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Double row athlitiatriko 2008
1. Double Row Arthroscopic
Rotator Cuff Repair
Manos Antonogiannakis
Director
Center for Shoulder Arthroscopy
IASO General Hospital
www.shoulder.gr
2. Rotator Cuff Function
1. Dynamic stabilizer of the shoulder
2. Contributes strength to the arm
(50% of the abduction strength is generated by
supraspinatus)
3. Couple forces stabilize and regulate the
motion of the shoulder
www.shoulder.gr
3. Rotator Cuff disease
Rotator cuff disease is a wide spectrum
of clinical conditions, which range
from asymptomatic partial
thickness tears to symptomatic rotator cuff
arthropathy
www.shoulder.gr
4. First Successful RC Repair
Codman EA. Rupture of the supraspinatus
tendon Boston Medical & Surgical
Journal 1911 Vol
clxiv (2) 708-10
McLaughlin HL. Lesions of the musculotendinous
cuff of the shoulder: the
exposure and repair of tears
with retraction. J Bone Joint Surg 1944;26:31-51.
First Description of RC tears
Smith JG. London. Med Gaz, 1834,14:280
Pathological appearances of seven cases
of injury of the shoulder joint, with
remarks. EA Codman
HL McLaughlin
The History of Rotator Cuff Repair
www.shoulder.gr
5. • In 1972 Neer defined the concept of
subacromial impingement
• Open Surgery
• Mini Open Surgery
• In the 90s’ the arthroscope changed the
treatment
www.shoulder.gr
The History of Rotator Cuff Repair
6. Tears’ Definitions
• Partial Thickness Tears =
absence of communication between the
glenohumeral joint and the subacromial
bursa.
• Full Thickness Tears =
communication between the glenohumeral
joint and the subacromial bursa.
• Massive Tear =
Involving 2 or 3 tendons [Gerbers]
or bigger than 5cm [Cofield]
www.shoulder.gr
7. How frequent are RC Tears?
• Rotator Cuff Frequency:
30% of population
• Significant correlation with
age [Sher JS, Arthroscopy 1995]
www.shoulder.gr
8. Full Thickness Tear
Age Frequency
40-60 4-13%
60-70 20%
70-80 50%
>80 80%
Partial Thickness Tear
Age Frequency
<40 4%
>60 25%
[Tempelhof S, JSES, 1999]
How Frequent are RC Tears?
www.shoulder.gr
9. Rot cuff disease etiology and
pathogenesis
1. Tendon degeneration
2. Vascular factors
3. Impingement
• Type of acromion as identified by Bigliani
• Acromial angle devised by Toivonen .
• Type I. Angle 0-12
• Type II. Angle 13-27
• Type III. Angle > 27 Popularized by Neer
4. Secondary impingement popularized by Jobe
5. Instability overload of the cuff - secondary superior migration
6. Trauma
7. Glenohumeral instability
8. Scapulothoracic dysfunction
www.shoulder.gr
10. Natural History of a Tear
• Tears DO NOT HEAL. Some but NOT ALL of them will
progress
• Rot cuff arthropathy is the end stage (4%)
• 50% of newly symptomatic tears will progress in size
• 20% of asymptomatic tears will progress.
• No Tear seem to decrease in size.
• 80% of partial tears progress in size or become full
thickness at 2 years
[Yamaguchi K., 2006, Nice Shoulder Course]
www.shoulder.gr
11. Current Knowledge
• RC tears DO NOT behave the same
in different patients
• Patients PROFILE plays
the most important role
• Size and Location of the tear
DOES MATTER
www.shoulder.gr
12. RC Treatment
Patient Profile
Size & Location
Symptoms
Tissue Quality
Other Lesions
MAKE YOURMAKE YOUR
DECISIONDECISION
www.shoulder.gr
13. Stable RC repair
Restoration of tensile strength
Creation of an environment that facilitates
healing mediated by the bursa
Prevention of bone/tendon gap formation
Example of applied basic science in surgery
The Goal of Operative Treatment
www.shoulder.gr
14. What kind of Repair is
NECESSARY?
• An anatomically deficient RC could be a biomechanically
intact rotator cuff
[Burkhart]
• Conservative treatment of chronic painful rot cuff tears
will result in a successful outcome in about 50% of
patients
[Cofield]
• Cuff tear arthropathy will develop in 4% of patients with
complete rot cuff tears
[Neer]]
www.shoulder.gr
15. What can we Repair?
• UP to 50% of cuff repairs had a postoperative defect
• This didn’t affected patient satisfaction or pain relief
• But it did affected shoulder strength
[Harryman et all J. B.J.S 1991]
www.shoulder.gr
16. Factors that affect RC Healing
• Age
• Sex
• Activity
• Size
• Location
• Tissue quality and
elasticity
• Muscle fat
degeneration
• Chronicity of the tear
• Concomitant lesions
• Smoking
• Family history
• Rehabilitation
Protocol
• NSAID
• Surgical Technique
www.shoulder.gr
17. Risk to Benefit Ratio
• Rot cuff tears DO NOT heal spontaneously
• Tear repairability
• Think of Size, Elasticity and Chronicity
• Fatty infiltration is not fully reversible
www.shoulder.gr
Operative Treatment
18. What is Bad Tissue Quality?
• Large or massive tears,
• Retracted tears,
• Coutallier three or four fatty infiltration
www.shoulder.gr
19. RC Arthroscopic Repair
1. Recognition, of the type of the tear
2. Retraction and releases
3. Repair Options:
Anchors: metallic or absorbable
Type of stitch: Mason-Allen,
Mc Stitch,
Mattress sutures,
Horizontal mattress,
Simple sutures
Restoration of footprint: Double row or
Single row www.shoulder.gr
20. The quality of Functional results
depends on:
1. The size of the persistent defect
2. Associated atrophy of the muscles
3. Integrity of the deltoid and the
coracoacromial arch
4. Functional demands of the patient
www.shoulder.gr
21. How to convert a Symptomatic tear
to an Asymptomatic re-tear
• Subacromial decompression and
debridmeut
• Biseps tenotomy
• Partial repair and healing of the rot cuff
• Adequate post-op rehabilitation
www.shoulder.gr
23. Early failure
of arthroscopic rot cuff repair
1. Failure of tendon-suture interface
2. Suture-anchor failure
3. Suture failure
www.shoulder.gr
24. RC Repair Results
• The rate of structural failure after open repair varies
from 20% to more 50%, while it is greater for
arthroscopic repairs
• First report of DOUBLE ROW repair:
Fealy S, Kingham TP, Altchek DW, Arthoscopy July 2002
Mini-open Rot cuff repair using a two row fixation technique
www.shoulder.gr
25. ANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOAD
OF THE REPAIR
www.shoulder.gr
52. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Medial Row
Lateral Row
Contact area
www.shoulder.gr
53. Double Row RotatorCuff Repair
SutureBridge technique
Bio-Corkscrew FT & PushLock
2 X 5.5 mm. Bio-Corkscrew FT Medial row
2 X 3.5 mm. PushLock Lateral Row
www.shoulder.gr
54. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
2 medial anchors tied, ….
Do NOT cut the sutures
Load separate sutures through
PushLock
www.shoulder.gr
55. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Disengage driver from anchor
6 counterclockwise rotations, cut
suture
Placement second PushLock
….. Done !
www.shoulder.gr
81. • Harryman et all J. B.J.S 1991 found that UP to
50% of cuff repairs had a postoperative defect.
This didn’t affected patient satisfaction or pain
relief but it did affected shoulder strength
• Klepps reported open repair of 32 medium and
large rot cuff tears. The retear rate by MRI at I
year was 31%. And patients with failed repairs
hod lower UCLA scores and worse pain scores
• Open or arthroscopic repairs are expected to
improve pain and function in 90% of patients
82. Arthroscopic repairs do not heal faster
Knowledge of biomechanical principles is
mandatory in choosing repair type
Cuff repair is feasible but technically demanding
www.shoulder.gr
83. Double Row Advantages
• BETTER restoration of the footprint
• Wider bone to tendon contact
• Stronger repair
• More points of fixation to share the loads
• Biomechanically superior to single row
• No clinical difference with single row
www.shoulder.gr
85. Conclusions
• Rot Cuf is extremely significant for the normal function of
the shoulder
• Rot Cuf tears can be asymptomatic
• Symptoms Produced by a tear depend on:
– Size
– Location
– Functional demands of the patient
www.shoulder.gr
86. Conclusions
• An anatomically deficient but biomechanical intact cuff is
possible
• Biomechanical intact cuff is the cuff that restores the
equilibrium of the force couples
• A cuff tear does not heal conservative
• A cuff tear after operative repair may yet not heal
• Partial healing may restore sufficient power to the cuff to
equilibrate the force couples
www.shoulder.gr
87. Conclusions
• Non-operative treatment strives to optimize the function
of the remaining cuff
• Rehabilitation after surgery strives to optimize the
function of the partially or completely healed cuff
www.shoulder.gr
88. ..so when we treat a RC tear…
We must try to:
• Optimize the anatomic integrity of the cuff by a repair
with minimal morbidity to the healthy tissues (mainly
deltoid) and maximum strength
THEN
• Rehabilitate vigorously the patient, to optimize the total
function of the shoulder
THEN
We can expect a majority of
satisfied patients
www.shoulder.gr
89. Conclusions
• Double row provides maximum strength of
initial fixation
• Restores the footprint of the rot cuff
• Although technically demanding probably
is more suitable for young overhead
athletes that stress vigorously the rot cuf
91. • Older patients
• Chronic symptoms
• Minimal loss of function
(strength-mobility)
• Less active
Non-Operative Treatment for:
•Older patients
•Massive tear
•Superior migration of the
humeral head
•Fatty infiltration of the muscles
•Retraction of the tendons
Trial of Non-Operative Treatment
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106. What to do???
• Patients with grade 3 or 4 fatty degeneration
DO NOT improve with rot cuff repair
[Goutallier]
Vs.
• Patients with grade 3 or 4 fatty degeneration
improved significant at 86% of cases after
arthroscopic repair
[Burkhart]
www.shoulder.gr
