Burkhart - Repair of Massivr RCT.pptx

5/4/15 Disclosure
Arthroscopic Repair of
Massive Rotator Cuff Tears:
Indications, Techniques, and Results
Stephen S. Burkhart, M.D. is a consultant
for, and receives inventor's royalties from
Arthrex, Inc., Naples, FL
Stephen S. Burkhart, M.D.,
San Antonio, Texas
What is a Massive Tear?
•  2 or more tendons
•  > 5 cm. diameter
Arthroscopic Massive Cuff Repair
Results of Arthroscopic Repair of
Massive Cuff Tears
Arthroscopic Massive Cuff Repair
- Denard & Burkhart, Arthroscopy 2012
Denard & Burkhart, Arthroscopy 2012
•  1998-2005 (341 repairs)
•  126 with f/u, 62.3 yrs old at surgery
–  107 complete repairs
–  19 partial repairs
•  62.3 yrs old at time of surgery
•  Interval slides 54 cases (43%)
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Mean follow-up over 8.2 years
Forward flexion 132 → 168
ASES 42 → 94
UCLA 16 → 31
–  Good or excellent 78%
•  81% with complete repair
•  58% with partial repair
•  75% with double interval slide
•  91% patient satisfaction
1 5/4/15 Arthroscopic Massive Cuff Repair
Denard & Burkhart, Arthroscopy 2012
•  Double-row vs. Single-row repairs
–  Excluded partial repairs for analysis
–  UCLA 15 → 33 vs. 16 → 30
–  ASES 42 → 94 vs. 43 → 84 (not
significant)
–  Patients rated shoulder 94% vs. 84 %
normal
–  Double-row 4.9 x more likely to lead to
good or excellent functional outcome
Is the Tear Repairable?
The Ugliest Cuff Tears
•  Tears with pseudoparalysis
•  Irreparable cuff tears
Pseudoparalysis
•  Yes…..in > 95% of cases (Burkhart
2004)
•  May need advanced techniques such as
interval slides
Arthroscopic Cuff Repair for
Pseudoparalysis
It’s Not Magic
-­‐ Denard, Jiwani, Burkhart. Arthroscopy 2012. It’s just a bunch of tricks.
•  75 month average follow-up (minimum 2 year)
•  35/39 (90%) regained overhead motion > 90
degrees
•  Forward flexion improved from 49° to 155°
•  1 re-operation (revision ARCR after a fall)
•  Patients reported shoulder 82% of normal
2 5/4/15 The Keys
•  Understand the anatomy
•  Understand the biomechanics
Cable-Crescent Complex
-­‐ Burkhart et al, Arthroscopy 1995 Suspension Bridge Analogy
•  Reinforce the cable attachments
What About the Anatomy?
•  Rotator cable-crescent complex
Suspension Bridge Analogy for
Rotator Cuff Tears
Biomechanical Principle
•  Balanced force couples are critical
3 5/4/15 Biomechanical Principle
Arthroscopic Anatomy
•  Expose the bony landmarks
•  Restore balanced force couples!
–  Scapular spine
–  Define the raphé between SS and IS
Use Bony Landmarks to Help
Define Cuff Tear Configuration
4 5/4/15 Subscap Tear Should Always Be
Repaired, Never Debrided
What about
the Subscapularis?
Origin of Comma Tissue
Medial sling of biceps (prior to tear)
•  Robust deep layer (medial head of CHL)
•  Tenuous superficial layer (SGHL)
•  Footprint of medial sling adjacent to subscap
footprint
Identifying the Comma
Creation of Comma Sign
•  Progressive tearing and retraction of
upper subscap
•  Avulsion of medial sling from humerus
•  Medial subluxation of biceps
Implications of Comma Anatomy
1. 
It leads to the superolateral subscap tendon
5 5/4/15 Implications of Comma Anatomy
2. 
The comma connects the subscap to the
supraspinatus
Finding the Retracted Subscap
•  Locate the comma and follow it to
subscap
Repairing the Subscap
•  Simple upper subscap tears
•  Single anchor repair
Repairing the Subscap
•  Mobile tendon
•  Double-row footprint repair
The Adhesed Retracted
Subscap Tear
•  Do 3-sided release
•  Single-row repair
•  Medialize bone bed 5 to 7 mm if
necessary
6 5/4/15 3-Sided Release
Medialization of Bone Bed
•  Anterior
•  5 to 7 mm if necessary
•  Ssup
•  Posterior
Factoids
•  The subscap is always present and is always
repairable
•  Degree of fatty infiltration does not matter
because……
•  Much of the subscap function is a tenodesis
effect
After Subscap Repair:
Repair SS/IS
Implications of Comma Anatomy
•  The comma leads to the supraspinatus
•  Subscap repair reduces the tension on
supraspinatus repair
Understanding Tear Patterns
•  The tear pattern is the repair pattern
7 5/4/15 Tear Pattern Recognition
Tear Pattern Recognition
Crescent Tear
Chronic U-Shaped Tear
Tear Pattern Recognition
Interval Slides
Chronic L-Shaped Tear
Anterior Interval Slide
•  Releases coracohumeral ligament (CHL)
•  2 ways to accomplish this:
Cut the comma •  Anterior and posterior
New “Modified” Double Interval Slide
•  Anterior interval slide in-continuity
•  Posterior interval slide
Release CHL “in-­‐con=nuity” 8 5/4/15 Dealing with the Massive
Adhesed Cuff Tear
Finding the Plane
Between Acromion and Cuff
Finding the Correct Plane
Dissect the Plane
•  Lateral viewing portal
•  Posterior working portal
•  Bounce off scapular spine and push
laterally through scar
9 5/4/15 Dissect Bursal Leaders
Expose Scapular Spine
•  Expose posterior gutter
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Excise Bursal Leaders
•  Excavate the rotator cuff
•  Better visualization of rotator cuff and
greater tuberosity
Anterior Interval
Slide In-Continuity
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
Posterior Interval Slide
10 5/4/15 Posterior Interval Slide
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)
Poor Tendon Quality
•  Rip-stop suture
What if Tissue is Deficient?
Load-Sharing Rip-Stop:
Reinforcement of Repair for Short
Poor-Quality Tendon
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Short tendon
Poor quality tissue
Load-sharing
Stress shielding of sutures from medial anchors
Load-Sharing Rip-Stop:
2 FiberTapes
•  1 rip-­‐stop tape per tendon 11 5/4/15 Biomechanical Testing
•  10 N pre-load
•  Then cyclic loading between 10 and 100
N at 1 Hz, for 200 cycles
•  Then pull to failure at 33 mm/sec
Results:
Ultimate Load to Failure
•  Control (371 ± 102 N); double-loaded
single-row repair with 2 anchors
•  Load-sharing rip-stop (616 ± 185 N)
l  Load-­‐sharing rip-­‐stop construct had load-­‐
to-­‐failure that was 1.7x as strong as control group !
One Additional Feature of
LSRS Fixation
•  Interlocking of 2 structurally distinct types
of single-row repairs
Indications for
Load-Sharing Rip-Stop
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Poor-quality tendon
Short tendon (e.g. tendon loss)
Revision repair
Any situation that requires
reinforcement
Interlocking Provides 3 Things
That Neither SR Construct Could
Achieve
•  Ripstop to prevent suture cut-out
•  Load-sharing between rows
•  Interlocking self-reinforcing system
Case 1
•  62 year old man
•  Fell 6 feet from ladder
12 5/4/15 What if the Tear Is
Not Repairable? (<5% of cases)
Augmentation/Bridging
with Dermal Allograft
•  Partial repair
•  Consider augmentation with dermal
allograft (Snyder et al)
•  Consider superior capsular reconstruction
if there is no meaningful tendon to attach
dermal graft to (Mihata et al, Arthroscopy
2012)
13 5/4/15 Superior Capsular Reconstruction (SCR):
Mihata Procedure
Typical Patch GraM SCR SCR Results
- Mihata et al, Arthroscopy 2013
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Superior Capsular Reconstruction (SCR):
Mihata Procedure
Acromiohumeral Interval
24 shoulders, 34 month average follow-up
Irreparable RCTs
Fascia lata patch
Elevation
–  Pre-op 84°
–  Post-op 148°
•  Acromiohumeral interval
–  Pre-op 4.6 mm
–  Post-op 8.7 mm
•  No progression of OA or cuff muscle atrophy
Pre-­‐Op Post-­‐Op The Role of
Posterior Interval Slide
•  Even if mobility of tendon is not improved,
the exposure of superior glenoid is
improved for medial fixation of dermal
allograft
14 5/4/15 Should You Do Reverse TSR for Massive
RCT in Patients < 65 Years Old?
•  Gerber et al, JSES 2013
–  46 rTSR’s, 65 y.o.
–  Irreparable RCT, with or without DJD
–  38% incidence of one or more complications!
Remember…
Massive cuff tears are almost
always reparable.
Irreparable SS and IS
•  Very uncommon
•  Consider combination of
1.  Posterior interval slide
2.  Superior capsular reconstruction (SCR) with
dermal allograft
Recognize the tear patterns
and apply the appropriate
biomechanical principles
15 5/4/15 Thank You!
Consider Dermal Allograft
Augmentation or SCR for the
Occasional Irreparable RCT
16