Chirurgie arthroscopique de la coiffe des rotateurs

Transcription

1 Université Paris VII Faculté de Médecine Xavier Bichat Service de Rhumatologie - Professeur Ph. Dieudé Hôpital Bichat, 46 rue Henri Huchard, Paris Année Universitaire Etap Hôtel Formule 1 Holiday Inn Faculté X. Bichat Hôpital Bichat DIPLOME INTER-UNIVERSITAIRE DE PATHOLOGIE LOCOMOTRICE LIEE A LA PRATIQUE DU SPORT Facultés de Paris VII, Grenoble, Lyon, Aix-Marseille II et Nice Directeur d enseignement à Paris VII : Dr Th. Boyer Chirurgie arthroscopique de la coiffe des rotateurs Liste d'hôtels Tout près de Bichat, le long du périphérique : Etap hôtel et Formule 1 Rue du Docteur Babinski, Paris. Tel : Holiday Inn 9 rue la Fontaine, Saint Ouen. Tel : Un peu plus loin dans le 18 ème Damrémont Hôtel** 110 rue Damrémont. Tel : Hôtel de Flore** 108 rue Lamarck. Tel : Séminaire sur l épaule du sportif Jeudi 12 et vendredi 13 Mars 2015 Organisé par le Dr Thierry Boyer Geoffroy Nourissat MD PhD 1 Clinique des Maussins 2 INSERM U938 3 Hôpital Saint Antoine Faculté Xavier Paris Bichat 16 rue Henri Huchard, Paris Service du Pr Philippe Dieudé - Hôpital Bichat Paris Epidémiologie Rupture de coiffe = Vieillissement Faut-il Réparer? Comment Réparer? 1

2 Patients 46 ans rupture massive de coiffe échec de la chirurgie A quoi sert la coiffe? Avoir de la force! Eviter l excentration et l extension des lésions. 2

3 Epidémiologie Faut-il Réparer? Coiffe symptomatique Coiffe asymptomatique??? Epidémiologie cp Comment Comment Comment Pr Thomazeau 3

4 Quelle imagerie? Cuff imaging: Identify the presence of a tear Asses the size of the tear Asses the trophycity of muscle Asses the fatty infiltration of muscle Asses the size of the tendon Faut- il réparer? But de la chirurgie Oui parce que ça marche: constant 43 > 80 (36 mois) On restaure la force Et si on ne fait rien, la maladie évolue.. 4

5 Indications? Avant 55 ans: Toute rupture de coiffe est chirurgicale... Après 55 ans: Les petites ruptures sont à surveiller Les lésions importantes sont à opérer Après 65 ans: La chirurgie des symptômes! Geste antalgiques Réparation pour des patients très demandeurs Rééducation pré-opératoire 5

6 Indications? motivation état général perte de force échec du traitement médical bon capital musclaire âge physiologique versant douloureux tabac... maladie professionnelle incurie infiltration graisseuse début d arthrose chirurgie réparatrice chirurgie de la douleur? Comment opérer? Si indication, en 2015 Rupture de coiffe = Arthroscopie 6

7 Quelles lésions? - Biceps - Tendinopathies - Petites Ruptures - Grandes Ruptures - Sous-scapulaire Biceps? - Un Biceps symptomatique le restera - Tenotomie ou ténodèse - Ténotomie > Ténodèse - geste systématique pour la douleur 7

8 Les Petites Ruptures - Ruptures partielles <50% épaisseur: arthrolyse >50% épaisseur: suture - Ruptures distales supra/infraspinatus (âge <65ans) Grandes Ruptures - Ruptures intermédiaires ou rétractées: mobilisable: réparation non mobilisable: palliatif 8

9 Réparation de coiffe - Quelle Technique utiliser? Simple rang Lafosse L, JBJS,2007! Double rang 9

10 Vaishnav S, JSES, 2010! Sans rang renforcé Simple rang renforcé 10

11 ! Biomécanique technique Double rang : double fixation : meilleure force - de cisaillement et glissement; Rééducation plus précoce? Clinique G.M. Gartsman et al G.M. Gartsman et al. Figure 2 Drawing demonstrating the final configuration of a double-row (transosseous equivalent) rotator cuff repair. We moved the arm into various positions of rotation, abduction, and elevation to test the security of the repair. The fluid was drained, the instruments removed, the skin closed routinely, and a sterile dressing and abduction sling applied. Postoperative management? > Nho Arthroscopy 2009 = Kim AJSM 2012 = Gartsman JSES Figure 1 Drawing demonstrating the final configuration of a single-row rotator cuff repair. single-loaded suture anchors were positioned just lateral to the humeral articular margin. Sutures from these anchors were passed sequentially through the medial aspect of supraspinatus tendon with the suture passer (Elite Suture Pass, SNE, Andover, MA, USA) in a horizontal mattress fashion from anterior to posterior. These sutures were then tied sequentially from posterior to anterior using arthroscopic square knots. This completed the medial row. For the lateral row, the surgeon retrieved 1 suture from the anterior and 1 suture from the posterior anchor through the lateral cannula. The 2 sutures (from the 2 different medial anchors) were placed into the lateral anchor. We used the FootPrint Anchor (SNE Andover, MA, USA). Through the lateral cannula, we used a power drill to drill a hole in the lateral cortex of the greater tuberosity in line (in the anterior posterior dimension) with the anterior medial anchor. The drill was removed and the anchor and sutures inserted. The suture tension was adjusted with the anchor and inserter in the bone. We pulled on each of the sutures until we felt we had obtained sufficient suture tension. Once the desired tension was achieved, the anchor inserter was removed and the sutures cut. This process was repeated with the posterior lateral row anchor aligned with the posterior medial row anchor (Fig. 2). Figure 2 Drawing demonstrating the final configuration of a double-row (transosseous equivalent) rotator cuff repair. We moved the arm into various positions of rotation, abduction, and elevation to test the security of the repair. The fluid was drained, the instruments removed, the skin closed routinely, and a sterile dressing and abduction sling applied. Postoperative management All patients followed the same rehabilitation protocol. The patients were immobilized in an abduction sling (Donjoy, Vista, CA, USA) for 6 weeks. During the period of immobilization, the patients were allowed out of the sling for bathing, dressing, and their rehabilitation exercises. Active shoulder elevation and abduction movements were forbidden. Active range of motion (ROM) of the fingers, wrist, and elbow was encouraged. The patients only shoulder exercise was pendulum circumduction. Patients were instructed to bend forward from the waist, let the operated arm relax and hang downward. They were to make diameter circles for 2 minutes. This was repeated 5 times per day. We did not employ continuous passive motion machines, overhead pulleys, or any type of manual stretching maneuvers. Patients were seen in the clinic 3 weeks after operation. We evaluated the wound status and obtained a single anterior posterior radiograph to confirm proper anchor position. The patients exercises and their allowed movements were reviewed. No change in the rehabilitation exercises was made. The patient returned 6 weeks after the operation. The sling was discontinued and the patient instructed in a home program of supine active assisted ROM exercises in elevation. Once the patient was comfortable with these exercises, they progressed to supine active elevation, followed by standing active assisted elevation, and, last, standing active elevation. The patients were allowed to perform any active movement that was comfortable, avoiding only abduction and behind the back internal rotation. At the time of the patients 3- month postoperative visit, we performed a diagnostic ultrasound and assessed the integrity of the rotator cuff repair. The patients were started on resistance exercises with surgical tubing in the movements of external rotation, internal rotation, and elbow Figure 1 Drawing demonstrating the final configuration of a single-row rotator cuff repair. single-loaded suture anchors were positioned just lateral to the humeral articular margin. Sutures from these anchors were passed sequentially through the medial aspect of supraspinatus tendon with the suture passer (Elite Suture Pass, SNE, Andover, MA, USA) in a horizontal mattress fashion from anterior to posterior. These sutures were then tied sequentially from posterior to anterior using arthroscopic square knots. This completed the medial row. For the lateral row, the surgeon retrieved 1 suture from the anterior and 1 suture from the posterior anchor through the lateral cannula. The 2 sutures (from the 2 different medial anchors) were placed into the lateral anchor. We used the FootPrint Anchor (SNE Andover, MA, USA). Through the lateral cannula, we used a power drill to drill a hole in the lateral cortex of the greater tuberosity in line (in the anterior posterior dimension) with the anterior medial anchor. The drill was removed and the anchor and sutures inserted. The suture tension was adjusted with the anchor and inserter in the bone. We pulled on each of the sutures until we All patients followed the same rehabilitation protocol. The patients were immobilized in an abduction sling (Donjoy, Vista, CA, USA) for 6 weeks. During the period of immobilization, the patients were allowed out of the sling for bathing, dressing, and their rehabilitation exercises. Active shoulder elevation and abduction movements were forbidden. Active range of motion (ROM) of the fingers, wrist, and elbow was encouraged. The patients only shoulder exercise was pendulum circumduction. Patients were instructed to bend forward from the waist, let the operated arm relax and hang downward. They were to make diameter circles for 2 minutes. This was repeated 5 times per day. We did not employ continuous passive motion machines, overhead pulleys, or any type of manual stretching maneuvers. Patients were seen in the clinic 3 weeks after operation. We evaluated the wound status and obtained a single anterior posterior radiograph to confirm proper anchor position. The patients exercises and their allowed movements were reviewed. No change in the rehabilitation exercises was made. The patient returned 6 weeks after the operation. The sling was discontinued and the patient instructed in a home program of supine active assisted ROM exercises in elevation. Once the patient was comfortable with these exercises, they progressed to supine active elevation, followed by standing active assisted elevation, and, last, standing active elevation. The patients were allowed to perform any active movement that was comfortable, avoiding only abduction and behind the back internal rotation. At the time of the patients 3-11

12 Chirurgie de la coiffe - Installation - Voies d abord - Exploration endo articulaire - Débridement sous acromial / Bursectomie - Réparation - Acromioplastie Installation 12

13 Technique Evolution classique... - Douleurs jours - pendulaire 6 semaines - Actif doux à 6 semaines - Pas de port de charge avant 3 mois - 6 mois de rééducation... épaule fonctionnelle - 12 mois... pour une épaule forte 13

14 Evolution inquiétante - Douleurs > 21 jours Croissantes Actif doux à 6 semaines - Pas de tenue à 3 mois (lâchage...) Rééducation post-opératoire Ce qui doit alerter raideur excessive: algodystrophie fièvre, écoulement... Ce qui peut nécessiter une reprise lâchage de suture Infection 14

15 Comment évaluer les résultats Thomazeau H, SFA, 2009! Cicatrisations totale partielle fuites échec Comment évaluer les résultats Lafosse L, JBJS, 2008! 15

16 Retour au sport Namdari JAT 2011 Retour au sport Tennis Bigliani AJSM patients 80% retour au même niveau Plus la lésion est petite, plus c est facile Sonnery Cottet AJSM 2002 Age moyen 51 ans 40 / 52 retour au même niveau de pratique 16

17 Retour au sport Rugby Tambe, Int J Shoulder Surg professionnel Retour au même niveau Merci 17