Arthroscopic Repair

Peter J. Millett, MD, MScDirector of Shoulder Surgery

The Steadman ClinicVail, CO

AANA/AOSSM/ASES Specialty Day

March 28, 2015

Las Vegas, Nevada

Disclosures

Peter J. Millett, MD, MScRelevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within this presentation are as follows:

Consultant and Royalties: Arthrex, Inc.

Consultant: Myos

Stock and Stock Options: GameReady, VuMedi

Research activities supported by the Steadman Philippon Research Institute (SPRI).

Corporate sponsorships for SPRI : Smith & Nephew, Arthrex, Siemens, Össur

Case Presentation

• 48 y/o M overhead worker

• Increasing pain

• Supraspinatus tear with Grade 2

atrophy and acute infraspinatus tear

–Treatment???

Arthroscopic Repair!!!

• Goals of Rotator Cuff Repair

– Restoration of anatomy

– Restoration of biomechanics

– Strong fixation

– Promote healing

– Improve shoulder function!

Arthroscopic Repair!!!

• Advantages

–Address concomitant pathologies

• SLAP, biceps pathology etc..

–Lower complication rates than RTSA

and tendon transfer

– Improved functional outcomes

Cuff Tear Pathogenesis

• Acute trauma

• Chronic degeneration

– Involves both extrinsic and intrinsic factors

• Extrinsic factors

– Coracoacromial arch

– Acromial morphology

– Coracoid morphology

– Glenoid inclination?

• Intrinsic factors

– Advanced age

– Tenuous blood supply

Normal Massive RCT

Can we Predict Cuff Degeneration?

• Critical Shoulder Angle (CSA)– < 30o associated with osteoarthritis

– > 35o associated with degenerative RCTs

• Moor, Gerber et al, Bone Joint J 2013

• Spiegl, Millett et al, JSES In Press

• Acromial Index (AI)– > 0.7 associated with degenerative RCTs

• Ames, Millett et al, JBJS 2012

• Moor,Gerber et al, Bone Joint J 2013

• MRI T2 Mapping• Anz, Ho, Millett et al, Eur J Radiol 2014

Critical Shoulder Angle

Acromial Index

Fatty Infiltration

• Burkhart et al Arthroscopy 2007

– Arthroscopic repair of massive

tears w/ advanced fatty infiltration

– Significant functional improvement

• Increased ROM

• Improved UCLA and Constant score

• Important to assess both

coronal and sagittal MRIs

Full-Thickness Tears

Advantage: 3-dimensional, predictable on MRI which allows a

prognosis to be estimated

• Classification - 2010

Tear Pattern Recognition

Crescent L / Reverse L U-ShapeMassive,

Contracted

Millett, Warth JAAOS 2014

Importance of Tear Patterns

• Three-dimensional tear pattern recognition is

required for modern arthroscopic rotator cuff

repair…

– Facilitates anatomic restoration

– Optimizes biomechanical properties

– Optimizes tendon biology

– Decreases failure rate

– Improves clinical outcomes!

Extended Speedbridge

Personal Experience

Arthroscopic RCR RTSA Lat Transfer

ASES 93 80 75

SANE 88 67 61

SF-12 PCS 53 44 43

QuickDASH 9 31 39

Median Satisfaction 9/10 9/10 10/10

Mean postoperative scores at time of final F/U

My surgeries in registry 2006-Present• >1100 RCR• >90 RTSA• >20 Lat Transfer

2 Years s/p Repair of Massive Tear

What about older patients?

Millett et al (AJSM in press)

– 49 full thickness rotator cuff tears

– Average age was 73.8 (range, 70-82)

– All patients were active, recreational

athletes

– ASES score improved from 56 to 90.3

– DASH improved from 34.1 to 11.3

– Mean patient satisfaction was 9/10

Improvement in pain affecting ADLs and

ability to participate in sporting activities

Conclusions

• Arthroscopic RCR is the best option in this

patient

• Proven to improve function and decrease

pain, even in the elderly

• Low complication rates

Thank you!!