Conflict of Interest New Strategies in Rotator Cuff Repair Sheri Lankford, BSN, CNOR I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am are presenting, other than the following: Learner Outcome Incorporate strategies that improve patient outcomes related to shoulder conditions and corrective surgical procedures Objectives 1. Anatomy of Shoulder 2. Signs and Symptoms of Rotator Cuff Tear 3. Surgical Technique 4. Post Op Rehab 1
Anatomy of Shoulder Anatomy of Shoulder Anatomy of Shoulder Anatomy of Shoulder SITS SUBSCAPULARIS; INFRASPINATUS; TERES MINOR; SUPRASPINATUS. These muscle and the musculotendinous rotator cuff stabilize the humeral head in the glenoid. 2
Anatomy of Shoulder The RTC lies under the acromion process with a bursal fluid sac between them which acts as a cushion. The RTC moves as a unit during movement of the shoulder. Rotator Cuff Dr. Patel likens the RTC to a piece of twine. Over time it unravels. Nearly everyone in their sixties have a RTC tear. But not all tears are symptomatic. Patient presents to clinic Pain At rest Lifting or lowering arm Pain at night Weakness Lifting / rotating arm Crepitus/ crackling in certain positions 3
Images Images Xrays obtained 1. Will not show soft tissue 2. May show bone spur Images Images MRI (Magnetic Resonance Imaging) ordered A. Confirm rotator cuff tear 1. Old vs new tear 2. Intensity of tear (involvement; retracted) 4
Images Repair vs Reconstruction ALWAYS ASSUME THAT YOU CAN REPAIR!! Dr. Patel s motto. A. Repair 1. Acute tear (Trauma ex: fall; MVA) 2. Small tear or large that is flexible/stretchable Repair vs Reconstruction B. Reconstruction 1. > 1 year chronicity a. bone spurs b. repetition (overuse; overhead) c. lack of blood supply 2. Retracted 3. Scarred in Superior Capsular Reconstruction What?!?! SCR (Superior capsular reconstruction) is rebuilding an irrepairable rotator cuff. With What?!?! Mature extracellular dermal matrix (Cadaver dermis graft) 5
Dermal Matrix Goal What is the overall goal? A. The rotator cuff keeps the humeral head centered on the deltoid when the arm is raised. B. If there is no rotator cuff, then humerus rubs on acromion, which leads to arthritis, which leads to a reverse total shoulder arthroplasty (rtsa). C. Not making a new rotator cuff. Just augmenting the cuff to buy a few years before getting a rtsa. Arthroscopic superior capsular reconstruction A. Patient is positioned in the beach chair position B. Surgeon looks into the shoulder with the arthroscope and determines if the tear is repairable or not. C. Decision is made to perform an SCR. Arthroscopic superior capsular reconstruction A. Subacromial bursa debridement is performed along with a biceps tenotomy or tenodesis. If patient had a previous RTC repair, then old sutures are removed. B. The graft will be attached medially to the glenoid and laterally on the humerus. C. The superior labrum is identified. Two anchors are placed just medially of the labrum percutaneously, anteriorly and posteriorly. 6
The superior labrum is identified. Two anchors are placed just medially of the labrum percutaneously, anteriorly and posteriorly. When placing the humeral (tuberosity) anchors, one will be placed in the anterior rotator cuff footprint and one in the posterior footprint. Anchors 7
Graft Measurments Arthroscopic superior capsular reconstruction A. Measurements are taken for the graft 1. The distance between the glenoid anchors is first. X 1 2. Next is the distance between the tuberosity anchors. X 2 3. Next is medial to lateral on posterior anchors. Y 1 4. Last is medial to lateral on anterior anchors. Y 2 Arthroscopic superior capsular reconstruction Graft Preparation A. Graft is presented sterilely to the back table. B. The anchor measurements are then marked on the graft. C. The graft is then cut to size with a 5mm border from the markings. This gives the graft a nice perimeter so the sutures do not cut through the graft. Arthroscopic superior capsular reconstruction D. Two holes are punched at the lateral anchor markings for easier suture passing. E. The graft will be passed through a 12 mm plastic, pliable cannula. All sutures from the anchors are pulled through this cannula. Suture management is imperative at this time! F. The graft is then slid into the cannula by a pulley mechanism and introduced to the prepared rotator cuff bed. 8
Arthroscopic superior capsular reconstruction G. The graft is then sutured down. The anterior side is not necessarily additionally anchored. If overconstrained, possible decreased range of motion (ROM). 9
Images F. Patient is placed in a shoulder immobilizer with an abduction pillow and taken to PACU. 10
Whatever Works Rehabilitation Rehabilitation A. Only pendulums to shoulder and AROM to wrist and elbow for the first 4 6 weeks. Rehab Maxine Formal Physical Therapy rotator cuff repair protocol will begin after the 6 weeks, determined by the surgeon. 11
THANK YOU!!! Thank you for your time! 12