1 / 54

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.

torn
Download Presentation

Rotator Cuff Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related