arthroscopic rotator cuff repair t. andrew israel, md luther midelfort orthopaedic & sports...
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ARTHROSCOPIC ROTATOR CUFF REPAIR
T. Andrew Israel, MDLuther Midelfort Orthopaedic &
Sports Medicine Center
OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS
• Treatment Options
• Treatment Principles
• Surgical Indications
• Advantages of ARCR
• Disadvantages of ARCR
• Technique for ARCR
• Results
TREATMENT OPTIONS
• ASAD/debridement without repair
• Open repair
• Mini-open repair
• Arthroscopic repair
TREATMENT PRINCIPLES
• Address associated pathology
• Adequate decompression• Assess tear-size, retraction, pattern, tissue
quality, repairability
• Tendon mobilization
• Secure repair
• Supervised rehabilitation program
SURGICAL INDICATIONS
• Pain
• Functional deficits
• Failure to respond to nonoperative care
• Full-thickness tear
• Extensive partial-thickness tear
• Acute injury
ADVANTAGES OF ARCR
• See both sides of cuff• Visualize all pathology-labral tears, biceps,
OA, etc.
• Easier releases(esp. capsule)
• Less pain, morbidity
• Smaller scars
• Better ROM
• PATIENTS WANT IT!
DISADVANTAGES OF ARCR
• Learning curve
• ? Smaller contact area with bone for healing
• High retear rate by ultrasound reported
• ? Pain from resorption of anchors
• Coding/reimbursement problems
TECHNIQUE FOR ARCR
• Define tear• Mobilize tendons• Prepare tuberosity• Cuff reduction• Place anchors• Suture management• Pass sutures through tear edge• Knot tying
DEFINE TEAR
• View from anterior and from posterior
• Measure with probe known size
• Trim ragged edges but preserve tissue
MOBILIZE TENDONS
• Place retention sutures
• Release capsule
• Anterior interval release
• Posterior interval release
MARGIN CONVERGENCE
• Begin cuff reduction
• Work medial to lateral
• Side to side sutures
• Tie knots
PLACE ANCHORS
• At lateral aspect of footprint
• Metal or biodegradable
• Make sure well fixed in bone
SUTURE MANAGEMENT
• Keep track of portals
• Avoid tangles
• Think one step ahead
• Move at steady pace
PASS SUTURES THROUGH TEAR EDGE
• Many devices available
• Avoid tearing tendon
• Line up puncture with anchor
RESULTS Gartsman, JBJS, 1998
• 73 arthroscopic RCR
• Average age 60.7 yrs
• All pts followed at least 2 yrs(30 mons)
• 78% G/E relief of pain
• 90% G/E satisfaction
• None of the shoulders were rated G/E preop, 84% G/E @ most recent f/u
RESULTS Burkhart, Arthroscopy, 2001
• 59 arthroscopic RCR
• Average follow-up 3.5 yrs
• 95% G/E result regardless of tear size
• Rapid return overhead function(4 mons)
CASE D.E.
• 53 male RHD farmer
• Left anterior shoulder pain x 2 years
• No prior injury or surgery
• Nonoperative Rx including PT, NSAIDS, injections, activity modifications, etc.
PHYSICAL EXAM
• Crepitus with PROM
• Tenderness greater tuberosity
• AROM 155/170, 55/75, L5/T10
• 3/5 power abduction & external rotation
• Positive impingement tests
SUMMARY
• Much recent enthusiasm regarding complete arthroscopic rotator cuff repair
• For many, this newer technique may be preferable alternative to more traditional mini-open rotator cuff repair
• Important that basic principles of rotator cuff repair not be compromised