29. www.shoulder.grwww.shoulder.gr
Partial Thickness Tear
Bursal side tears
Articular side tears
Intratendinus tears
Partial tear classification by Ellman
Grade I <3mm deep
Grade II 3-6mm deep
Grade III>6mm deep (i.e. >50% thickness)
30. www.shoulder.grwww.shoulder.gr
Partial Tears Treatment Options
1. Debride partial tear only
2. In-situ Repair
3. Convert to full thickness, Debride, Repair
Etiology makes the decision!!!
Because most tears are degenerative, option 3 should be the
best for most cases
Trauma or young athletes are candidates for in-situ repair
If partial tear causes significant pain then debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]
www.shoulder.gr
33. www.shoulder.grwww.shoulder.gr
Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear
End-to-
bone repair
Good to
excellent
2
Longitudinal
(L or U)
Long and narrow tear
Margin
convergence
Good to
excellent
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval
slides or
partial
repair
Fair to good
4
Cuff tear
arthropathy
Cuff tear arthropathy Arthroplast
y
Fair to good.
37. www.shoulder.grwww.shoulder.gr
Recognize the Tear Pattern
Tears must be repaired in the direction of
greatest mobility -> minimal strain
The muscle-tendon junction must be 2-3
mm medial of the edge of the cartilage
at the tuberosity after the repair
46. www.shoulder.grwww.shoulder.gr
L-Shaped & U-Shaped Tears
Side to side sutures from medial to
lateral
Progressively converge the margin of the
tear lateral to the bone bed
Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by a
factor of 6
[S. S .Burkhart]
50. www.shoulder.grwww.shoulder.gr
Complete loss of active external rotation
(external rotation lag ) is a bad
prognostic factor
Superior migration of the humeral head
in contact with the acromion – repair
attempt is going to be a failure
Rotator Cuff Arthropathy
What are the limits?
51. Latissimus Dorsi Transfer
The goal of the transfer is to use an internal rotator
as an external rotator of the shoulder
Subscapularis
Lat. Dorsi
58. Results - Literature
Pain relief with latissimus dorsi transfer found to be
very satisfactory in all studies
Excellent or good results in about two-thirds of
patients, provided subscapularis intact
Aoki et al. JBJS (Br) 1996; 78: 761-766
Gerber et al. J Bone Joint Surg (Am) 2006; 88: 113-120
Iannotti et al. JBJS (Am) 2006; 88: 342-348
59. Other Options prior to RSA?
Arthroscopic
Implantation of
inspace Baloon
Biodegradable implant
comprised of a co-
polymer of poly-L_lactide-
co-ε-caprolactone
60. Goal is to achieve painless ROM
avoiding superior migration of the
humeral head.
Provides sufficient lever and tension to
the Deltoid to produce forward flexion
and abduction
72. Glenoid ShapeGlenoid Shape
The inferior 2/3 of the glenoid is nearly a perfect circleThe inferior 2/3 of the glenoid is nearly a perfect circle
with avg diameter 24mmwith avg diameter 24mm
Huysman et al. JSES 2006Huysman et al. JSES 2006
74. Critical LimitCritical Limit
6.8 mm width of resection 21% to total length of the6.8 mm width of resection 21% to total length of the
glenoid - substantial loss of stabilityglenoid - substantial loss of stability
Cadaveric biomechanical studyCadaveric biomechanical study
Itoi et al. JBJS 2000Itoi et al. JBJS 2000
75. Quantification of Glenoid BoneQuantification of Glenoid Bone
lossloss
Glenoid Index in 3D CT scan of both shouldersGlenoid Index in 3D CT scan of both shoulders
Critical Limit Glenoid index 0.75Critical Limit Glenoid index 0.75
SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
76. What is the critical limit of GlenoidWhat is the critical limit of Glenoid
Bone loss?Bone loss?
Piasecki et al. AAOS J17 (8): 482. (2009)
Bone loss <15% (0-3.5mm) of ap width Soft
tissue repair incorporating the bone fragment if
possible
77. What is the critical limit of GlenoidWhat is the critical limit of Glenoid
Bone loss?Bone loss?
>25 – 30% bone loss 6.5 – 8.6mm ap
width
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)
78. Traumatic Glenohumeral Bone Defects and Their
Relationship to Failure of Arthroscopic Bankart Repairs:
Significance of the Inverted-Pear Glenoid and the Humeral
Engaging Hill-Sachs Lesion
S.S. Burkhart and J. F. De Beer, M.D.
Arthroscopy,October 2000
79. Glenoid Bone Loss >25-30%
Arthroscopic Latarjet procedure
L. Lafosse
Arthroscopic shoulder stabilization with a bone block
E. Taverna
Limitations of the
Arthroscopic Techniques
82. Engaging Hill-Sachs-glenoid bone loss
Limitations of the
Arthroscopic Techniques
Hill- Sachs Remplisage: An arthroscopic surgical
solution for the engaging Hill-Sachs
E.M. Wolf
88. Arthroscopic Bone Block combined withArthroscopic Bone Block combined with
arthroscopic repair – Bankart -arthroscopic repair – Bankart -
RemplissageRemplissage
89. www.shoulder.grwww.shoulder.gr
Conclusions
Evolution of Shoulder Arthroscopy Techniques and
Materials provide solutions for the management of
Shoulder Pathologies that could not be dealt with
arthroscopy in the past.
Nowadays the majoritry of shoulder pathology can be
treated with the arthroscope
It is not just a revolutionary technique
It is a whole new concept of management of shoulder
pathology a paradigm shift
