Cuff repair chris roberts

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<ul><li> 1. Rotator cuff repairMr Chris Roberts Consultant Orthopaedic SurgeonIpswich Hospital2nd Indian Watanabe meeting, Chennai 1</li></ul> <p> 2. Cuff repairs Which cuff tears needsurgery and when? Does patient age matter? Which tears will progress? Pick winners. How to repair a tear. 2 3. Age does matter Average age patients who heal 55 Average age patients who do not heal 65 Only 43% supraspinatus tears healed in patientsolder than 65 c/w 85% under 65(Boileau) 65 is correct cut off for aggressive vsconservative management cuff tears (YamaguchiICSES 2010)3 4. Which tears progress Maman More than 1 tendon Tear location - ant SST Duration of symptoms Moosmayer &gt;3cm Yamaguchi Full &gt; partial thickness 21% asymp symp over 2 years4 5. Factors affecting healing Tear size and retraction Patient age Fatty infiltration (Goutallier grade) Tangent sign (Thomazeau) Smoking Marcaine Failure to load (Botox)5 6. Tears under 65 Advise surgery New or sudden pain (= ? tear progression) &gt;1.5cm Anterior column supraspinatus involved Else patient choice Conservative vs operative Injection reasonable but not &gt;4 (Burkhead) 6 7. Tears over 65 Conservative initially Physiotherapy Activity modification Analgesia Injections Surgery if still symptomatic at 6 months 7 8. Spectrum of pathology Impingement Partial thickness tears Full thickness tears Biceps lesions ACJ degeneration Cuff tear arthropathy 8 9. Variables in cuff repair Biological: Extent and shape of tear Degree of retraction Quality of tendon Quality of muscle Quality of bone Mobility of tendon Healing of tendon to bone 9 10. Steps in cuff repair GHJ arthroscopy Bursectomy/soft tissue clearance Tear inspection/type/reduction/mobilisation Cuff and bed preparation Anchor placement Suture passage Knot tying Acromioplasty?10 11. Work to a system Most tears can be repaired using a standardisedsystem so familiarise yourself with one Techniques needed: Knot tying Sliding and non-sliding Suture passage Antegrade and retrograde Repair type Footprint: single or double row Side to side11 12. Set-up Beach chair/lateraldecubitus Traction Hypotensive anaesthesia Shavers/burrs/radiofrequency device Fluid management system Arthroscopic instruments Anchors/sutures Cannulae 12 13. PortalsAP13 14. GH Joint: Assessment of tear mobilityMedial-lateral reductionQuickTime and adecompressorare needed to see this picture.14 15. Bursal View: Assessment of tear mobility QuickTime and a decompressor are needed to see this picture. 15 16. Crescent-shaped Tears16 17. U-shaped Tears Firstly close side to side Then medial to lateral17 18. Margin Convergence 18 19. Reducing The Cuff Tear:- L-Shaped Tears L-Shaped Tears: (L-Shaped or Reverse-L) Reverse-L Tear S/Spinatus Greater Tuberosity Greater Tuberosity 19 20. L Shaped TearsL-shapeSide-to- Fix to side bone 20 21. Assessment of tear patternQuickTime and adecompressorare needed to see this picture.21 22. NB!! Bursectomy (? SAD first)QuickTime and adecompressorare needed to see this picture.22 23. Prepare footprint QuickTime and a decompressor are needed to see this picture. 23 24. Anchor Insertion Anchor fixation to bone(Mahar,Arthroscopy 2006, 22) Dead mans angle of anchor insertion (Burkhart, Arthroscopy, 95, 11) QuickTime and a decompressor are needed to see this picture. &lt; 40 Deg24 25. Anchor Insertion:Dead man Angle (Burkhart, 1995) &lt; 40 Deg25 26. Medial anchor insertion QuickTime and a decompressor are needed to see this picture. 26 27. Lateral rowQuickTime and adecompressorare needed to see this picture.27 28. Suture retrieval - retrograde QuickTime and a decompressor are needed to see this picture. 28 29. Suture Passing - retrograde QuickTime and a decompressor are needed to see this picture. 29 30. Suture Passing - antegrade QuickTime and a decompressor are needed to see this picture. 30 31. Suture Passing - shuttlingQuickTime and aQuickTime and adecompressordecompressorare needed to see this picture.are needed to see this picture.31 32. Current Preferred Technique: Suture-Bridge(Footprint Anchor for Lateral Row) Medial anchor: pass sutures through cuff medially and tie knots (increases tissue cut-out resistance) Suture limbs inserted into 1 or 2 lateral footprint anchors 32 33. Footprint AnchorStandard medial row anchor(s)and deep mattress suturesDont cut the sutures after tyingknots!!33 34. Conclusion Keys to success: Pick a winner Good anaesthesia Tension-free reduction Thorough bursectomy for visualisation Work to a system Variety of equipment invaluable My choice is Suture-bridge technique:some evidence of improvedbiomechanical strength34</p>

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