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Rotator Cuff Disease for the Fellowship Exam
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Rotator Cuff Disease for the Fellowship Exam
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Language: EN.
Segment:0 .
HITESH GOPALAN: A very good afternoon to everyone and welcome all of you to the 53rd live webinar on Orthopedic Principles. Today we have Professor Bijayendra Singh back with us. He's from Kent, United Kingdom and he's also associated with the Canterbury Christ Church University as Professor. Over to you Professor Singh.
BIJAYENDRA SINGH: Thank you, Hitesh. It's good to be back.
BIJAYENDRA SINGH: Today, I'm going to discuss a few things on the rotator cuff tears and how this will present or come at the fellowship exams. So with rotator cuff tears, you could get it in any scenarios, really. You could get it as an intermediate case for 15 minutes where you'd have to take the history exam in and make a management plan. It could be on the adult pathology why/web table as well.
BIJAYENDRA SINGH: And occasionally it may come as a short case so and I suspect that you will probably get at some point in time on your journey for the fellowship exam so it's quite vital that you are aware of the condition as well as the options so. In general, I mean, I'm not going to talk to you about the basics of the rotator cuff. I expect everybody to know about the basics, but the rotator cuff essentially is a group of four muscles.
BIJAYENDRA SINGH: And when the term rotator cuff is used in normal terminology, most of the time we talk, think about the supraspinatus and the infrasinatus. Yes, subscapularis, anterior minor are also part of the cuff. But when they are involved, they are spoken as those individual muscles. So in general, I would suggest that if there is just a talk about rotator cuff, we usually talk about the supraspinators and infraspinators.
BIJAYENDRA SINGH: Now the supraspinatus is the more or both of them are important but have different functions. The supraspinatus in search on the anterior superior aspect of the greater tuberosity with medial lateral, with that insertion of about 12 and 1/2 millimeters. The infraspinatus in fact, has a slightly wider, wider insertion than the Supraspinatus, but the supraspinatus is the one that is more commonly torn and gets affected.
BIJAYENDRA SINGH: The subscapularis inserts on a still larger footprint and is attached anteriorly. The teres minor is not that commonly affected. There is a small gap between the articular cartilage and the medial footprint and the anterior posterior diameter of the dimension of the footprint is 20 millimeters. So that's what we're talking about when we do a repair of these tendons.
BIJAYENDRA SINGH: The rotator cuff, when it attaches, it's in five different layers and in technical, I mean, these are histology, but in technical terms, we talk about the articular surface as well as the versus side tears. So the five different layers, the most superficial layer is towards the bursal side, which is composed of fibers from this coracoid humeral ligament and extends posteriorly and obliquely.
BIJAYENDRA SINGH: The second layer is composed of densely packed fibers. Layer three is of loosely organized bundles of collagen and layer four is mainly connective tissues and layer five, the deepest part, is your, the shoulder capsule. Now the blood supply to this is from all aspects about bursal side and articular surface side. So the subscapularis, the suprascapular and the humeral circumflex arteries supply them, and they're usually present in the superficial layers.
BIJAYENDRA SINGH: The bursa side is more vascular and the articular side is less vascular, and hence the bursa side tendon tears tend to respond better than to just the partial articular surface tears or the pasta tears. So why do cuff tears happen? We don't exactly know the reasons, but extrinsic factors repetitive use is probably the most common, and that's why we see the chronic degenerate tendon tears more often than an acute tears.
BIJAYENDRA SINGH: Although in young adults you can get acute tears and that's a completely different presentation and different kettle of fish, so to say. They may have some instability related issues generally with internal impingement types. The other extrinsic factors are acromial spurs, coracoid acromial ligament, osteophytes from the AC joint and these are the three main factors. Regarding the acromial spurs,
BIJAYENDRA SINGH: there's still no agreement, whether it is an effect or the cause of the impingement of cuff tears. There are some thoughts about the intrinsic factors where the blood supply becomes tenuous to the rotator cuff, which increases the tear. And hence, some people believe that steroids should not be used in early stages of tendinopathy, rotator cuff tendinopathy as this aggravates and makes the tear worse.
BIJAYENDRA SINGH: But there is no studies to confirm that doing steroid injection actually makes a clinical difference, yes, on microvascular levels, there is a difference for sure. So how do you classify tears? You can do partial or full thickness tears? Ellman classified the partial thickness tears as one: less than 3 millimeters or about 25% thickness two: is 3 to 6 millimeters and 25% to 50% tears, and three: is more than 6 millimeters or more than half.
BIJAYENDRA SINGH: So this becomes useful if you're dealing with a patient who has got partial thickness tears. If it is less than 25%, then most of us would leave it. If it is between 25 and 50%, then it would depend on the extent of the tear and which side the tear is. Again, the vast majority of them you could leave it. If it is more than 50%, then the options differ slightly in the sense that some group believe that this tear should be completed and repaired.
BIJAYENDRA SINGH: Some group do it in situ repair, especially of the articular surface tear. I personally come from the group where I believe that you should make the tear complete and then treat it like a full thickness tear. You can describe according to the location as we just, as I just said so you can have an articular side tear or a bursa side tear. Intertendronis tear
BIJAYENDRA SINGH: is a new terminology which has been picked up, especially since the MRI has started becoming more regular in use. And this just suggests degenerative changes rather than changing any surgical treatment for the patient. The Patte classification describes as to the extent of the retraction and this is one of the reasons why I generally prefer MRI or ultrasound in cuff tears
BIJAYENDRA SINGH: as you can see, the level of retraction and you can explain this to the patient and also helps you make a plan, whether this tendon is going to be repairable or not. So stage one is essentially where the tendon hasn't retracted at all. Stage two, when it moves slightly medially. But in vast majority of the cases, one should be able to do a repair fairly straightforward. When it is an glenoid level or thereabouts,
BIJAYENDRA SINGH: this is usually associated with other factors, like it's usually a big tear or a large tear or a massive tear. Often their tear is stiff, and quite regularly the muscle there is a fatty degeneration and atrophy so that all combines together, makes that kind of repair difficult and hence you can then explain to the patient what your plans are and how are you going to manage it.
BIJAYENDRA SINGH: So I just mentioned the MRI scan. I will just have a few slides on the MR. The MRI is usually performed in French. I'll have you on the first slide itself. Oh, it's not moving, is it?
HITESH GOPALAN: No, it isn't. Oh, my God. I was a bit surprised. I was just I thought he was talking, was continuing to speak to the slides.
BIJAYENDRA SINGH: OK, one second. I don't know what. Why does it say you are screen sharing? So shall I restart the whole thing again?
HITESH GOPALAN: Well, we have gone quite a lot OK OK so we can start from. Yeah, that's fine. Yeah, that's also if you could just have a recap, not an issue.
BIJAYENDRA SINGH: OK, so let's go to the MRI now.
BIJAYENDRA SINGH: Let me know. Are you getting changing?
HITESH GOPALAN: Yeah now it's showing MRI.
BIJAYENDRA SINGH: But you see, it's saying sharing is paused. Bring your shared window to the front. Can you see anything? is it just stuck on MRI?
HITESH GOPALAN: You can.
HITESH GOPALAN: It's on the MRI. All right. You can go to the previous version. I mean, just going before going full screen. Yeah, I think you can go from here. That's better.
BIJAYENDRA SINGH: But this is not full screen, is it? That's OK.
HITESH GOPALAN: That's OK.
BIJAYENDRA SINGH: That's better. Yeah OK, one second. Let me make this as big as I can. OK so now before you start recording again, just let check that it is working, OK? One second. Yeah OK.
BIJAYENDRA SINGH: Yeah shall I start again? Hitesh?
HITESH GOPALAN: Yeah, you're fine. So I think classification if you don't mind.
BIJAYENDRA SINGH: Classification that one. Yeah Yeah. So start off we were discussing about the classification for the rotator cuff tears and as I was alluding, so this is the classification which comes in quite handy for clinical making decisions because this helps me advise patients about the test itself and what to expect.
BIJAYENDRA SINGH: So stage one is when the stump is near the bone insertion. And this is most commonly seen with a small tear or acute tears as well. And this is a pretty straightforward and easy repair. Stage two is where there is some retraction up to the level of the humeral head, often up to the mid humeral head. And again, these are pretty straightforward ones to repair.
BIJAYENDRA SINGH: The stage 3 is where the end of the cuff is at the level of the glenoid or more proximal and this usually suggests that the tear is quite large or massive, is likely to be stiff, and it's also likely to have other changes, as in wasting and fatty degeneration within the rotator cuff, making the tear more difficult or often not possible and hence you can advise the patient accordingly.
BIJAYENDRA SINGH: So so. So the MRI is usually done in three different planes relative to the glenohumeral joint. And these are the three sequences that are typically done. One is the coronal oblique, which helps you decide the
BIJAYENDRA SINGH: retraction on the Patter classification. The sagittal oblique tells you about the fatty infiltration and the muscle wasting, and the X you'll see is used for looking at subscapularis as well as the extent of the tear. So these are a couple of slices on the MRI of the coronal oblique and you can see here that this one shows a partial thickness tear
BIJAYENDRA SINGH: whereas this one shows a full thickness tear and it helps you look at both the supraspinatus and the infraspinatus, the subacromial space and the labrum issues as well as biceps tendon. So this is a short video on the MRI going from the front to the back.
BIJAYENDRA SINGH: Then you can see that that's the tear starting to come up there and you can see it's a full thickness there, so this is like a Patter Grade 1 where you can see this is the supraspinatus, tender muscle belly forming a tendon and it's tore that the white is the fluid that is present and but it's more or less where it should be. And you can see it's a fairly large tear and this is now going into the infraspinatus territory where there is some partial thickness tear, but it's not involved significantly.
BIJAYENDRA SINGH: So that way you can advise the patient about the management. The MRI Sagittal Oblique helps you to look at the muscle atrophy so as you can see here, this is the quarterly classification and generally you would expect the supraspinatus to incorporate almost the whole of the supraspinatus fossa
BIJAYENDRA SINGH: but here you can see it's below that line, suggestive of some fatty infiltration and atrophy. The axial scans are useful to look at the biceps tendon, which is particularly important if well, it's important in all patients, particularly if you've got a traumatic cuff tear and often these are fairly massive tears. Look at the glenoid, the labrum, the subscapularis.
BIJAYENDRA SINGH: As you can see here, this is a patient where the biceps tendon has moved from its groove and is lying here medially and this often is associated with an subscapularis tear and at the bottom one, this is from an instability patient, we can see there is labrum disruption as well as a small loose body in the posterior aspect. So let's look at this axial CT, MRI scan.
BIJAYENDRA SINGH: So in the axial MR you can also look at the AC joint so this is now just coming up to the supraspinatus tendon and the humeral head in the glenoid coming in and if I pause it there you can see this is the subscapularis, the flue, on there. And again, you can see that this is the biceps tendon, that's the subscapularis and it should normally be seen quite thick band, robust, almost like you would see an ACL intact
BIJAYENDRA SINGH: ACL is it fairly firm and thick structure that cannot be missed and you can see the biceps tendon out of its groove right the way. So this patient has got a subscapularis tear as well as the supraspinatus. Now, briefly, about the ultrasound. Yes, the ultrasound used is increasing. It's a very good handy tool. My personal view is that it's best used by the person who is interpreting, interpreting the data.
BIJAYENDRA SINGH: If as a surgeon, I think it's best to use in your own hands, because otherwise you're relying on second hand information. The pictures are not dynamic and you're relying on the interpretation of the radiologist, but if you're doing it, then there needs to be a protocol of how you're going to look at these. So starting from the biceps and the subscapularis at the front, then the supraspinatus, then the subacromial bursa and then down the back.
BIJAYENDRA SINGH: And you need to understand what the anatomy looks like and one of the main reasons why the ultrasound is so much operator dependent, because if you look at these two images, this is of the same patient and what the difference is, the angle at which this probe is held is different. So here you can see which is held perpendicular and you can see the biceps tendon in there.
BIJAYENDRA SINGH: In this picture, the probe has been angled slightly so that the biceps appears to be empty. So if somebody was looking at the bottom picture, you would think that the biceps is missing. But in fact, the biceps is still very much there so that's the downside of the ultrasound tendon. So these are just the three sections of different MR so on the left is your normal looking rotator cuff tendon,
BIJAYENDRA SINGH: the supraspinatus is here. There is a partial articular surface tear and on this one, you can see there is a full thickness tear. So this is an example of a patient who had a fall whilst running and the fell with an abducted arm and you would get this on your way to a wywer table with these pictures and that history. So essentially, you've got to evaluate both the planes and see where the problem is.
BIJAYENDRA SINGH: So if we start with this top right hand corner MR. So this is a Coronal picture ah Coronal MR T2 most likely to be which is showing the supraspinatus muscle belly and forming a tendon and as it comes through its insertion, I can see there is a gap there and which is also seen on the further slide, further image, further down
BIJAYENDRA SINGH: there's a fair amount of fluid all around the glenoid and the humeral cartilage looks fairly normal. On the other pictures, this looks like a T1 image which shows on the top one. I can see the biceps tendon has moved out of its groove and the subscapularis also looks to be torn, which is seen even on the bottom picture. So looking at this, my diagnosis would most likely to be that this patient has got a large or a massive rotator cuff tear.
BIJAYENDRA SINGH: And I would like to examine and assess the patient, take a for good history and then make a management plan, which is most likely going to require a surgical repair. Now the question is whether these rotator cuff needs to be operated upon. So what's the natural history? This could be a potential question. So this is one of the studies looking at natural history of non operative treatment of symptomatic rotator cuff tear.
BIJAYENDRA SINGH: Now it's quite important to differentiate between a symptomatic cuff tear and an asymptomatic cuff tear so often people will bant around the asymptomatic cuff tear but we are not advising treatment for asymptomatic cuff tears. So this study looked at patients under the age of 60 who had 5 millimeters of bigger tears on ultrasound.
BIJAYENDRA SINGH: They followed up for at least two years or longer, and the ultrasonography was done by the same sonographer; they had 51 out of the 61 patients return. They showed about 50% increased in size and nearly similar numbers did not show any change. And also, a quarter of them found to have new tears. It's interesting to see that they did not find any correlation with the change size in the size, tear size, change related to patient age, previous injury or the size of the tear.
BIJAYENDRA SINGH: But importantly, they found that if the patient's tear size increases, then so does the symptoms increase as well, which is what you can reassure a patient with a small tear that if the symptom starts to get worse, then it is suggestive that the cuff is tear is becoming bigger and they may need to take advice. Now, when you come to cuff repairs, there are certain factors which are modifiable and certain factors which are unmodifiable.
BIJAYENDRA SINGH: So what you can modify is the type of repair you're doing, the technique of repair, types of sutures, anchors, whether you do an open or arthroscopic and the type of rehabilitation that one uses. Now, in vast most places these days, these cuff repairs are done arthroscopic. The advantages of open versus arthroscopic is only seen in the early stages.
BIJAYENDRA SINGH: More studies will code of outcomes at one year and yes, at one year there is no difference. But certainly in the first four to 6 weeks, the level of pain relief, complications, time off work and patient comfort is much better in the arthroscopic ones. There are certain things that is unmodifiable, which is the age, the type and age of the patient, the type and size of tear, the retraction and the fatty infiltration and the quality of bone.
BIJAYENDRA SINGH: What are we trying to achieve by doing a cuff repair? We're trying to provide a tendon to bone healing with the idea of providing pain relief, improve function and strength, and hopefully reduce progression to a cuff tear after opothy. So what does a successful repair require? It requires adequate decompression, restoration of footprint providing good compression of the tendon on the footprint and minimize tendon bone interface movements in the early stages.
BIJAYENDRA SINGH: These are the few steps that you need to be aware of when managing a patient with a cuff tear. Some of these are technical, which may not be acquired during the exams, but as a general principle in managing cufff tear, the positioning of the patient, fluid management, portals, instrumentation, biomechanics, the recognition of tear pattern, the approach: how are you going to repair it, whether a single or double row?
BIJAYENDRA SINGH: Those are factors that one may need to consider. Sorry. The key thing is work to a system when it comes to practical uses, although again, not so much of a fellowship related but more practical. Whether you tie knots, passing sutures, repair type, that's what you need to familiarize with. So here's a couple of short videos on single row and double row cuff repairs. So single row is where you put the stitches in on one side, only single row and attach it to the bone.
BIJAYENDRA SINGH: I use a knotless system, so this is what the technique is. So here you pass the sutures in with any suture passes that you use. I generally tend to use a mattress type of stitch as it's shown to provide better compression and less point loading of the tendon. Often I would pass a ripstop suture that would go across and under the mattress.
BIJAYENDRA SINGH: Once you've done that, you identify your spot where you're going to insert the anchor. This is a punch to make the pilot hole. And then the anchor going in and you can see the tendon has been brought in quite nicely.
BIJAYENDRA SINGH: Now there are different techniques that I use and for the fellowship exams, I would suggest to you talk about technique that you are familiar with or you have seen your bosses use it as it's easy to answer any questions, or especially if your boss is using something unusual, you won't be criticized for that.
BIJAYENDRA SINGH: This is the technique for the double row. As you can see here, this is a much bigger tear. That's the edge of the cuff. This is the articular surface. And this is the footprint. So the first step is to prepare using the burr and this shows nicely the size of the tear.
BIJAYENDRA SINGH: And what I'm doing is using it on reverse to just decorticate the bone, then checking the repairability and you can see it's quite a mobile tear and comes and sits nicely. Identifying my medial row anchors with a needle first before I make another portal.
BIJAYENDRA SINGH: The first medial anchor going in now. So again, I use a knotless system and the advantage of this system is that it locks the medial row sutures in so you don't have to tie the knot on it. Now this videos are available on my website so I'm going to skip it through
BIJAYENDRA SINGH: for time purposes. So those are the two medial row anchors going in. And then it passes sutures through the rotator cuff.
BIJAYENDRA SINGH: OK now the question is where? Why should one be using a single row or a double row? It's basically the strength of the repair. The single row provides about 220 Newtons of pull out strength. The double row increases that by about 50% and the suture bridge where you crisscross the stitches provides a higher pull out strength. Now, it's important to remember that a few basic studies to look at what the strength in the rotator cuff repair needs to be is actually quite low.
BIJAYENDRA SINGH: So the pull out strength is about needs to be about 180 Newtons so what it suggests is that even a single load repair is probably strong enough to provide the healing but more and more studies, as I will show, are coming up to show that the double row is better. Now the clinical outcomes of this use of single or double row shows that there is not a significant difference in the most of these patients,
BIJAYENDRA SINGH: but what we know that is certainly the larger size of cuff tears is the double row has shown lesser amounts of re-tear rates with a double row repair, and hence that's what people are advising. What about the rehabilitation? How does it affect the eventual outcomes? So this study looked at four different aspects of early versus delayed rehabilitation.
BIJAYENDRA SINGH: What they found was that a lot of studies showed that a range of movements is better if you get mobilization sooner, especially the elevation is better in early stages. And again, like with lots of range of movement things in orthopedics, pre-op range of movement is shown to be the most important factor to regain the movement, and again, there is no difference at one year.
BIJAYENDRA SINGH: There is no difference in the level of pain in early or late mobilization group. Muscle strength, there is no difference between early and late, but it still stays lower than the other side and reiterates this re-tear rates on MRI scan and this is variable and up to more than 90% but functionally there is no difference between. More so in fact, I now mobilise most of my patients at two weeks.
BIJAYENDRA SINGH: So to conclude the key to success is to pick a winner, have a good anesthesia, tension-free reduction and repair, need to do a thorough bursectomy for visualization, work to a system, this variety of equipment is invaluable and in my own practice for small tears I would do a single room mattress repair and for a larger and larger tear double row suture bridge type of technique.
BIJAYENDRA SINGH: Thank you.
HITESH GOPALAN: Bijay, thank you for that presentation and it's been very nice listening to you. There have been a couple of queries. BIJAYEDRA SINGH} Yeah? Both are related to the two trials. One is the UCUFF trial by Carr, which looked at arthroscopic versus open and said that the difference is not major. What do you think about it?
BIJAYENDRA SINGH: Yes, so as I said, see again, it's a lot of these studies actually focus on the six months or a year down the line. So, yes, you know, whether you do it open or arthroscopic, one year outcomes are no difference. And I don't think any shoulder surgeon will deny that fact that it's the initial part, the post-op recovery, the inpatient stay and also the risk
BIJAYENDRA SINGH: of infection and wound problems. And also I personally find that with the open repair your visualization is fairly limited with the arthroscopy, you get to see it more often. The other thing which, I mean, unless you are a surgeon who does still does a shoulder arthroscopy, does the decompression arthroscopy, and then does the repair open. that's one group, but that's OK.
BIJAYENDRA SINGH: But if you're just doing open cuff repairs and not doing the shoulder arthroscopy to begin with, you are likely to miss out on a lot of intra articular pathology. So a simple thing like a partial biceps tear or if there is a loose body or something like that. So that's my take on the open versus I mean, arthroscopic repair for people who are starting off have got equipment issues. Yes you know, you can learn to do it open and then move on to arthroscopic repair.
HITESH GOPALAN: Thank you Bijay. The other one is regarding the other very popular trial, the seesaw trial, which is published in Lancet, again, from the Oxford Press. And they note that they say that there is the role for subacromial decompression is like minimal or are there at all? What do you think?
BIJAYENDRA SINGH: OK so the seesaw, I mean, I was one of the contributing surgeons to the seesaw trials.
BIJAYENDRA SINGH: Now, what people actually forget is that all the patients certainly in the UK and certainly in my practice that who come to decompression have actually exhausted all the non operative means following surgery following the shoulder pain. The other important bit, because when this came, when did this come? This came in 20..2014 in Lancet (HITESH)
BIJAYENDRA SINGH: Was it 2014 Lancet? Yeah OK. I thought the seesaw was a bit later?
HITESH: No, seesaw was 2014 and 2017 was the UCON.
BIJAYENDRA SINGH: OK and basically what happened was we all looked at our and also there was a big article in the BMJ saying that all this shoulder surgery is not good.
BIJAYENDRA SINGH: And we all actually as shoulder surgeons, we looked at our own practice and what I found in my practice, because they did not see they don't classify as surgery for war. They put it all under shoulder pain surgery. So that the BMJ headline was surgery for shoulder pain is not good or something along those lines. And in fact, in my practice, only 15% of my shoulder arthroscopies are actually pure decompressions.
BIJAYENDRA SINGH: So 85% of my patients have either got a biceps problem or a labral problem or a cuff tear and along with that, an acj of pain and all of them, even the 15% who underwent a simple decompression have had the previous non operative treatment and I mean I haven't got, I haven't done promise on my patients but vast majority of them have got no post op.
BIJAYENDRA SINGH: You know, they're quite happy after the surgery.
HITESH GOPALAN: OK thanks, Bijay. What is your approach to a large tear? For example, if there's a defect, how do you bridge that? We use the phrase share or use.
BIJAYENDRA SINGH: Oh. So the options obviously depends if this is a fellowship exam question. The option depends on the age of the patient, the type of tear, what their expectations are and what their shoulder function is like.
BIJAYENDRA SINGH: Now most of the treatment except for a shoulder replacement is good if the patient does not have a pseudo paralytic arm. So they are good for pain relief, whatever you do, except for tendon transfers, I guess, which will help with the movement as well. So whether you do a superior capsular reconstruction type of procedure with whatever or whether you use a allograft or you use an autograft, they are all designed mainly to help with the pain.
BIJAYENDRA SINGH: I personally use the balloon into position arthroplasty for two reasons. One is A: it's arthroscopic.
B: is technically easier to do and C, you're not burning any bridges and the complications are fairly minimal. There's no more complication than any of the shoulder arthroscopy. With the superior capsular reconstruction,
BIJAYENDRA SINGH: it is technically a very demanding procedure, it's fairly expensive because even at the minimum, you're looking at four suture anchors at the least and also the outcomes haven't yet, I mean, there are studies coming out now, but it's not universally that everybody has had a good outcome. So that is second option. In some cases, you know, the one that you mentioned about the patch.
BIJAYENDRA SINGH: So essentially, the patch was originally described as a reinforcement mesh rather than a bridging type of gap. And I know there's a couple of, a few studies, actually, one big study from Leicester where they used it as a bridging graft and it has shown good outcomes. I personally don't have any experience with using those patch grafts. And of course, if the patient has got through the paralysis, then the only realistic option apart from physio and pain relief, is a reverse shoulder arthroplasty.
HITESH GOPALAN: Thank you Bijay and what is the principle behind the balloon into position that you describe?
BIJAYENDRA SINGH: So the balloon into position arthroplasty, the, as we all know and as we all see, there's lots of patients that we see who have got a big cuff tear and they still function very well, so they can use that arm. Yes, they are weak, but they can still move their arm and that is because their deltoid is functioning well.
BIJAYENDRA SINGH: And the idea of using the balloon into position is that it sort of tenses the deltoid, so it puts the deltoid at an optimum tension and allows the deltoid to take over that function because remember, the balloon is made out of PLAA as in the same material as y sutures and that gets absorbed in six months to 12 months maximum.
BIJAYENDRA SINGH: And so that effect is no longer there and hopefully by that time, the deltoid has been retrained and has started to take the function over. And I think what's his name, George Atwell, published some study, biomechanical study to show that effect.
HITESH GOPALAN: Yeah, George Atwell from Canada, right?
BIJAYENDRA SINGH: Yes, that's correct.
HITESH GOPALAN: Yeah OK. And do you keep it in the subacromial space where you leave the balloon there.
BIJAYENDRA SINGH: So it stays in the subacromial space so basically the steps would be that you do a bursectomy, you don't do the bony ecromioplasty, because you don't want any sharp edges. And then the balloon comes up, rolled up, and it's as you push the fluid in, it unfolds and just sits on top of this subacromial bursa or the humeral head.
HITESH GOPALAN: OK, Bijay, I think that's all the questions that we have and we have I mean, even in your previous lectures, I think we have touched a bit about the cuff, and I think this has been comprehensive and covered the entire aspect and (BIJAY: Thank you) I suggest yeah we can wind up this session.
BIJAYENDRA SINGH: Just one thing that on the YouTube, I have got a video channel.
BIJAYENDRA SINGH:
(HITESH): Yeah, please. So it's called Kent orthopedic practice. So if anybody is interested to have a look at them, then they can find the videos. And I think I've given you my email address. If anybody has any queries, I'm more than happy to answer. Thank you.
BIJAYENDRA SINGH:
HITESH: Thank you, Bijay once again for spending your valuable time.
BIJAYENDRA: Thank you Hitesh.
BIJAYENDRA SINGH: I must appreciate you, you work. so hard for all of this.
BIJAYENDRA SINGH:
HITESH: Thank you once again for your kind words and thank you.
BIJAYENDRA SINGH: No problem. Thank you. Catch up soon.
BIJAYENDRA SINGH:
HITESH: Yeah
Segment:0 .
HITESH GOPALAN: A very good afternoon to everyone and welcome all of you to the 53rd live webinar on Orthopedic Principles. Today we have Professor Bijayendra Singh back with us. He's from Kent, United Kingdom and he's also associated with the Canterbury Christ Church University as Professor. Over to you Professor Singh.
BIJAYENDRA SINGH: Thank you, Hitesh. It's good to be back.
BIJAYENDRA SINGH: Today, I'm going to discuss a few things on the rotator cuff tears and how this will present or come at the fellowship exams. So with rotator cuff tears, you could get it in any scenarios, really. You could get it as an intermediate case for 15 minutes where you'd have to take the history exam in and make a management plan. It could be on the adult pathology why/web table as well.
BIJAYENDRA SINGH: And occasionally it may come as a short case so and I suspect that you will probably get at some point in time on your journey for the fellowship exam so it's quite vital that you are aware of the condition as well as the options so. In general, I mean, I'm not going to talk to you about the basics of the rotator cuff. I expect everybody to know about the basics, but the rotator cuff essentially is a group of four muscles.
BIJAYENDRA SINGH: And when the term rotator cuff is used in normal terminology, most of the time we talk, think about the supraspinatus and the infrasinatus. Yes, subscapularis, anterior minor are also part of the cuff. But when they are involved, they are spoken as those individual muscles. So in general, I would suggest that if there is just a talk about rotator cuff, we usually talk about the supraspinators and infraspinators.
BIJAYENDRA SINGH: Now the supraspinatus is the more or both of them are important but have different functions. The supraspinatus in search on the anterior superior aspect of the greater tuberosity with medial lateral, with that insertion of about 12 and 1/2 millimeters. The infraspinatus in fact, has a slightly wider, wider insertion than the Supraspinatus, but the supraspinatus is the one that is more commonly torn and gets affected.
BIJAYENDRA SINGH: The subscapularis inserts on a still larger footprint and is attached anteriorly. The teres minor is not that commonly affected. There is a small gap between the articular cartilage and the medial footprint and the anterior posterior diameter of the dimension of the footprint is 20 millimeters. So that's what we're talking about when we do a repair of these tendons.
BIJAYENDRA SINGH: The rotator cuff, when it attaches, it's in five different layers and in technical, I mean, these are histology, but in technical terms, we talk about the articular surface as well as the versus side tears. So the five different layers, the most superficial layer is towards the bursal side, which is composed of fibers from this coracoid humeral ligament and extends posteriorly and obliquely.
BIJAYENDRA SINGH: The second layer is composed of densely packed fibers. Layer three is of loosely organized bundles of collagen and layer four is mainly connective tissues and layer five, the deepest part, is your, the shoulder capsule. Now the blood supply to this is from all aspects about bursal side and articular surface side. So the subscapularis, the suprascapular and the humeral circumflex arteries supply them, and they're usually present in the superficial layers.
BIJAYENDRA SINGH: The bursa side is more vascular and the articular side is less vascular, and hence the bursa side tendon tears tend to respond better than to just the partial articular surface tears or the pasta tears. So why do cuff tears happen? We don't exactly know the reasons, but extrinsic factors repetitive use is probably the most common, and that's why we see the chronic degenerate tendon tears more often than an acute tears.
BIJAYENDRA SINGH: Although in young adults you can get acute tears and that's a completely different presentation and different kettle of fish, so to say. They may have some instability related issues generally with internal impingement types. The other extrinsic factors are acromial spurs, coracoid acromial ligament, osteophytes from the AC joint and these are the three main factors. Regarding the acromial spurs,
BIJAYENDRA SINGH: there's still no agreement, whether it is an effect or the cause of the impingement of cuff tears. There are some thoughts about the intrinsic factors where the blood supply becomes tenuous to the rotator cuff, which increases the tear. And hence, some people believe that steroids should not be used in early stages of tendinopathy, rotator cuff tendinopathy as this aggravates and makes the tear worse.
BIJAYENDRA SINGH: But there is no studies to confirm that doing steroid injection actually makes a clinical difference, yes, on microvascular levels, there is a difference for sure. So how do you classify tears? You can do partial or full thickness tears? Ellman classified the partial thickness tears as one: less than 3 millimeters or about 25% thickness two: is 3 to 6 millimeters and 25% to 50% tears, and three: is more than 6 millimeters or more than half.
BIJAYENDRA SINGH: So this becomes useful if you're dealing with a patient who has got partial thickness tears. If it is less than 25%, then most of us would leave it. If it is between 25 and 50%, then it would depend on the extent of the tear and which side the tear is. Again, the vast majority of them you could leave it. If it is more than 50%, then the options differ slightly in the sense that some group believe that this tear should be completed and repaired.
BIJAYENDRA SINGH: Some group do it in situ repair, especially of the articular surface tear. I personally come from the group where I believe that you should make the tear complete and then treat it like a full thickness tear. You can describe according to the location as we just, as I just said so you can have an articular side tear or a bursa side tear. Intertendronis tear
BIJAYENDRA SINGH: is a new terminology which has been picked up, especially since the MRI has started becoming more regular in use. And this just suggests degenerative changes rather than changing any surgical treatment for the patient. The Patte classification describes as to the extent of the retraction and this is one of the reasons why I generally prefer MRI or ultrasound in cuff tears
BIJAYENDRA SINGH: as you can see, the level of retraction and you can explain this to the patient and also helps you make a plan, whether this tendon is going to be repairable or not. So stage one is essentially where the tendon hasn't retracted at all. Stage two, when it moves slightly medially. But in vast majority of the cases, one should be able to do a repair fairly straightforward. When it is an glenoid level or thereabouts,
BIJAYENDRA SINGH: this is usually associated with other factors, like it's usually a big tear or a large tear or a massive tear. Often their tear is stiff, and quite regularly the muscle there is a fatty degeneration and atrophy so that all combines together, makes that kind of repair difficult and hence you can then explain to the patient what your plans are and how are you going to manage it.
BIJAYENDRA SINGH: So I just mentioned the MRI scan. I will just have a few slides on the MR. The MRI is usually performed in French. I'll have you on the first slide itself. Oh, it's not moving, is it?
HITESH GOPALAN: No, it isn't. Oh, my God. I was a bit surprised. I was just I thought he was talking, was continuing to speak to the slides.
BIJAYENDRA SINGH: OK, one second. I don't know what. Why does it say you are screen sharing? So shall I restart the whole thing again?
HITESH GOPALAN: Well, we have gone quite a lot OK OK so we can start from. Yeah, that's fine. Yeah, that's also if you could just have a recap, not an issue.
BIJAYENDRA SINGH: OK, so let's go to the MRI now.
BIJAYENDRA SINGH: Let me know. Are you getting changing?
HITESH GOPALAN: Yeah now it's showing MRI.
BIJAYENDRA SINGH: But you see, it's saying sharing is paused. Bring your shared window to the front. Can you see anything? is it just stuck on MRI?
HITESH GOPALAN: You can.
HITESH GOPALAN: It's on the MRI. All right. You can go to the previous version. I mean, just going before going full screen. Yeah, I think you can go from here. That's better.
BIJAYENDRA SINGH: But this is not full screen, is it? That's OK.
HITESH GOPALAN: That's OK.
BIJAYENDRA SINGH: That's better. Yeah OK, one second. Let me make this as big as I can. OK so now before you start recording again, just let check that it is working, OK? One second. Yeah OK.
BIJAYENDRA SINGH: Yeah shall I start again? Hitesh?
HITESH GOPALAN: Yeah, you're fine. So I think classification if you don't mind.
BIJAYENDRA SINGH: Classification that one. Yeah Yeah. So start off we were discussing about the classification for the rotator cuff tears and as I was alluding, so this is the classification which comes in quite handy for clinical making decisions because this helps me advise patients about the test itself and what to expect.
BIJAYENDRA SINGH: So stage one is when the stump is near the bone insertion. And this is most commonly seen with a small tear or acute tears as well. And this is a pretty straightforward and easy repair. Stage two is where there is some retraction up to the level of the humeral head, often up to the mid humeral head. And again, these are pretty straightforward ones to repair.
BIJAYENDRA SINGH: The stage 3 is where the end of the cuff is at the level of the glenoid or more proximal and this usually suggests that the tear is quite large or massive, is likely to be stiff, and it's also likely to have other changes, as in wasting and fatty degeneration within the rotator cuff, making the tear more difficult or often not possible and hence you can advise the patient accordingly.
BIJAYENDRA SINGH: So so. So the MRI is usually done in three different planes relative to the glenohumeral joint. And these are the three sequences that are typically done. One is the coronal oblique, which helps you decide the
BIJAYENDRA SINGH: retraction on the Patter classification. The sagittal oblique tells you about the fatty infiltration and the muscle wasting, and the X you'll see is used for looking at subscapularis as well as the extent of the tear. So these are a couple of slices on the MRI of the coronal oblique and you can see here that this one shows a partial thickness tear
BIJAYENDRA SINGH: whereas this one shows a full thickness tear and it helps you look at both the supraspinatus and the infraspinatus, the subacromial space and the labrum issues as well as biceps tendon. So this is a short video on the MRI going from the front to the back.
BIJAYENDRA SINGH: Then you can see that that's the tear starting to come up there and you can see it's a full thickness there, so this is like a Patter Grade 1 where you can see this is the supraspinatus, tender muscle belly forming a tendon and it's tore that the white is the fluid that is present and but it's more or less where it should be. And you can see it's a fairly large tear and this is now going into the infraspinatus territory where there is some partial thickness tear, but it's not involved significantly.
BIJAYENDRA SINGH: So that way you can advise the patient about the management. The MRI Sagittal Oblique helps you to look at the muscle atrophy so as you can see here, this is the quarterly classification and generally you would expect the supraspinatus to incorporate almost the whole of the supraspinatus fossa
BIJAYENDRA SINGH: but here you can see it's below that line, suggestive of some fatty infiltration and atrophy. The axial scans are useful to look at the biceps tendon, which is particularly important if well, it's important in all patients, particularly if you've got a traumatic cuff tear and often these are fairly massive tears. Look at the glenoid, the labrum, the subscapularis.
BIJAYENDRA SINGH: As you can see here, this is a patient where the biceps tendon has moved from its groove and is lying here medially and this often is associated with an subscapularis tear and at the bottom one, this is from an instability patient, we can see there is labrum disruption as well as a small loose body in the posterior aspect. So let's look at this axial CT, MRI scan.
BIJAYENDRA SINGH: So in the axial MR you can also look at the AC joint so this is now just coming up to the supraspinatus tendon and the humeral head in the glenoid coming in and if I pause it there you can see this is the subscapularis, the flue, on there. And again, you can see that this is the biceps tendon, that's the subscapularis and it should normally be seen quite thick band, robust, almost like you would see an ACL intact
BIJAYENDRA SINGH: ACL is it fairly firm and thick structure that cannot be missed and you can see the biceps tendon out of its groove right the way. So this patient has got a subscapularis tear as well as the supraspinatus. Now, briefly, about the ultrasound. Yes, the ultrasound used is increasing. It's a very good handy tool. My personal view is that it's best used by the person who is interpreting, interpreting the data.
BIJAYENDRA SINGH: If as a surgeon, I think it's best to use in your own hands, because otherwise you're relying on second hand information. The pictures are not dynamic and you're relying on the interpretation of the radiologist, but if you're doing it, then there needs to be a protocol of how you're going to look at these. So starting from the biceps and the subscapularis at the front, then the supraspinatus, then the subacromial bursa and then down the back.
BIJAYENDRA SINGH: And you need to understand what the anatomy looks like and one of the main reasons why the ultrasound is so much operator dependent, because if you look at these two images, this is of the same patient and what the difference is, the angle at which this probe is held is different. So here you can see which is held perpendicular and you can see the biceps tendon in there.
BIJAYENDRA SINGH: In this picture, the probe has been angled slightly so that the biceps appears to be empty. So if somebody was looking at the bottom picture, you would think that the biceps is missing. But in fact, the biceps is still very much there so that's the downside of the ultrasound tendon. So these are just the three sections of different MR so on the left is your normal looking rotator cuff tendon,
BIJAYENDRA SINGH: the supraspinatus is here. There is a partial articular surface tear and on this one, you can see there is a full thickness tear. So this is an example of a patient who had a fall whilst running and the fell with an abducted arm and you would get this on your way to a wywer table with these pictures and that history. So essentially, you've got to evaluate both the planes and see where the problem is.
BIJAYENDRA SINGH: So if we start with this top right hand corner MR. So this is a Coronal picture ah Coronal MR T2 most likely to be which is showing the supraspinatus muscle belly and forming a tendon and as it comes through its insertion, I can see there is a gap there and which is also seen on the further slide, further image, further down
BIJAYENDRA SINGH: there's a fair amount of fluid all around the glenoid and the humeral cartilage looks fairly normal. On the other pictures, this looks like a T1 image which shows on the top one. I can see the biceps tendon has moved out of its groove and the subscapularis also looks to be torn, which is seen even on the bottom picture. So looking at this, my diagnosis would most likely to be that this patient has got a large or a massive rotator cuff tear.
BIJAYENDRA SINGH: And I would like to examine and assess the patient, take a for good history and then make a management plan, which is most likely going to require a surgical repair. Now the question is whether these rotator cuff needs to be operated upon. So what's the natural history? This could be a potential question. So this is one of the studies looking at natural history of non operative treatment of symptomatic rotator cuff tear.
BIJAYENDRA SINGH: Now it's quite important to differentiate between a symptomatic cuff tear and an asymptomatic cuff tear so often people will bant around the asymptomatic cuff tear but we are not advising treatment for asymptomatic cuff tears. So this study looked at patients under the age of 60 who had 5 millimeters of bigger tears on ultrasound.
BIJAYENDRA SINGH: They followed up for at least two years or longer, and the ultrasonography was done by the same sonographer; they had 51 out of the 61 patients return. They showed about 50% increased in size and nearly similar numbers did not show any change. And also, a quarter of them found to have new tears. It's interesting to see that they did not find any correlation with the change size in the size, tear size, change related to patient age, previous injury or the size of the tear.
BIJAYENDRA SINGH: But importantly, they found that if the patient's tear size increases, then so does the symptoms increase as well, which is what you can reassure a patient with a small tear that if the symptom starts to get worse, then it is suggestive that the cuff is tear is becoming bigger and they may need to take advice. Now, when you come to cuff repairs, there are certain factors which are modifiable and certain factors which are unmodifiable.
BIJAYENDRA SINGH: So what you can modify is the type of repair you're doing, the technique of repair, types of sutures, anchors, whether you do an open or arthroscopic and the type of rehabilitation that one uses. Now, in vast most places these days, these cuff repairs are done arthroscopic. The advantages of open versus arthroscopic is only seen in the early stages.
BIJAYENDRA SINGH: More studies will code of outcomes at one year and yes, at one year there is no difference. But certainly in the first four to 6 weeks, the level of pain relief, complications, time off work and patient comfort is much better in the arthroscopic ones. There are certain things that is unmodifiable, which is the age, the type and age of the patient, the type and size of tear, the retraction and the fatty infiltration and the quality of bone.
BIJAYENDRA SINGH: What are we trying to achieve by doing a cuff repair? We're trying to provide a tendon to bone healing with the idea of providing pain relief, improve function and strength, and hopefully reduce progression to a cuff tear after opothy. So what does a successful repair require? It requires adequate decompression, restoration of footprint providing good compression of the tendon on the footprint and minimize tendon bone interface movements in the early stages.
BIJAYENDRA SINGH: These are the few steps that you need to be aware of when managing a patient with a cuff tear. Some of these are technical, which may not be acquired during the exams, but as a general principle in managing cufff tear, the positioning of the patient, fluid management, portals, instrumentation, biomechanics, the recognition of tear pattern, the approach: how are you going to repair it, whether a single or double row?
BIJAYENDRA SINGH: Those are factors that one may need to consider. Sorry. The key thing is work to a system when it comes to practical uses, although again, not so much of a fellowship related but more practical. Whether you tie knots, passing sutures, repair type, that's what you need to familiarize with. So here's a couple of short videos on single row and double row cuff repairs. So single row is where you put the stitches in on one side, only single row and attach it to the bone.
BIJAYENDRA SINGH: I use a knotless system, so this is what the technique is. So here you pass the sutures in with any suture passes that you use. I generally tend to use a mattress type of stitch as it's shown to provide better compression and less point loading of the tendon. Often I would pass a ripstop suture that would go across and under the mattress.
BIJAYENDRA SINGH: Once you've done that, you identify your spot where you're going to insert the anchor. This is a punch to make the pilot hole. And then the anchor going in and you can see the tendon has been brought in quite nicely.
BIJAYENDRA SINGH: Now there are different techniques that I use and for the fellowship exams, I would suggest to you talk about technique that you are familiar with or you have seen your bosses use it as it's easy to answer any questions, or especially if your boss is using something unusual, you won't be criticized for that.
BIJAYENDRA SINGH: This is the technique for the double row. As you can see here, this is a much bigger tear. That's the edge of the cuff. This is the articular surface. And this is the footprint. So the first step is to prepare using the burr and this shows nicely the size of the tear.
BIJAYENDRA SINGH: And what I'm doing is using it on reverse to just decorticate the bone, then checking the repairability and you can see it's quite a mobile tear and comes and sits nicely. Identifying my medial row anchors with a needle first before I make another portal.
BIJAYENDRA SINGH: The first medial anchor going in now. So again, I use a knotless system and the advantage of this system is that it locks the medial row sutures in so you don't have to tie the knot on it. Now this videos are available on my website so I'm going to skip it through
BIJAYENDRA SINGH: for time purposes. So those are the two medial row anchors going in. And then it passes sutures through the rotator cuff.
BIJAYENDRA SINGH: OK now the question is where? Why should one be using a single row or a double row? It's basically the strength of the repair. The single row provides about 220 Newtons of pull out strength. The double row increases that by about 50% and the suture bridge where you crisscross the stitches provides a higher pull out strength. Now, it's important to remember that a few basic studies to look at what the strength in the rotator cuff repair needs to be is actually quite low.
BIJAYENDRA SINGH: So the pull out strength is about needs to be about 180 Newtons so what it suggests is that even a single load repair is probably strong enough to provide the healing but more and more studies, as I will show, are coming up to show that the double row is better. Now the clinical outcomes of this use of single or double row shows that there is not a significant difference in the most of these patients,
BIJAYENDRA SINGH: but what we know that is certainly the larger size of cuff tears is the double row has shown lesser amounts of re-tear rates with a double row repair, and hence that's what people are advising. What about the rehabilitation? How does it affect the eventual outcomes? So this study looked at four different aspects of early versus delayed rehabilitation.
BIJAYENDRA SINGH: What they found was that a lot of studies showed that a range of movements is better if you get mobilization sooner, especially the elevation is better in early stages. And again, like with lots of range of movement things in orthopedics, pre-op range of movement is shown to be the most important factor to regain the movement, and again, there is no difference at one year.
BIJAYENDRA SINGH: There is no difference in the level of pain in early or late mobilization group. Muscle strength, there is no difference between early and late, but it still stays lower than the other side and reiterates this re-tear rates on MRI scan and this is variable and up to more than 90% but functionally there is no difference between. More so in fact, I now mobilise most of my patients at two weeks.
BIJAYENDRA SINGH: So to conclude the key to success is to pick a winner, have a good anesthesia, tension-free reduction and repair, need to do a thorough bursectomy for visualization, work to a system, this variety of equipment is invaluable and in my own practice for small tears I would do a single room mattress repair and for a larger and larger tear double row suture bridge type of technique.
BIJAYENDRA SINGH: Thank you.
HITESH GOPALAN: Bijay, thank you for that presentation and it's been very nice listening to you. There have been a couple of queries. BIJAYEDRA SINGH} Yeah? Both are related to the two trials. One is the UCUFF trial by Carr, which looked at arthroscopic versus open and said that the difference is not major. What do you think about it?
BIJAYENDRA SINGH: Yes, so as I said, see again, it's a lot of these studies actually focus on the six months or a year down the line. So, yes, you know, whether you do it open or arthroscopic, one year outcomes are no difference. And I don't think any shoulder surgeon will deny that fact that it's the initial part, the post-op recovery, the inpatient stay and also the risk
BIJAYENDRA SINGH: of infection and wound problems. And also I personally find that with the open repair your visualization is fairly limited with the arthroscopy, you get to see it more often. The other thing which, I mean, unless you are a surgeon who does still does a shoulder arthroscopy, does the decompression arthroscopy, and then does the repair open. that's one group, but that's OK.
BIJAYENDRA SINGH: But if you're just doing open cuff repairs and not doing the shoulder arthroscopy to begin with, you are likely to miss out on a lot of intra articular pathology. So a simple thing like a partial biceps tear or if there is a loose body or something like that. So that's my take on the open versus I mean, arthroscopic repair for people who are starting off have got equipment issues. Yes you know, you can learn to do it open and then move on to arthroscopic repair.
HITESH GOPALAN: Thank you Bijay. The other one is regarding the other very popular trial, the seesaw trial, which is published in Lancet, again, from the Oxford Press. And they note that they say that there is the role for subacromial decompression is like minimal or are there at all? What do you think?
BIJAYENDRA SINGH: OK so the seesaw, I mean, I was one of the contributing surgeons to the seesaw trials.
BIJAYENDRA SINGH: Now, what people actually forget is that all the patients certainly in the UK and certainly in my practice that who come to decompression have actually exhausted all the non operative means following surgery following the shoulder pain. The other important bit, because when this came, when did this come? This came in 20..2014 in Lancet (HITESH)
BIJAYENDRA SINGH: Was it 2014 Lancet? Yeah OK. I thought the seesaw was a bit later?
HITESH: No, seesaw was 2014 and 2017 was the UCON.
BIJAYENDRA SINGH: OK and basically what happened was we all looked at our and also there was a big article in the BMJ saying that all this shoulder surgery is not good.
BIJAYENDRA SINGH: And we all actually as shoulder surgeons, we looked at our own practice and what I found in my practice, because they did not see they don't classify as surgery for war. They put it all under shoulder pain surgery. So that the BMJ headline was surgery for shoulder pain is not good or something along those lines. And in fact, in my practice, only 15% of my shoulder arthroscopies are actually pure decompressions.
BIJAYENDRA SINGH: So 85% of my patients have either got a biceps problem or a labral problem or a cuff tear and along with that, an acj of pain and all of them, even the 15% who underwent a simple decompression have had the previous non operative treatment and I mean I haven't got, I haven't done promise on my patients but vast majority of them have got no post op.
BIJAYENDRA SINGH: You know, they're quite happy after the surgery.
HITESH GOPALAN: OK thanks, Bijay. What is your approach to a large tear? For example, if there's a defect, how do you bridge that? We use the phrase share or use.
BIJAYENDRA SINGH: Oh. So the options obviously depends if this is a fellowship exam question. The option depends on the age of the patient, the type of tear, what their expectations are and what their shoulder function is like.
BIJAYENDRA SINGH: Now most of the treatment except for a shoulder replacement is good if the patient does not have a pseudo paralytic arm. So they are good for pain relief, whatever you do, except for tendon transfers, I guess, which will help with the movement as well. So whether you do a superior capsular reconstruction type of procedure with whatever or whether you use a allograft or you use an autograft, they are all designed mainly to help with the pain.
BIJAYENDRA SINGH: I personally use the balloon into position arthroplasty for two reasons. One is A: it's arthroscopic.
B: is technically easier to do and C, you're not burning any bridges and the complications are fairly minimal. There's no more complication than any of the shoulder arthroscopy. With the superior capsular reconstruction,
BIJAYENDRA SINGH: it is technically a very demanding procedure, it's fairly expensive because even at the minimum, you're looking at four suture anchors at the least and also the outcomes haven't yet, I mean, there are studies coming out now, but it's not universally that everybody has had a good outcome. So that is second option. In some cases, you know, the one that you mentioned about the patch.
BIJAYENDRA SINGH: So essentially, the patch was originally described as a reinforcement mesh rather than a bridging type of gap. And I know there's a couple of, a few studies, actually, one big study from Leicester where they used it as a bridging graft and it has shown good outcomes. I personally don't have any experience with using those patch grafts. And of course, if the patient has got through the paralysis, then the only realistic option apart from physio and pain relief, is a reverse shoulder arthroplasty.
HITESH GOPALAN: Thank you Bijay and what is the principle behind the balloon into position that you describe?
BIJAYENDRA SINGH: So the balloon into position arthroplasty, the, as we all know and as we all see, there's lots of patients that we see who have got a big cuff tear and they still function very well, so they can use that arm. Yes, they are weak, but they can still move their arm and that is because their deltoid is functioning well.
BIJAYENDRA SINGH: And the idea of using the balloon into position is that it sort of tenses the deltoid, so it puts the deltoid at an optimum tension and allows the deltoid to take over that function because remember, the balloon is made out of PLAA as in the same material as y sutures and that gets absorbed in six months to 12 months maximum.
BIJAYENDRA SINGH: And so that effect is no longer there and hopefully by that time, the deltoid has been retrained and has started to take the function over. And I think what's his name, George Atwell, published some study, biomechanical study to show that effect.
HITESH GOPALAN: Yeah, George Atwell from Canada, right?
BIJAYENDRA SINGH: Yes, that's correct.
HITESH GOPALAN: Yeah OK. And do you keep it in the subacromial space where you leave the balloon there.
BIJAYENDRA SINGH: So it stays in the subacromial space so basically the steps would be that you do a bursectomy, you don't do the bony ecromioplasty, because you don't want any sharp edges. And then the balloon comes up, rolled up, and it's as you push the fluid in, it unfolds and just sits on top of this subacromial bursa or the humeral head.
HITESH GOPALAN: OK, Bijay, I think that's all the questions that we have and we have I mean, even in your previous lectures, I think we have touched a bit about the cuff, and I think this has been comprehensive and covered the entire aspect and (BIJAY: Thank you) I suggest yeah we can wind up this session.
BIJAYENDRA SINGH: Just one thing that on the YouTube, I have got a video channel.
BIJAYENDRA SINGH:
(HITESH): Yeah, please. So it's called Kent orthopedic practice. So if anybody is interested to have a look at them, then they can find the videos. And I think I've given you my email address. If anybody has any queries, I'm more than happy to answer. Thank you.
BIJAYENDRA SINGH:
HITESH: Thank you, Bijay once again for spending your valuable time.
BIJAYENDRA: Thank you Hitesh.
BIJAYENDRA SINGH: I must appreciate you, you work. so hard for all of this.
BIJAYENDRA SINGH:
HITESH: Thank you once again for your kind words and thank you.
BIJAYENDRA SINGH: No problem. Thank you. Catch up soon.
BIJAYENDRA SINGH:
HITESH: Yeah
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