1. MANANGEMENT OF ROTATOR CUFF TEARS
DrT.K BYAKIKA
Consultant Orthopaedic Surgeon and Adjunct Professor COHES, JKUAT

2. Dawn of an era

3. Introduction Rotator cuff repair has evolved greatly in last 10 years
Improved understanding of the anatomy and pathoanatomy
“cover the hole” past thinking
Concept of the RTc balancing the force couple about the glenohumeral joint

4. Introduction
When faced with a rotator cuff tear the primary goal of surgery is to balance the force couples in both the transverse and coronal planes
Suspension bridge analogy
This contradicts the historical principle of covering the hole

5. Primary Goals Decrease pain Improve shoulder function
Limit cuff tendinopathy

6. Why? Arthroscopic The “ in thing” Better visualisation
Better diagnosis
Access to the
glenohumeral joint
Subacromial bursa
Acromioclavicular joint
Better results?
DR M Ferguson
Centre for
Sports medicine

7. Open vs arthroscopic Both give satisfactory outcomes but there are
Disadvantages of open repair:
Persistent pain
Longer rehabilitation
Postoperative stiffness
Unrecognized concomitant pathology
Deltoid morbidity

8. Mini open Arthroscopic joint inspection Arthroscopic acromioplasty
Deltoid split
Outcome equivalent or superior to open repair
Baker & Liu, Levy, Paulos, Weber

9. Arthroscopy Patients like it Better visualisation
Better I.D. of tear size,
configuration and mobility

10. outcomes SJ Snyder AANA speciality Day AAOS 1999 48 pts
Mean FU 3.5 yrs
Minimum 2cm tear
Outcomes
90% satisfied with pain relief
93% satisfied with function
Improved UCLA ASES scores

11. Transition to arthroscopic repair
Absolute guidelines
Be able to do an open repair
Do your best operation
Mini-open repair – goal for most of us
can do acromioplasty under 15 mins
> 50 cuff repairs / year
NB Judged by outcome in the long run

12. biomechanics Balance force couples Single centre of rotation
Avoid tension mismatch

13. Steep learning curve ACJ reconst Cuff repair ASAD Instability Surgery
Debride
Diagnosis
DR M Ferguson
Centre for
Sports medicine

14. Classification Location of tear Partial – I to IV Complete I to IV
A- Articular
B- bursal
C- complete
Partial – I to IV
Complete I to IV

15. Tear patterns 4 major types Crescent shaped U-shaped
L-shaped & reverse L-shaped
Massive contracted immobile tears

18. Double row repair

19. U shaped

20. U shaped

21. Reverse L Shaped

22. Massive adhesed contracted immobile RTC

23. Partial thickness rotator cuff tears
Twice as common as full thickness RTc tears
3 types
Articular surface
Bursal surface
Intrasubstance(interstitial tears)
Controversy as to how to measure depth of the tear and which partial thickness tears should be repaired
Weber recommends that > 50% tendon thickness should be repaired

24. Operative strategy Beach chair position Or lateral decubituus
Artrhoscopy tower
Arthropump
Radiofrequency
Shavers
Operative instruments
Cannulae
Suture anchors

25. Intraoperative approach
Usually 3 portals, posterior, lateral and anterior
glenohumeral joint arthroscopic inspection, LHB, SSC tendon, assess the rotator cuff, intra-articular tears, Osteoarthritis
Sub acromial space
Bursectomy,
Determine type of tear
Acromioplasty(+/-)
Cuff mobilisation(critical, coracohumeral lig, coracoid

26. Surgical procedure ctd
Repair site preparation
Mobility of the cuff
Anchor placement
Knotted or knotless
Single or double row repair/ pros and cons
Deadmans angle

27. Results 2014-2017 NO Average age Range Male 17 54 40-81 female 21 51
40-79
total 38
52.3

28. Operative time
Year
Average
2014
2.5hrs
2015
2hrs
2016
1.5hrs

29. Cases per year
YEAR
CASES
2014 7
2015 9
2016 11
2017

30. Tear patterns Cresecent 30 U shaped 2 Lshaped Reverse L Massive Total38

31. Discussion
Rotator cuff tears occur in the middle age and above as evidenced by our results which is in keeping with worldwide data
Arthroscopic rotator cuff surgery affords you the opportunity to classify the tears
The crescent tears are the commonest type of tears
Using operative time as a measure of skill,less intraoperative time shows skills improving
The instrumentation and also the use of knotless anchors has siginficantly influenced the ease with which perform surgery

32. Conclusions
Arthroscopic rotator cuff surgery is doable and affords superior diagnostic capability of tears
In my experience has a relatively long and steep learning curve
Suggest that those interested should follow the algorithm as advised
There are many patients with cuff problems as evidenced by rising numbers in my practice, “word of mouth”
Predictable good outcomes

33. Thank you for your attention