Dont Cut The Rotator Cuff: Maintain It, Repair In-Situ: Results - - PowerPoint PPT Presentation

Larry D. Field, M.D. Mississippi Sports Medicine and Orthopaedic Center Jackson, Mississippi

Don’t Cut The Rotator Cuff: Maintain It, Repair In-Situ: Results are Spectacular

Disclosures

The following relationships exist:

1.Royalties and stock options

• None

2.Consulting income

• Smith & Nephew

3.Research and educational support

• Arthrex
• Mitek
• Smith & Nephew

4.Other support

• None

Partial Thickness Rotator Cuff Tears

• Despite PRCTs occurring very

commonly – Identifying tears challenging – Defining extent difficult – Treatment controversial

Classification

• Ellman (1990)

– Grade I

• <25% (<3 mm)

– Grade II

• 25 – 50% (3 – 6 mm)

– Grade III

• >50% (>6 mm)
• Snyder

– Location

• A (articular) and B (bursal)

– Severity

• 0 - 4

PRCT Types

• Articular

– Degenerative – 2° internal impingement

• Repetitive contact
• Tight posterior capsule
• Lax anterior capsule
• Bursal

– Outlet impingement

• Intratendinous

– Traction (tensile overload) – Degenerative

Operative Treatment

Decision making for PRCTs

• Factors to consider

– Depth of tear − Articular or bursal – Patient age – Activity level – Associated pathology

Measuring Depth of Tear

NORMAL CUFF PARTIAL ARTICULAR TEAR

• Debridement of PRCTs more commonly

performed in overhead athletes

– “Less is More” concept

• Repair indicated in some patients
• A. Complete tear then repair?
• B. In-situ (trans-tendon) repair?
• C. Patch?

Operative Treatment

Debridement vs. Repair

• Tears <3 mm (A1 or B1)

– Debridement

• Larger tears don’t heal

– Yamanaka 1994

• 80% of 40 articular tears progressed

arthrographically

• Tears >50% often repaired

– Complete tear vs. In-situ repair – Near complete (~95%) tears best completed then repaired—”take down the tear”

• Very limited intact rotator cuff tissue

Near Complete PRCTs

Completing RC Tear “Risky”

• Marking suture helpful in localizing

adjacent bursal RC

– Commonly performed

• Marking suture must be placed accurately
• Non-anatomic “RC take down” creates

improper iatrogenic tear

– “Take down” is a blind technique

• Subacromial space view with shaver blade
• Inadvertent damage to intact RC cable or

biceps tendon Biceps

RC Cable

“Poor Marksman”

In-situ Repair Proven Technique

• Snyder et al

1999

• Lo and Burkhart

2004 (Arthroscopy)

• Ide et al

2005 (AJSM)

• Waibl and Buess

2005 (Arthroscopy)

• Castagna et al

2009 (AJSM)

• Shin

2012 (Arthroscopy)

• Kim at al

2013 (Knee Surg Tr. Arth)

• Franceschi et al

2013 (Int Orthop)

• Vinanti et al 2016 (Knee Sports)

• Shin, Arthroscopy 2012

– Prospective, randomized study

• 48 patients (24 in each group)
• >50% partial articular tears
• Trans-tendon vs. “take down”
• No differences in functional outcomes
• Post-op MRIs

– 2 re-tears in tendon “take down” group – No re-tears in trans-tendon repair group

Results

Biomechanical Superiority Of In-situ Fixation

• Gonzalez (JSES 2008)

– Cadaveric 50% tears created – In-situ repair stronger

• Mazzocca (AJSM 2008)

– Intra-articular strain normalized after in-situ repair

• Sethi (Orthopaedics 2013)

– Bursal RC strain lower with in-situ repair

SETHI et al

In-Situ Repair Technique

Requirements

• Adequate intact tendon

(≥25%)

• Intact tendon healthy after

debridement

In-Situ Repair Technique

• Reapproximate footprint anatomically

to minimize tension mismatch

Rudkzi 2008

In-situ Repair Technique

• Lateral oriented suture

angle reduces tension mismatch

• Retrograde suture

passage aids repair

• Improved biceps view

helps avoid incarceration

Arch Orthop Trauma Surg 2016

Summary

• Careful arthroscopic assessment important
• Debridement alone for Type I partial tears
• Large partial tears do not heal and often

enlarge

• Several repair techniques successful
• In-situ PRCT repair technique

– Lower re-tear rates in some studies – Significant biomechanical advantages – Reduces risk to healthy RC tendon and biceps

Heal It, Don’t Peel It!

Thank You