Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

A Comprehensive Evaluation of Factors Affecting Healing, Range of Motion, Strength, and Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair

Background

Rotator cuff repair (RCR) leads to improved patient outcomes, which may or may not coincide with biological healing of the tendon. Many patient factors may play a role in subjective and objective patient outcomes of surgery.

Purpose

To evaluate the effect of various patient factors and tendon healing on range of motion, strength, and functional outcomes after arthroscopic RCR.

Study Design

Case-control study; Level of evidence, 3.

Methods

We reviewed patients who underwent arthroscopic RCR. Postoperative endpoints included physical examination, repeat magnetic resonance imaging (MRI), and patient-reported outcome measures. The Short Form-36 (SF-36) was also completed at enrollment. Physical examination included range of motion and strength testing. Preoperative tear characteristics and postoperative healing on MRI were recorded. Associations between these characteristics and rotator cuff healing were determined. Multivariate models investigated factors affecting healing and final outcomes.

Results

A total of 81 patients had MRI before and a minimum of 1 year after RCR. Patient-reported outcomes were available for all patients at mean 2.7 years (range, 1-7.7 years) after RCR. Seventy-five patients had physical examination data. Patients were less likely to heal if they had tears involving multiple tendons (P = .037), tears >2.2 cm (P = .037), tears retracted >2.0 cm (P = .006), and tears with cumulative Goutallier grade ≥3 (P = .003). Patients who healed were stronger on manual muscle testing in forward elevation (P < .001) and external rotation (P = .005) and on forward elevation isometric testing (P = .033), and they reported better patient-reported outcomes (P ≤ .01) at final follow-up. In multivariate models, tendon healing was associated with less pain (P = .019) and better patient-reported outcomes (all P ≤ .006). Lower SF-36 mental component summary (MCS) score was associated with increased pain (P = .025) and lower final American Shoulder and Elbow Surgeons score (P = .035), independent of healing status.

Conclusion

Larger, more retracted tears with greater fatty infiltration are less likely to heal per MRI. Patients who do not heal are weaker and have worse patient-reported outcome measures. Lower SF-36 MCS score was associated with poorer patient-reported outcomes independent of tendon healing.

Comorbidity effect on speed of recovery after arthroscopic rotator cuff repair

Background

Comorbidities have been shown to affect rotator cuff healing and postoperative outcomes. The purpose of this study was to analyze the effect of comorbidities on speed of recovery (SOR) and overall outcomes after arthroscopic rotator cuff repair (RCR).

Methods

We identified 627 patients who underwent primary arthroscopic RCR from 2006 to 2015. Measured motion and patient-reported outcome measures for pain and function were analyzed for preoperative, 3-month, 6-month, and 1-year intervals. Subgroup analysis of overall outcome and plateau in maximum improvement was performed for diabetes, smoking, obesity, hypercholesterolemia, and age.

Results

Diabetic patients had worse pain (visual analog scale for pain) and functional outcome (American Shoulder and Elbow Surgeons function, Simple Shoulder Test, visual analog scale for function, and elevation) scores at 6 months and 1 year (P < .05), with an earlier plateau in recovery (6 months) for nearly all variables. Smoking had no impact on postoperative outcome scores; however, plateaus occurred earlier in smokers (6 months). Obese patients had worse American Shoulder and Elbow Surgeons function score and external rotation at 1 year (P < .05) with similar plateau points. No significant differences were observed in outcomes for patients with hypercholesterolemia; however, plateaus for Single Assessment Numeric Evaluation and motion occurred earlier (6 months). Outcome scores for patients older than 65 years were not significantly different from those for younger patients.

Conclusion

After arthroscopic RCR, SOR for pain outpaced that for function and motion. Diabetic patients had worse outcomes and earlier plateau points. Earlier plateaus were seen for smokers and for motion in patients with obesity or hypercholesterolemia. Obese patients showed lower functional scores and external rotation. Age did not significantly influence SOR.

Excellent healing rates and patient satisfaction after arthroscopic repair of medium to large rotator cuff tears with a single-row technique augmented with bone marrow vents

PURPOSE

This study evaluated the repair integrity and patient clinical outcomes following arthroscopic rotator cuff repair of medium to large rotator cuff tears using a single-row technique consisting of medially based, triple-loaded anchors augmented with bone marrow vents in the rotator cuff footprint lateral to the repair.

METHODS

This is a retrospective study of 52 patients (53 shoulders) comprising 36 males and 16 females with a median age of 62 (range 44-82) with more than 24-month follow-up, tears between 2 and 4 cm in the anterior-posterior dimension and utilizing triple-loaded anchors. Mann-Whitney test compared Western Ontario Rotator Cuff (WORC) outcome scores between patients with healed and re-torn cuff repairs. Multivariate logistic regression analysed association of variables with healing status and WORC score. Cuff integrity was assessed on MRI, read by a musculoskeletal fellowship-trained radiologist.

RESULTS

Magnetic resonance imaging (MRI) demonstrated an intact repair in 48 of 53 shoulders (91%). The overall median WORC score was 95.7 (range 27.6-100.0). A significant difference in WORC scores were seen between patients with healed repairs 96.7 (range 56.7-100.0) compared with a re-tear 64.6 (27.6-73.8), p < 0.00056.

CONCLUSIONS

Arthroscopic repair of medium to large rotator cuff tears using a triple-loaded single-row repair augmented with bone marrow vents resulted in a 91% healing rate by MRI and excellent patient reported clinical outcomes comparable to similar reported results in the literature.

LEVEL OF EVIDENCE

IV.

The clinical effect of rehabilitation following arthroscopic rotator cuff repair: A meta-analysis of early versus delayed passive motion

BACKGROUND

The argument on the recommended rehabilitation protocol following arthroscopic rotator cuff repair remains to be resolved. So this meta-analysis was presented to evaluate the differences of clinical effects between the 2 distinct rehabilitation protocols after arthroscopic rotator cuff repair.

METHODS

The PubMed, Cochrane Library, Web of Science, and EMBASE were systematically searched. Only randomized controlled trials (RCTs) published up to July 25, 2017, comparing early passive motion (EPM) versus delayed passive motion (DPM) rehabilitation protocols following arthroscopic rotator cuff repair were identified. The primary outcomes included range of motion and healing rate, while the secondary outcomes were Constant score, American Shoulder and Elbow Society (ASES) score, and Simple Shoulder Test (SST) score. The exclusion criteria contained biochemical trials, reviews, case reports, retrospective studies, without mention about passive motion exercise, no assessment of outcomes mentioned above, and no comparison of EPM and DPM rehabilitation protocols.

RESULTS

Eight RCTs with 671 patients were enrolled in this study. The EPM resulted in improved shoulder forward flexion at short term, mid-term, and long-term follow-ups. The EPM group was superior to the DPM group in terms of external rotation (ER) at short-term and mid-term follow-ups. However, the DPM performed better long-term ASES score. These 2 protocols were equivalent in terms of ER at long term, ASES score at mid-term, SST score, Constant score, and healing rate. After excluding 2 RCTs that examined only small- and medium-sized tears, the pooled results of healing rate decreased from 82.4% to 76.6% in the EPM and 86.9% to 85.9% in the DPM.

CONCLUSION

The meta-analysis suggests that the EPM protocol results in superior ROM recovery after arthroscopic rotator cuff repair but may adversely affect the shoulder function, which should be supported by further research. The healing rate at long-term follow-up is not clearly affected by the type of rehabilitation, but the EPM protocol might result in lower rates of tendon healing in the shoulder with large-sized tendon tears.

Changes of fatty infiltration according to the immediate postoperative time point in magnetic resonance imaging after arthroscopic rotator cuff repair

PURPOSE

Fatty infiltration (FI) is known to be an irreversible change which continues degeneration after rotator cuff repair. Previous studies evaluated postoperative changes in FI using a preoperative baseline. This study aimed to investigate the changes in FI using an immediate postoperative baseline. We hypothesized that FI was progressed more when measured relative to an immediate postoperative baseline than to a preoperative baseline.

METHODS

From 2008 to 2010, 77 patients who met the following criteria were included in this study: arthroscopic rotator cuff repair of a full-thickness rotator cuff tear and presence of preoperative (approximately 1 month before surgery), immediate postoperative (approximately 3 days after surgery), and 1-year postoperative (at least 9 months to 1 year after surgery) magnetic resonance imaging (MRI) undertaken. The exclusion criteria were: absence of any of the three MRIs, isolated subscapularis repair, and rotator cuff repair with margin convergence only. The MRIs were examined to assess the Goutallier grade of the rotator cuff muscles for the assessment of FI. Structural integrity was evaluated using the Sugaya classification. Measurements 1 year after surgery were compared with those at the preoperative and immediate postoperative time points according to the integrity.

RESULTS

In the total and retear group, FI in the supraspinatus and infraspinatus 1 year after surgery did not change significantly relative to the preoperative baseline (all n.s.), but progressed compared to the immediate postoperative baseline (all p < 0.001). In the retear group, FI in the supraspinatus and infraspinatus reduced for seven and two of 20 patients, respectively, compared with the preoperative baseline; however, no patients showed a reduced FI compared with the immediate postoperative baseline.

CONCLUSIONS

The results of the study showed that the changes in FI reduced, remained or progressed in accordance with the baseline and structural integrity. FI progressed when compared with the immediate postoperative baseline than with the preoperative baseline. The immediate postoperative time point would be considered as the baseline to monitor the true changes of FI after repair.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Predictive Factors of Retear in Patients With Repaired Rotator Cuff Tear on Shoulder MRI

OBJECTIVE

This study aimed to find independent prognostic factors related to retear of the rotator cuff tendon in patients with repaired full-thickness supraspinatus tendon tear by evaluation of pre- and postoperative MR images.

MATERIALS AND METHODS

Shoulder MR images were retrospectively analyzed for 83 patients who had undergone arthroscopic or open rotator cuff repair with acromioplasty for full-thickness supraspinatus tendon tear from April 2014 to March 2015. On preoperative MR images, the type of rotator cuff tear, extent of retraction of torn tendon, anteroposterior (AP) dimension of torn tendon, signal intensity of tear edge, degree of fat infiltration in supraspinatus and infraspinatus muscles, and acromiohumeral interval (AHI) were assessed. Postoperative cuff integrity seen on MR images was classified into five categories according to the Sugaya classification system, and patients were categorized into retear or intact groups. Factors assessed on preoperative MR images were compared between the two groups.

RESULTS

The overall retear rate was 57.8%. Significant differences were observed between the retear and intact groups in terms of the mean values of the extent of tendon retraction (20.4 vs 11.7 mm), AP dimension of the tear (16.1 vs 11.4 mm), AHI (6.8 vs 8.7 mm), and degree of fat infiltration of the supraspinatus and infraspinatus muscles (for the supraspinatus muscle, 3, 30, and 15 patients in the retear group vs 5, 27, and three patients in the intact group had Goutallier grade 1, grade 2, and grades 3 and 4 infiltration, respectively; for the infraspinatus muscle, 27, 12, and 9 patients in the retear group vs 29, 5, and one patient in the intact group had Goutallier grade 1, grade 2, and grades 3 and 4 infiltration, respectively). Multivariable analysis revealed that AHI and degree of tendon retraction were independent predictive factors affecting retear of rotator cuff after repair.

CONCLUSION

The retear rate of repaired rotator cuff tendon was about 57.8%. Independent prognostic factors of retear were degree of tendon retraction and AHI on preoperative MR images.

[Clinical research of arthroscopic separate double-layer suture bridge technique for delaminated rotator cuff tear]

Objective

To explore the effectiveness of the arthroscopic separate double-layer suture bridge technique in treatment of the delaminated rotator cuff tear.

Methods

Between May 2013 and May 2015, 54 patients with the delaminated rotator cuff tears were recruited in the study. They were randomly allocated into 2 groups to receive repair either using arthroscopic separate double-layer suture bridge technique (trial group, n=28) or using arthroscopic whole-layer suture bridge technique (control group, n=26). There was no significant difference in gender, age, injured side, tear type, and preoperative visual analogue scale (VAS) score, Constants score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) score, and the range of motion of shoulder joint between 2 groups ( P>0.05). Postoperative functional scores, range of motion, and recurrence rate of tear in 2 groups were observed and compared.

Results

The operation time was significant longer in trial group than in control group ( t=8.383, P=0.000). All incisions healed at stage Ⅰ without postoperative complication. All the patients were followed up 12 months. At 12 months postoperatively, the UCLA score, ASES score, VAS score, Constant score, and the range of motion were significantly improved when compared with the preoperative values in 2 groups ( P<0.05). However there was no significant difference in above indexes between 2 groups ( P>0.05). Four cases (14.3%) of rotator cuff tear recurred in trial group while 5 cases (19.2%) in control group, showing no significant difference ( χ²=0.237, P=0.626).

Conclusion

Compared with the arthroscopic whole-layer suture bridge technique, arthroscopic separate double-layer suture bridge technique presents no significant difference in the shoulder function score, the range of motion, and recurrence of rotator cuff tear, while having a longer operation time.

Superior Capsular Reconstruction With Superimposition of Rotator Cuff Repair for Massive Rotator Cuff Tear

Massive rotator cuff tears are particularly challenging to treat and severely limit the function of the shoulder. Compared with a small rotator cuff tear, massive tears are more unpredictable and usually present with low tendon quality. When performing an anatomical repair of the rotator cuff, the surgical treatment is often associated with failure of the construct. An alternative procedure that can be performed in the setting of a massive tear is superior capsular reconstruction (SCR), using an autograft or allograft. This procedure has been shown to be effective and is associated with positive treatment outcomes. Moreover, the combination of an SCR with an anatomic repair of the rotator cuff tendon may provide a stronger fixation for the rotator cuff and ultimately lead to a lower likelihood of retear and failure. The purpose of this Technical Note is to describe our preferred procedure for the treatment of a massive rotator cuff tear through SCR with superimposition of the repair of the native rotator cuff tendons.

Local rhBMP-12 on an Absorbable Collagen Sponge as an Adjuvant Therapy for Rotator Cuff Repair-A Phase 1, Randomized, Standard of Care Control, Multicenter Study: Part 2-A Pilot Study of Functional Recovery and Structural Outcomes

BACKGROUND

The high failure rate of rotator cuff repairs requires the development of methods to enhance healing at the tendon-bone junction of the repair site.

PURPOSE

To assess functional recovery and structural outcomes in detail after implanting recombinant human bone morphogenetic protein-12 (rhBMP-12)/absorbable collagen sponge (ACS) as adjuvant treatment during open rotator cuff repair in patients over a 1-year postoperative follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 20 patients were randomized into 2 groups, rhBMP-12/ACS and standard-of-care (SOC) control, with 16 and 4 patients, respectively. The patients underwent open repair of a rotator cuff tear at least 2 to 4 cm wide; in the rhBMP-12/ACS group, this was augmented with a bioscaffold containing rhBMP-12. Follow-up assessments were conducted with a 100-mm visual analog scale (VAS) for pain and active and passive ranges of motion (ROMs) including forward flexion, elevation in the scapular plane, abduction, and external rotation at 12, 16, 26, 39, and 52 weeks after surgery; isometric strength in scapular abduction and external rotation at 16, 26, 39, and 52 weeks; and magnetic resonance imaging (MRI) at 12 and 52 weeks.

RESULTS

The mean VAS score decreased from 37.9 mm preoperatively to 13.8 mm at week 52, and ROM and isometric strength recovered at week 52 in the rhBMP-12/ACS group. The mean VAS score decreased from 48.3 mm preoperatively to 1.5 mm at week 52, and ROM (excluding external rotation) and isometric strength recovered by week 52 in the SOC control group. Of the 16 patients in the rhBMP-12/ACS group, 14 showed an intact repair at week 12; the MRI scans of the other 2 patients could not be evaluated because of artifacts. In the SOC control group, 1 patient showed repair failure. At week 52, 14 repairs in the rhBMP-12/ACS group and 2 repairs with available MRI scans in the SOC control group remained intact.

CONCLUSION

Functional recovery and structural outcomes in patients in whom rhBMP-12/ACS was used as adjuvant therapy in rotator cuff repair justify conducting future, larger, multicenter, prospective studies.

REGISTRATION

NCT00936559, NCT01122498 (ClinicalTrials.gov identifier).

New insights into tenocyte-immune cell interplay in an in vitro model of inflammation

Inflammation plays an important role in the development and resolution of tendon diseases, but underlying mechanisms are poorly understood. We therefore aimed to analyze the response of human tenocytes to inflammatory stimuli and to uncover their interplay with macrophages in vitro. Tenocytes from human ruptured supraspinatus tendons (n = 10) were treated for three days with a stimulation mixture derived from activated mononuclear cells isolated from healthy human peripheral blood. Significantly increased expression levels of selected adhesion- and human leukocyte antigen (HLA)-molecules, and enhanced interleukin (IL)-6 release were detected by flow cytometry. Tenocyte stimulation with the pro-inflammatory cytokines interferon gamma, tumor necrosis factor alpha and IL-1ß triggered similar changes in surface markers and enhanced the release of IL-6, IL-8 and monocyte chemoattractant protein 1 (MCP-1). In co-cultures of macrophages with pre-stimulated tenocytes, macrophages significantly increased CD80 expression, but simultaneously decreased HLA-DR-expression, which are both typical pro-inflammatory polarization markers. Co-cultures also released more IL-6, IL-8, MCP-1 than tenocyte-cultures alone. We demonstrate that tenocytes respond to inflammatory environments in vitro with altered surface marker and cytokine profiles and influence macrophage polarization. Importantly, all changes detected in direct co-cultures were also present in a transwell setting, implicating that communication between the cells involves soluble factors.

The Effect of Hand Dominance on Functional Outcome Following Single Row Rotator Cuff Repair

Introduction:

Rotator cuff tears are a common cause of shoulder disability and pain. Excellent outcomes can be obtained with surgical treatment although this outcome is affected by several factors. We sought to investigate the effect of hand dominance on subjective functional outcome post rotator cuff repair.

Methods:

All patients who had rotator cuff repair over a calendar year were identified and followed up at 3 years post operatively. Patients were consented for inclusion in the study and demographic data, hand dominance and functional outcome data was collected. L’insalata shoulder questionnaire was used for outcome data collection. SPSS version 22 was used for statistical analysis where appropriate.

Results:

144 patients were included in this study. Mean age was 63 +/- 10.1 years in the dominant side group and 62 +/- 8.6 years in the non-dominant group. 92 patients had dominant side surgery and 52 had non-dominant side surgery. There was a statistically significant correlation between dominant hand and operated side (P=0.005). The mean overall outcome score was marginally higher in the dominant surgery group with a mean of 89.8 +/- 14.2 compared with a mean of 87.4 +/- 17.5 in the non-dominant group. Multi-variate linear regression analysis revealed this difference to be non-significant (p = 0.4).

Conclusion:

No difference was found in the functional outcome of rotator cuff repair between dominant and non-dominant side surgery. This information will help in counselling patients who are concerned about the potential impact of rotator cuff repair on the function of their dominant hand.

Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair

AIM

To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair.

METHODS

Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured.

RESULTS

Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were right-hand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 years old on average, 51.4% were female, 91.4% were right-hand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears (33.7) compared with those with non-traumatic tears (32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group (P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the non-traumatic group and 0.729 in the traumatic group (P = 0.224).

CONCLUSION

The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory.

High-grade bursal-side partial rotator cuff tears: comparison of mid- and long-term results following arthroscopic repair after conversion to a full-thickness tear

Background

Partial-thickness rotator cuff tears (PTRCTs) are one of the leading causes of shoulder dysfunction. Successful results have been reported with different treatment techniques, but the long-term consequences of these procedures are not yet clearly known. The purposes of this study were to evaluate and compare the mid- and long-term clinical outcomes of arthroscopically repaired bursal-side PTRCTs after conversion to full-thickness tears and identify the possible effects of age, gender, and hand dominance on clinical outcomes.

Methods

Twenty-nine patients who had undergone arthroscopic repair of a significant bursal-side PTRCT were functionally evaluated. The repair was made after conversion to a full-thickness tear. The average patient age was 55.2 years (range 35–69 years, SD ±7.6 years). Clinical outcomes were evaluated at 2 and 5 years after surgery. Constant Shoulder Score (CSS) and Visual Analogue Scale for Pain (VAS pain) were used as outcome measures.

Results

The average CSS improved from 38.9 preoperatively to 89.2 and 87.8 at 2 and 5 years after surgery, respectively (p < 0.001). The average VAS pain score decreased from 7.90 preoperatively to 1.17 and 1.31 at 2 and 5 years after surgery, respectively (p < 0.001). A significant improvement was detected in patient functional outcomes and VAS pain scores at 2 and 5 years after surgery compared with the preoperative period. The patients who underwent surgery from their non-dominant extremity showed a significantly higher CSS increase relative to those who underwent surgery on the dominant extremity (p = 0.022).

Conclusions

Arthroscopic repair of high-grade bursal-side PTRCTs after conversion to full-thickness tears is a reliable surgical technique with good functional outcomes and pain relief both at mid- and long-term follow-ups. Surgery on the non-dominant side may be related to better functional outcomes.

What Influence Does Progression of a Nonhealing Rotator Cuff Tear Have on Shoulder Pain and Function?

BACKGROUND

There have been numerous reports of clinical outcomes associated with tendon healing after repair that suggest a nonhealed tendon has a negative effect on postoperative clinical outcomes. However, to our knowledge, there has been no report on the relationship between tear size progression of nonhealed tendons and clinical outcomes.

QUESTIONS/PURPOSES

(1) Do patients with healed arthroscopic rotator cuff repairs have better outcomes, less pain, and more strength than patients whose repair did not heal? (2) In patients with nonhealed rotator cuff tendons, does tear size progression (increase or decrease) affect outcomes, pain, and strength? (3) Is there continued improvement beyond 6 months in outcomes, pain, and strength; and how do the improvements differ based on whether the tear size has increased or decreased?

METHODS

Between May 2008 and December 2012, 647 patients underwent arthroscopic rotator cuff repair for full-thickness tears at our institution. Of those, 442 patients (68%) had all MRI and clinical information available to permit inclusion in this retrospective study at a minimum of 2 years followup (mean, 33 ± 4 months; range, 24-43 months). Healing of the repaired tendon and tear size progression were assessed using MRI at 6 months postoperatively. Eighty-two of 442 tears (19%) were not healed. Of the nonhealed tears, 45 (55%) had a decrease and 37 (45%) had an increase in tear size. Shoulder function outcomes using the American Shoulder and Elbow Surgeon (ASES) and Constant scores and pain severity using VAS scores were evaluated preoperatively, at 6 months postoperatively, and at the latest followup. Isometric muscle strength was measured at 6 months postoperatively and at the latest followup.

RESULTS

Compared with patients with nonhealed tendons after arthroscopic rotator cuff repair, patients with healed repairs had improved ASES scores (healed, 93 ± 5; nonhealed, 89 ± 8; mean difference, 4; 95% CI, 3-5; p < 0.001), better Constant scores (healed, 91 ± 5; nonhealed, 85 ± 8; mean difference, 6; 95% CI, 4-7; p < 0.001), and greater strength ([flexion: healed, 96% ± 7%; nonhealed, 85% ± 12%; mean difference, 11%; 95% CI, 9%-13%; p < 0.001]; [external rotation: healed, 92% ± 8%; nonhealed, 80% ± 12%; mean difference, 11%; 95% CI, 9%-14%; p < 0.001]; [internal rotation: healed, 97% ± 8%; nonhealed, 92% ± 8%; mean difference, 5%; 95% CI, 3%-7%; p < 0.001]); however there was no difference in pain level based on VAS scores (healed, 0.9 ± 0.8; nonhealed, 1.0 ± 0.8; mean difference, 0.2; 95% CI, 0.0-0.4; p = 0.226). Compared with patients with increased tear size, patients with decreased tear size had better ASES scores (decreased, 91 ± 6; increased, 8 6 ± 8; p = 0.001), improved Constant scores (decreased, 88 ± 6; increased, 82 ± 9; p = 0.003), greater flexion strength (decreased, 91% ± 9%; increased, 78% ± 11%; p < 0.001), and greater external rotation strength (decreased, 86% ± 10%; increased, 73% ± 11%; p < 0.001). However, the difference does not seem to meet a minimal clinically important difference. Patients with increased tear size differed from those with decreased tear size with respect to flexion and external rotation strength where the former had no improvement. There was no improvement in flexion (6 months, 78% ± 11%; latest followup, 78% ± 11%; p = 0.806) and external rotation strength (6 months, 74% ± 12%; latest followup, 73% ± 11%; p = 0.149).

CONCLUSIONS

Patients who had healed tendons after arthroscopic rotator cuff repair had better shoulder function than patients who had nonhealed tendons. Among patients with nonhealed rotator cuff tendons after surgery, those with decreased tear size, observed on their 6-month postoperative MRI, compared with their initial tear size, showed better shoulder function and muscle strength than those with increased tear size beyond 6 months. Although results are statistically different, they seem insufficient to achieve clinically important differences.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Texture Analysis of Torn Rotator Cuff on Preoperative Magnetic Resonance Arthrography as a Predictor of Postoperative Tendon Status

OBJECTIVE

To evaluate texture data of the torn supraspinatus tendon (SST) on preoperative T2-weighted magnetic resonance arthrography (MRA) using the gray-level co-occurrence matrix (GLCM) for prediction of post-operative tendon state.

MATERIALS AND METHODS

Fifty patients who underwent arthroscopic rotator cuff repair for full-thickness tears of the SST were included in this retrospective study. Based on 1-year follow-up, magnetic resonance imaging showed that 30 patients had intact SSTs, and 20 had rotator cuff retears. Using GLCM, two radiologists measured independantly the highest signal intensity area of the distal end of the torn SST on preoperative T2-weighted MRA, which were compared between two groups.The relationships with other well-known prognostic factors, including age, tear size (anteroposterior dimension), retraction size (mediolateral tear length), grade of fatty degeneration of the SST and infraspinatus tendon, and arthroscopic fixation technique (single or double row), also were evaluated.

RESULTS

Of all the GLCM features, the retear group showed significantly higher entropy (p < 0.001 and p = 0.001), variance (p = 0.030 and 0.011), and contrast (p = 0.033 and 0.012), but lower angular second moment (p < 0.001 and p = 0.002) and inverse difference moment (p = 0.027 and 0.027), as well as larger tear size (p = 0.001) and retraction size (p = 0.002) than the intact group. Retraction size (odds ratio [OR] = 3.053) and entropy (OR = 17.095) were significant predictors.

CONCLUSION

Texture analysis of torn SSTs on preoperative T2-weighted MRA using the GLCM may be helpful to predict postoperative tendon state after rotator cuff repair.

Clinico-radiological evaluation of retear rate in arthroscopic double row versus single row repair technique in full thickness rotator cuff tear

BACKGROUND

Rotator cuff tear is most troublesome issue in shoulder surgery. Retear is seen in arthroscopically repaired rotator cuff tear.

PURPOSE

The functional outcome and retear rate in primary full thickness rotator cuff tear operated by single and double row repair technique.

METHODS

56 cases with full thickness tear of rotator cuff operated by single or double (28 each) were studied. Retear rate is evaluated after at least 6 months after surgery.

RESULTS

There was a statistical difference in retear rate between double row and single row repair (p value <0.01).

CONCLUSION

Retear rate is low in double row repair technique.

The Impact of Re-tear on the Clinical Outcome after Rotator Cuff Repair Using Open or Arthroscopic Techniques - A Systematic Review

Background:

It is generally accepted that rotator cuff repair gives satisfactory results in the long term, although most studies have so far shown a fairly high rate of structural failure or re-tear. The purpose of this review study is to assess whether failure of the repaired cuff to heal could negatively affect the functional outcome.

Methods:

This article includes an extensive Internet PubMed based research in the current English-language literature including level I to level V studies as well as systematic reviews.

Results:

According to this extended study research, the results are mixed; certain reports show that patients with a healed rotator cuff repair have improved function and strength compared to those with structural failure, whereas other studies support the generally perceived concept that tendon re-tear does not lead to inferior clinical outcome.

Conclusion:

Further high-level prospective studies with larger numbers of patients and longer follow up are needed to overcome the current debate over function between healed and failed rotator cuff repairs.

Molecular signatures of age-associated chronic degeneration of shoulder muscles

Chronic muscle diseases are highly prevalent in the elderly causing severe mobility limitations, pain and frailty. The intrinsic molecular mechanisms are poorly understood due to multifactorial causes, slow progression with age and variations between individuals. Understanding the underlying molecular mechanisms could lead to new treatment options which are currently limited. Shoulder complaints are highly common in the elderly, and therefore, muscles of the shoulder's rotator cuff could be considered as a model for chronic age-associated muscle degeneration. Diseased shoulder muscles were characterized by muscle atrophy and fatty infiltration compared with unaffected shoulder muscles. We confirmed fatty infiltration using histochemical analysis. Additionally, fibrosis and loss of contractile myosin expression were found in diseased muscles. Most cellular features, including proliferation rate, apoptosis and cell senescence, remained unchanged and genome-wide molecular signatures were predominantly similar between diseased and intact muscles. However, we found down-regulation of a small subset of muscle function genes, and up-regulation of extracellular region genes. Myogenesis was defected in muscle cell culture from diseased muscles but was restored by elevating MyoD levels. We suggest that impaired muscle functionality in a specific environment of thickened extra-cellular matrix is crucial for the development of chronic age-associated muscle degeneration.

Characterization of Rotator Cuff Tears: Ultrasound Versus Magnetic Resonance Imaging

Ultrasound and magnetic resonance imaging (MRI) are both capable of diagnosing full-thickness rotator cuff tears. However, it is unknown which imaging modality is more accurate and precise in evaluating the characteristics of full-thickness rotator cuff tears in a surgical population. This study reviewed 114 patients who underwent arthroscopic repair of a full-thickness rotator cuff tear over a 1-year period. Of these patients, 61 had both preoperative MRI and ultrasound for review. Three musculoskeletal radiologists evaluated each ultrasound and MRI in a randomized and blinded fashion on 2 separate occasions. Tear size, retraction status, muscle atrophy, and fatty infiltration were analyzed and compared between the 2 modalities. Ultrasound measurements were statistically smaller in both tear size (P=.001) and retraction status (P=.001) compared with MRI. The 2 image modalities showed comparable intraobserver reliability in assessment of tear size and retraction status. However, MRI showed greater interobserver reliability in assessment of tear size, retraction status, and atrophy. Independent observers are more likely to agree on measurements of the characteristics of rotator cuff tears when using MRI compared with ultrasound. As tear size increases, the 2 image modalities show greater differences in measurement of tear size and retraction status. Additionally, compared with MRI, ultrasound shows consistently low reliability in detecting subtle, but clinically important, degeneration of the soft tissue envelope. Although it is inexpensive and convenient, ultrasound may be best used to identify a tear, and MRI is superior for use in surgical planning for larger tears. [Orthopedics. 2017; 40(1):e124-e130.].

[Rotator cuff repair: single- vs double-row. Clinical and biomechanical results]

BACKGROUND

The goal of rotator cuff repair is a high initial mechanical stability as a requirement for adequate biological recovery of the tendon-to-bone complex. Notwithstanding the significant increase in publications concerning the topic of rotator cuff repair, there are still controversies regarding surgical technique.

OBJECTIVES

The aim of this work is to present an overview of the recently published results of biomechanical and clinical studies on rotator cuff repair using single- and double-row techniques.

MATERIALS AND METHODS

The review is based on a selective literature research of PubMed, Embase, and the Cochrane Database on the subject of the clinical and biomechanical results of single- and double-row repair.

RESULTS

In general, neither the biomechanical nor the clinical evidence can recommend the use of a double-row concept for the treatment for every rotator cuff tear. Only tears of more than 3 cm seem to benefit from better results on both imaging and in clinical outcome studies compared with the use of single-row techniques.

CONCLUSIONS

Despite a significant increase in publications on the surgical treatment of rotator cuff tears in recent years, the clinical results were not significantly improved in the literature so far. Unique information and algorithms, from which the optimal treatment of this entity can be derived, are still inadequate. Because of the cost-effectiveness and the currently vague evidence, the double-row techniques cannot be generally recommended for the repair of all rotator cuff tears.

Orthopedic Interface Repair Strategies Based on Native Structural and Mechanical Features of the Multiscale Enthesis

The enthesis is an organ that connects a soft, aligned tissue (tendon/ligament) to a hard, amorphous tissue (bone) via a fibrocartilage interface. Mechanically, the enthesis sustains a dynamic loading environment that includes tensile, compressive, and shear forces. The structural components of the enthesis act to minimize stress concentrations and control stretch at the interface. Current surgical repair of the enthesis, such as in rotator cuff repair and anterior cruciate ligament reconstruction, aim to bridge the gap between the injured ends via reattachment of soft-to-hard tissues or graft replacement. In this review, we discuss the multiscale, morphological, and mechanical characteristics of the fibrocartilage attachment. Additionally, we review historical and recent clinical approaches to treating enthesis injury. Lastly, we explore new technological advancements in tissue-engineered biomaterials that have shown promise in preclinical studies.

Optimal Lateral Row Anchor Positioning in Posterior-Superior Transosseous Equivalent Rotator Cuff Repair: A Micro-Computed Tomography Study

Background:

The optimal placement of suture anchors in transosseous-equivalent (TOE) double-row rotator cuff repair remains controversial.

Purpose:

A 3-dimensional (3D) high-resolution micro–computed tomography (micro-CT) histomorphometric analysis of cadaveric proximal humeral greater tuberosities (GTs) was performed to guide optimal positioning of lateral row anchors in posterior-superior (infraspinatus and supraspinatus) TOE rotator cuff repair.

Study Design:

Descriptive laboratory study.

Methods:

Thirteen fresh-frozen human cadaveric proximal humeri underwent micro-CT analysis. The histomorphometric parameters analyzed in the standardized volumes of interest included cortical thickness, bone volume, and trabecular properties.

Results:

Analysis of the cortical thickness of the lateral rows demonstrated that the entire inferior-most lateral row, 15 to 21 mm from the summit of the GT, had the thickest cortical bone (mean, 0.79 mm; P = .0001), with the anterior-most part of the GT, 15 to 21 mm below its summit, having the greatest cortical thickness of 1.02 mm (P = .008). There was a significantly greater bone volume (BV; posterior, 74.5 ± 27.4 mm³; middle, 55.8 ± 24.9 mm³; anterior, 56.9 ± 20.7 mm³; P = .001) and BV as a percentage of total tissue volume (BV/TV; posterior, 7.3% ± 2.7%, middle, 5.5% ± 2.4%; anterior, 5.6% ± 2.0%; P = .001) in the posterior third of the GT than in intermediate or anterior thirds. In terms of both BV and BV/TV, the juxta-articular medial row had the greatest value (BV, 87.3 ± 25.1 mm³; BV/TV, 8.6% ± 2.5%; P = .0001 for both) followed by the inferior-most lateral row 15 to 21 mm from the summit of the GT (BV, 62.0 ± 22.7 mm³; BV/TV, 6.1% ± 2.2%; P = .0001 for both). The juxta-articular medial row had the greatest value for both trabecular number (0.3 ± 0.06 mm^–1; P = .0001) and thickness (0.3 ± 0.08 μm; P = .0001) with the lowest degree of trabecular separation (1.3 ± 0.4 μm; P = .0001). The structure model index (SMI) has been shown to strongly correlate with bone strength, and this was greatest at the inferior-most lateral row 15 to 21 mm from the summit of the GT (2.9 ± 0.9; P = .0001).

Conclusion:

The inferior-most lateral row, 15 to 21 mm from the tip of the GT, has good bone stock, the greatest cortical thickness, and the best SMI for lateral row anchor placement. The anterior-most part of the GT 15 to 21 mm below its summit had the greatest cortical thickness of all zones. The posterior third of the GT also has good bone stock parameters, second only to the medial row. The best site for lateral row cortical anchor placement is 15 to 21 mm below the summit of the GT.

Clinical Relevance:

Optimal lateral anchor positioning is 15 to 21 mm below the summit of the greater tuberosity in TOE.

Rotator Cuff Repair in Patients over 75 Years of Age: Clinical Outcome and Repair Integrity

Background

Some studies have shown significant functional improvement after rotator cuff (RC) repair in elderly patients. However, few studies have reported the healing potential of RC tears in elderly patients.

Methods

Twenty-five patients aged ≥ 75 years who underwent RC repair were enrolled. The mean age at the time of surgery was 78.3 years (range, 75 to 88 years) while the mean follow-up was 36.3 months (range, 18 to 114 months). We evaluated clinical and structural outcomes after RC repair in the retear and healed groups.

Results

Of 25 patients, 16 (64%) had healed RC lesions and 9 (36%) had retorn cuff lesions. The retear rate increased significantly with increasing initial tear size (small to medium, 13%; large, 60%; massive, 80%; p = 0.024) but not with increasing age (p = 0.072). The mean visual analog scale (VAS), University of California Los Angeles (UCLA), and Constant scores significantly improved from 5.2, 15.8, and 49.3 preoperatively to 1.4, 31.1, and 71.9 in the healed group and from 6.0, 14.4, and 39.5 preoperatively to 2.4, 28.3, and 63.6 in the retear group at the final follow-up (p < 0.05, respectively). There were no significant differences in clinical outcomes between the 2 groups at the final follow-up. Retear was significantly correlated with initial tear size (p = 0.001; odds ratio [OR], 2.771; 95% confidence interval [CI], 1.394 to 5.509 for large to massive tears) (p = 0.001; OR, 0.183; 95% CI, 0.048 to 0.692 for small to medium tears).

Conclusions

There were significant improvements in clinical outcomes after RC repair in patients ≥ 75 years. Structural integrity after cuff repair did not affect the final clinical outcome. Even in elderly patients aged ≥ 75 years, healing of repaired RC can be expected in cases of small to medium tears. Although the retear rate was relatively high for large to massive tears, clinical outcomes still showed significant improvement.

Single-row and transosseous sutures for supraspinatus tendon tears: a retrospective comparative clinical and strength outcome at 2-year follow-up

INTRODUCTION

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.

AIM

We performed a study to compare single-row repair and suture-bridge (SB) technique (a TOE technique) in terms of the recovery of the strength and functional outcome.

MATERIAL AND METHOD

The purpose of the retrospective study was to compare 44 patients treated for a rotator cuff repair with the single-row (24) or suture-bridge techniques (20). At 24-month FU, there were not statistically significant differences for the UCLA score, Individual Constant Score, pain, ROM, and strength on the treated and contra-lateral arm. Comparing the mean values of the differences in strength obtained between the treated arm and the contra lateral in each group, the final results appeared significantly different in favor of SB (p = 0.03).

CONCLUSION

Patients treated with DR could expect to regain the same strength of the contra-lateral side, while patients treated with SR could expect globally good results, overall in terms of pain relief and functionality, but lower strength.

Advances in biologic augmentation for rotator cuff repair

Rotator cuff tear is a very common shoulder injury that often necessitates surgical intervention for repair. Despite advances in surgical techniques for rotator cuff repair, there is a high incidence of failure after surgery because of poor healing capacity attributed to many factors. The complexity of tendon-to-bone integration inherently presents a challenge for repair because of a large biomechanical mismatch between the tendon and bone and insufficient regeneration of native tissue, leading to the formation of fibrovascular scar tissue. Therefore, various biological augmentation approaches have been investigated to improve rotator cuff repair healing. This review highlights recent advances in three fundamental approaches for biological augmentation for functional and integrative tendon-bone repair. First, the exploration, application, and delivery of growth factors to improve regeneration of native tissue are discussed. Second, applications of stem cell and other cell-based therapies to replenish damaged tissue for better healing are covered. Finally, this review will highlight the development and applications of compatible biomaterials to both better recapitulate the tendon-bone interface and improve delivery of biological factors for enhanced integrative repair.

Repair of Rotator Cuff Tear With Delamination: Independent Repairs of the Infraspinatus and Articular Capsule

We propose a technique to repair delamination, which often occurs during rotator cuff repair surgery. We have reported that the infraspinatus occupies most of the greater tuberosity with the articular capsule attached to a very wide area, and that the superficial layer is mainly composed of the infraspinatus, and the deep layer is mainly composed of the articular capsule. To repair such delamination with consideration of the detailed anatomy, we developed the following repair method with independent repair of the superficial layer (infraspinatus) and the deep layer (articular capsule): (1) the deep layer is pulled laterally and joined to the medial margin of the greater tuberosity using 4 simple sutures from 2 anchors; (2) the paired limbs (same color) of 4 knots are passed over the posterior leaf of the superficial layer at intervals; (3) a push-in anchor loaded with 1 thread each of 4 knots is placed on the anterolateral corner of the greater tuberosity to pull the superficial layer anterolaterally; (4) another push-in anchor (remaining threads) is pushed on the posterior corner of the greater tuberosity. We believe that this technique can recover the function of both the articular capsule and rotator cuff, thereby facilitating better treatment outcomes after surgery.

Further Research Is Needed to Define the Benefits of Non-operative Rotator Cuff Treatment

Kukkonen et al.'s "Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up" compared the efficacy of physical therapy, acromioplasty, and rotator cuff repair for the treatment of degenerative supraspinatus tendon tears in patients aged over 55. This review examines the authors' findings and their implications on clinical practice. Kukkonen et al. reported no significant difference in clinical outcome among patients treated operatively versus non-operatively for degenerative rotator cuff tears. The authors concluded that non-operative treatment is an appropriate option for patients aged 55 or older. Rotator cuff treatment outcomes are closely linked to patient age, and while this level I study found no evidence of a benefit of surgical treatment, the age range in the studied demographic was perhaps too wide to draw generalizable conclusions. Furthermore, 2-year follow-up may be inadequate to fully demonstrate the differences in outcomes between these treatment options.

Morphologic Risk Factors in Predicting Symptomatic Structural Failure of Arthroscopic Rotator Cuff Repairs: Tear Size, Location, and Atrophy Matter

PURPOSE

To evaluate whether morphologic characteristics of rotator cuff tear have prognostic value in determining symptomatic structural failure of arthroscopic rotator cuff repair independent of age or gender.

METHODS

Arthroscopic rotator cuff repair cases performed by five fellowship-trained surgeons at our institution from 2006 to 2013 were retrospectively reviewed. Data extraction included demographics, comorbidities, repair technique, clinical examination, and radiographic findings. Failure in symptomatic patients was defined as structural defect on postoperative magnetic resonance imaging or pseudoparalysis on examination. Failures were age and gender matched with successful repairs in a 1:2 ratio.

RESULTS

A total of 30 failures and 60 controls were identified. Supraspinatus atrophy (P = .03) and tear size (18.3 mm failures v 13.9 mm controls; P = .02) were significant risk factors for failure, as was the presence of an infraspinatus tear greater than 10 mm (62% v 17%, P < .01). Single-row repair (P = .06) and simple suture configuration (P = .17) were more common but similar between groups. Diabetes mellitus and active tobacco use were not significantly associated with increased failure risk but psychiatric medication use was more frequent in the failure group.

CONCLUSIONS

This study confirms previous suspicions that tear size and fatty infiltration are associated with failure of arthroscopic rotator cuff repair but independent of age or gender in symptomatic patients. There is also a quantitative cutoff on magnetic resonance imaging for the size of infraspinatus involvement that can be used clinically as a predicting factor. Although reported in the literature, smoking and diabetes were not associated with failure.

LEVEL OF EVIDENCE

Level III, retrospective case control.

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears

PURPOSE

To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.

METHODS

An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair.

RESULTS

For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.

CONCLUSIONS

Arthroscopic rotator cuff repair-despite high rates of tendon retearing-for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients. LEVEL OF EVIDENCE: Level II, economic decision analysis.

Is the arthroscopic modified tension band suture technique suitable for all full-thickness rotator cuff tears?

BACKGROUND

We aimed to identify the clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears of all sizes with a modified tension band suture technique.

METHODS

Among 63 patients who underwent arthroscopic rotator cuff repair for a full-thickness rotator cuff tear with the modified tension band suture technique at a single hospital between July 2011 and March 2013, 47 were enrolled in this study. The mean follow-up period was 29 months. Visual analog scale scores, range of motion, American Shoulder and Elbow Surgeons scores, Constant scores, and Shoulder Strength Index were measured preoperatively and at the final follow-up. For radiologic evaluation, we conducted magnetic resonance imaging 6 months postoperatively and ultrasonography at the final follow-up. We allocated the small and medium tears to group A and the large and massive tears to group B and then compared clinical outcomes and repair integrity.

RESULTS

Postoperative clinical outcomes at the final follow-up showed significant improvements compared with those seen during preoperative evaluations (P < .001). However, group B showed worse clinical results than group A. Evaluation with magnetic resonance imaging performed 6 months postoperatively and ultrasonography taken at the final follow-up revealed that group B showed a significantly higher retear rate than did group A (69% vs. 6%, respectively; P < .001).

CONCLUSION

Arthroscopic repair with the modified tension band suture technique for rotator cuff tears was a more suitable method for small to medium tears than for large to massive tears.

Editorial Commentary: Low Reoperation Rates for Outpatient Rotator Cuff Repairs: Proof of Efficacy?

The reoperation rate for people younger than 65 years is approximately 8% at a minimum 2-year follow-up. The low rate is another indicator that outpatient rotator cuff repair is a good operation with acceptable failure risks.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

PURPOSE

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR).

METHODS

We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored.

RESULTS

Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P = .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P < .001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001).

CONCLUSIONS

We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes After Patch Use in Rotator Cuff Repair

PURPOSE

To provide a comprehensive review of clinical outcomes and retear rates after patch use in rotator cuff repair, and to determine the differences between available graft types and techniques.

METHODS

A systematic review was conducted from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting outcome data with 9 months' minimum follow-up. Studies were assessed by 2 reviewers who collected pertinent data, with outcomes combined to generate frequency-weighted means.

RESULTS

Twenty-four studies met the inclusion criteria. The frequency-weighted mean age was 61.9 years with 35.4 months' follow-up. The mean improvements in postoperative range of motion in the forward elevation, abduction, external rotation, and internal rotation planes were 58.6°, 66.2°, 16.6°, and 16.1°, respectively, and postoperative abduction strength improved by 3.84 kg. American Shoulder and Elbow Surgeons, University of California-Los Angeles, Constant, Penn, and Oxford scores improved by 39.3, 10.7, 40.8, 34.4, and 17.6, respectively. Augmentation and interposition techniques showed similar improvements in range of motion, strength, and patient-reported outcomes (PROs), whereas xenografts showed less improvement in PROs compared with other graft types. Studies reported improvements in pain and activities of daily living (ADLs), with greater than 90% overall satisfaction, although few patients (13%) were able to return to preinjury activity. Whereas interposition and augmentation techniques showed similar improvements in pain and ADLs, xenografts showed less improvement in ADLs than other graft types. The overall retear rate was 25%, with rates of 34% and 12% for augmentation and interposition, respectively, and rates of 44%, 23%, and 15% for xenografts, allografts, and synthetic grafts, respectively.

CONCLUSIONS

We report improvements in clinical and functional outcomes, with similar results for augmentation and interposition techniques, whereas xenografts showed less improvement than synthetic grafts and allografts in PROs and ADLs. Retear rates may be lower with the interposition technique or in patients with synthetic grafts or allografts.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Prognosis Driven Rehabilitation After Rotator Cuff Repair Surgery

Background:

Rehabilitation after rotator cuff repair surgery has been the focus of several clinical trials in the past decade. Many illuminate new evidence with regard to the prognosis of structural and functional success after surgery.

Methods:

A selective literature search was performed and personal physiotherapeutic and surgical experiences are reported.

Results:

Post-operative rehabilitation parameters, namely the decision to delay or allow early range of motion after surgery, play a large role in the overall success after surgery. Using a prognosis driven rehabilitation program offers clinicians a means of prescribing optimal rehabilitation parameters while ensuring structural and functional success. This commentary aims to synthesize the evidence in a spectrum of prognostic factors to guide post-operative rehabilitation.

Conclusion:

The optimal rehabilitation program after rotator cuff repair surgery is debatable; therefore, we suggest using a spectrum of prognostic factors to determine a rehabilitation program suited to ensure structural and functional success, quickly and safely.

Retraction pattern of delaminated rotator cuff tears: dual-layer rotator cuff repair

BACKGROUND

There has been no report to date regarding retraction patterns of delaminated rotator cuff tears. The purpose of this study was to evaluate the incidence and tearing patterns of delamination and repair integrity after the dual-layer repair of delaminated cuff tears.

METHODS/DESIGN

A consecutive series of 64 patients with posterosuperior rotator cuff tears underwent arthroscopic rotator cuff repair from August 2011 to September 2012. Among the patients, 53 who received either dual-layer double-row (DLDR) repair or dual-layer suture bridge (DLSB) repair and 11 who received a single-layer repair were evaluated. The mean follow-up period after surgery was 26.5 months. The retraction direction of the deep and superficial layers was analyzed, and the integrity of the repaired constructs was determined in 37 patients through magnetic resonance imaging at a mean of 12.1 months after surgery.

RESULTS

The incidence of delamination was 82.8 %. Posteromedial retraction of the deep and superficial layers was observed in 98.1 and 88.5 % of cases, respectively. The Constant score and UCLA score increased preoperatively to postoperatively, showing no significant differences between the dual-layer repair group and single-layer repair group. Retear was found in two (7.6 %) patients in the dual-layer repair group and three (27.2 %) patients in the single-layer repair group (p = 0.016).

CONCLUSIONS

Differential rotator cuff repair strategies are needed to address rotator cuff tears, since recent studies have changed our concept of rotator cuff tears. We have focused on three areas: incidence, retraction patterns, and clinical outcomes. The incidence of delamination was extremely high. Both the superficial layer and deep layer were mainly retracted posteromedially. The retraction of the deep layer and superficial layer may be affected by the infraspinatus. Dual-layer rotator cuff repair based on the retraction pattern of delamination is recommended for improvement of repair integrity and of clinical outcomes.

Diagnostic Performance of MR Arthrography with Anterior Trans-Subscapularis versus Posterior Injection Approach for Subscapularis Tendon Tears at 3.0T

OBJECTIVES

To compare the diagnostic performance of shoulder magnetic resonance arthrography (MRA) with the anterior trans-subscapularis versus posterior injection approach to diagnose subscapularis tendon (SCT) tears.

METHODS

One hundred and sixty-seven arthroscopically confirmed patients (84 anterior and 83 posterior approaches) were included. Two readers retrospectively scored SCT tears. Proportions of correctly graded tears between MR arthrography and arthroscopy were calculated. Retrospective error analysis was performed.

RESULTS

The sensitivity and specificity were 80 % (24/30) and 72 % (39/54) by reader 1, 73 % (22/30) and 76 % (41/54) by reader 2 in the anterior approach, and 86 % (30/35) and 79 % (38/48) by reader 1, 80 % (28/35) and 88 % (42/48) by reader 2 in the posterior approach, respectively. There were no significant differences in sensitivity and specificity between the two groups. Proportions of correctly graded tears of both readers were 48 % and 36 % in the anterior approach, and 70 % and 68 % in the posterior approach, respectively. The intratendinous collection of contrast material was not statistically significantly different between anterior (n = 8) and posterior (n = 3) approach group.

CONCLUSIONS

For the MRA diagnosis of SCT tears, there was no significant difference between the anterior trans-subscapularis and the posterior approach.

KEY POINTS

• Anterior trans-subscapularis and posterior approaches showed no significant difference for SCT tears • Intratendinous collection of gadolinium is more frequent in anterior trans-subscapularis approach • Extent of SCT tears tends to be overestimated in anterior trans-subscapularis approach • Posterior approach should be considered for diagnosing SCT tear.

Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]

BACKGROUND

Uncertainty exists regarding the best management of patients with degenerative tears of the rotator cuff.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of arthroscopic and open rotator cuff repair in patients aged ≥ 50 years with degenerative rotator cuff tendon tears.

DESIGN

Two parallel-group randomised controlled trial.

SETTING

Nineteen teaching and district general hospitals in the UK.

PARTICIPANTS

Patients (n = 273) aged ≥ 50 years with degenerative rotator cuff tendon tears.

INTERVENTIONS

Arthroscopic surgery and open rotator cuff repair, with surgeons using their usual and preferred method of arthroscopic or open repair. Follow-up was by telephone questionnaire at 2 and 8 weeks after surgery and by postal questionnaire at 8, 12 and 24 months after randomisation.

MAIN OUTCOME MEASURES

The Oxford Shoulder Score (OSS) at 24 months was the primary outcome measure. Magnetic resonance imaging evaluation of the shoulder was made at 12 months after surgery to assess the integrity of the repair.

RESULTS

The mean OSS improved from 26.3 [standard deviation (SD) 8.2] at baseline to 41.7 (SD 7.9) at 24 months for arthroscopic surgery and from 25.0 (SD 8.0) at baseline to 41.5 (SD 7.9) at 24 months for open surgery. When effect sizes are shown for the intervention, a negative sign indicates that an open procedure is favoured. For the intention-to-treat analysis, there was no statistical difference between the groups, the difference in OSS score at 24 months was -0.76 [95% confidence interval (CI) -2.75 to 1.22; p = 0.452] and the CI excluded the predetermined clinically important difference in the OSS of 3 points. There was also no statistical difference when the groups were compared per protocol (difference in OSS score -0.46, 95% CI -5.30 to 4.39; p = 0.854). The questionnaire response rate was > 86%. At 8 months, 77% of participants reported that shoulder problems were much or slightly better, and at 24 months this increased to 85%. There were no significant differences in mean cost between the arthroscopic group and the open repair group for any of the component resource-use categories, nor for the total follow-up costs at 24 months. The overall treatment cost at 2 years was £2567 (SD £176) for arthroscopic surgery and £2699 (SD £149) for open surgery, according to intention-to-treat analysis. For the per-protocol analysis there was a significant difference in total initial procedure-related costs between the arthroscopic group and the open repair group, with arthroscopic repair being more costly by £371 (95% CI £135 to £607). Total quality-adjusted life-years accrued at 24 months averaged 1.34 (SD 0.05) in the arthroscopic repair group and 1.35 (SD 0.05) in the open repair group, a non-significant difference of 0.01 (95% CI -0.11 to 0.10). The rate of re-tear was not significantly different across the randomised groups (46.4% and 38.6% for arthroscopic and open surgery, respectively). The participants with tears that were impossible to repair had the lowest OSSs, the participants with re-tears had slightly higher OSSs and the participants with healed repairs had the most improved OSSs. These findings were the same when analysed per protocol.

CONCLUSION

In patients aged > 50 years with a degenerative rotator cuff tear there is no difference in clinical effectiveness or cost-effectiveness between open repair and arthroscopic repair at 2 years for the primary outcome (OSS) and all other prespecified secondary outcomes. Future work should explore new methods to improve tendon healing and reduce the high rate of re-tears observed in this trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN97804283.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 80. See the NIHR Journals Library website for further project information.

Serial structural MRI evaluation of arthroscopy rotator cuff repair: does Sugaya's classification correlate with the postoperative clinical outcomes?

INTRODUCTION

Sugaya's classification is the most commonly used for postoperative evaluation of rotator cuff repairs. However, the correlation between this classification and clinical outcomes after supraspinatus tendon repair were not performed with serial MRI examinations in standardized time intervals.

MATERIALS AND METHODS

This prospective case series involved 54 patients undergoing repair of the supraspinatus tendon tear. Magnetic resonance imaging (MRI, 1.5 T) was used to determine the Sugaya's classifications at 3, 6, and 12 months, and these data were correlated with the visual analog scale for pain (VAS), Constant and University of California at Los Angeles (UCLA) assessments.

RESULTS

Patients with types I, II, and ≥III of Sugaya's classification experienced pain of 1.27 ± 1.95, 1.00 ± 1.40, and 3.43 ± 3.36, respectively (p = 0.010), according to the VAS. The Constant and UCLA scales did not differ significantly. Type II predominated, though their percentage decreased over time (from 77.8 to 66.7 %), whereas type I became more frequent (from 1.9 to 20.4 %).

CONCLUSIONS

The pain was more intense in patients classified as types III, IV, or V of Sugaya's classification. The postoperative appearance of the supraspinatus tendon was not correlated with the Constant and UCLA scales. The occurrence of type II, the most prevalent, decreased over time, whereas the occurrence of type I increased; these differences were not significant. Level de evidence: prospective cohort evaluation-level III.

Identification of a genetic variant associated with rotator cuff repair healing

BACKGROUND

A familial and genetic predisposition for the development of rotator cuff tearing has been identified. The purpose of this study was to determine if a familial predisposition exists for healing after rotator cuff repair and if the reported significant association with a single-nucleotide polymorphism (SNP) in the ESRRB gene is present in patients who fail to heal.

MATERIALS AND METHODS

The study recruited 72 patients undergoing arthroscopic rotator cuff repair for a full-thickness posterosuperior tear. Magnetic resonance imaging studies were performed at a minimum of 1 year postoperatively (average, 2.6 years). Healing failures were classified as lateral or medial. Self-reported family history of rotator cuff tearing data and genome-wide genotypes were available. Characteristics of cases with and without a family history of rotator cuff tearing were compared, and a comparison of the frequency of SNP 1758384 (in ESRRB) was performed between patients who healed and those who failed to heal.

RESULTS

Of the rotator cuff repairs, 42% failed to heal; 42% of patients reported a family history of rotator cuff tear. Multivariate regression analysis showed a significant association between familiality and overall healing failure (medial and lateral failures) (P = .036) and lateral failures independently (P = .006). An increased risk for the presence of a rare allele for SNP rs17583842 was present in lateral failures compared with those that healed (P = .005).

CONCLUSIONS

Individuals with a family history of rotator cuff tearing were more likely to have repair failures. Significant association of a SNP variant in the ESRRB gene was also observed with lateral failure.

Developmental Biology and Regenerative Medicine: Addressing the Vexing Problem of Persistent Muscle Atrophy in the Chronically Torn Human Rotator Cuff

Persistent muscle atrophy in the chronically torn rotator cuff is a significant obstacle for treatment and recovery. Large atrophic changes are predictive of poor surgical and nonsurgical outcomes and frequently fail to resolve even following functional restoration of loading and rehabilitation. New insights into the processes of muscle atrophy and recovery gained through studies in developmental biology combined with the novel tools and strategies emerging in regenerative medicine provide new avenues to combat the vexing problem of muscle atrophy in the rotator cuff. Moving these treatment strategies forward likely will involve the combination of surgery, biologic/cellular agents, and physical interventions, as increasing experimental evidence points to the beneficial interaction between biologic therapies and physiologic stresses. Thus, the physical therapy profession is poised to play a significant role in defining the success of these combinatorial therapies. This perspective article will provide an overview of the developmental biology and regenerative medicine strategies currently under investigation to combat muscle atrophy and how they may integrate into the current and future practice of physical therapy.

Patch-augmented rotator cuff repair: influence of the patch fixation technique on primary biomechanical stability

INTRODUCTION

There is an ongoing debate about the potential of patch augmentation to improve biomechanical stability and healing associated with rotator cuff repair. The biomechanical properties of three different patch-augmented rotator cuff repair techniques were assessed in vitro and compared with a standard repair. Dermal collagen patch augmentation may increase the primary stability and strength of the repaired tendon in vitro, depending on the technique used for patch application.

METHODS AND MATERIALS

Forty cadaveric sheep shoulders with dissected infraspinatus tendons were randomized into four groups (n = 10/group) for tendon repair using a knotless double-row suture anchor technique. A xenologous dermal extracellular matrix patch was used for augmentation in the three test groups using an "integrated", "cover", or "hybrid" technique. Tendons were preconditioned, cyclically loaded from 10 to 30 N at 1 Hz, and then loaded monotonically to failure. Biomechanical properties and the mode of failure were evaluated.

RESULTS

Patch augmentation significantly increased the maximum load at failure by 61 % in the "cover" technique test group (225.8 N) and 51 % in the "hybrid" technique test group (211.4 N) compared with the non-augmented control group (140.2 N) (P ≤ 0.015). For the test group with "integrated" patch augmentation, the load at failure was 28 % lower (101.6 N) compared with the control group (P = 0.043). There was no significant difference in initial and linear stiffness among the four experimental groups. The most common mode of failure was tendon pullout. No anchor dislocation, patch disruption or knot breakage was observed.

CONCLUSION

Additional patch augmentation with a collagen patch influences the biomechanical properties of a rotator cuff repair in a cadaveric sheep model. Primary repair stability can be significantly improved depending on the augmentation technique.

Serial MRI evaluation following arthroscopic rotator cuff repair in double-row technique

INTRODUCTION

So far, recurrent rotator cuff defects are described to occur in the early postoperative period after arthroscopic repair. The aim of this study was to evaluate the musculotendinous structure of the supraspinatus, as well as bone marrow edema or osteolysis after arthroscopic double-row repair. Therefore, magnetic resonance (MR) images were performed at defined intervals up to 2 years postoperatively.

STUDY DESIGN

Case series; Level of evidence, 3.

MATERIALS AND METHODS

MR imaging was performed within 7 days, 3, 6, 12, 26, 52 and 108 weeks after surgery. All patients were operated using an arthroscopic modified suture bridge technique. Tendon integrity, tendon retraction ["foot-print-coverage" (FPC)], muscular atrophy and fatty infiltration (signal intensity analysis) were measured at all time points. Furthermore, postoperative bone marrow edema and signs of osteolysis were assessed.

RESULTS

MR images of 13 non-consecutive patients (6f/7m, ∅ age 61.05 ± 7.7 years) could be evaluated at all time points until ∅ 108 weeks postoperatively. 5/6 patients with recurrent defect at final follow-up displayed a time of failure between 12 and 24 months after surgery. Predominant mode of failure was medial cuff failures in 4/6 cases. The initial FPC increased significantly up to 2 years follow-up (p = 0.004). Evaluations of muscular atrophy or fatty infiltration were not significant different comparing the results of all time points (p > 0.05). Postoperative bone marrow edema disappeared completely at 6 months after surgery, whereas signs of osteolysis appeared at 3 months follow-up and increased to final follow-up.

CONCLUSIONS

Recurrent defects after arthroscopic reconstruction of supraspinatus tears in modified suture bridge technique seem to occur between 12 and 24 months after surgery. Serial MRI evaluation shows good muscle structure at all time points. Postoperative bone marrow edema disappears completely several months after surgery. Signs of osteolysis seem to appear caused by bio-absorbable anchor implantations.

Massive Rotator Cuff Tears: Trends in Surgical Management

Compared with smaller tears, massive rotator cuff tears present significant clinical management dilemmas for the treating surgeon because they are often fraught with structural failure and poor outcomes. To optimize healing, current surgical methods look to optimize footprint coverage and enhance the biological environment for healing. Double-row techniques have demonstrated clear biomechanical advantages in controlled cadaveric studies, but have yet to demonstrate clear clinical efficacy over more simple repair techniques. When repairs for massive rotator cuff tears fail, options include revision repair or superior capsular reconstruction, an option to bridge the tissue gap with human dermal allograft or fascia lata autograft in hopes of containing the humeral head from superior migration and precluding rotator cuff arthropathy. Although latissimus transfers remain a reasonable option for massive, irreparable rotator cuff tears in appropriately indicated patients, clinical results are often unpredictable. Older patients with chronic, massive rotator cuff tears with pseudoparalysis can achieve predictable, often excellent clinical results with a reverse total shoulder arthroplasty. [Orthopedics. 2016; 39(3):145-151.].

Early postoperative repair status after rotator cuff repair cannot be accurately classified using questionnaires of patient function and isokinetic strength evaluation

BACKGROUND

This study investigated if patients with an intact tendon repair or partial-thickness retear early after rotator cuff repair display differences in clinical evaluations and whether early tendon healing can be predicted using these assessments.

METHODS

We prospectively evaluated 60 patients at 16 weeks after arthroscopic supraspinatus repair. Evaluation included the Oxford Shoulder Score, 11-item version of the Disabilities of the Arm, Shoulder and Hand, visual analog scale for pain, 12-item Short Form Health Survey, isokinetic strength, and magnetic resonance imaging (MRI). Independent t tests investigated clinical differences in patients based on the Sugaya MRI rotator cuff classification system (grades 1, 2, or 3). Discriminant analysis determined whether intact repairs (Sugaya grade 1) and partial-thickness retears (Sugaya grades 2 and 3) could be predicted.

RESULTS

No differences (P < .05) existed in the clinical or strength measures. Although discriminant analysis revealed the 11-item version of the Disabilities of the Arm, Shoulder and Hand produced a 97% true-positive rate for predicting partial thickness retears, it also produced a 90% false-positive rate whereby it incorrectly predicted a retear in 90% of patients whose repair was intact. The ability to discriminate between groups was enhanced with up to 5 variables entered; however, only 87% of the partial-retear group and 36% of the intact-repair group were correctly classified.

CONCLUSIONS

No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16 weeks. An intact repair or partial-thickness retear could not be accurately predicted. Our results suggest that correct classification of healing in the early postoperative stages should involve imaging.

A 3D finite element model for geometrical and mechanical comparison of different supraspinatus repair techniques

BACKGROUND

Contact pressure and contact area are among the most important mechanical factors studied to predict the effectiveness of a rotator cuff repair. The suture configurations can strongly affect these factors but are rarely correlated with each other. For example, there is a significant difference between the single-row technique and the transosseous or transosseous-like approaches in terms of footprint contact area coverage. A finite element model-based approach is presented and applied to account for various parameters (eg, suture pretension, geometry of the repair, effect of the sutures, geometry of the lesion) and to compare the efficacy of different repair techniques in covering the original footprint.

METHODS

The model allows us to evaluate the effect of parameters such as suture configuration and position and suture pretension. The validity of such an approach was assessed in comparing 3 different repair techniques: single row, transosseous equivalent, and double row.

RESULTS

Results from the application of the models show that the double-row and transosseous-equivalent techniques lead to progressive increase of the contact area compared with the single-row approach, supporting the conclusion that transosseous-equivalent fixation leads to an increase of the contact area and a better distribution of the pressure coverage.

CONCLUSION

The 3-dimensional finite element model approach allows multiple variables to be assessed singularly, weighing the specific influence. Moreover, the approach presented in this study could be a valid tool to predict and to reproduce different configurations, identifying how to reduce the stress over the tendon and when a repair could be effective or not.

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair

PURPOSE

Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique.

MATERIALS AND METHODS

A consecutive series of 107 patients and 109 shoulders underwent arthroscopic TO (anchorless) rotator cuff repair for a symptomatic full-thickness tear. Pre and postoperative range of motion (ROM) was compared at an average of 11.8 months. Postoperative outcome scores were obtained at an average of 38.0 months. Statistical analysis was performed to compare pre and postoperative ROM data. Univariate analysis was performed using Student's t-test to compare the effect of other clinical characteristics on final outcome.

RESULTS

Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted.

CONCLUSIONS

Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.

LEVEL OF EVIDENCE

Level IV.

Healing disturbance with suture bridge configuration repair in rabbit rotator cuff tear

BACKGROUND

Medial row failure has been reported in the suture bridge technique of rotator cuff repair. This study compared the healing response of suture bridge configuration repair (SBCR) and parallel type transosseous repair (PTR).

METHODS

Acute rotator cuff repair was performed in 32 rabbits. Both shoulders were repaired using PTR or SBCR. In PTR, simple PTR was performed through 2 parallel transosseous tunnels created using a microdrill. In SBCR, 2 additional crisscross transosseous tunnels were added to mimic arthroscopic SBCR. At 1, 2, and 5 weeks postoperatively, comparative biomechanical testing was performed in 8 rabbits, and histologic analysis, including immunohistochemical staining for CD31, was performed in 4 rabbits.

RESULTS

Failure loads at 1 week (38.12 ± 20.43 N vs 52.00 ± 27.23 N; P = .284) and 5 weeks (97.93 ± 48.35 N vs 119.60 ± 60.81 N; P = .218) were not statistically different between the SBCR and PTR groups, respectively, but were significantly lower in the SBCR group than in the PTR group (23.56 ± 13.56 N vs. 44.25 ± 12.53 N; P = .009), respectively, at 2 weeks. Markedly greater fibrinoid deposition was observed in the SBCR group than in the PTR group at 2 weeks. For vascularization, there was a tendency that more vessels could be observed in PTR than in SBCR at 2 weeks (15.9 vs 5.6, P = .068).

CONCLUSIONS

In a rabbit acute rotator cuff repair model, SBCR exhibited inferior mechanical strength, and fewer blood vessels were observed at the healing site at 2 weeks postoperatively. Medial row tendon failure was more common in SBCR. Surgeons should consider the clinical effect of SBCR when performing rotator cuff repair.

Management of failed rotator cuff repair: a systematic review

Importance

Recurrent tear after rotator cuff repair (RCR) is common. Conservative, and open and arthroscopic revisions, have been advocated to treat these failures.

Aim or objective

The purpose of this systematic review was to evaluate the different options for managing recurrent rotator cuff tears.

Evidence review

A search was conducted of level I through 4 studies from January 2000 to October 2015, to identify studies reporting on failed RCR. 10 articles were identified. The overall quality of evidence was very low.

Findings

Mid-term to long-term follow-up of patients treated conservatively revealed acceptable results; a persistent defect is a well-tolerated condition that only occasionally requires subsequent surgery. Conservative treatment might be indicated in most patients, particularly in case of posterosuperior involvement and poor preoperative range of motion. Revision surgery might be indicated in a young patient with a repairable lesion, a 3 tendon tear, and in those with involvement of the subscapularis.

Conclusions and relevance

The current review indicates that arthroscopic revision RCR can lead to improvement in functional outcome despite a high retear rate. Further studies are needed to develop specific rehabilitation in the case of primary rotator cuff failure, to better understand the place of each treatment option, and, in case of repair, to optimise tendon healing.