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M. Antonogiannakis Director Center for Shoulder arthroscopy IASO Gen. Hospital Athens Greece

Arthroscopic repair of massive rot cuff tears. M. Antonogiannakis Director Center for Shoulder arthroscopy IASO Gen. Hospital Athens Greece. Massive Rot Cuff Tears. Definition: Involving 2 or more Tendon Tears (Gerber) >5cm Tear (Cofield). The problem. Poor tendon quality

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M. Antonogiannakis Director Center for Shoulder arthroscopy IASO Gen. Hospital Athens Greece

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  1. Arthroscopic repair of massive rot cuff tears M. Antonogiannakis Director Center for Shoulder arthroscopy IASO Gen. Hospital Athens Greece

  2. Massive Rot Cuff Tears Definition: • Involving 2 or more Tendon Tears (Gerber) • >5cm Tear (Cofield)

  3. The problem • Poor tendon quality • Muscle tendon retraction • Muscular atrophy The three central issues • Passive range of motion • Tendon retraction • Muscle viability

  4. Recognize the Tear Pattern • Tears must be repaired in the direction of greatest mobility -> minimal strain

  5. Subacromial view

  6. Tear Patterns • Crescent shaped • L-shaped (or reverse L) • U-Shaped • Massive Contracted Immobile tears

  7. Crescent-Shaped Tear • Simple double row repair, even when the tear is massive

  8. Double Row Fixation Restoration of the footprint www.shoulder.gr

  9. L-Shaped & U-Shaped Tears • Side to side sutures from medial to lateral • Progressively converge the margin of the tear lateral to bone bed • Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [Burkhart]

  10. Cuff repair Side to Side Repair

  11. Cuff repair Tendon to bone repair

  12. Massive Contracted Immobile Tears • No mobility from medial to lateral or from anterior to posterior • Subcategories: • Massive Contracted Longitudinal Tears • Massive Contracted Crescent Tears • Represent 9.6% of massive tears [Burkhart]

  13. Massive Contractive Tears • Anterior Interval Slide and/or • Posterior Interval Slide

  14. Massive Tears associated with Subscapularis Tears • Subscapularis must be mobilized and repaired prior to the rest of the cuff • Interval slide in continuity

  15. When to Release and When NOT to Release • According to Tear Pattern and Mobility • Test mobility with grasper

  16. Massive Tears • Easy Repair • Difficult Repair (anterior & posterior Slide) • Medialized Repair • Impossible Repair • Incomplete Repair • Graft Jackets

  17. Final Subacromial view

  18. Results for massive tears • 95% Good to Excellent Results independent to tear size [Burkhart, 2001] • With interval slide • Improve UCLA score (10->28.3) • Improve Active ROM, Strength [Burkhart, 2004] • Graft Jacket Repair • Improve UCLA score (18->32) [Snyder, 2008]

  19. What to do??? • Patients with grade 3 or 4 fatty degeneration DO NOT improve with rot cuff repair [Goutallier] Vs. • Patients with grade 3 or 4 fatty degeneration improved significant at 86% of cases after arthroscopic repair [Burkhart]

  20. Conclusions • Acute Crescent Tears • Standard Techniques • U- or L- shaped Tears • Side to side • Marginal Converge Repair • Partial mobile tears • Anterior / Posterior Slide • Medialized Repair • Irreparable Tears • Partial Repair • Grafts

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