1. Rotator Cuff Repair Indications, Patient Selection, Outcomes James C. Vailas, M.D. New Hampshire Orthopaedic Center September 14, 2013 New Hampshire Musculoskeletal Institute 20 th Annual Symposium

2. Evolution of Arthroscopic Repair Lanny Johnson, M.D., 1985, staple repair Eugene Wolf, M.D., 1990, suture repair with metal anchor (Mitek GII)

3. Evolution of Arthroscopic Repair Similar to capsulorraphy –Diagnostic convert to open –Treating other pathologies – Learning curve – Continuous improvement techniques – Continuous improvement in outcomes –Decreased morbidity –Outpatient –Rehabilitation

4. TRENDS OF REPAIRS 141% increase 1996-2006 141% increase 1996-2006 –Arthroscopic increased 600% open 34% –Repairs done ASCs quadrupled Colvin et al, JBJS Am, Feb. 2012 Acromioplasties decreased 10% 2004-09 Acromioplasties decreased 10% 2004-09 –Mauro et al, JBJS Am, Aug. 2012

5. Rotator Cuff Repair Anatomy Anatomy –Gross and Arthroscopic Pathological anatomy Pathological anatomy Surgical Indications for Repair Surgical Indications for Repair –Patient Selection Arthroscopy Set-up Arthroscopy Set-up Surgical Procedures / Techniques Surgical Procedures / Techniques Rehabilitation Rehabilitation Clinical Outcomes Clinical Outcomes

6. Shoulder Girdle Humerus Scapula Clavicle Coracoid 1 st Rib Bicipital groove

7. Glenohumeral Joint Humeral Head Coracoid Process Glenoid Acromion

8. Rotator Cuff Subscapularis Anterior View

9. Rotator Cuff Supraspinatus Infraspinatus Teres Minor Acromion

10. Outlet View Biceps Tendon CA Ligament Acromion Coracoid

11. Rotator Cuff Supraspinatus Infraspinatus Teres Minor Subscapularis Lateral View Coracohumeral ligament

12. Acromion ClassificationBigliani I. Flat II. Curved III. Hooked

13. MRI ANATOMY Supraspinatus capsule

14. Rotator Cuff Tear Supraspinatus tear Intraartiuclar tear Bursal tear

15. Intra-articular Biceps

16. Rotator Cuff Tear Humeral Head Cuff

17. Associated Diagnoses & Pathology –Impingement: Bursitis; –Biceps: Tendonitis, tears, SLAP –Acromioclavicular arthritis –Instability

18. Surgical Indications Patient Selection Symptoms - History Symptoms - History –True shoulder pain  Lateral acromial and arm, not forearm –Duration >3mos. –night pain –functional disability with ADLs –Failed rehab

19. Surgical Indications Patient Selection Physical Exam Physical Exam –Painful active ROM impingement –Cuff weakness  Comparative  Drop-arm- supraspinatus  Horn Blowers- infraspinatus  Belly press test- subscapularis  Lift-off test

20. Surgical Indications Patient Selection MRI MRI –Complete tears MRI arthrogram MRI arthrogram –Partial tears: >50%

21. Surgical Relative Contra-indications Age: >65y.o. Age: >65y.o. Fatty atrophy of muscle (Goutallier 4) Fatty atrophy of muscle (Goutallier 4) Arthritis Arthritis Large tears, high demands Large tears, high demands Massive tears (2 tendons retracted) Massive tears (2 tendons retracted) Adhesive capsulitis Adhesive capsulitis

22. Arthroscopy Setup Lateral Decubitus

23. Arthroscopy Setup Sitting- Captain’s Chair

24. Surgical Procedures –Decompression –SLAP Repair –Rotator Cuff Repair –Distal clavulectomy –Biceps tenodesis/ tenotomy

25. Decompression Acromion

26. Rotator Cuff Repair

27. Preop Preparation -Inflammation & pain  Pre-emptive meds –COX2 NSAID 48hrs –Acetaminophen: 1grm. –Motion: balance flexibility –Patient education & expectations  Immobilization  ADL’s  Return to work/sport  Long-term symptoms & function

28. Surgical Technique Cuff Preparation Portal Position Portal Position Bursectomy- visualization Bursectomy- visualization Tear Pattern- crescent, laminated, L, partial Tear Pattern- crescent, laminated, L, partial Tendon Debridement Tendon Debridement Mobilization / Releases Mobilization / Releases

29. Surgical Technique Trans-tendon Trans-tendon Single row anchors Single row anchors Double row anchors Double row anchors –Crossbridging Augments Massive tears Augments Massive tears Platelet Rich Plasma Platelet Rich Plasma

30. Rehabilitation Debate Debate –Early Passive motion necessary?  Kim et al, Level I PRC study, 105 pts no motion vs passive first four wks -ASES, SST, cuff integrity- no difference ……is likely safe, it is also not inherently necessary AJSM 2012 April

31. Rehabilitation Debate Debate Early aggressive vs. limited passive motion –Lee et al, Level II RC, 64 pts motion increased 3mos.; same 1 yr trend for increase tears Arthroscopy 2012 Jan

32. Rehabilitation Immobilizer Immobilizer Passive motion- Passive motion- –7-10 days Active assisted 6-8 wks Active assisted 6-8 wks Resistance exercise 3 months Resistance exercise 3 months Strenuous exercise 5- 6 months Strenuous exercise 5- 6 months Full “normal” 9- 15mos. Full “normal” 9- 15mos.

33. Open repairs Outcomes Coefield JBJS 1985 Coefield JBJS 1985 –87% pain relief –77% pt. Satisfaction Baker & Liu,AJSM 1995 Baker & Liu,AJSM 1995 –80% good –excellent –88% pt. satisfaction Overall results: 71-92% Overall results: 71-92% –Improved pain, function, strength  Smaller tears had better healing and functional outcome Gazielly et al CORR 1994

34. Open repairs Outcomes Residual defects: 34-90% Eugene Wolf, Arthroscopy, 2004 20 % with SS tendon repair 57% with 2 tendon repairs 66% with 3 tendon repairs Harryman et al JBJS 1991 41% with 2 tendon repairs Gazielly et al CORR 1994

35. Comparison Mini-open vs. All-Arthroscopic Weber et al, 2004 AOSSM Weber et al, 2004 AOSSM –154pts. mini-open & 126 All-arthro Large tears excludedLarge tears excluded –min. f/u 6yrs. –ASES, UCLA, SST scores equivalent –Retear rates similar  All-arthro significant reduction peri- operative morbidity

36. All Arthroscpic Repair Massive Tears Galatz & Yamagucchi, JBJS ’04 Galatz & Yamagucchi, JBJS ’04 –18pts. 2 or more tendon tears –Ave.age 61 –min. f/u 2yrs; ave 36mos. –ASES scores: Pre-op 48.3 – Post-op 79.9 –U/S evaluation: 17/18 retears –All pts. satisfied Possible causes for retears: 1 anchor/1 suture technique; immediate active pulley exercise

37. All Arthroscopic Repairs >90% Satisfaction long term 10yrs >90% Satisfaction long term 10yrs –6-8% continued pain and/or weakness Intrinsic factors: A-C jt, G-H jt OA; labrum, biceps, deltoid, impingement, adhesive capsulitis, instability Extrinsic factors: cervical spine, suprascapular nerve Millet PJ et al, JSES 2011

38. All Arthroscopic Repairs Literature review 6-24mos f/u Literature review 6-24mos f/u –60-90% healed by imaging –Significant difference in strength/function healed vs. un-healed healed vs. un-healed Not all repairs that fail to heal are symptomatic Slabaugh et al, Arthroscopy 2010

39. Outcomes Summary All repair techniques Patient satisfaction high Patient satisfaction high Pain relief high Pain relief high Despite structural failures, outcomes better Despite structural failures, outcomes better Larger the tear the poorer outcome Larger the tear the poorer outcome Better cuff integrity, better functional outcome Better cuff integrity, better functional outcome

40. Current Challenges Current Challenges –Younger, active pt. with large tear –Better tendon healing –Modifying rehabilitation appropriate for biology of healing –Decrease cost of instruments and anchors –Establish easier techniques

41. All Arthroscopic Advantage Visualizing and magnifying cuff tear Visualizing and magnifying cuff tear Multiple angles to tear Multiple angles to tear Treating associated pathology Treating associated pathology Short term recovery Short term recovery  Pain and ROM Large tears Large tears –Avoiding deltoid morbidity –Better mobilization Historical progression of orthopaedic surgery Historical progression of orthopaedic surgery

42. All-arthroscopic Rotator Cuff Repairs All-arthroscopic Rotator Cuff Repairs Surgeon Specific Technique Poorly done arthroscopic repair is worse than a well-done mini-open repair.

43. Thank You!