Fact. However. Historically 5/4/15. Arthroscopic Revision Cuff Repair. Revision Rotator Cuff Repair: How To Do It Better
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1 Fact Revision Rotator Cuff Repair: How To Do It Better Stephen S. Burkhart, MD San Antonio, Texas Functional outcome after cuff repair is better in patients with a healed rotator cuff. Harryman et al. JBJS (Am) Boileau et al. JBJS (Am) However Many patients have satisfactory outcomes despite persistent cuff defects Jost, Gerber et al. JBJS (Am) Galatz, Ball, Yamaguchi et al. JBJS (Am) So When should we do a revision cuff repair? Historically Mixed results from open revision cuff repair DeOrio & Cofield. JBJS (Am) Only 17% good results overall Only 12.5% good results for massive tears Djurasovic, Bigliani et al. JBJS (Am) Satisfactory (excellent, good, or fair) results in 67% of massive tears Arthroscopic Revision Cuff Repair 1
2 Arthroscopic Revision Cuff Repair Lo & Burkhart, Arthroscopy Keener, Galatz, Yamaguchi et al, JBJS (Am) Paisecki, Verma, Nho, Cole, Nicholson, Romeo et al. AJSM Laedermann, Denard, Burkhart, Arthroscopy Arthroscopic Revision Repair Results Lo & Burkhart, Arthroscopy patients 2 year follow-up 63% good/excellent 93% satisfied Results much be1er than with open revision. Arthroscopic Revision Repair Results Laedermann, Denard, & Burkhart, Arthroscopy patients, 53 massive 5 year average follow-up 78% significantly improved and satisfied No difference in functional outcome between massive and non-massive ASES scores improved between 1 year and 5 years (results are durable) Relevant Questions for Post-Op Painful Shoulder Is it re-torn? Does it need surgery again? Can surgery make the patient better? What can be done better the second time? How can we do it? Is It Re-Torn? 48 year old female 4 months post-op arthroscopic cuff repair Pain and weakness MRI: recurrent cuff tear 2
3 MRI Can be deceptive in the vascular phase (up to 5 months post-op) MRI High-strength suture can cause artifact that looks like a cuff defect In general, wait at least 6 months before considering post-op MRI. Can Surgery Improve The Patient? In general, yes 78% improved and satisfied If pseudoparalysis after failed surgery, prognosis is guarded Pseudoparalysis without prior surgery, 90% regained overhead Pseudoparalysis after prior surgery, 40% regained overhead Fact Revision surgery for post-op pseudoparalysis must have a guarded prognosis What Can Be Done Better? How Do We Do It? Failure of Cuff Repair: Patient Factors and Extrinsic Factors Intrinsic non-healing (age, smoking) Intrinsic over-healing (post-op stiffness) Non-compliance Overly aggressive P.T. 3
4 Impact of Fatty Degeneration Traditional teaching If 50% F.I., patients will not improve with repair My experience Even if 50% F.I. (up to 75% FI), strength and function improve significantly after repair - Burkhart et al, Arthroscopy 2007 Impact of Retraction: BRASS Study Group patients with pre-op pseudoparalysis (worst-case scenario; most were retracted) 53/56 reversed their pseudoparalysis (95%) 51/56 were fully repairable (91%) Reparability of Massive RCT 107/126 (85%) fully reparable during Denard & Burkhart, Arthroscopy 2012 Current Reparability Rate for Massive RCT 95% fully reparable with current methods Failure of Cuff Healing: Surgeon Factors Failure to detect all the pathology (e.g. subscap) Failure to properly detect tear pattern Failure to provide adequate mechanical fixation Failure to prescribe appropriate rehab (e.g. overly aggressive) When Can Revision Surgery Be Successful? Post-op stiffness If surgeon failures are strongly suspected 4
5 Step Wise Approach Address the Biceps and Subscap Normal Torn Subscap Subluxed Biceps Coracoplasty Subscap Repair Biceps Tenodesis Excavate SS/IS Dealing with the Massive Adhesed Cuff Tear Finding the Plane Between Acromion and Cuff Finding the Correct Plane Lateral viewing portal Posterior working portal Bounce off scapular spine and push laterally through scar 5
6 Dissect the Plane Dissect Bursal Leaders Expose posterior gutter Expose Scapular Spine Excise Bursal Leaders Excavate the rotator cuff Better visualization of rotator cuff and greater tuberosity Remove fat pad posterior to AC joint Follow acromial arc posteromedially Keel-shaped bone is scapular spine The keel defines border between SS and IS Repair Supra & Infraspinatus If mobile tear, repair with single or double row If non-mobile tear, consider double interval slide 6
7 Anterior Interval Slide In-Continuity Posterior Interval Slide Posterior Interval Slide 7
8 What if SS Will Not Reach Bone Bed After Interval Slides? Do repair of IS (balance force couples) Do side-to-side repair of SS to IS Leave residual defect (partial repair) Case Presentation 48-year old man Failed repair of SS/IS Weak ER Positive belly-press Positive bear-hug Case Presentation 2 prior opinions Lat dorsi transfer Reverse TSR SS, IS Missed subscap Recurrent Tear Subscap Repair 8
9 SS/IS Repair L-shaped tear pattern Double row repair Post-op Rehab Avoid aggressive rehab No stretches for 6 weeks Strengthening at 4 months Conclusion Arthroscopic revision cuff repair can give significant improvement Surgery requires meticulous attention to detail Rehab should be slow to avoid re-rupture 9
10 Thank you! 10
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