Massive Rotator Cuff Tears Arthroscopic Treatments - Brian D. Busconi, MD Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center ...
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Massive Rotator Cuff Tears
Arthroscopic Treatments
Brian D. Busconi, MD
Chief of Sports Medicine & Arthroscopy
UMass Memorial Medical Center
Brian.Busconi@umassmemorial.org
Disclosures
Consultant
Arthrex
Mitek
I (and/or my co-authors) have something to disclose.
Detailed disclosure information is available via:
Printed Final Program
or
AAOS Orthopaedic Disclosure Program on the AAOS website at
http://www.aaos.org/disclosure
Disclosure • I am a Joint Preservationist !! • I Prefer Biologic Options • Dr. Mc Millan prefers Metal and Plastic • .JPG
Thank You • AOAO
Thank You Jeffrey Murray,DO
This is hard….
"It's supposed to be hard. If it wasn't hard, everyone
would do it. The hard is what makes you great.”
- Tom Hanks, A League of Their Own
Managing Expectations
Arthroscopy, 2017
Patient satisfaction is the most important quality outcome metric
and will affect physician reimbursement
Patient satisfaction directly linked to a patient’s pre-operative
expectations
Less Pain and More Function
Occupation
100
93.9%
902017
AJO,
82.7%
80
What do they want? 70
60
Prefer Strong
50 Shoulder/Mild Pain
40 Prefer Weak
Shoulder/No Pain
30
20 17.3%
10 6.1%
Less Pain 0
Labor Non-Labor Class
More Function
Overview
• The Problem
• The Options
• Patient Paradigm
• How willof
Recentering youHumeral
choose? Head
Source of the Problem • 62 M fall onto shoulder • C/O weakness and pain
Massive RCT Options
v Non-Surgical
v Debride/Repair
v Bridge ECM
KSST 2016 AJSM 2017
v SCR
v
Arthroscopy 2013 AOTS 2017
SA Balloon
v Tendon Transfer
v Reverse TSA JBJS 2014Massive RCT Classification • DeOrio: >5cm either M-L or A-P • Gerber: At least 2 tendons involved • Descriptive: acute vs chronic, retraction, atrophy
Physical Exam • Supraspinatus: Empty can • Infraspinatus: Weakness with ER at 0 deg abduction, ER lag sign* • Teres Minor: Hornblower • Other Pearls: evaluate for trapezial recruitment, atrophy, winging
Imaging – My Pearls
• Acromiohumeral Interval: 8-11mmCORR 1990
Repair /SCR Repair /SCR
AHI > 6 mm AHI < 5 mm Acetabulization
*
Excavated Spur along CAL HH Collapse
acromion
GH JSN * Concave AcromionImaging
• Decreased AHI, with OA → REVERSE!Imaging
• Critical shoulder angle
– 35 associated with
degenerative rotator cuff
tearsMRI Based Algorithm
Massive Cuff Tear
≥ 5 cm²
≥ 2 tendons
(≥ Grade 3 Fatty deg.)
Repair Tendon Transfer
Reverse Prosthesis
± Augmentation (Latissimus)
± Latissimus
± Bridge Graft (Pectoralis)
Superior Capsule Reconstruction
Mihata T, Arthroscopy 2013MRI Considerations
JSES,
Correlation between fatty 2012
atrophy and…
1. Functional Outcome
2. Risk of Anatomic Failure
3. Reparability Flurin et al., Rev Chir Orthop, 2005
Fuchs et al., JBJS 2006Fatty Infiltration = RTSA • Arthroscopic repair can provide significant functional improvement (39.3 mo FU) • Grade 3 shoulders had better results than grade 4 • Overall, 86.4% satisfaction
Options for Massive RC Tears
Traditional Biologic
• Debridement • Superior Capsular
• Biceps tenotomy Reconstruction
• Partial repair
• Latissimus dorsi transfer
• Interposition patch graft /
“Bridging”
• Reverse arthroplastyDebridement +/- biceps procedure
• Ideal for: pain relief with low functional demand
– Sick, elderly
• Pros: quick case, easy rehab, not relying on body to heal anything
Cons: limited functional gain, likely continued progression of cuff atrophy and OA
• Rockwood et al, JBJS 1995
– showed 83% satisfaction at 6.5 years post op
– Mean forward flexion improved from 105 to 140, despite not performing
any repair
• Gartsman et al, JBJS 1997
– Sig decrease in pain, increase in ROM and ability to perform ADLs
– No improvement in strengthPartial Repairs – Marginal Convergence
• Restores biomechanical force couples in
shoulder
– Enhances axial compressive force
– Increases AHI
– Reduces pain, improves function
– Persistent abnormal kinematics despite the
centering effect
Burkhart 1994, Duralde 2005
DiBenedetto et al, Acta Biomed 2017
Good short to medium results with a limit of 6-7 years
Cuff et al, JSES 2016
Reasonable outcomes at 5 yrs, 29% failure
Shon et al, AJSM 2015
Over half of 31 patients at years, unsatisfied with outcome
Kim et al, Arthroscopy 2012
Satisfactory short term outcomesComplete Repair • Goal - tension free, anatomic repair of entire tendon • Complete healing is the goal, but healing rates may not correlate with clinical outcomes • Patient selection is key! – 78 y/o diabetic, smoker vs 65 y/o with no PMH – Understand their goals for surgery – Establish realistic expectations
Complete Repair - Surgical Pearls • Visualize entire extent of tear - thorough bursectomy, SAD • Debride non-viable cuff tissue • Margin Convergence stitches • Mobilization – Subacromial, supraglenoid adhesions – Anterior/posterior interval slides • Biology - footprint preparation, crimson duvet, biologics
Complete Repair - Surgical Options
• Single row
• Double row (traditional)
• Double row - linked/transosseous equivalent
• Biologic adjuncts?
– PRP
– Crimson duvet
– Patch augmentationRepair is Possible in Some
N=56 @ 1 yr
Significant Improvements
Reversed Pseudoparalysis in 53/56
AJSM, 2015
N=67
Posterior Repair
SST 4.6à9.0
Constant 44à73
Restored AHI
JSES, 2011
N=107 @ 5 yr
91% satisfied
DR 5x likelihood of G/E
Arthroscopy, 2012
IS Atrophy predicted failure
AJSM, 2013 Decreased AHI predicted failureComplete Repair - Outcomes • Overall retear rates: – Single Row: 68/263 (25.9%)* – Double Row: 37/261 (14.2%)* • No difference in functional outcomes (ASES, UCLA,Constant)
Complete Repair - Outcomes
• High patient satisfaction
• All measured outcome scores showed significant
improvement
• MRI documented retear rate, min 1 year: 26%
– No correlation with functional outcomes
• Conclusion: arthroscopic RCR is safe and effective in
patients > 75 years oldRepair of the Massive RCT
History
• 72 yo 10 year h/o R
shoulder pain and weakness
w repeated non-operative
treatmentImaging
What was done…
Latissimus Dorsi Muscle Transfers
• Namdari et al, Systematic review, JBJS-A
2012
– 10 studies included
– Improved shoulder function, ROM,
strength, pain relief
• But not normal shoulder or complete
relief
– Risks of neuropraxia, infectionIntercalary Placement
“Bridging” / “Spanning”
• Biomechanical studies showing equivalent load-to-
failure and mechanical properties, but few articles
show success clinically
• – Gupta, Toth et al., AJSM 2012
24 pts interposition repair using human dermal
–
allograft
–
Minimum f/u 29 mos
–
ASES 66.6 -> 88.7 (p=0.0003)
–
Improvements in pain / ROM
Ultrasound demonstrated intact repairs in 76%
Snyder et al, IJSS 2007
Schlamberg et al, JSES 20What if it looked like this?
Superior Capsular Reconstruction
• Technique described by Hanada
(1993) & Mihata (2007)
• No option for Reverse TSR
• Needed option for massive
irreparable RCT
• Re-center the humeral head using
fascia lata autograftWhat is the SCR?
Papers Describing Surgical Technique
8
Papers Describing Outcomes
1How Does SCR Work?
• Lowers center of humeral head
rotation
• Couples functioning rotator cuff to
superior capsular checkrein
• Stabilized glenohumeral joint
rotational platform to regain maximal
shoulder function and avoids RSA in
the younger cuff deficient patientsSuperior Capsular Folding
Intact superior capsule Superior capsule reconstruction
Courtesy of Dr. Teruhisa MiArthroscopic Superior Capsule Reconstruction
Teruhisa Mihata, MD
• Mihata et al, Arthroscopy, 2013
– Methods:
• 24 shoulders over 2 years
• Autograft fascia lata used to reconstruct superior capsule
– Results:
• A-H distance: 4.6±2.2 mm to 8.7±2.6 mm (p < 0.0001)
• ASES Score: 23.5 to 92.9 points (p < 0.0001)
• Twenty patients (83.3%) had no graft tear or tendon re-
tear
Mihata et al, Arthroscopy 2013
Nagasawa, ISAKOS PresentationMihata et al., Arthroscopy 2016
“Graft Size Affects Shoulder Stability after Superior Capsule Reconstruction for Irreparable
Rotator Cuff Tear”
• Fascia lata SCR 4 & 8 mm normalized
subacromial contact pressures
• Superior translation differences
– 4 mm - partially restored
– 8 mm - fully restoredArthroFlex Human Allograft Dermis • Ready to use • Hydrated • Room temperature storage • Sterile (10-6 SAL) • 3 year shelf life • Biocompatible – > 97% DNA removal • Excellent suture retention strength • Intact framework Matracell Process • Variable thickness (0.5 – 3.5 mm)
Biomechanical Comparison
Fascia Lata, Doubled ArthroFlex, 3.5 mm
Failure = 180 N Failure = 550 N
Double Surgeon’s Knot = 480 NSolid Surgical “Game Plan”
Critical
• Flow of case
• Specific instruments & accessories
• Specific implants and suturing technique to
ease graft passage and deployment
• Measure twice, cut once (dermal graft)Mihata et al., AAOS 2016
“Superior Capsule Reconstruction Using Human Dermal Allograft: A Biomechanical Cadaveric Study”
Fascia Lata Human Dermal Allograft
• Fully restored: • Partially restored:
– Superior humeral head – Superior humeral head translation
translation
– Subacromial contact • Fully restored:
characteristics – Subacromial contact characteristics
– Superior glenohumeral – Superior glenohumeral joint force
joint force • Significantly improved ROM compared
• Stiffer to FLMargin Convergence?
• Mihata et al, AJSM 2016 • Dermal allograft
– Posterior margin convergence – More elastic than fascia lata
necessary to restore
biomechanics
– Need to consider anterior
margin convergence
– When using fascia lata, – If no rotator interval tissue,
anterior margin convergence then attach graft into or
anterior to biceps groove
does not effect outcomePreparation: Tape off the room
• Hemostasis
• Cannulas and flexible Passport (radial cut)
• Adequate bursectomy
• Glenoid preparation (consider Neviaser portal)
• Stab incisions to “park” sutures
• Exact measurements at glenoid, greater tuberosity and
medial to lateral
• Streamlined graft passage planPearls to Success • Span the defect with graft & anchors Decorticate laterally and centrally • Glenoid anchors medial to labrum - min 3 • Neutral arm position • Accurately measure between anchors • Punch graft for suture sliding • Double pulley technique Ant/Post central knotless • 12 mm Passport for graft passage • Must incorporate infraspinatus repair Posterior Key • Do NOT over-constrain the shoulder But graft must have good tension!!!
Option 1
Superior Capsular Reconstruction
History
• 58 yo R Shoulder pain
• Prior massive RCR and “never got
better”
• Continued pain and weakness
• Unresponsive to additional non
surgical care
• FE 140, ER 50, Strength 3/5 SS, ISImaging
Arthroscopy
Current Technique
Radiographic Outcome
2 months post-op SCR
Pre-op Post-op
AH Distance = 2.0 mm AH Distance = 8.4 mmRadiologic Outcome
4 months post-op MRI
Normal Pre-op Post-opRadiographic Outcome 8 months post-op Ultrasound
When it was done…
Summary
Mihata Busconi
• Fascia lata autograft • ArthroFlex allograft
– 180 N – 550 N
• A-H distance • A-H distance
– 4.6 mm to 8.7 mm – 4.8 mm to 8.7 mm
• ASES Scores • ASES Scores
– 23.5 to 92.9 – 41.2 to 88.0
• 83.3% - No graft or re-tear • Complications (1) – Fall / Torn IS
n = 24 patients / Follow up 24-51 mos n = 14 patients / Follow up 6-18 mosWhy Not RSA?
• Subject to overuse
– Too commonly seen as solution for previously
untrestable shouder pathologies
• Challenging surgical technique
– Requires extensive training and experience limits
availability
• Wide range of significant complications rates
• Arthroplasty has limited lifespan- bridge burnerImplant Cost*
• SCR • RTSA
• $6,700 • $10,400
*Estimated that total cost for RTSA is 15-22K more than SCRMy Indications
Inclusion Exclusion
• • Moderate to severe arthropathy
•
Irreparable supraspinatus and/or
infraspinatus tears
•
Bone defects
Failed conservative management •
•
Absence of deltoid, latissimus dorsi, or
pec function
•
Intolerable shoulder pain
• Subjectively unacceptable dysfunction Shoulder stiffnessFinal Thoughts:
Rock, Paper, Scissors
• Having a biologic force coupler trumps no cuff whatsoever
• SCR trumps RSA, especially in younger non-arthritic cuff
deficient shoulders
• Four definable steps
1.Bony prep
2.Anchor placement
3.ArthroFlex graft prep
4.Graft deployment
• Now let’s go save some shoulders!!Thank You It’s about solving your patient’s Problem
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