.

Mr Lee Van Rensburg

2014

.

.

J Bone Joint Surg Am. 2014;96:265

.

Farmer Falls from tractor

Pain and weakness in shoulder

.

.

Diffuse pain in upper arm, following fall X rays show some arthritis Weakness and pain

.

See’s physio - 2 weeks later Pain slightly better Affecting sleep Still struggling with elevation 90°

? Rotator cuff tear

.

Why ? tear Jobe’s

.

.

- Apley's Scratch Test - Jobes Supraspinatus test - Dawburn's sign- Sherry Party sign- Codman's Sign (Drop Arm Sign)- Rent Test- Zero Degree Abduction Test - Burkhead's Thumbs down & Burkhead's Thumbs up

.

J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34

175175

.

Image

Inject

Start rehab?

.

? Tear in tendon Special scan Stop using it tear get worse……

Keep it moving !

.

Full thickness tear Supraspinatus Infraspinatus

.

60-69 =30% FTRCT

70-79 = 50% FTRCT

80-89 = 80% FTRCT

Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299

1953 - 61

1930 - 84

1936 - 78

.

Surgery Rehabilitation

.

Agency for healthcare research and qualityUSA July 2010

.

1 study

.

J BJS - Br January 2010 vol. 92-B no. 1 83-91

Age 59 (44-75) Age 61 (46-75)

Symptoms 10 - 12 months

+- 50:50 traumatic and atraumatic

.

J BJS - Br January 2010 vol. 92-B no. 1 83-91

.

J BJS - Br January 2010 vol. 92-B no. 1 83-91

Constant score

SatisfactionPhysiotherapy 7.2 (1-10)Surgery 9 (1-10)

.

J BJS - Br January 2010 vol. 92-B no. 1 83-91

Secondary surgery group

Delay in surgery 5 monthsFinal outcome 7.5 points less constant score

.

J BJS - Br January 2010 vol. 92-B no. 1 83-91

42 Happy not surgery

9 no surgery constant score 7.5 less

Surgery did better

BUT

.

.

Clin Orthop 1983;175:18-24.

N = 37 Group 1 – Operated within 3 weeks (n=12) Group 2 – Operated within 3 to 6 weeks (n=6) Group 3 – Operated within 6-12 weeks (n=19)

F/U ave. 7.0 years (range, 1 - 21 years) Abduction

Group 1 = 168° Group 2 = 126° Group 3 = 129°

Pain relief good for all Repair best within 3 weeks

.

J Shoulder Elbow Surg (2011) 20, 62-68

N= 36 3 groups

Group 1 - 0-8 weeks Group 2 - 8-16 weeks Group 3 - > 16 weeks

All improved Pain 7 down to 1Elevation 55 to 133

.

Surgery Rehabilitation

.

Anaesthetic Infection Stiffness Incomplete resolution Recurrence Re tear Rehab

.

Day case overnight stay 60-80% better Drive 6-8 weeks (2 weeks)

Desk top 4-6 weeks Manual work 3 months

Healed 6 weeks 60% 3 months 80%

.

.

Sling till arm awake Stay out of kitchen Most wear off 8 Hours

Pre emptive analgesia

.

Many different types of procedures Single row Vs double row Multiple anchor variations

Knotless anchors Metal vs PEEK Vs Absorbable Biological, vented

.

.

- “footprint” (Smith & Nephew)

.

Double-row have Significantly lower re-tear rate Higher ASES score Greater range of motion of internal rotation

Particularly in tears >30 mm

J Shoulder Elbow Surg (2014) 23, 182-188

.

Single row resulted in significantly higher re-tear rates compared with double-row repairs

No detectable differences in improvement in outcomes scores between single-row and double-row repairs

Shoulder Elbow Surg (2014) 23, 586-597

.

Sling 3 weeks all time

except when doing physio/ bath or shower 6 Weeks or social protection

Assisted range of movement “Nothing heavier than a cup of tea 6 weeks” No strengthening 6 weeks

.

J Shoulder Elbow Surg (2014) 23, 1631-1639

.

.

.

Mepore Dressings

.

Pad

.

J Shoulder Elbow Surg (2011) 20, 326-332

.

J Shoulder Elbow Surg (2012) 21, 61-65

.

Non operative Relative rest NSAID Physio Steroid injection (controversial) Supra scapular nerve block

Operative

JSES - 2008;17:863-870

3 months

.

Non operative Operative

Arthroscopic Debridement Reverse decompression Biceps tenotomy Suprascapular nerve ablation

Open Reverse shoulder replacement

JSES - 2008;17:863-870

3 months