Rotator Cuff Principles of Rehab: 1. PASSIVE motion - the technique of moving the gleno humeral joint without stressing the RC repair site, i.e. Not letting the rotator muscle pull on the tendon(s).
57 Decision Making in Rotator Cuff Treatment
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59 Rehab of the Rotator Cuff Protocols: surgery. Our Design based on all considerations of PHASE 1 Principles - allowance for Primary healing -introduction of passive motion with maximum protection of repair.
60 Rehab of the Rotator Cuff Principles: Postural stabilization of Unrepaired structures Cervical, upper thoracic, RHOMBOID muscles
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62 Rehab of the Rotator Cuff What about biceps?
63 Rehab of the Rotator Cuff Risks of Rehab -Early Overzealous force causing damage to construct. Vs. Failing to restore Capsular joint motion.
64 Rehab of the Rotator Cuff Dependent on the tolerance of the Repair to stress. Which is dependent on the Integrity of the Tissue. Which depends on the proliferative capacity of tissue Teno-osseointegration
65 Decision Making in Rotator Cuff Treatment
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67 Rehab of the Rotator Cuff Conditions required: Blood supply/ Repair factors - ALL healing requires it. BUT tendons don t have much by design! -Science of healing
68 Repair and Rehab of the Rotator Cuff Inflammation - the process of bringing various cell types to injured tissue to promote repair- teno osseosintegration. ~ required for initiating the maturation process of healing. Requires complex cascade of proteins. Is it enough?
69 Decision Making in Rotator Cuff Treatment
70 Rehab of the Rotator Cuff xxxxxx
71 Rehab of the Rotator Cuff xxxxxxxxxx
72 Repair and Rehab of the Rotator Cuff Various Attempts to maximize healing integrity: Protein Rich Plasma ~ PRP Stem cells Amniontic tissue/fluids Allografting
73 Rehab of the Rotator Cuff Conditions required: Stable Construct
74 Decision Making in Rotator Cuff Treatment
75 Rehab of the Rotator Cuff Decision Making: How to decide: Information Experience Results
76 Rehab of the Rotator Cuff PHASE 2 Begins when there is some certainty that healing of the repair is capable for stress loading. Timing: 6 weeks?/ 8 weeks? / not healing
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78 ??
79 Rehab of the Rotator Cuff Useful information - healing soft tissue is weakest approximately days after insult (surgery or trauma), because of the infiltration of macrophage cells,and proven by histology to look like wet noodles. Soooo..?? defer PT, to stressing. allow more defined healing prior
80 Rehab of the Rotator Cuff Phase 2 Assumptions made, construct is healing.
81 Rehab of the Rotator Cuff Phase 2 ~ Relying on the developing integrity of repair. ~ Is slow progressive Assistive active loading ( AAROM ). ~ No improvement in function unless arc of motion is present, So phase 1 more important. Extreme weakness is found in isolated loading of Cuff.
82 Phase 2 Rehab of the Rotator Cuff
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85 Decision Making in Rotator Cuff Treatment
86 Rehab of the Rotator Cuff Phase 3 -- varies based on all factors known. Functional phase beginning- adaptive use of extremity. Assumes phase 1 ( ROM) satisfactory, phase 2 improvement. Job specifics influence training regimen. ** Recovery lag becoming apparent.
87 Phase 2 Rehab of the Rotator Cuff xxxxxxx 10-14
88 Rehab of the Rotator Cuff???/!!! By design
89 The Repair and Rehab of the Rotator cuff Conclusions Statistically 75-80% of RC tears heal with demonstrated improvement scores of good outcome, and ALL studies demonstrate lesser outcomes in occupationally injured subgroups. A small but significant percentage do not heal radiographically or clinically or improve satisfactorily, regardless of treatment. Future treatments are evolving...
90 The Repair and Rehab of the Rotator Cuff Thank you, Toby B. Husserl,MD
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