Μερική ρήξη υπερακανθίου: Συρραφή επιτόπου ή ολοκλήρωση και συρραφή; – Partial Thickness Rotator Cuff tears – Completion or in situ repair? Techniques
18 Φεβρουαρίου, 2019 comments
Γράφει ο κ.Ματαράγκας Ηλίας. Ορθοπαιδικός Χειρουργός
-The incidence of partial tears is unclear, because most, especially intratendinous lesions, can be very difficult to identify, and MRI may demonstrate partial tears in asymptomatic individuals -Fukuda et al reported a prevalence of 7% full thickness and 13% partial-thickness tears (of which 18% were bursal- sided, 27% articular-sided, and 55% intratendinous) in 249 cadavers.
Among the three subtypes of partial tear, PASTA are two to three times more common than Bursal Side Tears
Degenerative Traumatic Internal impingement in overhead athletes (excessive compression of the articular-side of the tendon against the glenoid and labrum)
Common May be caused by: The relatively poor blood supply within the crescent of the supraspinatus. Differences in biomechanical and histologic properties of bursal and articular side The bursal side is composed mostly of tendon bundles, whereas the articular side is a complex of tendon, ligament, and capsule. The bursal side is able to undergo a greater deformation and has a greater tensile strength
40% of the asymptomatic partial tears that become symptomatic progress to full thickness tears
Based on patient lifestyle and demands, the location and dimensions of the tear, and the response to conservative treatment. Most patients should attempt a course of nonoperative treatment that includes flexibility and strengthening exercises. Those patients that fail to improve are candidates for surgical treatment
High-demand patients may be at greater risk for failure. When a time-dependent recovery is important, surgical repair of the lesion is easier to explain to patients than telling them to “wait and see.”
By far the most common partial tears are Articular-side, vascular or age relateted Traditionally partial tears classifications are based to 50% BUT “How healthy is the remaining, intact tissue?”
Histopathology of the Residual Tendon in High-Grade Articular-Sided Partial-Thickness Rotator Cuff Tears (PASTA lesions) Arthroscopy confirmed bursal-sided fibers were macroscopically intact, however, myxoid degeneration (95%), rounding of the tenocyte nuclei (71%), vascular proliferation (38%), chondroid metaplasia (38%), hyalinization (38%), and calcification (9.5%) were observed histologically.
1. Debride only 2. In-situ Repair 3. Convert to full thickness, Debride, Repair Etiology makes the decision!!! Because most tears are degenerative, option 3 should be the best for most cases Trauma or young athletes are candidates for in-situ repair [Yamaguch K, 2006 Nice Shoulder Course]
No statistically significant difference between the two treatment options Patient age, tendon quality and tear depth is still taken into consideration
Histopathology of the Residual Tendon in High-Grade Articular-Sided Partial-Thickness Rotator Cuff Tears (PASTA lesions) Our results suggest that the transtendon technique leaves degenerative thin bursal-side fibers at the repair site, which may increase the risk of re-rupture, postoperative stiffness, or pain. Residual PASTA lesion tendon tissues were highly degenerative histologically in our study population. Completion of the tear and repair would be prudent in cases with PASTA lesions.
Transtendinous repair of partial articular sided supraspinatus tears is associated with higher rates of stiffness and significantly inferior early functional scores than tear completion and repair: A systematic review. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.007
Any potential increase in stiffness after TTR could also be a result of a mismatch in tension between the articular and bursal layers in the initial period restricting motion Shin SJ.A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25–33. Partial tendon tears are at higher risk of stiffness post-operatively regardless of the surgical technique used to repair them. Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Inci-dence and treatment of postoperative stiffness following arthroscopic rotatorcuff repair. Arthroscopy 2009;25:880–90.
-PASTA lesions are 2-3 times more common than bursal side tears -Tendon degeneration is the most common cause for PASTA -Subacromial impingement is common cause for bursal sided tears -Internal impingement is a probable cause for throwers -TTR – CTR yield satisfactory long term results -TTR has a higher rate of stiffness and pain early postop
Η παραπάνω εργασία παρουσιάστηκε από τον κ. Ματαράγκα Ηλία στο 3rd Athens Shoulder Course.