MANANGEMENT OF ROTATOR CUFF TEARS DrT.K BYAKIKA Consultant Orthopaedic Surgeon and Adjunct Professor COHES, JKUAT

Dawn of an era

Introduction Rotator cuff repair has evolved greatly in last 10 years Improved understanding of the anatomy and pathoanatomy “cover the hole” past thinking Concept of the RTc balancing the force couple about the glenohumeral joint

Introduction When faced with a rotator cuff tear the primary goal of surgery is to balance the force couples in both the transverse and coronal planes Suspension bridge analogy This contradicts the historical principle of covering the hole

Primary Goals Decrease pain Improve shoulder function Limit cuff tendinopathy

Why? Arthroscopic The “ in thing” Better visualisation Better diagnosis Access to the glenohumeral joint Subacromial bursa Acromioclavicular joint Better results? DR M Ferguson Centre for Sports medicine

Open vs arthroscopic Both give satisfactory outcomes but there are Disadvantages of open repair: Persistent pain Longer rehabilitation Postoperative stiffness Unrecognized concomitant pathology Deltoid morbidity

Mini open Arthroscopic joint inspection Arthroscopic acromioplasty Deltoid split Outcome equivalent or superior to open repair Baker & Liu, Levy, Paulos, Weber

Arthroscopy Patients like it Better visualisation Better I.D. of tear size, configuration and mobility

outcomes SJ Snyder AANA speciality Day AAOS 1999 48 pts Mean FU 3.5 yrs Minimum 2cm tear Outcomes 90% satisfied with pain relief 93% satisfied with function Improved UCLA ASES scores

Transition to arthroscopic repair Absolute guidelines Be able to do an open repair Do your best operation Mini-open repair – goal for most of us can do acromioplasty under 15 mins > 50 cuff repairs / year NB Judged by outcome in the long run

biomechanics Balance force couples Single centre of rotation Avoid tension mismatch

Steep learning curve ACJ reconst Cuff repair ASAD Instability Surgery Debride Diagnosis DR M Ferguson Centre for Sports medicine

Classification Location of tear Partial – I to IV Complete I to IV A- Articular B- bursal C- complete Partial – I to IV Complete I to IV

Tear patterns 4 major types Crescent shaped U-shaped L-shaped & reverse L-shaped Massive contracted immobile tears

Double row repair

U shaped

U shaped

Reverse L Shaped

Massive adhesed contracted immobile RTC

Partial thickness rotator cuff tears Twice as common as full thickness RTc tears 3 types Articular surface Bursal surface Intrasubstance(interstitial tears) Controversy as to how to measure depth of the tear and which partial thickness tears should be repaired Weber recommends that > 50% tendon thickness should be repaired

Operative strategy Beach chair position Or lateral decubituus Artrhoscopy tower Arthropump Radiofrequency Shavers Operative instruments Cannulae Suture anchors

Intraoperative approach Usually 3 portals, posterior, lateral and anterior glenohumeral joint arthroscopic inspection, LHB, SSC tendon, assess the rotator cuff, intra-articular tears, Osteoarthritis Sub acromial space Bursectomy, Determine type of tear Acromioplasty(+/-) Cuff mobilisation(critical, coracohumeral lig, coracoid

Surgical procedure ctd Repair site preparation Mobility of the cuff Anchor placement Knotted or knotless Single or double row repair/ pros and cons Deadmans angle

Results 2014-2017 NO Average age Range Male 17 54 40-81 female 21 51 40-79 total 38 52.3

Operative time Year Average 2014 2.5hrs 2015 2hrs 2016 1.5hrs

Cases per year YEAR CASES 2014 7 2015 9 2016 11 2017

Tear patterns Cresecent 30 U shaped 2 Lshaped Reverse L Massive Total 38

Discussion Rotator cuff tears occur in the middle age and above as evidenced by our results which is in keeping with worldwide data Arthroscopic rotator cuff surgery affords you the opportunity to classify the tears The crescent tears are the commonest type of tears Using operative time as a measure of skill,less intraoperative time shows skills improving The instrumentation and also the use of knotless anchors has siginficantly influenced the ease with which perform surgery

Conclusions Arthroscopic rotator cuff surgery is doable and affords superior diagnostic capability of tears In my experience has a relatively long and steep learning curve Suggest that those interested should follow the algorithm as advised There are many patients with cuff problems as evidenced by rising numbers in my practice, “word of mouth” Predictable good outcomes

Thank you for your attention