Chirurgie arthroscopique de la coiffe des rotateurs Epidémiologie

13/03/15
Université Paris VII
Faculté de Médecine Xavier Bichat
Service de Rhumatologie - Professeur Ph. Dieudé
Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris
Année Universitaire 2014-2015
DIPLOME INTER-UNIVERSITAIRE DE
PATHOLOGIE LOCOMOTRICE LIEE A
LA PRATIQUE DU SPORT
Etap Hôtel
Formule 1
Facultés de Paris VII, Grenoble, Lyon, Aix-Marseille II et Nice
Holiday Inn
Directeur d’enseignement à Paris VII : Dr Th. Boyer
Faculté X. Bichat
Chirurgie arthroscopique de la coiffe
des rotateurs
Hôpital Bichat
Liste d'hôtels
Tout près de Bichat, le long du périphérique :
• Etap hôtel et Formule 1
Rue du Docteur Babinski, 75018 Paris. Tel : 01 49 21 90 90
• Holiday Inn
9 rue la Fontaine, 93400 Saint Ouen. Tel : 01 49 18 66 66
Un peu plus loin dans le 18ème
• Damrémont Hôtel** 110 rue Damrémont. Tel : 01 42 64 25 75
• Hôtel de Flore** 108 rue Lamarck. Tel : 01 46 06 31 15
Séminaire sur l’épaule du sportif
Jeudi 12 et vendredi 13 Mars 2015
Organisé par le Dr Thierry Boyer
Geoffroy
Nourissat MD PhD
Service du Pr Philippe Dieudé - Hôpital Bichat Paris
1 Clinique des Maussins
2 INSERM U938
3 Hôpital Saint Antoine
Faculté Xavier
Paris Bichat
16 rue Henri Huchard, 75018 Paris
Epidémiologie
Rupture de coiffe = Vieillissement
Faut-il Réparer ?
Comment Réparer ?
1
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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 .
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Epidémiologie
Faut-il Réparer ?
Coiffe symptomatique…
Coiffe asymptomatique???
Epidémiologie
cP Comment Comment Comment
Pr Thomazeau
3
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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
✔
But de la chirurgie
Faut- il réparer?
Oui parce que ça marche:
constant 43 > 80 (36 mois)
On restaure la force
Et si on ne fait rien, la maladie évolue..
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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
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Indications?
motivation
versant douloureux
état général
tabac...
perte de force
maladie professionnelle
échec du traitement médical
incurie
bon capital musclaire
infiltration graisseuse
âge physiologique
début d’arthrose
chirurgie réparatrice
chirurgie de la douleur?
Comment opérer?
Si indication, en 2015
Rupture de coiffe = Arthroscopie
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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
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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
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Réparation de coiffe
- Quelle Technique utiliser?
Simple rang
Double rang
Lafosse L, JBJS,2007!
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Sans rang renforcé
Vaishnav S, JSES, 2010 !
Simple rang renforcé
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Biomécanique
technique
!
Double rang : double fixation : meilleure force - de cisaillement et
glissement; Rééducation plus précoce?
Clinique….
1482
G.M. Gartsman et al.
1482
?
>
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
Figure 1
Drawing demonstrating the final configuration of
a single-row rotator cuff repair.
Figure 2 Drawing demonstrating the final configuration of
a double-row (transosseous equivalent) rotator cuff repair.
Nho Arthroscopy 2009 =
Kim AJSM 2012 =
Gartsman JSES 2013 +
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
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 800 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-
G.M. Gartsman et al.
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).
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 800 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’ 3month 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
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Chirurgie de la coiffe
- Installation
- Voies d abord
- Exploration endo articulaire
- Débridement sous acromial / Bursectomie
- Réparation
- Acromioplastie
Installation
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Technique
Evolution classique...
- Douleurs +++ 15 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
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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
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Comment évaluer les résultats
Thomazeau H, SFA, 2009!
Cicatrisations
totale
partielle fuites
échec
Comment évaluer les résultats
Lafosse L, JBJS, 2008!
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Retour au sport…
Namdari JAT 2011
Retour au sport…
Tennis Bigliani AJSM 1992
23 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
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Retour au sport…
Rugby Tambe, Int J Shoulder Surg 2009
12 professionnel
Retour au même niveau Merci
17