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Rotator Cuff Disease

Rotator Cuff Disease. Current Surgical Management. Chris Pullen. Historical Aspects. Codman in 1934 Impingement syndrome Arthroscopic SAD. Shoulder Arthroscopy. Rotator Cuff Disease. Tendinopathy/Impingement Rotator Cuff Tear Cuff Tear Arthropathy.

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Rotator Cuff Disease

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  1. Rotator Cuff Disease Current Surgical Management Chris Pullen

  2. Historical Aspects • Codman in 1934 • Impingement syndrome • Arthroscopic SAD

  3. Shoulder Arthroscopy

  4. Rotator Cuff Disease Tendinopathy/Impingement Rotator Cuff Tear Cuff Tear Arthropathy

  5. PARTIAL THICKNESS TEARS(IMPINGEMENT/TENDINOPATHY)

  6. PTT –Surgery • Open • Mini – open • Arthroscopic*

  7. PTT - Arthroscopy • Advantages • Visualisation • Treatment • articular tears

  8. PTT - Arthroscopy • Bursal surface tear • SAD • Articular surface tear • Debridement only • Repair • >50% Thickness tear • Active patients

  9. PTT - Arthroscopy • Results • Debridement +/- SAD • Repair

  10. FULL THICKNESS TEARS

  11. FTT - Surgical Approaches • Arthroscopic* • Arthroscopic assisted/mini-open* • Open

  12. FTT - Arthroscopic RCR • Gleno-humeral Joint • PTT • Labral tears • Ligament injuries • Cartilage tears • Significant lesions in 12.5%

  13. FTT – Arthroscopic RCR • Repair Site Preparation • Removal of ragged or degenerate tissue • Decortication of bone

  14. FTT – Arthroscopic RCR • Suture Placement

  15. FTT – Arthroscopic RCR • Anchor Placement • Foot print • Double row technique

  16. FTT – Arthroscopic RCR • Other Tendon Lesions • Infraspinatus • Teres minor • Subscapularis • Biceps

  17. FTT – Arthroscopic RCR • Biceps • Debridement • Tenotomy • Tenodesis

  18. FTT – Arthroscopic RCR • Post – operative Treatment • Sling • Cryotherapy • PROM • AROM • Strengthening

  19. FTT – Arthroscopic RCR • Results • 90% satisfaction • 78% pain relief • AROM

  20. MASSIVE TEARS

  21. Massive Tears – Surgery • Debridement • Open • Arthroscopic* • Rotator Cuff Repair* • Tendon transfer* • Synthetic interposition • Arthrodesis • Arthroplasty

  22. Massive Tears - Debridement • Debridement alone • Low demand patients • Results tend to deteriorate over time • Arthroscopic debridement • easier • more rapid rehabilitation

  23. Massive Tears - Debridement • Limited acromioplasty • coracoacromial arch is maintained • Biceps tenotomy / tenodesis • subluxation, dislocation, or partial tearing • enhance the ability to alleviate shoulder pain

  24. Massive Tears - RCR • Good function & pain relief 80-90% • Goal of surgery is to repair the cuff without disrupting the coraco-acromial arch

  25. Massive Tears - RCR • Rehabilitation • Sling / Abduction splint • PROM • AAROM • Strengthening • Overall recovery may take >12 months

  26. Massive Tears - RCR • Results • Inferior • Better within 6 weeks (Bassett & Cofield 1983) • Shoulder dislocation >40 • 85-90% good to excellent ( Bigliani 1992)

  27. Massive Tears – Tendon transfer Latissimus Dorsi* Pectoralis Major* Teres Minor Subscapularis Deltoid muscle flap Trapezius

  28. Massive Tears – Latissimus Dorsi • Supraspinatus/Infraspinatus loss • Restore ER & head depression forces

  29. Massive Tears – Latissimus Dorsi • Results • 82% satisfactory (Miniaci & MacLeod 1999) • Intact subscapularis • Little or no restoration of strength in overhead activity

  30. Massive Tears – Pectoralis Major • Subscapularis tears

  31. Massive Tears - Reconstruction • Tissue implants • Autologous • Autogenous • Freeze-dried cadaveric tissue

  32. CUFF TEAR ARTHROPATHY

  33. CTA - Surgery Arthroscopic debridement* Humeral tuberoplasty Shoulder arthrodesis Total Shoulder Replacement Hemiarthroplasty* Reverse Shoulder Arthroplasty*

  34. CTA - Hemiarthroplasty • Indications • <70 years • Active elevation >90° • CTA Head • Variation of the hemiarthroplasty

  35. CTA - Hemiarthroplasty • Results • Functional results limited, pain relief is excellent (Williams & Rockwood 1996) • Zuckerman et al (2000) decreased pain, increased FF86 & ER 30. • Sanchez-Sotelo et al (2001) 67% successful at 5 year follow-up

  36. CTA - Hemiarthroplasty • Results • intact coracoacromial arch essential

  37. CTA- Reverse Shoulder Arthroplasty • Semiconstrained reverse ball and socket • Grammont 1985

  38. CTA - RSA • Biomechanics (Boileau et al 2005) • Large glenosphere • Medialisation of the centre of rotation • Lowers humeral head

  39. CTA - RSA • Indications • > 70 years or no active elevation • Low demand

  40. CTA - RSA • Results (Boileau et al 2005, De Buttet et al 1997, Rittmeister et al 2001) • Excellent pain reduction • Improved active abduction

  41. CTA - RSA • Complications • High • Rate revision is high (4.2-13%) • Not for the occasional operator

  42. REHABILITATION

  43. Rehabilitation -Biomechanics • Rotator Cuff • Stabilises gleno-humeral joint • Depresses the humeral head • Protective overlap • Subscapularis • Scapulo-thoracic dyskinesia • Compensatory impairment leads to winging • Alter orientation of the acromial arch

  44. Rehabilitation – Tendon Healing • Spontaneous healing ?? • Phases • Inflammatory • Proliferative • Maturation • Maximal load to failure 12-26 weeks

  45. Rehabilitation - Immobilisation Early ROM Abduction splint Shoulder immobilisation with an abduction-type splint for 4-6 weeks

  46. Rehabilitation - Cryotherapy • Speer et al 1996 • Less pain 1st 24 post-operative hours • Better sleep • Lesser analgesic requirement • Less swelling • Better able to tolerate rehabilitation

  47. Rehabilitation - PTT • Goals • Full ROM • Reducing impingement • Physical therapy plus exercise program better than exercise alone

  48. Rehabilitation - RCR • Goals • Mobilise the joint early • Load the repaired tendons safely • Strengthen the rotator cuff progressively

  49. Rehabilitation - RCR • Phases • Immediate post-operative period (week 0-6) • Protection & active ROM (week 6-12) • Early strengthening (week 10-16) • Advanced strengthening (week 16-22)

  50. Rehabilitation – Phase 1 • Goals • Maintain / Protect repair integrity • Gradual increase PROM • Diminish pain & inflamation • Prevent muscle inhibition • Exercises • Sling/abduction splint 6 weeks • Immediate PROM (depends on repair tension) • Pendular exercises • Cryotherapy • Hydrotherapy

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