A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair

Effect of shoulder abduction angle on biomechanical properties of the repaired rotator cuff tendons with 3 types of double-row technique

BACKGROUND

After rotator cuff repair, the shoulder is immobilized in various abduction positions. However, there is no consensus on the proper abduction angle.

PURPOSE

To assess the effect of shoulder abduction angle on the biomechanical properties of the repaired rotator cuff tendons among 3 types of double-row techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-two fresh-frozen porcine shoulders were used. A simulated rotator cuff tear was repaired by 1 of 3 double-row techniques: conventional double-row repair, transosseous-equivalent repair, and a combination of conventional double-row and bridging sutures (compression double-row repair). Each specimen underwent cyclic testing followed by tensile testing to failure at a simulated shoulder abduction angle of 0° or 40° on a material testing machine. Gap formation and failure loads were measured.

RESULTS

Gap formation in conventional double-row repair at 0° (1.2 ± 0.5 mm) was significantly greater than that at 40° (0.5 ± 0.3mm, P = .01). The yield and ultimate failure loads for conventional double-row repair at 40° were significantly larger than those at 0° (P < .01), whereas those for transosseous-equivalent repair (P < .01) and compression double-row repair (P < .0001) at 0° were significantly larger than those at 40°. The failure load for compression double-row repair was the greatest among the 3 double-row techniques at both 0° and 40° of abduction.

CONCLUSION

Bridging sutures have a greater effect on the biomechanical properties of the repaired rotator cuff tendon at a low abduction angle, and the conventional double-row technique has a greater effect at a high abduction angle.

CLINICAL RELEVANCE

Proper abduction position after rotator cuff repair differs between conventional double-row repair and transosseous-equivalent repair. The authors recommend the use of the combined technique of conventional double-row and bridging sutures to obtain better biomechanical properties at both low and high abduction angles.

Medial versus lateral supraspinatus tendon properties: implications for double-row rotator cuff repair

BACKGROUND

Rotator cuff repair retear rates range from 25% to 90%, necessitating methods to improve repair strength. Although numerous laboratory studies have compared single-row with double-row fixation properties, little is known regarding regional (ie, medial vs lateral) suture retention properties in intact and torn tendons.

HYPOTHESIS

A torn supraspinatus tendon will have reduced suture retention properties on the lateral aspect of the tendon compared with the more medial musculotendinous junction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human supraspinatus tendons (torn and intact) were randomly assigned for suture retention mechanical testing, ultrastructural collagen fibril analysis, or histologic testing after suture pullout testing. For biomechanical evaluation, sutures were placed either at the musculotendinous junction (medial) or 10 mm from the free margin (lateral), and tendons were elongated to failure. Collagen fibril assessments were performed using transmission electron microscopy.

RESULTS

Intact tendons showed no regional differences with respect to suture retention properties. In contrast, among torn tendons, the medial region exhibited significantly higher stiffness and work values relative to the lateral region. For the lateral region, work to 10-mm displacement (1592 ± 261 N-mm) and maximum load (265 ± 44 N) for intact tendons were significantly higher (P < .05) than that of torn tendons (1086 ± 388 N-mm and 177 ± 71 N, respectively). For medial suture placement, maximum load, stiffness, and work of intact and torn tendons were similar (P > .05). Regression analyses for the intact and torn groups revealed generally low correlations between donor age and the 3 biomechanical indices. For both intact and torn tendons, the mean fibril diameter and area density were greater in the medial region relative to the lateral (P ≤ .05). In the lateral tendon, but not the medial region, torn specimens showed a significantly lower fibril area fraction (48.3% ± 3.8%) than intact specimens (56.7% ± 3.6%, P < .05).

CONCLUSION

Superior pullout resistance of medially placed sutures may provide a strain shielding effect for the lateral row after double-row repair. Larger diameter collagen fibrils as well as greater fibril area fraction in the medial supraspinatus tendon may provide greater resistance to suture migration.

CLINICAL RELEVANCE

While clinical factors such as musculotendinous integrity warrant strong consideration for surgical decision making, the present ultrastructural and biomechanical results appear to provide a scientific rationale for double-row rotator cuff repair where sutures are placed more medially at the muscle-tendon junction.

Single versus double-row repair of the rotator cuff: does double-row repair with improved anatomical and biomechanical characteristics lead to better clinical outcome?

PURPOSE

Several techniques for arthroscopic repair of rotator cuff defects have been introduced over the past years. Besides established techniques such as single-row repairs, new techniques such as double-row reconstructions have gained increasing interest. The present article therefore provides an overview of the currently available literature on both repair techniques with respect to several anatomical, biomechanical, clinical and structural endpoints.

METHODS

Systematic literature review of biomechanical, clinical and radiographic studies investigating or comparing single- and double-row techniques. These results were evaluated and compared to provide an overview on benefits and drawbacks of the respective repair type.

RESULTS

Reconstructions of the tendon-to-bone unit for full-thickness tears in either single- or double-row technique differ with respect to several endpoints. Double-row repair techniques provide more anatomical reconstructions of the footprint and superior initial biomechanical characteristics when compared to single-row repair. With regard to clinical results, no significant differences were found while radiological data suggest a better structural tendon integrity following double-row fixation.

CONCLUSION

Presently published clinical studies cannot emphasize a clearly superior technique at this time. Available biomechanical studies are in favour of double-row repair. Radiographic studies suggest a beneficial effect of double-row reconstruction on structural integrity of the reattached tendon or reduced recurrent defect rates, respectively.

Tension, abduction, and surgical technique affect footprint compression after rotator cuff repair in an ovine model

INTRODUCTION

Shoulder motion after rotator cuff repair may result in changes in tension and contact pressure at the repair site. Our goal was to determine how tension and motion affect a repair and what type of repair best tolerates these variables.

METHODS

Rotator cuff tears were created ex vivo in 30 ovine shoulders divided into 5 groups: single-row repair, double-row repair, tension-band repair, suture bridge repair, and double-row tension-band repair. A pressure probe was passed through a hole created in the footprint to dynamically measure footprint pressure. The rotator cuffs were repaired, and contact pressure was measured with variable tension placed on the repaired tendon from 10 to 30 N and variable shoulder abduction from -10° to +10°. Repair strength was determined by use of a pull-to-failure test.

RESULTS

Increasing tension on the repaired tendon resulted in an increase in contact pressure whereas increasing the abduction angle resulted in a decrease in contact pressure in all 5 groups. For all abduction and tension combinations, the suture-bridge and double-row tension band groups recorded the highest contact pressures (P < .05), followed by the tension-band, single-row, and double-row repairs. Load to failure was greatest for the 2 double-row techniques, followed by the tension-band, suture-bridge, and single-row repairs.

DISCUSSION

Contact pressure increases as tension increases across the repair and decreases as the shoulder is abducted. The double-row tension-band rotator cuff repair showed the best combination of contact pressure and repair strength.

Biomechanical comparison of 4 double-row suture-bridging rotator cuff repair techniques using different medial-row configurations

PURPOSE

Biomechanical comparison of different suture-bridge configurations of the medial row with respect to initial construct stability (time 0, porcine model).

METHODS

In 40 porcine fresh-frozen shoulders, the infraspinatus tendons were dissected from their insertions. All specimens were operated on by use of the suture-bridge technique, only differing in terms of the medial-row suture-grasping configuration, and randomized into 4 groups: (1) single-mattress (SM) technique, (2) double-mattress (DM) technique, (3) cross-stitch (CS) technique, and (4) double-pulley (DP) technique. Identical suture anchors were used for all specimens (medial: Bio-Corkscrew FT 5.5 [Arthrex, Naples, FL]; lateral: Bio-PushLock 3.5 [Arthrex]). All repairs were cyclically loaded from 10 to 60 N until 10 to 200 N (20-N stepwise increase after 50 cycles each) with a material testing machine. Forces at 3 and 5 mm of gap formation, mode of failure, and maximum load to failure were recorded.

RESULTS

The DM technique had the highest ultimate tensile strength (368.6 ± 99.5 N) compared with the DP (248.4 ± 122.7 N), SM (204.3 ± 90 N), and CS (184.9 ± 63.8 N) techniques (P = .004). The DM technique provided maximal force resistance until 3 and 5 mm of gap formation (90.0 ± 18.1 N and 128.0 ± 32.3 N, respectively) compared with the CS (72 ± 8.9 N and 108 ± 20.2 N, respectively), SM (66.0 ± 8.9 N and 90.0 ± 26.9 N, respectively), and DP (62.2 ± 6.2 N and 71 ± 13.2 N, respectively) techniques (P < .05 for each 3 and 5 mm of gap formation). The main failure mode was suture cutting through the tendon.

CONCLUSIONS

Comparing the 4 different suture-bridge techniques, we found that modified application of suture-bridge repair with double medial mattress stitches significantly enhanced biomechanical construct stability at time 0 in this porcine ex vivo model.

CLINICAL RELEVANCE

This technique increases initial stability and resistance to suture cutting through the rotator cuff tendon after arthroscopic suture-bridge repair.

Comparison of mechanical stability in double-row rotator cuff repairs between a knotless transtendon construct versus the addition of medial knots

PURPOSE

Our purpose was to investigate the importance of medial-row knot tying to mechanical stability in a double-row rotator cuff repair by comparing a knotless construct with transtendon anchor passage versus a similar construct implementing medial knots.

METHODS

A standard defect was created in the infraspinatus tendons of 14 bovine humeri. All defects were repaired with 2 medial and 2 lateral anchors (SutureCross System; KFx Medical, Carlsbad, CA). The medial anchors were either placed by transtendon passage in a knotless construct or placed directly into bone with needle passage of suture to create bursal-sided knots medially. Constructs were subjected to a cyclic loading protocol and then loaded to failure.

RESULTS

The medially knotted constructs had a statistically higher stiffness at both the initial and final cycles (P < .001 and P < .001, respectively) and a lower displacement during cyclic loading (P < .02). There were strong trends toward decreased gauge displacement (P = .12) and decreased cycles to 3 mm of displacement (P = .07) in the medially knotted group. Maximal yield strength was greater in the medially knotted group (350 +/- 270 N v 650 +/- 530 N), although this was not found to be statistically significant (P = .5).

CONCLUSIONS

Our data suggest that creation of medial knots increases construct stiffness and stability in arthroscopic double-row cuff repair. This is likely because of increased load transfer to the lateral anchor and suture-tendon interface in the knotless construct.

CLINICAL RELEVANCE

Medial knots create increased mechanical stability that theoretically may improve rotator cuff healing. This mechanical advantage must be weighed against surgical efficiency, with consideration given to factors such as tissue quality.

Comparison of patient and surgeon ratings of outcome 12 months after spine surgery

Object

The contemporary assessment of spine surgical outcome primarily relies on patient-centered reports of symptoms and function. Such measures are considered to reduce bias compared with traditional surgeon-based outcome ratings. This study examined the agreement between patients' and surgeons' ratings of outcome 1 year after spine surgery.

Methods

The study involved 404 patients (mean age 56.6 ± 16.4 years; 259 women, 145 men) and their treating surgeons. At baseline and 12 months postoperatively patients completed the Core Outcome Measures Index (COMI) rating pain, function, quality of life, and disability. At 12 months postoperatively, they also rated the global outcome of surgery and their satisfaction with treatment. The surgeon, blinded to the patient's evaluation, rated the global outcome of surgery as excellent, good, fair, or poor.

Results

Seventy-six percent of the patients who were considered by the surgeon to have an excellent or good outcome achieved the minimum clinically important difference (MCID) of a 2.2-point reduction on the COMI; 24% achieved less than the MCID. There was a significant correlation between the surgeons' and patients' global outcome ratings (Spearman ρ = 0.56; p < 0.0001). The degree of absolute agreement between them was significantly influenced by surgeon seniority: senior surgeons “overrated” the outcome in 24.5% of cases (compared with patients' ratings) and “underrated” it in 17.5% of cases. Junior surgeons overrated in 7.8% of cases and underrated in 43.8% of cases (p < 0.0001). Surgeon overrating occurred significantly more frequently for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment). In a multivariate model, the independent variables “senior surgeon” and “patient dissatisfaction with care” were the most significant unique predictors of surgeon overrating of the global outcome (p < 0.0001; adjusted R2for the model = 0.16).

Conclusions

Overall, agreement between surgeon and patient was reasonably good. The majority of patients who were rated as excellent/good by the surgeons had achieved the MCID in the prospectively measured COMI score. Discrepancies in outcome ratings were influenced by surgeon seniority and patient satisfaction. For a balanced view of the surgical result, outcomes should be assessed from the perspectives of both the patient and the surgeon.

Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique

BACKGROUND

A subset of patients is often seen with an unusual pattern of tendon failure after arthroscopic rotator cuff repair using a suture bridge technique.

PURPOSE

To evaluate retear patterns in cases with structural failure after arthroscopic primary repairs of rotator cuff tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Forty-six cases revealing retear on magnetic resonance imaging performed at least 6 months after arthroscopic repair for the treatment of full-thickness rotator cuff tear were evaluated. A single-row technique had been performed in 19 cases and a suture bridge in 27 cases. According to retear patterns on postoperative magnetic resonance imaging, cases were divided into type 1 (cuff tissue repaired at the insertion site of rotator cuff was not observed remaining on the greater tuberosity) and type 2 (remnant cuff tissue remained at the insertion site in spite of retear).

RESULTS

In the single-row group, 14 cases (73.7%) had type 1 and 5 cases (26.3%) type 2 retear. In the suture bridge group, 7 cases (25.9%) had type 1 and 20 cases (74.1%) type 2. There were statistically significant differences between groups (P = .049). Extent of fatty degeneration of the rotator cuff did not affect retear patterns in the single-row group (P = .160). In the suture bridge group, the percentage of type 1 retear increased with severity of fatty degeneration (P = .030). Extent of muscle atrophy did not affect retear patterns of the single-row group; in the suture bridge group, the percentage of type 1 retear increased with severity of muscle atrophy (P = .904 vs .029).

CONCLUSION

The suture bridge technique tended to better preserve the cuff tissue repaired to the insertion site of the rotator cuff than a single-row technique did; the retear in cases with a suture bridge technique was mainly in the musculotendinous junction. Direct retear at the footprint of the rotator cuff increased with severity of fatty degeneration or muscle atrophy in cases with a suture bridge technique.

Activation of the shoulder musculature during pendulum exercises and light activities

STUDY DESIGN

Prospective, single-group, repeated-measures design.

OBJECTIVES

To evaluate electromyographic (EMG) signal amplitude in the supraspinatus, infraspinatus, and deltoid muscles during pendulum exercises and light activities in a group of healthy subjects.

BACKGROUND

There are numerous rehabilitation protocols used after rotator cuff repair. One of the most commonly used exercises in these protocols is the pendulum. Patients can easily perform these exercises incorrectly, and may also perform light activities of daily living without knowing that they may be putting excessive stress on the repair. The effect of improperly performed pendulum exercises and light activities after rotator cuff repair is unknown.

METHODS

Muscle activity was recorded in 13 subjects performing pendulum exercises incorrectly and correctly in both large (51-cm) and small (20-cm) diameters, and while typing, drinking, and brushing their teeth.

RESULTS

Incorrect and correct large pendulums and drinking elicited more than 15% maximum voluntary isometric contraction in the supraspinatus and infraspinatus. The supraspinatus EMG signal amplitude was greater during large, incorrectly performed pendulums than during those performed correctly. Both correct and incorrect large pendulums resulted in statistically higher muscle activity in the supraspinatus than the small pendulums.

CONCLUSION

Larger pendulums may require more force than is desirable early in rehabilitation after rotator cuff repair.

Medial-row failure after arthroscopic double-row rotator cuff repair

We report 4 cases of medial-row failure after double-row arthroscopic rotator cuff repair (ARCR) without arthroscopic subacromial decompression (ASAD), in which there was pullout of mattress sutures of the medial row and knots were caught between the cuff and the greater tuberosity. Between October 2006 and January 2008, 49 patients underwent double-row ARCR. During this period, ASAD was not performed with ARCR. Revision arthroscopy was performed in 8 patients because of ongoing symptoms after the index operation. In 4 of 8 patients the medial rotator cuff failed; the tendon appeared to be avulsed at the medial row, and there were exposed knots on the bony surface of the rotator cuff footprint. It appeared that the knots were caught between the cuff and the greater tuberosity. Three retear cuffs were revised with the arthroscopic transtendon technique, and one was revised with a single-row technique after completing the tear. ASAD was performed in all patients. Three of the four patients showed improvement of symptoms and returned to their preinjury occupation. Impingement of pullout knots may be a source of pain after double-row rotator cuff repair.

In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions

HYPOTHESIS

We assessed bone-tendon contact surface and pressure with a continuous and reversible measurement system comparing 3 different double- and single-row techniques of cuff repair with simulation of different joint positions.

MATERIALS AND METHODS

We reproduced a medium supraspinatus tear in 24 human cadaveric shoulders. For the 12 right shoulders, single-row suture (SRS) and then double-row bridge suture (DRBS) were used. For the 12 left shoulders, DRBS and then double-row cross suture (DRCS) were used. Measurements were performed before, during, and after knot tying and then with different joint positions.

RESULTS

There was a significant increase in contact surface with the DRBS technique compared with the SRS technique and with the DRCS technique compared with the SRS or DRBS technique. There was a significant increase in contact pressure with the DRBS technique and DRCS technique compared with the SRS technique but no difference between the DRBS technique and DRCS technique.

CONCLUSIONS

The DRCS technique seems to be superior to the DRBS and SRS techniques in terms of bone-tendon contact surface and pressure.

Arthroscopic rotator cuff repair: scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system

BACKGROUND

Rotator cuff repair has shown to improve shoulder function and reduce pain experienced by patients. Successful repairs should have high fixation strength, allow minimal gap formation, maintain stability, and restore normal anatomy and function of the supraspinatus footprint. The purpose of this study is to describe our preferred method for rotator cuff repair using a knotless self-reinforcing double-row system, and to cite biomechanical data rationalizing its use.

METHODS AND MATERIAL

Seventeen of 22 patients were identified as undergoing primary rotator cuff repair with minimum follow-up of 1 year (mean, 535 days; range, 370-939). The average age was 63 (range, 43-79). Data collected included average pain today, average worst pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction.

RESULTS

For all patients, average pain today and average worst pain decreased and functional scores (SANE) increased. Patient satisfaction was 9.8 out of 10 (range, 7-9). The patients also began rehabilitation earlier and returned to full activities at 4 months.

CONCLUSION

These results indicate that the knotless self-reinforcing double-row repair system is a viable option in treating rotator cuff tears. This system provides improved contact area and restores the native footprint of the tendon leading to better outcomes.

Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older?

PURPOSE

The aim of this study was to assess tendon healing and clinical results of rotator cuff tears (RCTs) repaired arthroscopically in patients aged 65 years or older.

METHODS

Between January 2001 and December 2004, 88 patients with a mean age of 70 years (range, 65 to 85 years) had arthroscopic RCT repair. The repair was performed on 54 women (61%). The dominant arm was involved in 72 patients (82%). RCT included more than 2 tendons in 45 cases. Functional outcomes were assessed by use of the Constant score and Simple Shoulder Test. Tendon healing was estimated by use of a computed tomography (CT) arthrogram, which was obtained 6 months postoperatively, and was classified into 3 categories: stage 1, watertight and anatomic healing; stage 2, watertight and partial healing; and stage 3, not watertight and retear.

RESULTS

The mean duration of follow-up was 41 months (range, 24 to 77 months). The mean clinical outcome scores all improved significantly at the time of the final follow-up (P < .01). Computed tomography arthrogram imaging showed 27 shoulders with a stage 1 repair, 20 with a stage 2 repair, and 34 with a stage 3 repair. The retear rate was 42% (34 of 81). The patients with tendon healing stage 1 or 2 had a significantly superior functional outcome in terms of overall scores and strength compared with the stage 3 repairs (P < .01). In our study we had 39 isolated supraspinatus tears (small or medium tears); 11 (28.9%) had a retear (stage 3).

CONCLUSIONS

Arthroscopic repair in patients aged 65 years or older can yield tendon healing resulting in significant functional improvement. Our data suggest that arthroscopic repair can be considered successful for the older patient specifically when the tear is limited to the supraspinatus tendon.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Single-row versus double-row rotator cuff repair: techniques and outcomes

Double-row rotator cuff repair techniques incorporate a medial and lateral row of suture anchors in the repair configuration. Biomechanical studies of double-row repair have shown increased load to failure, improved contact areas and pressures, and decreased gap formation at the healing enthesis, findings that have provided impetus for clinical studies comparing single-row with double-row repair. Clinical studies, however, have not yet demonstrated a substantial improvement over single-row repair with regard to either the degree of structural healing or functional outcomes. Although double-row repair may provide an improved mechanical environment for the healing enthesis, several confounding variables have complicated attempts to establish a definitive relationship with improved rates of healing. Appropriately powered rigorous level I studies that directly compare single-row with double-row techniques in matched tear patterns are necessary to further address these questions. These studies are needed to justify the potentially increased implant costs and surgical times associated with double-row rotator cuff repair.

Suture anchor loading after rotator cuff repair: effects of an additional lateral row

HYPOTHESIS

Our initial hypothesis was that the medial row of double-row rotator cuff repair techniques would bear most of the load on the repaired cuff.

MATERIALS AND METHODS

Six cadaver shoulders underwent simulated rotator cuff repairs using sequential single row, double-row, and suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions by specially designed, instrumented anchors.

RESULTS

Significantly greater suture tensions were measured in the anchors in a single row repair construct than either the double row repair or suture bridge repair construct (P < .001). In the double-row and suture bridge techniques, there was no apparent difference in the loads born by the medial and lateral row anchors. Shoulder abduction from 45 degrees to 60 degrees had little effect on anchor tensions; 45 degrees internal and external rotation significantly (P = .032) increased loads on the anterior and posterior anchors by at least 125%.

DISCUSSION

Forces are transmitted through the entire portion of the tendon at its humeral fixation, loading the lateral anchors as well as the medial row for the techniques studied. This "load sharing" can explain the higher fixation strengths of double row techniques seen experimentally.

CONCLUSION

The magnitude and distribution of anchor suture tensions could have important implications for lateral row fixation devices and post-operative positioning and activity.

LEVEL OF EVIDENCE

Basic Science.

Biomechanical evaluation of a single-row versus double-row repair for complete subscapularis tears

The purpose of the study was to compare a single-row repair and a double-row repair technique for the specific characteristics of a complete subscapularis lesion. Ten pairs of human cadaveric shoulder human shoulder specimens were tested for stiffness and ultimate tensile strength of the intact tendons in a load to failure protocol. After a complete subscapularis tear was provoked, the specimens were assigned to two treatment groups: single-row repair (1) and a double-row repair using a "suture bridge" technique (2). After repair cyclic loading a subsequent load to failure protocol was performed to determine the ultimate tensile load, the stiffness and the elongation behaviour of the reconstructions. The intact subscapularis tendons had a mean stiffness of 115 N/mm and a mean ultimate load of 720 N. The predominant failure mode of the intact tendons was a tear at the humeral insertion site (65%). The double-row technique restored 48% of the ultimate load of the intact tendons (332 N), while the single-row technique revealed a significantly lower ultimate load of 244 N (P = 0.001). In terms of the stiffness, the double-row technique showed a mean stiffness of 81 N/mm which is significantly higher compared to the stiffness of the single-row repairs of 55 N/mm (P = 0.001). The double-row technique has been shown to be stronger and stiffer when compared to a conventional single-row repair. Therefore, this technique is recommended from a biomechanical point of view irrespectively if performed by an open or arthroscopic approach.

2009 survey results: surgeon practice patterns regarding arthroscopic surgery

A survey was conducted to collect information on the surgical management and practice preferences of the audience members at a recent continuing medical education conference. Participants were polled on a variety of surgical topics, and their responses were recorded using a wireless audience response system. The answers were tabulated and are presented in this report. The majority of respondents preferred an arthroscopic repair for rotator cuff tears (52%) and shoulder instability (71%). Most (50%) perform single-row repair; 33% perform double-row repair. For simple knee arthroscopy, most use preoperative antibiotics (85%), no tourniquet (53%), and no chemical anticoagulation or only compression boots (69%). For cruciate ligament reconstruction, the majority preferred only a preoperative antibiotic (67%), no chemical anticoagulation or only compression boots (56%), and single-bundle reconstruction (88%) using a transtibial femoral tunnel (78%). Most (47%) prefer an all inside suture-based meniscus repair device.

Clinical outcomes of double-row versus single-row rotator cuff repairs

PURPOSE

The purpose of this review was to determine whether there is a difference in the clinical outcome between single-row and double-row rotator cuff repairs.

METHODS

We performed a systematic review of the results of clinical studies investigating and comparing double-row and single-row repair techniques. The articles meeting the inclusion and exclusion criteria were assessed for quality of the study; the results were then reviewed to provide a concise conclusion regarding the clinical outcomes of double-row versus single-row rotator cuff repair.

RESULTS

There were 3 Level I studies and 2 Level II studies comparing the clinical outcomes of double-row and single-row rotator cuff repair. At 1-year follow-up, there was no statistically significant clinical difference between patients who had undergone double-row repair and those who had undergone single-row rotator cuff repair.

CONCLUSIONS

Arthroscopic rotator cuff repairs with double-row repair show no significant difference compared with single-row repair in clinical outcome at 1-year follow-up. Additional prospective, randomized controlled trials are needed with longer-term follow-up to determine whether there is any clinical difference between the 2 techniques.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Does the literature support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor configuration

PURPOSE

The purpose of this study was to compare the clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair with a systematic review of the published literature.

METHODS

We searched all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials for the following key words: shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, arthroscopic-assisted, single row, double row, and transosseous equivalent. The inclusion criteria were cohort studies (Levels I to III) that compared SR and DR suture anchor configuration for the arthroscopic treatment of full-thickness rotator cuff tears. The exclusion criteria were studies that lacked a comparison group, and, therefore, case series were excluded from the analysis.

RESULTS

There were 5 studies that met the criteria and were included in the final analysis: 5 in the SR group and 5 in the DR group. Data were abstracted from the studies for patient demographics, rotator cuff tear characteristics, surgical procedure, rehabilitation, range of motion, clinical scoring systems, and imaging studies.

CONCLUSIONS

There are no clinical differences between the SR and DR suture anchor repair techniques for arthroscopic rotator cuff repairs. At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing.

LEVEL OF EVIDENCE

Level III, systematic review of Levels I to III studies.

Double-row vs single-row rotator cuff repair: a review of the biomechanical evidence

HYPOTHESIS

A review of the current literature will show a difference between the biomechanical properties of double-row and single-row rotator cuff repairs.

BACKGROUND

Rotator cuff tears commonly necessitate surgical repair; however, the optimal technique for repair continues to be investigated. Recently, double-row repairs have been considered an alternative to single-row repair, allowing a greater coverage area for healing and a possibly stronger repair.

MATERIALS AND METHODS

We reviewed the literature of all biomechanical studies comparing double-row vs single-row repair techniques. Inclusion criteria included studies using cadaveric, animal, or human models that directly compared double-row vs single-row repair techniques, written in the English language, and published in peer reviewed journals. Identified articles were reviewed to provide a comprehensive conclusion of the biomechanical strength and integrity of the repair techniques.

RESULTS

Fifteen studies were identified and reviewed. Nine studies showed a statistically significant advantage to a double-row repair with regards to biomechanical strength, failure, and gap formation. Three studies produced results that did not show any statistical advantage. Five studies that directly compared footprint reconstruction all demonstrated that the double-row repair was superior to a single-row repair in restoring anatomy.

CONCLUSIONS

The current literature reveals that the biomechanical properties of a double-row rotator cuff repair are superior to a single-row repair.

LEVEL OF EVIDENCE

Basic Science Study, SRH = Single vs. Double Row RCR.

Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including debridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.

Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree?

Patient-orientated questionnaires are becoming increasingly popular in the assessment of outcome and are considered to provide a less biased assessment of the surgical result than traditional surgeon-based ratings. The present study sought to quantify the level of agreement between patients' and doctors' global outcome ratings after spine surgery. 1,113 German-speaking patients (59.0 +/- 16.6 years; 643 F, 470 M) who had undergone spine surgery rated the global outcome of the operation 3 months later, using a 5-point scale: operation helped a lot, helped, helped only little, didn't help, made things worse. They also rated pain, function, quality-of-life and disability, using the Core Outcome Measures Index (COMI), and their satisfaction with treatment (5-point scale). The surgeon completed a SSE Spine Tango Follow-up form, blind to the patient's evaluation, rating the outcome with the McNab criteria as excellent, good, fair, and poor. The data were compared, in terms of (1) the correlation between surgeons' and patients' ratings and (2) the proportions of identical ratings, where the doctor's "excellent" was considered equivalent to the patient's "operation helped a lot", "good" to "operation helped", "fair" to "operation helped only little" and "poor" to "operation didn't help/made things worse". There was a significant correlation (Spearman Rho = 0.57, p < 0.0001) between the surgeons' and patients' ratings. Their ratings were identical in 51.2% of the cases; the surgeon gave better ratings than the patient ("overrated") in 25.6% cases and worse ratings ("underrated") in 23.2% cases. There were significant differences between the six surgeons in the degree to which their ratings matched those of the patients, with senior surgeons "overrating" significantly more often than junior surgeons (p < 0.001). "Overrating" was significantly more prevalent for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment; each p < 0.001). In a multivariate model controlling for age and gender, "low satisfaction with treatment" and "being a senior surgeon" were the most significant unique predictors of surgeon "overrating" (p < 0.0001; adjusted R (2) = 0.21). Factors with no unique significant influence included comorbidity (ASA score), first time versus repeat surgery, one-level versus multilevel surgery. In conclusion, approximately half of the patient's perceptions of outcome after spine surgery were identical to those of the surgeon. Generally, where discrepancies arose, there was a tendency for the surgeon to be slightly more optimistic than the patient, and more so in relation to patients who themselves declared a poor outcome. This highlights the potential bias in outcome studies that rely solely on surgeon ratings of outcome and indicates the importance of collecting data from both the patient and the surgeon, in order to provide a balanced view of the outcome of spine surgery.

Rotator cuff repair fluid extravasation characteristics are influenced by repair technique

BACKGROUND

This study evaluates rotator cuff repair fluid extravasation characteristics for different rotator cuff repair techniques.

METHODS

Eight fresh-frozen cadaveric shoulders were dissected free of soft tissues, with the glenohumeral joint capsule and rotator cuff muscles being left intact. A custom fluid infusion device was used to deliver fluid at constant pressure into the glenohumeral joint. The shoulders were tested in conditions of (1) intact rotator cuff, (2) supraspinatus tear, (3) repaired supraspinatus tear with a single-row technique, and (4) repaired supraspinatus tear with a double-row suture bridge technique.

RESULTS

The volume per minute of saline solution extravasation for single-row repair and double-row suture bridge repair was 48.53 mL/min and 11.73 mL/min, respectively, at 2 psi; 73.3 _ 24.1 mL/min and 24.5 _ 19.7 mL/min, respectively, at 3 psi; and 95.2 _ 22.6 mL/min and 39.2 _ 23.8 mL/min, respectively, at 4 psi. There was a statistically significant greater fluid extravasation for the single-row repair compared with the double-row suture bridge repair at all 3 pressures tested (P < .05).

CONCLUSION

Single-row rotator cuff repair exposes the healing zone to greater extravasation of fluid compared with double-row suture bridge repair. Therefore, double-row repair potentially enhances rotator cuff healing.

LEVEL OF EVIDENCE

Controlled laboratory study.

A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: the SwiveLock-FiberChain construct versus standard double-row repair

PURPOSE

The purpose of this study was to compare the biomechanical fixation parameters of a standard double-row rotator cuff repair with those of a knotless footprint reconstruction using the double-row SwiveLock-FiberChain technique (Arthrex, Naples, FL).

METHODS

Seven matched pairs of human cadaveric shoulders were used for testing (mean age, 48 +/- 10.3 years). A shoulder from each matched pair was randomly selected to receive a standard 4-anchor double-row repair of the supraspinatus tendon, and the contralateral shoulder received a 4-anchor double-row SwiveLock-FiberChain repair. The tendon was cycled from 10 N to 100 N at 1 Hz for 500 cycles, followed by a single-cycle pull to failure at 33 mm/s. Yield load, ultimate load, cyclic displacement, and mode of failure were recorded.

RESULTS

Yield load and ultimate load were higher for the SwiveLock-FiberChain repair compared with the standard double-row repair for 6 of the 7 treatment pairs; however, 1 cadaver had a contrary outcome, so the overall mean differences in yield load and ultimate load were not significantly different from 0 by Student t test (P > .15). Furthermore, smaller differences between yield load and ultimate load for the SwiveLock-FiberChain repair in 5 of the 7 treatment pairs showed a self-reinforcing mechanism.

CONCLUSIONS

Double-row footprint reconstruction with the knotless SwiveLock-FiberChain system in this study had yield loads, ultimate loads, and cyclic displacements that were statistically equivalent to those of standard double-row rotation cuff reconstructions.

CLINICAL RELEVANCE

The SwiveLock-FiberChain system's combination of strength, self-reinforcement, and decreased operating time may offer advantages to the surgeon, particularly when dealing with older patients in whom poor tissue quality and total operative time are important considerations.

Differential suture loading in an experimental rotator cuff repair

BACKGROUND

Repairs of large rotator cuff tears often fail to heal. A possible factor in these failures is excessive tension in the repair sutures, causing them to pull through the tendon.

HYPOTHESIS

Arm positions encountered during early rehabilitation after cuff repair can dramatically increase the relative tension in the different sutures of the cuff repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

In a cadaver model, a 4-suture supraspinatus repair was carried out with transosseous sutures. After the repair, the arm was placed in 12 different positions. The tension in each suture was monitored using individual load cells.

RESULTS

When the arm was externally rotated relative to the plane of the scapula, the tension in the anterior suture was over 10 times that in the posterior suture (P < .001). When the arm was internally rotated, the tension in the posterior suture was over 10 times that in the anterior suture (P < .0005). When the arm was in neutral rotation, there was no significant difference in the suture tension.

CONCLUSIONS

This study is the first report of direct suture tension measurement after a model rotator cuff repair. In this model, 30 degrees of either internal or external rotation of the arm in relation to the plane of the scapula created substantial imbalances in the tension between the most anterior and most posterior sutures of a supraspinatus repair, regardless of the position of abduction.

CLINICAL RELEVANCE

Avoiding external rotation stretching during the healing of supraspinatus repairs may prevent tension overload in the critical anterior suture.

Biomechanical characteristics of single-row repair in comparison to double-row repair with consideration of the suture configuration and suture material

The aim of the study was to evaluate the time zero mechanical properties of single- versus double-row configuration for rotator cuff repair in an animal model with consideration of the stitch technique and suture material. Thirty-two fresh-frozen sheep shoulders were randomly assigned to four repair groups: suture anchor single-row repair coupled with (1) braided, nonabsorbable polyester suture sized USP No. 2 (SRAE) or (2) braided polyblend polyethylene suture sized No. 2 (SRAH). The double-row repair was coupled with (3) USP No. 2 (DRAE) or (4) braided polyblend polyethylene suture No. 2 (DRAH). Arthroscopic Mason-Allen stitches were used (single-row) and combined with medial horizontal mattress stitches (double-row). Shoulders were cyclically loaded from 10 to 180 N. Displacement to gap formation of 5- and 10-mm at the repair site, cycles to failure, and the mode of failure were determined. The ultimate tensile strength was verified in specimens that resisted to 3,000 cycles. DRAE and DRAH had a lower frequency of 5- (P = 0.135) and 10-mm gap formation (P = 0.135). All DRAE and DRAH resisted 3,000 cycles while only three SRAE and one SRAH resisted 3,000 cycles (P < 0.001). The ultimate tensile strength in double-row specimens was significantly higher than in others (P < 0.001). There was no significant variation in using different suture material (P > 0.05). Double-row suture anchor repair with arthroscopic Mason-Allen/medial mattress stitches provides initial strength superior to single-row repair with arthroscopic Mason-Allen stitches under isometric cyclic loading as well as under ultimate loading conditions. Our results support the concept of double-row fixation with arthroscopic Mason-Allen/medial mattress stitches in rotator cuff tears with improvement of initial fixation strength and ultimate tensile load. Use of new polyblend polyethylene suture material seems not to increase the initial biomechanical aspects of the repair construct.

Single-row modified mason-allen versus double-row arthroscopic rotator cuff repair: a biomechanical and surface area comparison

PURPOSE

The purpose of this study was to compare the time-zero biomechanical strength and the surface area of repair between a single-row modified Mason-Allen rotator cuff repair and a double-row arthroscopic repair.

METHODS

Six matched pairs of sheep infraspinatus tendons were repaired by both techniques. Pressure-sensitive film was used to measure the surface area of repair for each configuration. Specimens were biomechanically tested with cyclic loading from 20 N to 30 N for 20 cycles and were loaded to failure at a rate of 1 mm/s. Failure was defined at 5 mm of gap formation.

RESULTS

Double-row suture anchor fixation restored a mean surface area of 258.23 +/- 69.7 mm(2) versus 148.08 +/- 75.5 mm(2) for single-row fixation, a 74% increase (P = .025). Both repairs had statistically similar time-zero biomechanics. There was no statistical difference in peak-to-peak displacement or elongation during cyclic loading. Single-row fixation showed a higher mean load to failure (110.26 +/- 26.4 N) than double-row fixation (108.93 +/- 21.8 N). This was not statistically significant (P = .932). All specimens failed at the suture-tendon interface.

CONCLUSIONS

Double-row suture anchor fixation restores a greater percentage of the anatomic footprint when compared with a single-row Mason-Allen technique. The time-zero biomechanical strength was not significantly different between the 2 study groups. This study suggests that the 2 factors are independent of each other.

CLINICAL RELEVANCE

Surface area and biomechanical strength of fixation are 2 independent factors in the outcome of rotator cuff repair. Maximizing both factors may increase the likelihood of complete tendon-bone healing and ultimately improve clinical outcomes. For smaller tears, a single-row modified Mason-Allen suture technique may provide sufficient strength, but for large amenable tears, a double row can provide both strength and increased surface area for healing.

Repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair

BACKGROUND

Successful healing after arthroscopic rotator cuff repair remains a challenge. Earlier studies have shown a relatively high rate of failure. New surgical techniques may improve healing potential. The purpose of this study was to provide an objective evaluation of repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair.

HYPOTHESIS

Rotator cuff tears repaired using the transosseous-equivalent suture-bridge technique will show a higher intact rate on postoperative magnetic resonance imaging (MRI) evaluation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The first 25 patients who underwent arthroscopic rotator cuff repair using the transosseous-equivalent suture-bridge technique underwent MRI evaluation of the postoperative shoulder. Minimum follow-up was 1 year. Demographic, clinical, and surgical factors, including tear size, were evaluated.

RESULTS

Postoperative MRI demonstrated intact surgical repair sites in 22 of 25 patients (88%). Tears limited to the supraspinatus tendon were intact in 16 of 18 patients (89%). Tears of the supraspinatus involving part or all of the infraspinatus showed an 86% intact rate (6 of 7 patients). Of these tears, 3 were considered massive (complete 2-tendon or greater). These demonstrated an intact cuff on MRI.

CONCLUSIONS

The transosseous-equivalent suture-bridge technique demonstrates a high healing rate on imaging studies at 1 year. Of the first 25 patients repaired with the technique, 88% had an intact rotator cuff repair on MRI evaluation. This indicates excellent cuff healing, as judged by the intact repair sites, compared with most standard arthroscopic rotator cuff repair series. In this early report of the technique, a persistent tear could not be correlated with age or initial tear size; however, this may be due to the relatively small sample size.

Biomechanical comparison of single-row arthroscopic rotator cuff repair technique versus transosseous repair technique

This study determined the effect of tear size on gap formation of single-row simple-suture arthroscopic rotator cuff repair (ARCR) vs transosseous Mason-Allen suture open RCR (ORCR) in 13 pairs of human cadaveric shoulders. A massive tear was created in 6 pairs and a large tear in 7. Repairs were cyclically tested in low-load and high-load conditions, with no significant difference in gap formation. Under low-load, gapping was greater in massive tears. Under high-load, there was a trend toward increased gap with ARCR for large tears. All repairs of massive tears failed in high-load. Gapping was greater posteriorly in massive tears for both techniques. Gap formation of a modeled RCR depends upon the tear size. ARCR of larger tears may have higher failure rates than ORCR, and the posterior aspect appears to be the site of maximum gapping. Specific attention should be directed toward maximizing initial fixation of larger rotator cuff tears, especially at the posterior aspect.

A biomechanical comparison of 2 technical variations of double-row rotator cuff fixation: the importance of medial row knots

BACKGROUND

Previous studies have shown comparable biomechanical properties of double-row fixation versus double-row fixation with a knotless lateral row. SutureBridge is a construct that secures the cuff with medial row mattress suture anchors and knotless lateral row fixation of the medial suture ends. Recent completely knotless constructs may lead to lesser clinical outcomes if the construct properties are compromised from lack of suture knots.

HYPOTHESIS

A completely knotless construct without medial row knots will compromise the biomechanical properties in both cyclic and failure-testing parameters.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six matched pairs of cadaveric shoulders were randomized to 2 groups of double row fixation with SutureBridge: group 1 with medial row knots, and group 2 without medial row knots. The specimens were placed in a materials test system at 30 degrees of abduction. Cyclic testing to 180 N at 1 mm/sec for 30 cycles was performed, followed by tensile testing to failure at 1 mm/sec.

RESULTS

Data included cyclic and failure data from the materials test system and gap data using a video digitizing system. All data from paired specimens were compared using paired Student t tests. Group 1 had a statistically significant difference (P < .05) for gap formation for the 1st (3.47 vs 5.05 mm) and 30th cycle (4.22 vs 8.10 mm) and at yield load (5.2 vs 9.1 mm). In addition, there was a greater energy absorbed (2805 vs 1648 N-mm), yield load (233 vs 183.1 N), and ultimate load (352.9 vs 253.9 N) for group 1. The mode of failure for the majority (4/6) of group 2 was lateral row failure, whereas all group 1 specimens failed at the clamp.

CONCLUSION

Although lateral row knotless fixation has been shown not to sacrifice structural integrity of this construct, the addition of a knotless medial row compromises the construct leading to greater gapping and failure at lower loads.

CLINICAL RELEVANCE

This may raise concerns regarding recently marketed completely knotless double row constructs.

The Roman Bridge: a "double pulley - suture bridges" technique for rotator cuff repair

Background

With advances in arthroscopic surgery, many techniques have been developed to increase the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing.

Methods

We present an arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon-footprint contact area and mean pressure.

Results

Two medial row 5.5-mm Bio-Corkscrew suture anchors (Arthrex, Naples, FL), which are double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL), are placed in the medial aspect of the footprint. Two suture limbs from a single suture are both passed through a single point in the rotator cuff. This is performed for both anchors. The medial row sutures are tied using the double pulley technique. A suture limb is retrieved from each of the medial anchors through the lateral portal, and manually tied as a six-throw surgeon's knot over a metal rod. The two free suture limbs are pulled to transport the knot over the top of the tendon bridge. Then the two free suture limbs that were used to pull the knot down are tied. The end of the sutures are cut. The same double pulley technique is repeated for the other two suture limbs from the two medial anchors, but the two free suture limbs are used to produce suture bridges over the tendon, by means of a Pushlock (Arthrex, Naples, FL), placed 1 cm distal to the lateral edge of the footprint.

Conclusion

This technique maximizes the advantages of two techniques. On the one hand, the double pulley technique provides an extremely secure fixation in the medial aspect of the footprint. On the other hand, the suture bridges allow to improve pressurized contact area and mean footprint pressure. In this way, the bony footprint in not compromised by the distal-lateral fixation, and it is thus possible to share the load between fixation points. This maximizes the strength of the repair and provides a barrier preventing penetration of synovial fluid into the healing area of tendon and bone.

Arthroscopic rotator cuff repair with double-row fixation

BACKGROUND

The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique.

METHODS

Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff.

RESULTS

The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores.

CONCLUSIONS

Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Clinical evidence shows no difference between single- and double-row repair for rotator cuff tears

Tears of the rotator cuff may be repaired by single- or double-row techniques. Single-row methods do not restore the rotator cuff footprint but do provide a good functional outcome. We surveyed the literature to ascertain the origin of the current trend of using double-row methods of repair. The footprint repair is a benefit of double-row fixation with strong evidence of its biomechanical success. However, the functional outcome of double-row fixation is equivalent to single-row fixation. Given the lack of scientific evidence and despite the enthusiasm of surgeons for this new technique, single-row fixation remains an acceptable method for managing these injuries, and it is our opinion that it is the preferable method.

Outcomes of shoulder arthroplasty in Olmsted County, Minnesota: a population-based study

Most studies on shoulder arthroplasty include a diverse group of patients presenting to a tertiary care center. Little information is available regarding outcomes in a community setting. We reviewed 98 residents (110 shoulders) of Olmsted County, Minnesota who had shoulder arthroplasties from 1976 to 2000. There were 65 total shoulder arthroplasties and 45 humeral head replacements. The most common indications were osteoarthritis for total shoulder arthroplasties (48/65) and acute fracture for hemiarthroplasties (27/45). The Neer ratings were excellent or satisfactory in 92% of total shoulder arthroplasties and 56% of hemiarthroplasties. The 10-year survival rate was 96%. The mean postoperative active forward elevation was greater in patients who had a total shoulder arthroplasty (132 degrees) compared with a hemiarthroplasty (113 degrees), as was external rotation (total shoulder arthroplasties = 58 degrees, humeral head replacements = 38 degrees). The outcomes for total shoulder arthroplasty and hemiarthroplasty compared favorably with outcomes reported in the literature. There was a high rate of satisfactory or excellent results after total shoulder arthroplasty for osteoarthritis. Hemiarthroplasty offered less satisfactory results, most likely related to the use of this procedure for trauma. This information will assist the community surgeon in counseling patients and weighing the risks and benefits of a shoulder arthroplasty.