1. Reconstruction of Massive Rotator Cuff Tear Using Embroidered Polyester Cuff Reinforcement Nottingham Shoulder and Elbow Unit I-H Jeon, WA Wallace, L Neumann, J Ellis, A McLeod

2. Introduction Treatment of rotator cuff tear has been evolved. However, there are no definite solution for massive rotator cuff tear. Conservative treatment Conservative treatment Debridement Debridement Muscle transfer Muscle transfer

3. Introduction Modes of failure in bone tunnel method Modes of failure in bone tunnel method suture migration through bone Modes of failure in Mode of failure in suture anchor technique Mode of failure in suture anchor technique Loosening and backing out of anchor screws (different behaviour of humeral anchors than glenoid anchors ) anchors )  Augmentation device Treatment of rotator cuff tear has been evolved. However, there are no definite solution for massive rotator cuff tear. Treatment of rotator cuff tear has been evolved. However, there are no definite solution for massive rotator cuff tear. Conservative treatment Conservative treatment Debridement Debridement Muscle transfer Muscle transfer

4. Introduction Augmentation device Augmentation device Gerber C, Schneeberger AG, Perren SM, Nyffeler RW.Experimental rotator cuff repair. A preliminary study.J Bone Joint Surg Am. 1999 Sep;81(9):1281- 90.

5. Introduction Polyester has been proposed for ligament augmentation device and substitute in the knee.Literature demonstrated that Scaffold for soft tissue ingrowth Scaffold for soft tissue ingrowth Mechanical support: appropriate initial strength to meet the biomechanical demands of the injured area, Mechanical support: appropriate initial strength to meet the biomechanical demands of the injured area, Less foreign body reaction Less foreign body reaction

6. Introduction The purpose of this study was to evaluate the application of Polyester Embroidery Reinforcement (Nottingham augmentation device) and investigate the outcome in massive full thickness RCTs previously considered irreparable using this method.

7. Materials and Methods Patients were added to the study if they had clinical weakness and pain and if magnetic resonance imaging confirmed a massive rotator cuff tear. 22 patients (13 men/ 9 women) 22 patients (13 men/ 9 women) 13 patients followed up > 10 months 13 patients followed up > 10 months Mean age of 60 years (range 46-78) Mean age of 60 years (range 46-78) Patients with combined glenohumeral Patients with combined glenohumeral arthritis have been excluded. arthritis have been excluded. F.U 10-23 months (mean 12 months). F.U 10-23 months (mean 12 months).

8. Duration of symptoms : 19 (4-36) months. Pre-op symptoms were moderate to severe shoulder pain on lifting and shoulder weakness. Materials and Methods

9. Pre-op MRI scans in 8 cases revealed FT large or massive tears of the RC with Goutallier grade III-IV fatty degeneration. Materials and Methods * *

10. Operative Technique 1 2 Identify the retracted distal stump and release adhesion

11. Operative Technique 3 4 Insertion involves anchoring the device to the undersurface of the retracted RC tendon with 10-12 stitches Make a bone tunnel under the G.T.

12. Operative Technique 5 6 Pass the other end of the device through a tunnel under the greater tuberosity Anchoring the device, under tension, to the proximal humerus with 1 or 2 large AO screws

13. Operative Technique

14. The proximal fixation is similar to “spot-welding” The distal fixation is a “flexible plate” type of fixation. Operative Technique The device is made of polyester, embroidered for good tissue ingrowth and provides good initial mechanical strength, thus fixing the cuff to the head during the healing process

15. Clinical Results-Constant score

17. Range of motion Clinical Results-Constant score

18. Power at abduction 90 Clinical Results-Constant score

19. Overall Constant Score: Clinical Results-Constant score A A* N-A N-A*

20. Ten reported a marked improvement in the early post-operative period. Results

21. Radiographic Results

22. Case-1 F/69 Postop 12 mo CS: 35  78

23. Case-1 Preop Elevation 90 ER 50 Constant score: 87/34 (R/L) Postop Elevation 180 ER 90 Constant score: 90/67 (R/L)

24. Case- 3 CS 64  25  61 M/62 postop 6mo

25. Case-2 Postop 4 mo F/46 Preop

26. Case-2 Postop 4 mo CS:38/85 Severe fatty degeneration at supra+infra Re-rupture of tendon at 10 months postop

27. Re-rupture of RC: 2 Re-rupture of RC: 2 Stiff shoulder: 1 (MUA+ arthro debriment) Stiff shoulder: 1 (MUA+ arthro debriment) Deep infection: 0 (No foreign body reaction) Deep infection: 0 (No foreign body reaction) Complications M/46 re-rupture of supraspinatus at 12 months

28. Biomechanical property of Nottingham Augmentation Device (in vitro) Nottingham Augmentation Device (in vitro) Discussion Fatigue test in saline at 200 and 300N, maximum elongation of 0.38mm. at 200 and 300N, maximum elongation of 0.38mm.

29. Reaction of Polyester Discussion Polyester fibres Fibrin Fascia-like Collagen HPF: Patient 4 (at 14 years) P Durani, I-H Jeon, TA McCulloch, A McLeod, WA Wallace The Histological In- growth of soft tissue into the Nottingham hood prosthesis, British Orthop Research Society 2003

30. Treatment of massive RC tears is Treatment of massive RC tears is still controversial. still controversial. This polyester augmentation device This polyester augmentation device provides initial mechanical strength, prevent tendon stripping, & provides scaffold for soft tissue ingrowth with less foreign body reaction. Conclusion

31. Biomechanical study of polyester augmentation device Biomechanical study of polyester augmentation device What happens to tendon-device interface What happens to tendon-device interface How to adjust proper tension How to adjust proper tension Future Study Randomized comparative study between repair and debridement Randomized comparative study between repair and debridement

32. Thank You