Download episcopo [Lecture seule]

Episcopo procedure to restore
active external rotation
Ph Valenti
Institut de la Main
Shoulder department
Clinique Jouvenet
Paris FRANCE
Episcopo procedure (OBPP)
James Sever (1878-1964)
Joseph B. L'Episcopo (1890-1947)
•Sever(1927): Capsulotomy ant and section subscapularis
•Epicospo(1934):Transfer(TM+LD) dorsal aspect humerus
and Sever T : Two incisions ant post
•Merle D’Aubigné,Gerard(1947) :LD & TM
Delto pectoral or axillary A
Indications
rotator cuff deficiency
IS Tm atrophic / Fatty infiltration III/IV
NO active ER
Active AE
No active ER
No active AE( <60°)
(tumor, E arthritis)
LD + TM alone
LD + TM + RSP
• Beach chair position
• Short delto-pectoral
approach
8 – 10 cm
• Cephalic vein retracted
laterally
• Conjoined tendon gently
retracted medialy
TM
CT
LD
LD
• PM tendon totally or partially detached
Danger is nerve
• Medially Axillary and musculo cutaneous
nerves are close
Safe distance
< 6 – 8 cm from the humerus
• LD &TM are detached
(with an osteo-periostal flap)
• Medial release
• Tag sutures are placed
in the tendons free ends
• LD : Thin tendon, long
excursion
• TM : Short tendon, bulky
muscle, short excursion.
• Proximaly to the PM a
tunnel is created at
the posterior side of
the humerus
• The tendons are
passed with a “Curve
clamp”
• Control axillary nerve !!!
at the inferior border
of the glenoid rim.
• The Two tendons are
sutured to the
lateral side of the
humerus and the
bicipital groove
(anchors – trans
osseous)
• In external rotation
Hornblower sign
No active
External rotation
Reverse shoulder prosthesis
associated with tendon transfer
Delta RSP
pseudoparalytic shoulder
•
Gold standard for restoring
Active anterior elevation
130°
BUT
• No improvement External rotation
• Internal rotation is limited
Reverse shoulder prosthesis
doesn’t improve external rotation ?
3 reasons
1. Medialization of the center of rotation:
decreasing the lateral offset
impingement medial PE cup to the post part of the
scapula
slackening of the remaining rotator cuff
no recruiting Deltoid posterior fibers
Reverse shoulder prosthesis
doesn’t improve external rotation ?
3 reasons
2. Lesion of SS nerve by posterior
screw(IS)
3. Teres minor absent,atrophic,fatty infiltration
Coracoid notch
Tm
RSP alone
Gain in external rotation ?
RSP center rotation Medialized (L offset <)
(Delta D, Aequalis Tornier…)
• SOFCOT 2006 Delta 484 c
8°to12°
24°to42°
5°to7°
29°to43°
RCO 2007
• Wall B et Al Delta/Tornier 199 c
JBJS Am 2007
• Werner et Al Delta 58c
Less 5°
JBJS Am 2005
• Boileau P et Al Delta 45c
7°to11°
JSES 2005
. Sirveaux et Al Delta 80c
23°to32° 17°to40°
RSP alone
Gain in external rotation?
RSP center rotation lateralized (L offset >)
(Encore M, Arrow FH)
ER1
Frankle M et Al 2005 JBJS
60 RSP FU>2y
12°to41°
Valenti Ph et Al 2008 in press
76 RSP FU>2y
15°to30°
ER2
19°to49°
GAIN in ER is higher with lateralized RSP
RSP (DELTA, Depuy, Warsaw)
Medialization center rotation
Decreasing lateral offset
Normal
anatomy
RSP ( Encore Medical,Texas)
Lateralization center rotation
Increasing lateral offset
RSP(Arrow, FH,Mulhouse F)
Lateralization center rotation
Increasing lateral offset
RSP + Tendon transfer
Indications
• Pseudoparalytic shoulder
(after > 6 months of physiotherapy)
• No active External rotation
with the arm at the side
with the arm at 60° abduction
• Hornblower sign : Lack of Active ER
Transfer LD and TM around the humerus
RSP and tendon transfer
surgical technique
•
•
•
•
•
Deltopectoral approach
Section PM
Section and release LD and TM
Implantation of RSP
Before to do reduction of the RSP
transfer of the 2 tendons around the
humerus at the same level
• Fixation with ankles in ER arm at the side
• Immobilization 6 weeks in 30° Abd / ER
Episcopo procedure n=6
lack of active ER
•
3 cases with RSP
revison surgery
1 CTA / 1 failure of 3 repairing cuff
1 post traumatic
•
•
1 with Anatomic SP (neurologic disease)
2 for Massive cuff tear with excellent
active elevation but hornblower sign
Episcopo procedure n=6
Results
pre op ER1
post op ER1
ER2
•
3 with RSP
0°
30°
30°
•
1 with ASP
0°
50°
60°
•
2 for MCT
0°
60°
80°
BETTER result if
Pre op Complete passive ROM
Irreparable RCT
Pseudoparalytic shoulder
No active AE
RSP
No active ER
RSP + Tendon Transfer
Post operative
Conclusion
• Good knowledge of the anatomy
• Key points
– Good release of the muscles
– Preserve nerve during dissection ( arm position)
– Strong bone fixation
• The more important : Good Indication !
Conclusion
futur for tendon
transfer
• Decrease donor site morbidity
(arthroscopic harvesting)
• A reinforcement of tendon repair
If muscle atrophic or fatty degeneration
(stage 2,3)
• Combined 2 tendons transfers
• Tendon transfer with prosthesis
MERCI
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