My Techniques for Shoulder Joint Preservation
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A presentation on different techniques for shoulder joint preservation in regards to the advances in technology for rotator cuff pathology, from tendonitis to cuff tear arthropathy.
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My Techniques for Shoulder Joint Preservation
- 1. My Techniques for Shoulder Joint Preservation Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder & knee surgery
- 2. Historical View of Rotator Cuff Pathology Diagnosis • Tendonitis / Impingement • Rotator cuff tear Treatment • Conservative treatment • Surgical treatment – Decompression – Open rotator cuff repair
- 3. Prehistoric The Future • Orthopaedic Surgeons – –
- 4. Spectrum of Rotator Cuff Disease • Tendonitis / Low grade PASTA lesion • High grade PASTA lesion / Rotator cuff tear • Reparable massive rotator cuff tear • Irreparable rotator cuff tear • Cuff tear arthropathy
- 5. TENDONITIS & LOW GRADE PARTIAL CUFF TEAR
- 6. Options for Tendonitis / Low-Grade Partial RC Tear Traditional • • Physical Therapy • Cortisone • Surgery – Decompression / Acromioplasty – Debridement Advanced Technology • Platelet-rich plasma (PRP) • Stem cells (BMAC) (?)
- 7. Goals of Treatment • Decrease pain & inflammation • Create vascular channels • Promote stem cell migration • Achieve healing of tissue B A B 1.5 1 0.5 0 CONTROL ACP HA LOG HAS-2 FOLD CHANGE OVER CONTROL HA IN SYNOVIOCYTES 20 10 MMP 13-IN SYNOVIOCYTES A B A 0 -1 -2 CONTROL ACP HA LOG MMP-13 FOLD CHANGE OVER CONTROL A B B 0 CONTROL ACP HA TNF-Α (PG/ML) TNF- Α Fortier et al, AJSM, 2014
- 8. Stem Cells Proliferation & Migration Significantly Increased with PRP – Kakudo et al, Plast Recontr Surg 2008 – Zaky et al, J Tissue Eng Regen Med 2008 – Drengk et al, Cells Tissues Organs 2009 – Mishra et al, Tissue Eng Part C Methods 2009 – Kruger et al, J Orthop Res 2012 – Moreira Teixeira et al, Biomaterials 2012 – Murphy et al, Biomaterials 2012 – Hildner et al, J Tissue Eng Regen Med 2013
- 9. Platelet-Rich Plasma vs. Cortisone Injections for the Non-surgical Treatment of Shoulder Pain PRP > Cortisone • Inflammatory & calcific processes – Tendonopathy • Partial tears & degenerative processes – Tendon, ligament, muscle • Pain relief PRP = Cortisone • Full thickness tears – Rotator cuff, SLAP, instability • Adhesive capsulitis • Advanced DJD of shoulder • 740 patients with injection of cortisone or PRP (ACP) under ultrasound guidance • 208 Study (PRP) patients / 532 Control (cortisone) patients
- 10. Type of Tendonopathy Will Determine Mode of Treatment • Inflammatory (Tendonitis) • Degenerative • Partial tear – Acute traumatic – Semi-acute non-traumatic – Chronic • Full tear • Peri-tendon / One • Intra-tendon / One+ – Intra-tendon / One – Intra-tendon / One+ – Intra-tendon / 2 or 3 • Peri-tendon / One
- 11. Other Considerations • h/o Cortisone • In season • Out of season • Multiple injections • Peri-tendon / Pain control • Attempt to heal
- 12. Injecting to Heal • Degenerative tendons – Lat / Med epicondylitis – Patellar / Quad tendonitis – Achilles tendonitis • Partial tears of ligaments – UCL – MCL – NOT Intra-articular ligaments or tendons • Calcific tendons – Rotator cuff – Patellar – Achilles
- 13. HIGH GRADE PARTIAL CUFF TEAR & REPAIRABLE FULL-THICKNESS RC TEAR
- 14. Options for High Grade PASTA Lesion Traditional • Debridement • Decompression / Acromioplasty • Repair – – Trans-osseous repair – Trans-tendon repair Advanced Technology • PASTA Bridge • Platelet-rich plasma (PRP) • Stem cells (BMAC) • FlexiGraft DBM sponge
- 15. Options for Repairable Cuff Tear Traditional • Repair – Trans-osseous – Suture anchors – SutureBridge Advanced Technology • SpeedFix • SpeedBridge • Platelet-rich plasma (PRP) • Stem cells (BMAC) • FlexiGraft DBM sponge
- 16. PASTA Bridge Technique • Percutaneous • Safer • Improved Construct
- 17. Extension Bridge
- 18. SpeedBridge • FiberTape – Tissue pull through • Vented Swivelocks – BioComposite material – Full thread anchors – Cannulation • Improved Accessories – FastPass Scorpion – PassPorts – Synergy • Improved Construct – Knotless Technology
- 19. FlexiGraft DBM Sponge • Partially demineralized cancellous sponges – Ground – Cubes – Strips • Demineralized cortical fibers
- 20. FlexiGraft DBM Sponge • DBM produced significantly more fibrocartilage & mineralized fibrocartilage at 12- week post-op, showing a more mature, organized tendon-bone interface Sundar et al., J Biomed Mater Res. 2009; 88B: 115- 122 Sundar et al., J Bone Joint Surg Br. 2009;91;(9)1257- 62
- 21. FlexiGRAFT with RC Repair James Cook, DVM, PhD • Chronic infraspinatus model – n = 10 dogs – Bilateral shoulders, release tendon – Repair after 4 wks • FlexiGRAFT / PRP vs. Direct Repair – Modified SpeedFix configuration • SutureTak medially • 12 week sacrifice, outcome measures – MRI, Histo, and Biomechanical testing
- 22. FlexiGRAFT Strip with RC Repair Standard FlexiGRAFT T = Tendon; I = Interface; A = Anchor Standard has more fibrous tissue at interface and is more edematous
- 23. FlexiGRAFT Strip with RC Repair Standard FlexiGRAFT
- 24. FlexiGRAFT Strip with RC Repair (Lower = Better, both are significant)
- 26. FlexiGraft PASTA Bridge 2nd Look 5 mos post-op
- 27. Case • PASTABridge with FlexiGraft 9/2012 • 2nd Look 2/2013
- 28. Results - PASTABridge Pain Scores ASES Scores 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Pre-op 1 Control Group: n = 35 Study Group: n = 12 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Pre-op 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month
- 29. SpeedBridge Augmented with FlexiGraft
- 30. SpeedBridge with FlexiGraft A Better Way
- 31. Results - SutureBridge Pain Scores 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Pre-op 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month ASES Scores 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Pre-op 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month Control Group: n = 45 Study Group: n = 7
- 32. REPAIRABLE LARGE-MASSIVE ROTATOR CUFF TEAR
- 33. Options for Repairable Massive Tear Traditional • Repair – Trans-osseous – Suture anchors – SutureBridge Advanced Technology • SpeedBridge • Rip Stop • Platelet-rich plasma (PRP) • Stem cells (BMAC) • FlexiGraft DBM sponge • Patch augmentation
- 34. ECM Patches • Justification – Failure rates: 20 57% reported for RC repairs – In vivo animal studies: Support use of acellular dermal grafts for augmentation – Biomechanical studies: Dermal grafts superior suture retention over SIS or BM patches • But – acellular significant DNA • GraftJacket, Restore, TissueMend Adams et al, Arthroscopy 2006. Aurura et al, J Shoulder Elbow Surg 2007. Coons et al, Sports Med Arthrosc Rev 2006.
- 35. RC Repair Augmentation • Peer reviewed clinical studies do not support SIS grafts • Iannotti et al, (JBJS 2006) - Randomized prospective controlled trial using (Restore) augmentation for massive tears showing no benefit using SIS. Discontinued study early! • Walton et al. (JBJS 2007) - 19 pts. 4 of which had severe early inflammatory rxn. 2 yr. MRI shows no difference in failure rate vs non-augmented, abandoned study early! Porcine graft (Level 3) • Schlamberg et al. (J Shoulder Elbow Surg 2004) All patients re-tore • Zheng et al. (J Biomed Mater Res B Appl Biomater 2005) Adverse outcomes related to retained cellular elements • Dermis grafts show potential • Burkhead et al. (Semin Arthroplasty 2007) 17 pts, GJA augmentation, 1.2 yrs F/U, improved UCLA scores but 3 retears per MRI & no reversal of atrophy or fatty infiltration. No Control group Iannotti et al, JBJS 2006 Walton et al, JBJS 2007 Schlamberg et al, JSES 2004 Zheng et al, J Biomed Mater Res B Appl Biomater 2005 Burkhead et al, Semin Arthroplasty 2007
- 36. ArthroFlex • Ready to use • Hydrated • Room temperature storage • Sterile (10-6 SAL) • 3 year shelf life • Biocompatible – > 97% DNA removal • Excellent suture retention strength • Intact framework
- 37. Strength Comparison: ArthroFlex vs. Other ECM Patches Barber et al, Arthroscopy 2009
- 38. DNA Residuals 273 135 16 300 250 200 150 100 50 0 Alloderm GraftJacket ArthroFlex The DNA content for the three materials averaged: Alloderm1 272.8±168.8 ng/mg; GraftJacket2 134.6 ± 44.0 ng/mg dry weight; ArthroFlex 15.97±4.8 ng/mg dry weight.3 Choe et al. J Urol. 2001. Derwin et al. JBJS-A. 2006. Data on file, LifeNet Health.
- 39. In vivo Study Devitalized Human Dermis • Preserved with 15% glycerol and gamma irradiated at delivered dose 12.8 - 17.8 kGy • Implanted subcutaneously in athymic mice – In-life period was 4 weeks • H&E Staining Post Implantation Arrows pointing to new blood vessels with red blood cells in them Lifenet. Data on file. Capito et al, Ann Plast Surg. 2012.
- 40. Placement • Dermal side – Shiny, smooth, absorbs blood – Applied in the down position against the wound or most vascularized tissue • Basement membrane – Dull and rough in appearance – Repels blood – Place in up position – Packaged in view
- 41. RCR with Graft Augmentation
- 42. SpeedBridge with ArthroFlex Augmentation
- 43. BioBridge
- 44. IRREPARABLE ROTATOR CUFF TEAR
- 45. Options for Irreparable RC Tears Traditional • Debridement • Partial repair • Biceps tenotomy • Latissimus dorsi transfer • • Reverse arthroplasty Advanced Technology • Superior Capsular Reconstruction
- 46. Disadvantages to Reverse Total Shoulder • Subject to overuse • Too easily seen as a solution for all previously untreatable shoulder pathologies • Challenging surgical technique • Requires extensive training and experience limits availability • Arthroplasty • Limited life span • Wide range of complication rates
- 47. Intercalary Placement • Biomechanical studies showing equivalent load-to-failure and mechanical properties, but few articles show success clinically Snyder et al, IJSS 2007 Schlamberg et al, JSES 2004
- 48. Bridging vs. SCR Conventional Patch Graft Superior Capsular Reconstruction Courtesy of Dr. Teruhisa Mihata
- 49. Biomechanical Effects of SCR Teruhisa Mihata, MD Initial Superior Force Mihata et al, AJSM 2012
- 50. Arthroscopic Superior Capsule Reconstruction Teruhisa Mihata, MD • Methods: • 24 shoulders over 2 years • Autograft fascia lata used to reconstruct superior capsule • Results: • A-H distance: 4.6 2.2 mm to 8.7 2.6 mm (p < 0.0001) • ASES Score: 23.5 to 92.9 points (p < 0.0001) • Twenty patients (83.3%) had no graft tear or tendon re-tear Mihata et al, Arthroscopy 2013
- 51. Harvest of Fascia Lata Teruhisa Mihata, MD
- 52. Superior Capsular Reconstruction Alan M Hirahara, MD, FRCSC Medial: Glenoid PASTA Bridge Lateral: SpeedBridge
- 53. ArthroFlex Sizes Available • AFLEX100 3.5 cm x 3.5 cm x 1.5 mm $2,225 • AFLEX101 4.0 cm x 7.0 cm x 1.5 mm $2,650 • AFLEX103 5.0 cm x 9.0 cm x 1.5 mm $3,600 • AFLEX150 1.5 cm x 14.0 cm x 1.5 mm $2,000 • AFLEX200 3.5 cm x 3.5 cm x 2.0 mm $2,975 • AFLEX201 4.0 cm x 7.0 cm x 2.0 mm $3,600 • AFLEX301 4.0 cm x 7.0 cm x 3.5 mm $3,850 • AFLEX400 4.0 cm x 4.0 cm x 1.0 mm $2,050 • AFLEX401 4.0 cm x 7.0 cm x 1.0 mm $2,500 • AFLEX500 3.0 cm x 4.0 cm x .5 mm $1,150
- 54. Biomechanical Comparison Fascia Lata, Doubled ArthroFlex, 3.5 mm Failure = 180 N Failure = 550 N
- 56. 2nd Look Terahisu Mihata, MD
- 57. Case #1 • 59 year old female • h/o R shoulder RCR x 3 • ROM – Full passive ROM – Active FF 90o • Strength – 3-/5 AH Distance = 2 mm
- 58. Surgery SCR
- 59. Radiographic Outcome 2 months post-op SCR Pre-op Post-op AH Distance = 2.0 mm AH Distance = 8.4 mm
- 60. Radiographic Outcome 2 months post-op SCR Long Axis Short Axis
- 61. Radiologic Outcome 4 months post-op SCR Normal Pre-op Post-op
- 62. Clinical Outcome 3 months post-op SCR Pre-op Post-op • VAS Scores: 5 1 • ASES Scores: 58 82 • Forward flex: 90 160
- 63. Case #2 • 61 year old male • h/o L shoulder RCR 6/13 • ROM – Full passive ROM – Active FF 10o • Strength – 3-/5 AH Distance = 3.5 mm
- 64. Surgery - SCR Before After
- 65. Radiologic Outcome 1 month post-op SCR Pre-op Post-op AH Distance = 3.5 mm AH Distance = 9.6 mm
- 66. Radiographic Outcome 1 month post-op SCR Long Axis Short Axis
- 67. Clinical Outcome 1 month post-op SCR
- 68. Case #3 AH Distance = 7.9 mm • 67 year old male • ROM – Full passive ROM – Active FF 90o • Strength – 4-/5
- 69. Surgery - SCR Before After
- 70. Radiologic Outcome 1 week post-op SCR Pre-op Post-op AH Distance = 7.9 mm AH Distance = 8.3 mm
- 71. Radiographic Outcome 1 month post-op SCR / Post Fall!!! Long Axis Short Axis
- 72. Clinical Outcome 1 month post-op SCR
- 73. Summary Mihata • Fascia lata autograft – 180 N • A-H distance – 4.6 mm to 8.7 mm • ASES Scores – 23.5 to 92.9 • 83.3% - No graft or re-tear Hirahara • ArthroFlex allograft – 550 N • A-H distance – 4.5 mm to 8.8 mm • ASES Scores – 45.3 to 82.0 • No complications yet n = 24 patients / Follow up 24-51 mos n = 3 patients / Follow up 2-4 mos
- 74. for my patients? • NO Bone Loss! • NO Large Incisions! • NO Prolonged Rehabiliation • NO Burned Bridges! • NO Reverse Prosthesis! • Less pain! • Better Function!!
- 76. Options Traditional • Reverse arthroplasty Advanced Technology • ArthroFlex resurfacing + SCR • Biologic total shoulder
- 77. The Future?
- 78. Technology has no will without someone behind the mask/curtain!
- 79. HiraharaMD.com