(Go: >> BACK << -|- >> HOME <<)
SlideShare a Scribd company logo

Rotator Cuff Evidence Update

•Download as PPTX, PDF•
•
The Arm Clinic
The Arm Clinic

This document provides an overview of rotator cuff disorders and evidence related to diagnosis and management. Key points include: - Rotator cuff tears can be caused by mechanical or degenerative factors and progress from tendinosis to partial or full thickness tears. - Physical exams have low diagnostic accuracy for tears but clusters of tests may help. Investigations like ultrasound and MRI can better identify soft tissue pathology. - Factors like age, tear size, tendon retraction and fatty infiltration affect outcomes, with larger/retracted tears and more fatty changes correlating to poorer prognosis. - Initial management focuses on rest, analgesics and physiotherapy, with surgery for failed non-operative treatment. Surgical techniques like

1 of 58
Evidence Update- Rotator Cuff Disorders Mr Puneet Monga Consultant Orthopaedic Shoulder Surgeon Wrightington Hospital
The Rotator Cuff Image Courtesy- www.patient.info
Understanding Cuff Function & Tears
Kinematics -Vectors Supraspinatus Subscap + Infra Deltoid Text Denard PJ et al. 2012 Nov;28(11):1587-91. Inman et l 1996
Equatorial Concept Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363 Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
Equatorial Concept Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363 Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
Rotator Cuff Evidence Update
Rotator Cuff Evidence Update
Transverse plane couple
Restoring RC function is all about keeping the ball under water ! (and not just “covering the Hole”)
The Pathology of RC disease
Rotator Cuff Disorders • Impingement - • Tendonitis / Tendinosis / Bursitis / Tendon Entrapment • Rotator Cuff Tears • Calcific Tendonitis
Causation of Cuff Disease • Mechanical (Extrinsic) • Degenerative / Vascular (Intrinsic)
Progression • Stage 1- Edema and Hemorrhage. • Age <25 year • Stage 2- Fibrosis and Tendinosis. • Age 25-40 years • Stage 3 - Bone spurs and Tendon rupture. • Age>40 years
Cuff Disease Progression Bursitis Tendinosis Impingement Calcific Tendonosis Oedema Hemorrhag e Partial Tears Spurs Full Thickness Tears Cuff tear Arthritis
Acromial shapes Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986 Higher proportion of RC tears seen in Curved and Hooked Acromions Image courtesy- Shoulderdoc.co.uk
Sub-acromial Wringer
Coronal Plane Patho- anatomy AbductionNeutral Position Post- Decompression
Sagittal - oblique Plane Pathoanatomy Sub-Acromial volume
Arch Decompression Sub-Acromial volume
Intrinsic Theory Extrinsic Theory doesn’t explain • RCT- Bursectomy vs Bursectomy + acromioplasty- No Difference • Articular surface tendon damage more common • No direct relation between acromial shape and impingement symptoms • Outcomes not proportional to extent of acromioplasty Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011 Hence Tendon degeneration likely to play important role
Making a Diagnosis
Positive Special Test = Diagnosis!
Using a Cluster approach recommended • History • Look Feel Move + Special Tests • Investigations Making a Diagnosis
History and physical examination provide little guidance on diagnosis of rotator cuff tears. Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.
Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. doi: 10.1002/14651858.CD007427.pub2. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Cochrane Database review 33 Studies - 4002 shoulders 170 Target Conditions / test combinations ! Only 6 instances where the test was performed and interpreted similarly No Clear Evidence to support a test
Subscapularis • Bear Hug Sensitivity 60% Specificity 100% • Belly Press Sensitivity 40% Specificity 97.9% • Napolean Sensitivity 25% Specificity 97.9% • Lift off Sensitivity 17.6% Specificity 91.7% • Internal Rotation Resistance test at Maximal Abduction (IRRTM) 76.5% sensitivity Bear Hug Test: A new and sensitive test for subscap tears. Barth et al. Arthroscopy 2006 Lin Et al 2015 Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions.
Supraspinatus • Hug Up Test 94% sensitivity, 76% specificity • Empty Can 84% sensitivity 74% specificity • Full Can 74% sensitivity 81% specificity • Lag Signs are not conclusive The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears. Chin Med J (Engl). 2016 20th Jan;129(2):147-153. doi: 10.4103/0366-6999.173461. Liu YL, Ao YF, Yan H, Cui GQ Miller CA1, Forrester GA, Lewis JS The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. . Arch Phys Med Rehabil. 2008 Jun;89(6):1162-8.
Infraspinatus • Ext Rotation Resistance • Lag sign Merolla, G., De Santis, E., Campi, F., Paladini, P., & Porcellini, G. (2010). Infraspinatus scapular retraction test: a reliable and practical method to assess infraspinatus strength in overhead athletes with scapular dyskinesis.Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology, 11(2), 105–110.
Teres Minor • ER Lag sign >40’ 100% sensitivity 92% specificity • ER Lag Sign >10’ 100% sensitivity 52% specificity • Patte Sign (Hornblower) 93% Sensitivity 72% specificity • Drop Sign 87% sensitivity 88% specificity Collin P1, Treseder T, Denard PJ, Neyton L, Walch G, Lädermann A. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.
Role of Investigations • Ultrasound - Good for soft tissues & dynamic • Xray- Good screening tool for Bone / joint • CT- Good for bone • MRI- Good for soft tissues and cross sectional
Ultrasound Versus MRI Ultrasound • One Stop clinic • Operator dependent • Post op assessment • Interactive • Dynamic MRI • Cross sectional anatomy • Bone and Joint • Partial Thickness & Interstitial Tears • Visual record • Muscle wasting and Fatty Atrophy
When to use Ultrasound • “Go-to” Investigation for Impingement and Rotator Cuff Syndrome. • Check integrity of Cuff repair within 1 year of surgery • Guided injections
When to use MRI scan • Pre-operatively to assess for Muscle Wasting and Fatty atrophy • Atypical symptoms • Large patients
Management
First line Management • Rest • Simple Analgesia • NSAIDs • Physiotherapy- Posture, motor control, stretching, strengthening, Manual therapy- 6 weeks • Sub-acromial Steroid Injection- 1 only BOA/ BESS commissioning guide
Indications for Surgery Failure of First line treatment
Notable Exception Acute Rotator Cuff Tears Early surgery has better outcomes Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.
Factors affecting Outcomes
Age Age > 65 years associated with relatively inferior outcomes Cho NS, Lee BG, Rhee YG. Arthroscopic cuff repair using suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011; 39: 2108-16
Tendon Vascularity Hypovascular Zone 10-15 mm prox to insertion (Codman) Vascularity at edge of torn tendon normal...? artifact in earlier studies (Goodmurphy et al) Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, Mass.: T. Todd company; 1934: 123-37 Goodmurphy CW, Osborn J, Akesson EJ et al. An immunohistochemical analysis of torn rotator cuff tendon taken at the time of repair. J Shoulder Elbow Surg 2003; 12:368-74.
Tear Size Large / Massive tear have inferior healing / poorer outcomes Good function still possible in cases of non healing repairs D Factor and B Dale. Current concepts of rotator cuff tendinopathy. The International Journal of sports physical therapy 2014; 9(2): 274-82. Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83. Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
Tendon Retraction Initial retraction due to Muscle contraction and secondarily involves tendon shortening Increasing Gap associated with inferior outcomes Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012; 40:2242-2247
Fatty Atrophy / Wasting
Fatty Atrophy, Muscle Wasting Both independent risk factors Higher re-operation rates, poor outcomes and poor tendon healing in presence of fatty atrophy Goutallier D, Postel JM, Gleyze P, Leguillox P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 2003; 12:550-554. Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after cuff repair and correlate with poor functional outcome. Am J Sports Med 2007; 35: 719-728. Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
Reversibility of FA/ Wasting Fatty Atrophy Irreversible but halts after successful RC Healing Muscle wasting potentially reversible but usually halts after successful RC healing Fatty Atrophy / Wasting worsen in cases where RC does not heal. Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83. Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
Smoking Higher Risk of Cuff Disease Inferior Outcome Baumgarten KM, Gerlach D, Galatz LM, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical orthopaedics and related research. Jun 2010;468(6):1534-1541. Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Mar-Apr 2004;13(2):129-132.
Acromial Shape Related to Risk of RC tears No difference in outcomes of decompression with / out acromioplasty Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture to rotator cuff disease. Clinics in sports medicine. 1991;10(4):823-838 Henkus HE1, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study.J Bone Joint Surg Br. 2009 Apr;91(4):504-10.
Single vs Double Row repair Double Row has better biomechanical characteristics- decreased gap formation and higher load to failure Improved outcomes in large / massive tears No difference in clinical outcomes in small / medium size tears Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med 2008; 36: 1310-1316
Repair configurations Knotted / Knotless Number of sutures Different Suture configuations No difference Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012; 94: e48 Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs. Arthroscopy 2010; 26: 316-323
Post op Rehab Early vs Delayed No Difference Better pain relief and ROM in short term Slightly higher retear in early mobilization in large / massive tears Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med 2012; 40: 815-821 Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg 2012; 21:1450-1455 Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: 1034-1039. Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy 2012; 28: 34-42
Addition of Growth factors BMP PDGF - Promising FGF TGF-β - Promising Gulotta LV, Kovacevic D, Packer JD, Ehteshami JR, Rodeo SA. Adenoviral mediated gene transfer of human bone morphogenic protein -13 does not improve rotator cuff healing in rat model. Am J Sports Med 2011.; 39: 180-7 Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497 Uggen JC, Dines J, Uggen C.W et al.Tendon gene therapy modulates the local repair environment in the shoulder. The Journal of the American Osteopathic Association 2005, 105: 20–21 M. Kobayashi, E. Itoi,H.Minagawa et al. Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits. Journal of Shoulder and Elbow Surgery 2006; 15: 371–377. Thomopoulos S, Harwood FL, Silva MJ, Amiel D, Gelberman RH. Effect of several growth factors on canine flexor tendon fibroblast proliferation and collagen synthesis in vitro. J Hand Surg Am 2005; 30: 441–7. Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med 2009; 28:13–23 C. N. Manning, H. M. Kim, S. Sakiyama-Elbert, L. M. Galatz, N. Havlioglu, and S. Thomopoulos, Sustained delivery of transforming growth factor beta three enhances tendon-to bone healing in a rat model. Journal of Orthopaedic Research 2011; 29: 1099–1105. Kovacevic D, Fox A J, Bedi A et al. Calcium-phosphate matrix with or without TGF-𝛽3 improves tendon-bone healing after rotator cuff repair. American Journal of Sports Medicine 2011; 39: 811–819
PRP No difference (2) / improved outcomes (2) Currently role unclear Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497 Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study. Am J Sports Med 2013; 41: 263-270 Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy 2011; 27: 1029-1035 Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med 2013; 41: 2240-2248
Mesenchymal stem cells Bone Marrow injection - promising 45 patients 10 year FU Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case- controlled study. Int Orthop 2014; 38: 1811-1818
Augmentation / scaffolds • Biological (Type I Collagen) /Artificial • Higher Resistance to Failure • RCT - Better Scores and healing when Graftjacket Augmentation used along with Cuff repair Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15
Massive Cuff tears
Massive Cuff Tears Biceps tenotomy/Tenodesis Boileau et al 2007 68 78%good Good for pain relief. Tendon Transfer Tauber et al, 2010 42 10-27% poor results Not applicable with subscap / teres minor tears Dermal Subsitute Gupta et al, 2012 24 76% intact All reported pain relief. Costly. InSpace Balloon Savarese et al 20 ? Scores improved on average. Under trial. Suprascapular nerve ablation Nizian et al 2009 20 75% good to excellent Indication intractable shoulder pain Superior Capsular Reconstruction Mihata et al 2013 24 83% healing. ? early days Partial Repair Monga et al personal audit 19 82% reversal of psudoparalysis Practical Reverse geometry Ek et al, 2013 46 37.5% had complications Salvage option
Over to Julia, Chrissy and Tanya… Credits- A Desai

More Related Content

What's hot

total hip arthroplasty
total hip arthroplastytotal hip arthroplasty
total hip arthroplasty
Sunil Poonia
 
Basal Joint Arthritis Of The Thumb
Basal Joint Arthritis Of The ThumbBasal Joint Arthritis Of The Thumb
Basal Joint Arthritis Of The Thumb
Christian Veillette
 
Recurrent patellar dislocation
Recurrent patellar dislocationRecurrent patellar dislocation
Recurrent patellar dislocation
boneheallerortho
 
Carpometacarpal ( C)
Carpometacarpal ( C)Carpometacarpal ( C)
Carpometacarpal ( C)
drmomusa
 
Lisfranc injuries
Lisfranc injuriesLisfranc injuries
Lisfranc injuries
LalisaMerga
 
Soft Tissue Balancing in Primary Total Knee Arthroplasty
Soft Tissue Balancing in Primary Total Knee ArthroplastySoft Tissue Balancing in Primary Total Knee Arthroplasty
Soft Tissue Balancing in Primary Total Knee Arthroplasty
Ihab El-Desouky
 
Classification perthes Disease
Classification perthes DiseaseClassification perthes Disease
Classification perthes Disease
Anoop GC
 
meniscal injuries
meniscal injuriesmeniscal injuries
meniscal injuries
Anubhav Verma
 
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPURMENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
Dr.RAJAT JANGIR Orthopaedic surgeon Jaipur
 
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent AthleteACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
Hospital for Special Surgery
 
syndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject reviewsyndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject review
Sunil Poonia
 
Implant Selection In Revision T.K.R
Implant Selection In Revision T.K.RImplant Selection In Revision T.K.R
Implant Selection In Revision T.K.R
Murtuza Rassiwala
 
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
drashraf369
 
ACL disorders
ACL disordersACL disorders
ACL disorders
Krishna Caitanya
 
Clinical prediction rule in spinal pain
Clinical prediction rule in spinal painClinical prediction rule in spinal pain
Clinical prediction rule in spinal pain
Nityal Kumar
 
Modified sauve kapandji procedure for patients with old fractures
Modified sauve kapandji procedure for patients with old fracturesModified sauve kapandji procedure for patients with old fractures
Modified sauve kapandji procedure for patients with old fractures
Ponnilavan Ponz
 
Wrist arthroplasty
Wrist arthroplastyWrist arthroplasty
Wrist arthroplasty
Dr Gandhi Kota
 
Post polio residual paralysis of foot and ankle
Post polio residual paralysis of foot and anklePost polio residual paralysis of foot and ankle
Post polio residual paralysis of foot and ankle
GIRIDHAR BOYAPATI
 
Multi ligamentous knee injury
Multi ligamentous knee injuryMulti ligamentous knee injury
Multi ligamentous knee injury
Jose Austine
 
Carpal instability
Carpal instabilityCarpal instability
Carpal instability
Raunak Milton
 

What's hot (20)

total hip arthroplasty
total hip arthroplastytotal hip arthroplasty
total hip arthroplasty
 
Basal Joint Arthritis Of The Thumb
Basal Joint Arthritis Of The ThumbBasal Joint Arthritis Of The Thumb
Basal Joint Arthritis Of The Thumb
 
Recurrent patellar dislocation
Recurrent patellar dislocationRecurrent patellar dislocation
Recurrent patellar dislocation
 
Carpometacarpal ( C)
Carpometacarpal ( C)Carpometacarpal ( C)
Carpometacarpal ( C)
 
Lisfranc injuries
Lisfranc injuriesLisfranc injuries
Lisfranc injuries
 
Soft Tissue Balancing in Primary Total Knee Arthroplasty
Soft Tissue Balancing in Primary Total Knee ArthroplastySoft Tissue Balancing in Primary Total Knee Arthroplasty
Soft Tissue Balancing in Primary Total Knee Arthroplasty
 
Classification perthes Disease
Classification perthes DiseaseClassification perthes Disease
Classification perthes Disease
 
meniscal injuries
meniscal injuriesmeniscal injuries
meniscal injuries
 
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPURMENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
 
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent AthleteACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
 
syndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject reviewsyndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject review
 
Implant Selection In Revision T.K.R
Implant Selection In Revision T.K.RImplant Selection In Revision T.K.R
Implant Selection In Revision T.K.R
 
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...
 
ACL disorders
ACL disordersACL disorders
ACL disorders
 
Clinical prediction rule in spinal pain
Clinical prediction rule in spinal painClinical prediction rule in spinal pain
Clinical prediction rule in spinal pain
 
Modified sauve kapandji procedure for patients with old fractures
Modified sauve kapandji procedure for patients with old fracturesModified sauve kapandji procedure for patients with old fractures
Modified sauve kapandji procedure for patients with old fractures
 
Wrist arthroplasty
Wrist arthroplastyWrist arthroplasty
Wrist arthroplasty
 
Post polio residual paralysis of foot and ankle
Post polio residual paralysis of foot and anklePost polio residual paralysis of foot and ankle
Post polio residual paralysis of foot and ankle
 
Multi ligamentous knee injury
Multi ligamentous knee injuryMulti ligamentous knee injury
Multi ligamentous knee injury
 
Carpal instability
Carpal instabilityCarpal instability
Carpal instability
 

Viewers also liked

Rotator Cuff Tendinopathy
Rotator Cuff TendinopathyRotator Cuff Tendinopathy
Rotator Cuff Tendinopathy
The Arm Clinic
 
A practical guide to Rotator Cuff Rehab
A practical guide to Rotator Cuff RehabA practical guide to Rotator Cuff Rehab
A practical guide to Rotator Cuff Rehab
The Arm Clinic
 
Elbow Tendinopathy
Elbow TendinopathyElbow Tendinopathy
Elbow Tendinopathy
The Arm Clinic
 
Relationship between extrinsic factors and the acromio humeral distance (1)
Relationship between extrinsic factors and the acromio humeral distance (1)Relationship between extrinsic factors and the acromio humeral distance (1)
Relationship between extrinsic factors and the acromio humeral distance (1)
The Arm Clinic
 
Management of a Painful Neuroma
Management of a Painful NeuromaManagement of a Painful Neuroma
Management of a Painful Neuroma
The Arm Clinic
 
Atraumatic/MDI - Physiotherapy Principles and Management
Atraumatic/MDI - Physiotherapy Principles and ManagementAtraumatic/MDI - Physiotherapy Principles and Management
Atraumatic/MDI - Physiotherapy Principles and Management
The Arm Clinic
 
What is Pain?
What is Pain?What is Pain?
What is Pain?
The Arm Clinic
 
Shoulder Impingement : The Surgeon's Approach
Shoulder Impingement : The Surgeon's ApproachShoulder Impingement : The Surgeon's Approach
Shoulder Impingement : The Surgeon's Approach
The Arm Clinic
 
Atraumatic Shoulder Instability Principles and Assessment
Atraumatic Shoulder Instability Principles and AssessmentAtraumatic Shoulder Instability Principles and Assessment
Atraumatic Shoulder Instability Principles and Assessment
The Arm Clinic
 
Non-Surgical Management of a Painful Neuroma
Non-Surgical Management of a Painful NeuromaNon-Surgical Management of a Painful Neuroma
Non-Surgical Management of a Painful Neuroma
The Arm Clinic
 
The role of suprascapular nerve decompression - Jeremy Granville-Chapman
The role of suprascapular nerve decompression - Jeremy Granville-ChapmanThe role of suprascapular nerve decompression - Jeremy Granville-Chapman
The role of suprascapular nerve decompression - Jeremy Granville-Chapman
Wrightington Upper Limb Unit
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndrome
Hardev Singh
 
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
Lennard Funk
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndrome
Ratan Khuman
 
Tendinopathy Overview
Tendinopathy OverviewTendinopathy Overview
Tendinopathy Overview
Richard Collins
 

Viewers also liked (15)

Rotator Cuff Tendinopathy
Rotator Cuff TendinopathyRotator Cuff Tendinopathy
Rotator Cuff Tendinopathy
 
A practical guide to Rotator Cuff Rehab
A practical guide to Rotator Cuff RehabA practical guide to Rotator Cuff Rehab
A practical guide to Rotator Cuff Rehab
 
Elbow Tendinopathy
Elbow TendinopathyElbow Tendinopathy
Elbow Tendinopathy
 
Relationship between extrinsic factors and the acromio humeral distance (1)
Relationship between extrinsic factors and the acromio humeral distance (1)Relationship between extrinsic factors and the acromio humeral distance (1)
Relationship between extrinsic factors and the acromio humeral distance (1)
 
Management of a Painful Neuroma
Management of a Painful NeuromaManagement of a Painful Neuroma
Management of a Painful Neuroma
 
Atraumatic/MDI - Physiotherapy Principles and Management
Atraumatic/MDI - Physiotherapy Principles and ManagementAtraumatic/MDI - Physiotherapy Principles and Management
Atraumatic/MDI - Physiotherapy Principles and Management
 
What is Pain?
What is Pain?What is Pain?
What is Pain?
 
Shoulder Impingement : The Surgeon's Approach
Shoulder Impingement : The Surgeon's ApproachShoulder Impingement : The Surgeon's Approach
Shoulder Impingement : The Surgeon's Approach
 
Atraumatic Shoulder Instability Principles and Assessment
Atraumatic Shoulder Instability Principles and AssessmentAtraumatic Shoulder Instability Principles and Assessment
Atraumatic Shoulder Instability Principles and Assessment
 
Non-Surgical Management of a Painful Neuroma
Non-Surgical Management of a Painful NeuromaNon-Surgical Management of a Painful Neuroma
Non-Surgical Management of a Painful Neuroma
 
The role of suprascapular nerve decompression - Jeremy Granville-Chapman
The role of suprascapular nerve decompression - Jeremy Granville-ChapmanThe role of suprascapular nerve decompression - Jeremy Granville-Chapman
The role of suprascapular nerve decompression - Jeremy Granville-Chapman
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndrome
 
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
Superior Capsular Reconstruction for Massive Rotator Cuff Tears 2017
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndrome
 
Tendinopathy Overview
Tendinopathy OverviewTendinopathy Overview
Tendinopathy Overview
 

Similar to Rotator Cuff Evidence Update

Rotator cuff evidence update
Rotator cuff evidence updateRotator cuff evidence update
Rotator cuff evidence update
Puneet Monga
 
Comparative study of functional outcome of lateral locking plate fixation an...
Comparative study of functional outcome of lateral locking plate fixation an...Comparative study of functional outcome of lateral locking plate fixation an...
Comparative study of functional outcome of lateral locking plate fixation an...
Om Patil
 
Enthesopathies ul
Enthesopathies ulEnthesopathies ul
Enthesopathies ul
Dinesh Dhar
 
Shoulder Pain
Shoulder PainShoulder Pain
Shoulder Pain
Ade Wijaya
 
AAOS.2001.adult reconstruction.pdf
AAOS.2001.adult reconstruction.pdfAAOS.2001.adult reconstruction.pdf
AAOS.2001.adult reconstruction.pdf
alhassansaad1
 
Recurrent Anterior instability of Shoulder with bone loss
Recurrent Anterior instability of Shoulder with bone lossRecurrent Anterior instability of Shoulder with bone loss
Recurrent Anterior instability of Shoulder with bone loss
Moazzam Jah
 
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos keralaArthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
Sujit Jos
 
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
Dr.RAJAT JANGIR Orthopaedic surgeon Jaipur
 
Total shoulder replacement
Total shoulder replacementTotal shoulder replacement
Total shoulder replacement
Puneet Monga
 
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
TheRightDoctors
 
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee InjuriesTaddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
Nicola Taddio
 
Management dilemma when knee osteoarthritis coexists with Spine.pptx
Management dilemma when knee osteoarthritis coexists with Spine.pptxManagement dilemma when knee osteoarthritis coexists with Spine.pptx
Management dilemma when knee osteoarthritis coexists with Spine.pptx
KaustavMukherjee33
 
2009 oite review
2009 oite review2009 oite review
2009 oite review
ssweet3237
 
Reverse Total Shoulder Arthroplasty Research Presentation
Reverse Total Shoulder Arthroplasty Research PresentationReverse Total Shoulder Arthroplasty Research Presentation
Reverse Total Shoulder Arthroplasty Research Presentation
tylers56
 
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
TheRightDoctors
 
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
Nicola Taddio
 
Acl Injury Hacks: By Dr. Dhruv Taneja
Acl Injury Hacks: By Dr. Dhruv Taneja Acl Injury Hacks: By Dr. Dhruv Taneja
Acl Injury Hacks: By Dr. Dhruv Taneja
dhruv taneja
 
Revision ACL Reconstruction - A Case Presentation and Literature Review
Revision ACL Reconstruction - A Case Presentation and Literature ReviewRevision ACL Reconstruction - A Case Presentation and Literature Review
Revision ACL Reconstruction - A Case Presentation and Literature Review
Jeremy Burnham
 
Evidence based medicine dr. saumya
Evidence based medicine dr. saumyaEvidence based medicine dr. saumya
Evidence based medicine dr. saumya
Central Institute of Orthopaedics, Safdarjang Hospital and VMMC, New Delhi
 
Tendinopatie del rotuleo Bisciotti
Tendinopatie del rotuleo BisciottiTendinopatie del rotuleo Bisciotti
Tendinopatie del rotuleo Bisciotti
Calzetti & Mariucci Editori
 

Similar to Rotator Cuff Evidence Update (20)

Rotator cuff evidence update
Rotator cuff evidence updateRotator cuff evidence update
Rotator cuff evidence update
 
Comparative study of functional outcome of lateral locking plate fixation an...
Comparative study of functional outcome of lateral locking plate fixation an...Comparative study of functional outcome of lateral locking plate fixation an...
Comparative study of functional outcome of lateral locking plate fixation an...
 
Enthesopathies ul
Enthesopathies ulEnthesopathies ul
Enthesopathies ul
 
Shoulder Pain
Shoulder PainShoulder Pain
Shoulder Pain
 
AAOS.2001.adult reconstruction.pdf
AAOS.2001.adult reconstruction.pdfAAOS.2001.adult reconstruction.pdf
AAOS.2001.adult reconstruction.pdf
 
Recurrent Anterior instability of Shoulder with bone loss
Recurrent Anterior instability of Shoulder with bone lossRecurrent Anterior instability of Shoulder with bone loss
Recurrent Anterior instability of Shoulder with bone loss
 
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos keralaArthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
Arthrolatarjet (Arthroscopic Latarjet Proc) Dr Sujit Jos kerala
 
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
PCL Posterior Cruciate Ligament Knee Injury: Is it Benign I Dr.RAJAT JANGIR ...
 
Total shoulder replacement
Total shoulder replacementTotal shoulder replacement
Total shoulder replacement
 
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
An MRI Based Double Blinded Obseravational Study of Posterior Tibial Slope in...
 
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee InjuriesTaddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
Taddio Isokinetic London 2012: Football Medicine Strategies for Knee Injuries
 
Management dilemma when knee osteoarthritis coexists with Spine.pptx
Management dilemma when knee osteoarthritis coexists with Spine.pptxManagement dilemma when knee osteoarthritis coexists with Spine.pptx
Management dilemma when knee osteoarthritis coexists with Spine.pptx
 
2009 oite review
2009 oite review2009 oite review
2009 oite review
 
Reverse Total Shoulder Arthroplasty Research Presentation
Reverse Total Shoulder Arthroplasty Research PresentationReverse Total Shoulder Arthroplasty Research Presentation
Reverse Total Shoulder Arthroplasty Research Presentation
 
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Rep...
 
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
Taddio Nicola Knee Remplacement Rehabilitation The Battle 2018 Cattolica (ITA)
 
Acl Injury Hacks: By Dr. Dhruv Taneja
Acl Injury Hacks: By Dr. Dhruv Taneja Acl Injury Hacks: By Dr. Dhruv Taneja
Acl Injury Hacks: By Dr. Dhruv Taneja
 
Revision ACL Reconstruction - A Case Presentation and Literature Review
Revision ACL Reconstruction - A Case Presentation and Literature ReviewRevision ACL Reconstruction - A Case Presentation and Literature Review
Revision ACL Reconstruction - A Case Presentation and Literature Review
 
Evidence based medicine dr. saumya
Evidence based medicine dr. saumyaEvidence based medicine dr. saumya
Evidence based medicine dr. saumya
 
Tendinopatie del rotuleo Bisciotti
Tendinopatie del rotuleo BisciottiTendinopatie del rotuleo Bisciotti
Tendinopatie del rotuleo Bisciotti
 

More from The Arm Clinic

Atraumatic Shoulder Instability
Atraumatic Shoulder InstabilityAtraumatic Shoulder Instability
Atraumatic Shoulder Instability
The Arm Clinic
 
MDI - Rehab or Surgery???
MDI - Rehab or Surgery???MDI - Rehab or Surgery???
MDI - Rehab or Surgery???
The Arm Clinic
 
Tendon Transfers around the Shoulder
Tendon Transfers around the ShoulderTendon Transfers around the Shoulder
Tendon Transfers around the Shoulder
The Arm Clinic
 
Incidence of Rotator Cuff Repair in Rugby Players
Incidence of Rotator Cuff Repair in Rugby PlayersIncidence of Rotator Cuff Repair in Rugby Players
Incidence of Rotator Cuff Repair in Rugby Players
The Arm Clinic
 
Post-operative recovery telephone call: the patients' perspective
Post-operative recovery telephone call: the patients' perspectivePost-operative recovery telephone call: the patients' perspective
Post-operative recovery telephone call: the patients' perspective
The Arm Clinic
 
Atraumatic Shoulder Instability Management
Atraumatic Shoulder Instability ManagementAtraumatic Shoulder Instability Management
Atraumatic Shoulder Instability Management
The Arm Clinic
 
Hydrodilatation for Frozen Shoulder
Hydrodilatation for Frozen ShoulderHydrodilatation for Frozen Shoulder
Hydrodilatation for Frozen Shoulder
The Arm Clinic
 
Frozen Shoulder Symptoms and Treatment Options
Frozen Shoulder Symptoms and Treatment OptionsFrozen Shoulder Symptoms and Treatment Options
Frozen Shoulder Symptoms and Treatment Options
The Arm Clinic
 
Physiotherapy for the Stiff Shoulder
Physiotherapy for the Stiff ShoulderPhysiotherapy for the Stiff Shoulder
Physiotherapy for the Stiff Shoulder
The Arm Clinic
 
Physiotherapy in the Management of Frozen Shoulder
Physiotherapy in the Management of Frozen ShoulderPhysiotherapy in the Management of Frozen Shoulder
Physiotherapy in the Management of Frozen Shoulder
The Arm Clinic
 
Assessment and Management of Frozen Shoulder
Assessment and Management of Frozen ShoulderAssessment and Management of Frozen Shoulder
Assessment and Management of Frozen Shoulder
The Arm Clinic
 

More from The Arm Clinic (11)

Atraumatic Shoulder Instability
Atraumatic Shoulder InstabilityAtraumatic Shoulder Instability
Atraumatic Shoulder Instability
 
MDI - Rehab or Surgery???
MDI - Rehab or Surgery???MDI - Rehab or Surgery???
MDI - Rehab or Surgery???
 
Tendon Transfers around the Shoulder
Tendon Transfers around the ShoulderTendon Transfers around the Shoulder
Tendon Transfers around the Shoulder
 
Incidence of Rotator Cuff Repair in Rugby Players
Incidence of Rotator Cuff Repair in Rugby PlayersIncidence of Rotator Cuff Repair in Rugby Players
Incidence of Rotator Cuff Repair in Rugby Players
 
Post-operative recovery telephone call: the patients' perspective
Post-operative recovery telephone call: the patients' perspectivePost-operative recovery telephone call: the patients' perspective
Post-operative recovery telephone call: the patients' perspective
 
Atraumatic Shoulder Instability Management
Atraumatic Shoulder Instability ManagementAtraumatic Shoulder Instability Management
Atraumatic Shoulder Instability Management
 
Hydrodilatation for Frozen Shoulder
Hydrodilatation for Frozen ShoulderHydrodilatation for Frozen Shoulder
Hydrodilatation for Frozen Shoulder
 
Frozen Shoulder Symptoms and Treatment Options
Frozen Shoulder Symptoms and Treatment OptionsFrozen Shoulder Symptoms and Treatment Options
Frozen Shoulder Symptoms and Treatment Options
 
Physiotherapy for the Stiff Shoulder
Physiotherapy for the Stiff ShoulderPhysiotherapy for the Stiff Shoulder
Physiotherapy for the Stiff Shoulder
 
Physiotherapy in the Management of Frozen Shoulder
Physiotherapy in the Management of Frozen ShoulderPhysiotherapy in the Management of Frozen Shoulder
Physiotherapy in the Management of Frozen Shoulder
 
Assessment and Management of Frozen Shoulder
Assessment and Management of Frozen ShoulderAssessment and Management of Frozen Shoulder
Assessment and Management of Frozen Shoulder
 

Recently uploaded

virus pharmaceutical microbiology .pdf..
virus pharmaceutical microbiology .pdf..virus pharmaceutical microbiology .pdf..
virus pharmaceutical microbiology .pdf..
Bhagyashree Gajbhare
 
Metabolic interrelationship MBBS II.pptx
Metabolic interrelationship MBBS II.pptxMetabolic interrelationship MBBS II.pptx
Metabolic interrelationship MBBS II.pptx
apeksha40
 
A comparative study on uroculturome antimicrobial susceptibility in apparentl...
A comparative study on uroculturome antimicrobial susceptibility in apparentl...A comparative study on uroculturome antimicrobial susceptibility in apparentl...
A comparative study on uroculturome antimicrobial susceptibility in apparentl...
Bhoj Raj Singh
 
Hb electrophoresis- Types, Procedure and Analysis
Hb electrophoresis- Types, Procedure and AnalysisHb electrophoresis- Types, Procedure and Analysis
Hb electrophoresis- Types, Procedure and Analysis
Reenaz Shaik
 
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
Gian Luca Grazi
 
Nursing management of patient with peritoneal dialysis
Nursing management of patient with peritoneal dialysisNursing management of patient with peritoneal dialysis
Nursing management of patient with peritoneal dialysis
shivalingatalekar1
 
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptxPOTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
souravpaul769171
 
Mainstreaming #CleanLanguage in healthcare.pptx
Mainstreaming #CleanLanguage in healthcare.pptxMainstreaming #CleanLanguage in healthcare.pptx
Mainstreaming #CleanLanguage in healthcare.pptx
Judy Rees
 
chemical kinetics part 1 mkv ppt pharmacy
chemical kinetics part 1 mkv ppt pharmacychemical kinetics part 1 mkv ppt pharmacy
chemical kinetics part 1 mkv ppt pharmacy
KrishnaveniManubolu
 
Jurnalul Fericirii Life Care - Iulie 2024
Jurnalul Fericirii Life Care - Iulie 2024Jurnalul Fericirii Life Care - Iulie 2024
Jurnalul Fericirii Life Care - Iulie 2024
Life Care Romania
 
Nursing Lecture 428 slide presentation. PDF
Nursing Lecture 428 slide presentation. PDFNursing Lecture 428 slide presentation. PDF
Nursing Lecture 428 slide presentation. PDF
MuhammadMunirAbdulka1
 
Embyonal Stem Cells - Properties and Classification
Embyonal Stem Cells - Properties and ClassificationEmbyonal Stem Cells - Properties and Classification
Embyonal Stem Cells - Properties and Classification
Reenaz Shaik
 
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in DohaAbortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
maishakhanam230
 
Comfort, Rest, Sleep and Pain.pptx
Comfort, Rest, Sleep and Pain.pptxComfort, Rest, Sleep and Pain.pptx
Comfort, Rest, Sleep and Pain.pptx
Nandish Sannaiah
 
BASIC PRINCIPLES OF CELL INJURY & ADAPTATION
BASIC PRINCIPLES OF CELL INJURY & ADAPTATIONBASIC PRINCIPLES OF CELL INJURY & ADAPTATION
BASIC PRINCIPLES OF CELL INJURY & ADAPTATION
JaiDivyaTella
 
Coronary Bifurcation techniques in a nutshell
Coronary Bifurcation techniques in a nutshellCoronary Bifurcation techniques in a nutshell
Coronary Bifurcation techniques in a nutshell
AhmedElBorae1
 
Introduction to Removable partial dneture.pptx
Introduction to Removable partial dneture.pptxIntroduction to Removable partial dneture.pptx
Introduction to Removable partial dneture.pptx
Shamsuddin Mahmud
 
How to build a successful medical tourism practice
How to build a successful medical tourism practiceHow to build a successful medical tourism practice
How to build a successful medical tourism practice
Arlen Meyers, MD, MBA
 
Prodrug design for Sustained Drug action -.KB.pptx
Prodrug design for Sustained Drug action -.KB.pptxProdrug design for Sustained Drug action -.KB.pptx
Prodrug design for Sustained Drug action -.KB.pptx
ANAGHA K B
 
Gene therapy - Types, Advantages and genetic manifestations in molecular med...
Gene therapy - Types, Advantages and genetic manifestations in molecular med...Gene therapy - Types, Advantages and genetic manifestations in molecular med...
Gene therapy - Types, Advantages and genetic manifestations in molecular med...
Reenaz Shaik
 

Recently uploaded (20)

virus pharmaceutical microbiology .pdf..
virus pharmaceutical microbiology .pdf..virus pharmaceutical microbiology .pdf..
virus pharmaceutical microbiology .pdf..
 
Metabolic interrelationship MBBS II.pptx
Metabolic interrelationship MBBS II.pptxMetabolic interrelationship MBBS II.pptx
Metabolic interrelationship MBBS II.pptx
 
A comparative study on uroculturome antimicrobial susceptibility in apparentl...
A comparative study on uroculturome antimicrobial susceptibility in apparentl...A comparative study on uroculturome antimicrobial susceptibility in apparentl...
A comparative study on uroculturome antimicrobial susceptibility in apparentl...
 
Hb electrophoresis- Types, Procedure and Analysis
Hb electrophoresis- Types, Procedure and AnalysisHb electrophoresis- Types, Procedure and Analysis
Hb electrophoresis- Types, Procedure and Analysis
 
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
Hepatocarcinoma today between guidelines and medical therapy. The role of sur...
 
Nursing management of patient with peritoneal dialysis
Nursing management of patient with peritoneal dialysisNursing management of patient with peritoneal dialysis
Nursing management of patient with peritoneal dialysis
 
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptxPOTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
 
Mainstreaming #CleanLanguage in healthcare.pptx
Mainstreaming #CleanLanguage in healthcare.pptxMainstreaming #CleanLanguage in healthcare.pptx
Mainstreaming #CleanLanguage in healthcare.pptx
 
chemical kinetics part 1 mkv ppt pharmacy
chemical kinetics part 1 mkv ppt pharmacychemical kinetics part 1 mkv ppt pharmacy
chemical kinetics part 1 mkv ppt pharmacy
 
Jurnalul Fericirii Life Care - Iulie 2024
Jurnalul Fericirii Life Care - Iulie 2024Jurnalul Fericirii Life Care - Iulie 2024
Jurnalul Fericirii Life Care - Iulie 2024
 
Nursing Lecture 428 slide presentation. PDF
Nursing Lecture 428 slide presentation. PDFNursing Lecture 428 slide presentation. PDF
Nursing Lecture 428 slide presentation. PDF
 
Embyonal Stem Cells - Properties and Classification
Embyonal Stem Cells - Properties and ClassificationEmbyonal Stem Cells - Properties and Classification
Embyonal Stem Cells - Properties and Classification
 
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in DohaAbortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
Abortion pills for sale in Qatar(+919707208804)Buy Cytotec tablet in Doha
 
Comfort, Rest, Sleep and Pain.pptx
Comfort, Rest, Sleep and Pain.pptxComfort, Rest, Sleep and Pain.pptx
Comfort, Rest, Sleep and Pain.pptx
 
BASIC PRINCIPLES OF CELL INJURY & ADAPTATION
BASIC PRINCIPLES OF CELL INJURY & ADAPTATIONBASIC PRINCIPLES OF CELL INJURY & ADAPTATION
BASIC PRINCIPLES OF CELL INJURY & ADAPTATION
 
Coronary Bifurcation techniques in a nutshell
Coronary Bifurcation techniques in a nutshellCoronary Bifurcation techniques in a nutshell
Coronary Bifurcation techniques in a nutshell
 
Introduction to Removable partial dneture.pptx
Introduction to Removable partial dneture.pptxIntroduction to Removable partial dneture.pptx
Introduction to Removable partial dneture.pptx
 
How to build a successful medical tourism practice
How to build a successful medical tourism practiceHow to build a successful medical tourism practice
How to build a successful medical tourism practice
 
Prodrug design for Sustained Drug action -.KB.pptx
Prodrug design for Sustained Drug action -.KB.pptxProdrug design for Sustained Drug action -.KB.pptx
Prodrug design for Sustained Drug action -.KB.pptx
 
Gene therapy - Types, Advantages and genetic manifestations in molecular med...
Gene therapy - Types, Advantages and genetic manifestations in molecular med...Gene therapy - Types, Advantages and genetic manifestations in molecular med...
Gene therapy - Types, Advantages and genetic manifestations in molecular med...
 

Rotator Cuff Evidence Update

  • 1. Evidence Update- Rotator Cuff Disorders Mr Puneet Monga Consultant Orthopaedic Shoulder Surgeon Wrightington Hospital
  • 2. The Rotator Cuff Image Courtesy- www.patient.info
  • 4. Kinematics -Vectors Supraspinatus Subscap + Infra Deltoid Text Denard PJ et al. 2012 Nov;28(11):1587-91. Inman et l 1996
  • 5. Equatorial Concept Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363 Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
  • 6. Equatorial Concept Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363 Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472
  • 10. Restoring RC function is all about keeping the ball under water ! (and not just “covering the Hole”)
  • 11. The Pathology of RC disease
  • 12. Rotator Cuff Disorders • Impingement - • Tendonitis / Tendinosis / Bursitis / Tendon Entrapment • Rotator Cuff Tears • Calcific Tendonitis
  • 13. Causation of Cuff Disease • Mechanical (Extrinsic) • Degenerative / Vascular (Intrinsic)
  • 14. Progression • Stage 1- Edema and Hemorrhage. • Age <25 year • Stage 2- Fibrosis and Tendinosis. • Age 25-40 years • Stage 3 - Bone spurs and Tendon rupture. • Age>40 years
  • 15. Cuff Disease Progression Bursitis Tendinosis Impingement Calcific Tendonosis Oedema Hemorrhag e Partial Tears Spurs Full Thickness Tears Cuff tear Arthritis
  • 16. Acromial shapes Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986 Higher proportion of RC tears seen in Curved and Hooked Acromions Image courtesy- Shoulderdoc.co.uk
  • 18. Coronal Plane Patho- anatomy AbductionNeutral Position Post- Decompression
  • 19. Sagittal - oblique Plane Pathoanatomy Sub-Acromial volume
  • 21. Intrinsic Theory Extrinsic Theory doesn’t explain • RCT- Bursectomy vs Bursectomy + acromioplasty- No Difference • Articular surface tendon damage more common • No direct relation between acromial shape and impingement symptoms • Outcomes not proportional to extent of acromioplasty Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011 Hence Tendon degeneration likely to play important role
  • 23. Positive Special Test = Diagnosis!
  • 24. Using a Cluster approach recommended • History • Look Feel Move + Special Tests • Investigations Making a Diagnosis
  • 25. History and physical examination provide little guidance on diagnosis of rotator cuff tears. Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.
  • 26. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. doi: 10.1002/14651858.CD007427.pub2. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Cochrane Database review 33 Studies - 4002 shoulders 170 Target Conditions / test combinations ! Only 6 instances where the test was performed and interpreted similarly No Clear Evidence to support a test
  • 27. Subscapularis • Bear Hug Sensitivity 60% Specificity 100% • Belly Press Sensitivity 40% Specificity 97.9% • Napolean Sensitivity 25% Specificity 97.9% • Lift off Sensitivity 17.6% Specificity 91.7% • Internal Rotation Resistance test at Maximal Abduction (IRRTM) 76.5% sensitivity Bear Hug Test: A new and sensitive test for subscap tears. Barth et al. Arthroscopy 2006 Lin Et al 2015 Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions.
  • 28. Supraspinatus • Hug Up Test 94% sensitivity, 76% specificity • Empty Can 84% sensitivity 74% specificity • Full Can 74% sensitivity 81% specificity • Lag Signs are not conclusive The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears. Chin Med J (Engl). 2016 20th Jan;129(2):147-153. doi: 10.4103/0366-6999.173461. Liu YL, Ao YF, Yan H, Cui GQ Miller CA1, Forrester GA, Lewis JS The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. . Arch Phys Med Rehabil. 2008 Jun;89(6):1162-8.
  • 29. Infraspinatus • Ext Rotation Resistance • Lag sign Merolla, G., De Santis, E., Campi, F., Paladini, P., & Porcellini, G. (2010). Infraspinatus scapular retraction test: a reliable and practical method to assess infraspinatus strength in overhead athletes with scapular dyskinesis.Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology, 11(2), 105–110.
  • 30. Teres Minor • ER Lag sign >40’ 100% sensitivity 92% specificity • ER Lag Sign >10’ 100% sensitivity 52% specificity • Patte Sign (Hornblower) 93% Sensitivity 72% specificity • Drop Sign 87% sensitivity 88% specificity Collin P1, Treseder T, Denard PJ, Neyton L, Walch G, Lädermann A. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.
  • 31. Role of Investigations • Ultrasound - Good for soft tissues & dynamic • Xray- Good screening tool for Bone / joint • CT- Good for bone • MRI- Good for soft tissues and cross sectional
  • 32. Ultrasound Versus MRI Ultrasound • One Stop clinic • Operator dependent • Post op assessment • Interactive • Dynamic MRI • Cross sectional anatomy • Bone and Joint • Partial Thickness & Interstitial Tears • Visual record • Muscle wasting and Fatty Atrophy
  • 33. When to use Ultrasound • “Go-to” Investigation for Impingement and Rotator Cuff Syndrome. • Check integrity of Cuff repair within 1 year of surgery • Guided injections
  • 34. When to use MRI scan • Pre-operatively to assess for Muscle Wasting and Fatty atrophy • Atypical symptoms • Large patients
  • 36. First line Management • Rest • Simple Analgesia • NSAIDs • Physiotherapy- Posture, motor control, stretching, strengthening, Manual therapy- 6 weeks • Sub-acromial Steroid Injection- 1 only BOA/ BESS commissioning guide
  • 37. Indications for Surgery Failure of First line treatment
  • 38. Notable Exception Acute Rotator Cuff Tears Early surgery has better outcomes Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.
  • 40. Age Age > 65 years associated with relatively inferior outcomes Cho NS, Lee BG, Rhee YG. Arthroscopic cuff repair using suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011; 39: 2108-16
  • 41. Tendon Vascularity Hypovascular Zone 10-15 mm prox to insertion (Codman) Vascularity at edge of torn tendon normal...? artifact in earlier studies (Goodmurphy et al) Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, Mass.: T. Todd company; 1934: 123-37 Goodmurphy CW, Osborn J, Akesson EJ et al. An immunohistochemical analysis of torn rotator cuff tendon taken at the time of repair. J Shoulder Elbow Surg 2003; 12:368-74.
  • 42. Tear Size Large / Massive tear have inferior healing / poorer outcomes Good function still possible in cases of non healing repairs D Factor and B Dale. Current concepts of rotator cuff tendinopathy. The International Journal of sports physical therapy 2014; 9(2): 274-82. Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83. Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.
  • 43. Tendon Retraction Initial retraction due to Muscle contraction and secondarily involves tendon shortening Increasing Gap associated with inferior outcomes Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012; 40:2242-2247
  • 45. Fatty Atrophy, Muscle Wasting Both independent risk factors Higher re-operation rates, poor outcomes and poor tendon healing in presence of fatty atrophy Goutallier D, Postel JM, Gleyze P, Leguillox P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 2003; 12:550-554. Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after cuff repair and correlate with poor functional outcome. Am J Sports Med 2007; 35: 719-728. Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
  • 46. Reversibility of FA/ Wasting Fatty Atrophy Irreversible but halts after successful RC Healing Muscle wasting potentially reversible but usually halts after successful RC healing Fatty Atrophy / Wasting worsen in cases where RC does not heal. Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83. Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.
  • 47. Smoking Higher Risk of Cuff Disease Inferior Outcome Baumgarten KM, Gerlach D, Galatz LM, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical orthopaedics and related research. Jun 2010;468(6):1534-1541. Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Mar-Apr 2004;13(2):129-132.
  • 48. Acromial Shape Related to Risk of RC tears No difference in outcomes of decompression with / out acromioplasty Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture to rotator cuff disease. Clinics in sports medicine. 1991;10(4):823-838 Henkus HE1, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study.J Bone Joint Surg Br. 2009 Apr;91(4):504-10.
  • 49. Single vs Double Row repair Double Row has better biomechanical characteristics- decreased gap formation and higher load to failure Improved outcomes in large / massive tears No difference in clinical outcomes in small / medium size tears Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med 2008; 36: 1310-1316
  • 50. Repair configurations Knotted / Knotless Number of sutures Different Suture configuations No difference Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012; 94: e48 Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs. Arthroscopy 2010; 26: 316-323
  • 51. Post op Rehab Early vs Delayed No Difference Better pain relief and ROM in short term Slightly higher retear in early mobilization in large / massive tears Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20. Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med 2012; 40: 815-821 Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg 2012; 21:1450-1455 Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: 1034-1039. Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy 2012; 28: 34-42
  • 52. Addition of Growth factors BMP PDGF - Promising FGF TGF-β - Promising Gulotta LV, Kovacevic D, Packer JD, Ehteshami JR, Rodeo SA. Adenoviral mediated gene transfer of human bone morphogenic protein -13 does not improve rotator cuff healing in rat model. Am J Sports Med 2011.; 39: 180-7 Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497 Uggen JC, Dines J, Uggen C.W et al.Tendon gene therapy modulates the local repair environment in the shoulder. The Journal of the American Osteopathic Association 2005, 105: 20–21 M. Kobayashi, E. Itoi,H.Minagawa et al. Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits. Journal of Shoulder and Elbow Surgery 2006; 15: 371–377. Thomopoulos S, Harwood FL, Silva MJ, Amiel D, Gelberman RH. Effect of several growth factors on canine flexor tendon fibroblast proliferation and collagen synthesis in vitro. J Hand Surg Am 2005; 30: 441–7. Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med 2009; 28:13–23 C. N. Manning, H. M. Kim, S. Sakiyama-Elbert, L. M. Galatz, N. Havlioglu, and S. Thomopoulos, Sustained delivery of transforming growth factor beta three enhances tendon-to bone healing in a rat model. Journal of Orthopaedic Research 2011; 29: 1099–1105. Kovacevic D, Fox A J, Bedi A et al. Calcium-phosphate matrix with or without TGF-𝛽3 improves tendon-bone healing after rotator cuff repair. American Journal of Sports Medicine 2011; 39: 811–819
  • 53. PRP No difference (2) / improved outcomes (2) Currently role unclear Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497 Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study. Am J Sports Med 2013; 41: 263-270 Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy 2011; 27: 1029-1035 Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med 2013; 41: 2240-2248
  • 54. Mesenchymal stem cells Bone Marrow injection - promising 45 patients 10 year FU Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case- controlled study. Int Orthop 2014; 38: 1811-1818
  • 55. Augmentation / scaffolds • Biological (Type I Collagen) /Artificial • Higher Resistance to Failure • RCT - Better Scores and healing when Graftjacket Augmentation used along with Cuff repair Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15
  • 57. Massive Cuff Tears Biceps tenotomy/Tenodesis Boileau et al 2007 68 78%good Good for pain relief. Tendon Transfer Tauber et al, 2010 42 10-27% poor results Not applicable with subscap / teres minor tears Dermal Subsitute Gupta et al, 2012 24 76% intact All reported pain relief. Costly. InSpace Balloon Savarese et al 20 ? Scores improved on average. Under trial. Suprascapular nerve ablation Nizian et al 2009 20 75% good to excellent Indication intractable shoulder pain Superior Capsular Reconstruction Mihata et al 2013 24 83% healing. ? early days Partial Repair Monga et al personal audit 19 82% reversal of psudoparalysis Practical Reverse geometry Ek et al, 2013 46 37.5% had complications Salvage option
  • 58. Over to Julia, Chrissy and Tanya… Credits- A Desai