spalla fkt 2009
DESCRIPTION
Dottor Franco Rossi Specialista in Ortopedia | Chirurgia del ginocchio, della spalla e dell'anca | Policlinico Abano Terme | Istituto Clinico Città di BresciaTRANSCRIPT
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GIORNALI
TELEVISIONE
MEDICI
TERAPISTI “ VOX POPULI”
Lesione della cuffia dei rotatori
FACEBOOK!!!
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Lesione della cuffia dei rotatori
• metodologia ( aggiornamento-confronto)
• letteratura!!!!!!
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anamnesi
• Durata della sintomatologia
• Meccanismo di insorgenza ( trauma !?, tipo di trauma!?)
• Tipologia del dolore ( diagnosi differenziale)
• Attività lavorativa • Lato dominante • Attivita ricreativa ( sport)
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EO
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Scapolotoracica
• Piano tra sottoscapolare e dentato anteriore che permette lo scivolamento della scapola sul torace
• Movimento : “scivolamento”ant-post sul torace ( intra-extra), rotazione sul piano della scapola ( antiorario durante elevazione)
• Elevazione della spalla: 40% del movimento avviene sul piano scapolotoracico (artrodesi); durante l’elevazione la scapola ruota sul proprio piano orientando la glena verso l’alto
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Scapolotoracica: controllo muscolare
Dott. Giovanni Di Giacomo
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Accertamenti radiologici
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Calcificazioni bursali !!!
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TUTTE LE LESIONI DELLA CUFFIA DEI ROTATORI
VANNO RIPARATE CHIRURGICAMENTE?
Lesione della cuffia dei rotatori
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Tutte le lesioni vanno riparate?!
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Lesione della cuffia dei rotatori
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Limiti class. SJ Snyder Fukuda H, Craig EV, Yamanaka K, Partial thickness cuff tears, in Burkhead WZ, ed.
Rotator cuff disorders, Baltimora: Williams & Wilkins, 1996:174-181
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C2 C3
Lesione della cuffia dei rotatori
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Lesioni parziali
• traumatiche (P.A.S.T.A)
• instabilità
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Lesione: parziale o completa
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the "suture marker technique“
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Tendini coinvolti
• SS: sovraspinato
• IS: infraspinato
• SbS: sottoscapolare
• RI: intervallo dei rotatori
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Dimensione della lesione
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e ancora.........
• Retrazione e mobilità del tendine
• Forma della lesione
• Qualita del tendine
• Qualità del muscolo
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Retrazione e mobilità del tendine
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Forma della lesione
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Qualita del tendine e del muscolo
• Molto difficile da valutare (lesioni parziali, lesioni intratendinea)
• Segno della “bandiera al vento” (Castagna A.: Arthroscopic rotator cuff findings; San Diego Shoulder Arthroscopy Inc.,1999 )
• Degenerazione grassa del muscolo (RMN)
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Indicazioni alla chirurgia Clin Orthop Relat Res, Oct 2008 ( metanalisi 98 studi)
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Algoritmo trattamento LESIONI PARZIALI
Giovane (!?!)
( Conflitto SA flogosi subacromiale ) Instabilità
RRF ( 6 mesi )
SAD +
riparazione
RRF ( 6-9 mesi)
Stabilizzazione +
Riparazione cuffia
OK
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Algoritmo trattamento LESIONI PARZIALI
Over 50 ma attivo o lavoro pesante ( Conflitto SA ) Instabilità
RRF ( 6 mesi )
SAD +
riparazione
RRF ( 6-9 mesi)
Stabilizzazione +
Riparazione cuffia
OK
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Algoritmo trattamento LESIONI PARZIALI
Over 50 poco attivo o over 60 ( Conflitto SA ) Instabilità ?
RRF ( 12 mesi )
SAD (?) +
riparazione
RRF
Lesione completa
Riparazione cuffia
OK
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Algoritmo trattamento LESIONI COMPLETE
< 60 aa (50) o attivo 1 tendine Più tendini
RRF ( solo per evitare rigidità e ipotrofia muscolare )
SAD (?) +
riparazione
RRF (solo per evitare rigidità e ipotrofia muscolare)
Riparazione cuffia
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Algoritmo trattamento LESIONI COMPLETE
> 60 aa ma < 70 aa: attivo
1 tendine Più tendini
RRF ( 6-9 mesi )
SAD (?) +
riparazione
RRF
Riparazione cuffia
RMN ?
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LESIONI COMPLETE > 70 aa
SJ Snyder, Shoulder Arthroscopy - 2nd edition 2003 - Lippincott Williams & Wilkins
Lesione della cuffia dei rotatori
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Lesione della cuffia dei rotatori
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Lesione della cuffia dei rotatori
• Non è mai un’urgenza • Lesione traumatica • Meccanismo traumatico • Età del paziente • Aspettative funzionali
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Indicazioni
E. Taverna, F. Battistella. La Spalla - G. Porcellini, A Castagna, F Campi, P Paladini 2003 - Verduci Editore
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Gerber C, Meyer DC, Schneeberger AG, Hoppeler H, von Rechenberg B J Bone Joint Surg Am, 2004 Sept;86-A (9): 1973-82
Modello lesioni traumatiche
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Coleman SH, Altchek DW, Warren RF et Alii J Bone Joint Surg Am, 2003 Dec;85-A (12): 2391-402
Modello lesioni traumatiche
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Take home message
• Lesione traumatica completa • Paziente con età inferiore a 60 anni o molto attivo • Rapido peggioramento del complesso muscolotedineo
“...... the sooner the better!!!!!”
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Obiettivi della chirurgia
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Obiettivi della chirurgia
• Eliminare il dolore • Recupero rom • Recupero della forza
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Operiamo......!!!
Open (miniopen) vs Artroscopia
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Sutura al foot print
• In trincea ossea • Ancore(!!!!): metalliche,
riassorbibili, varie fome, vari tests pull out.....
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Clb: tenotomia vs tenodesi
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Acromionplastica
• solo se sintomatologia all’EO
• solo se conflitto a cuffia suturata
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Mini open VS arthroscopy: risultati ?
• Breve-Lungo termine • Non esiste una differenza
significativa ad un anno dall’intervento, Knee Surg Sports Traumatol, 2008 Nov, 12
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W chirurgia artroscopica !!! Ma.....
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Posizione paziente
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Entriamo nella spalla....
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Sutura artroscopica
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Post op
• Necessità di un adeguato periodo di immobilizzazione per cicatrizzazione
• Necessità di evitare la rigità
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Cause di fallimento della chirurgia
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Grazie!!!
Dott. Cesana Marco
Spec . Ortopedia e Traumatologia
Ch. del Ginocchio e della Spalla
Policlinico Abano