The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique

Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears

HYPOTHESIS

Double-row rotator cuff repair leads to superior cuff integrity and clinical results compared with single-row repair.

MATERIALS AND METHODS

The study enrolled 68 patients with a full-thickness rotator cuff tear who were divided into 2 groups of 34 patients according to repair technique. The patients were followed-up for at least 2 years. The results were evaluated by Constant score.

DISCUSSION

Despite the biomechanical studies and cadaver studies that proved the superiority of double-row fixation over single-row fixation, our clinical results show no difference in functional outcome between the two methods. It is evident that double-row repair is more technically demanding, expensive, and time-consuming than single-row repair, without providing a significant improvement in clinical results.

RESULTS

Comparison between groups did not show significant differences. At the final follow-up, the Constant score was 82.2 in the single-row group and 78.8 in the double-row group. Functional outcome was improved in both groups after surgery, but the difference between the 2 groups was not significant.

CONCLUSIONS

At long-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair in small to medium tears.

Does an arthroscopic suture bridge technique maintain repair integrity?: a serial evaluation by ultrasonography

Biomechanical studies suggest a suture bridge technique enhances rotator cuff tendon footprint contact area, holding strength, and mean contact pressure. Based on these studies, we asked whether (1) the suture bridge technique would provide a high rate of cuff integrity after surgery, (2) the status of the repaired cuff would change with time, (3) preoperative factors could predict postoperative cuff integrity, and (4) patients with retears had less favorable pain, functional scores, range of motion (ROM), and muscle strength compared with those with intact repairs. We prospectively followed 78 patients with arthroscopic repairs in whom we used the suture bridge technique. The integrity of the rotator cuff repair was determined using ultrasonographic evaluation at 4.5 and 12 months after surgery. Ultrasonography revealed intact cuffs in 91% at 4.5 months postoperatively, all of which were maintained at the 12-month followup. Failure rates were 17.6% (three of 17) for massive tears, 11.1% (two of 18) for large tears, 6.3% (two of 32) for medium tears, and no failures for small tears. Preoperative fatty degeneration of the supraspinatus muscle was a strong predictor of cuff integrity. We found no correlation between the integrity and clinical outcomes except for a temporary decrease of abduction strength at 6 months. Arthroscopic repair using suture bridge technique can achieve a low retear rate in shoulders treated for rotator cuff tears, but the occurrence of retear did not influence the outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair?

PURPOSE

Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies.

METHODS

Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies.

RESULTS

Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies.

CONCLUSIONS

The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review.

Cost-effectiveness of open versus arthroscopic rotator cuff repair

BACKGROUND

Economic evaluation of surgical procedures is necessary in view of more expensive newer techniques emerging in an increasingly cost-conscious health care environment. This study compares the cost-effectiveness of open rotator cuff repair with arthroscopic repair for moderately size tears.

MATERIALS AND METHODS

This was a prospective study of 30 consecutive patients, of whom 15 had an arthroscopic repair and 15 had an open procedure. Clinical effectiveness was assessed using Oxford and Constant shoulder scores. Costs were estimated from departmental and hospital financial data.

RESULTS

At last follow-up, no difference Oxford and Constant shoulder scores was noted between the 2 methods of repair. There was no significant difference between the groups in the cost of time in the operating theater, inpatient time, amount of postoperative analgesia, number of postoperative outpatient visits, physiotherapy costs, and time off work. The incremental cost of each arthroscopic rotator cuff repair was pound675 ($1248.75) more than the open procedure. This was mainly in the area of direct health care costs, instrumentation in particular.

DISCUSSION

Health care policy makers are increasingly demanding evidence of cost-effectiveness of a procedure. This study showed both methods of repair provide equivalent clinical results.

CONCLUSION

Open cuff repair is more cost-effective than arthroscopic repair and is likely to have lower cost-utility ratio. In addition, the tariff for the arthroscopic procedure in some health care systems is same as open 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.

Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005).

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.

A biomechanical comparison of 2 transosseous-equivalent double-row rotator cuff repair techniques using bioabsorbable anchors: cyclic loading and failure behavior

PURPOSE

A novel double-row configuration was compared with a traditional double-row configuration for rotator cuff repair.

METHODS

In 10 matched-pair sheep shoulders in vitro repair was performed with either a double-row technique with corkscrew suture anchors for the medial row and insertion anchors for the lateral row (group A) or a double-row technique with a new tape-like suture material with insertion anchors for both the medial and lateral rows (group B). Each specimen underwent cyclic loading from 10 to 150 N for 100 cycles, followed by unidirectional failure testing. Gap formation and strain within the repair area for the first and last cycles were analyzed with a video digitizing system, and stiffness and failure load were determined from the load-elongation curve.

RESULTS

The results were similar for the 2 repair types. There was no significant difference between the ultimate failure loads of the 2 techniques (421 +/- 150 N in group A and 408 +/- 66 N in group B, P = .31) or the stiffness of the 2 techniques (84 +/- 26 N/mm in group A and 99 +/- 20 N/mm in group B, P = .07). In addition, gap formation was not different between the repair types. Strain over the repair area was also not different between the repair types.

CONCLUSIONS

Both tested rotator cuff repair techniques had high failure loads, limited gap formation, and acceptable strain patterns. No significant difference was found between the novel and conventional double-row repair types.

CLINICAL RELEVANCE

Two double-row techniques-one with corkscrew suture anchors for the medial row and insertion anchors for the lateral row and one with insertion anchors for both the medial and lateral rows-provided excellent biomechanical profiles at time 0 for double-row repairs in a sheep model. Although the sheep model may not directly correspond to in vivo conditions, all-insertion anchor double-row constructs are worthy of further investigation.

The effect of abduction and rotation on footprint contact for single-row, double-row, and modified double-row rotator cuff repair techniques

BACKGROUND

An abduction pillow and abduction and rotation exercises are commonly used after rotator cuff repair. The effect of glenohumeral abduction and rotation on footprint contact has not been elucidated.

HYPOTHESIS

Abduction will decrease tendon-to-bone contact for all repairs. A modified double-row repair will maintain footprint contact more effectively at each position of humeral abduction and rotation than double- or single-row repairs.

STUDY DESIGN

Controlled laboratory study.

METHODS

In 6 fresh-frozen human shoulders, a modified double-row supraspinatus tendon repair was performed; a suture limb from each of 2 medial anchors was bridged over the tendon and fixed laterally. Double- and single-row repairs were performed sequentially; a total of 3 repairs were tested. For all repairs, a Tekscan pressure sensor was fixed at the tendon-footprint interface. The tendon was loaded with 30 N. The shoulders were tested at 0 degrees , 30 degrees , and 60 degrees of abduction with 0 degrees of rotation. For both dual-row repairs, 5 rotation positions were tested.

RESULTS

The greatest contact areas at neutral rotation were achieved at 0 degrees of abduction for the modified double-row, double-row, and single-row repairs (151.3 +/- 10.7 mm2, 80.7 +/- 30.0 mm2, and 61.3 +/- 26.1 mm2, respectively), with values decreasing as abduction increased. Each repair was significantly different from one another at each abduction angle (P < .05), except between single- and double-row repairs at 0 degrees of abduction. Mean interface pressure exerted over the footprint was greater for the modified double-row technique than for the other techniques at each abduction angle (P < .05). With respect to rotation, the modified double-row repair had significantly more footprint contact than did the double-row repair at each position tested (P < .05).

CONCLUSION

For a given repair, increasing abduction at neutral rotation reduced footprint contact. Internal rotation to 60 degrees provided among the highest contact measurements. The modified double-row technique provided the most contact.

CLINICAL RELEVANCE

Results are consistent with the practice of immobilizing the shoulder with 30 degrees or less of abduction and up to 60 degrees of internal rotation to optimize footprint contact. A dual-row repair may maximize contact when initiating rehabilitation that involves abduction and rotation.

Impingement syndrome of the shoulder following double row suture anchor technique for arthroscopic rotator cuff repair: a case report

Introduction

Arthroscopic repair of the rotator cuff is a demanding surgery. Accurate placement of anchors is key to success.

Case presentation

A 38-year-old woman received arthroscopic repair of her rotator cuff using a double row suture anchor technique. Postoperatively, she developed impingement syndrome which resulted from vertical displacement of a suture anchor once the shoulder was mobilised. The anchor was removed eight weeks following initial surgery and the patient had an uneventful recovery.

Conclusion

Impingement syndrome following arthroscopic repair of the rotator cuffs using double row suture anchor has not been widely reported. This is the first such case where anchoring has resulted in impingement syndrome.

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.

Anatomic reduction and next-generation fixation constructs for arthroscopic repair of crescent, L-shaped, and U-shaped rotator cuff tears

Emerging techniques and instrumentation have allowed orthopaedic surgeons to achieve rotator cuff repair through an all-arthroscopic technique. The most critical steps in rotator cuff repair consist of proper identification of the cuff tear pattern and anatomic restoration of the torn tendon footprint. With anatomic reduction of the rotator cuff tendons, a sound fixation construct can help restore rotator cuff contact pressure and kinematics, allowing for decreased repair tension and optimal healing potential. We provide surgical methods to recognize tear patterns and present a repair construct that will restore the anatomic footprint of the torn rotator cuff tendon. The key, initial maneuver to restore the anatomic footprint of the cuff includes placement of a suture anchor at the anterolateral corner for L-shaped tears and at the posterolateral corner for reverse L-shaped and U-shaped tears. After insertion of the medial-row anchors, the tendon stitches should be planned by use of a grasper to hold the tendon in a reduced position and guide location of the stitch. The lateral row with suture bridge can be visualized, and the final repair construct should produce an anatomic restoration of the rotator cuff footprint.

Rotator cuff tears: pathology and repair

By virtue of its anatomy and function, the rotator cuff is vulnerable to considerable morbidity, often necessitating surgical intervention. The factors contributing to cuff disease can be divided into those extrinsic to the rotator cuff (most notably impingement) and those intrinsic to the cuff (age-related degeneration, hypovascularity and inflammation amongst others). In an era of emerging biologic interventions, our interventions are increasingly being modulated by our understanding of these core processes, many of which remain uncertain today. When we do intervene surgically, the techniques we employ are particularly challenging in the context of the tremendous pace of advancement. Several recent studies have shown that arthroscopic repair gives similar functional results to that of mini-open and open procedures, with all the benefits of minimally invasive surgery. However, the 'best' repair construct remains unknown, with wide variations in surgeon preference. Here we present a literature review encompassing recent developments in our understanding of basic science in rotator cuff disease as well as an up-to-date evidence-based comparison of different techniques available to the surgeon for cuff repair.

Open versus two forms of arthroscopic rotator cuff repair

There have been technologic advances in the methods for repairing torn rotator cuffs. We compared the clinical and structural outcomes of three different forms of rotator cuff repair with up to 24 months' followup. We wished to assess how surgical technique affected clinical outcomes and see how these correlated to repair integrity. Three cohorts of patients had repair of a symptomatic rotator cuff tear using (1) an open technique (n = 49); (2) arthroscopic knotted (n = 53); or (3) arthroscopic knotless (n = 57) by one surgeon. Standardized patient- and examiner-determined outcomes were obtained preoperatively and at 6 weeks, 3 and 6 months, and 2 years postoperatively. Ultrasound studies were performed with a validated protocol at 6 months and 2 years postsurgery. Clinical outcomes were similar with the exception that the arthroscopic groups had, on average, 20% better American Shoulder and Elbow Surgeons scores than the open group at 6 months and 2 years. Retear correlated with tear size and operation time and occurred more frequently after open repair (39%) than after arthroscopic knotted (25%) and arthroscopic knotless (16%) repair. An intact cuff on ultrasound corresponded to better results for supraspinatus strength, patient outcomes, and rotator cuff functional ability.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

Single-row versus double-row arthroscopic rotator cuff repair: a prospective randomized clinical study

PURPOSE

The purpose of this study was to compare the clinical outcome of arthroscopic rotator cuff repair with single-row and double-row techniques.

METHODS

Eighty patients with a full-thickness rotator cuff tear underwent arthroscopic repair with suture anchors. They were divided into 2 groups of 40 patients according to repair technique: single row (group 1) or double row (group 2). Results were evaluated by use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires, normalized Constant score, and muscle strength measurement. On analyzing the results at a 2-year follow-up, we considered the following independent variables: baseline scores; age; gender; dominance; location, shape, and area of cuff tear; tendon retraction; fatty degeneration; treatment of biceps tendon; and rotator cuff repair technique (anchors or anchors and side to side). Univariate and multivariate statistical analyses were performed to determine which variables were independently associated with the outcome. Significance was set at P < .05.

RESULTS

Of the patients, 8 (10%) were lost to follow-up. Comparison between groups did not show significant differences for each variable considered. Overall, according to the results, the mean DASH scores were 15.4 +/- 15.6 points in group 1 and 12.7 +/- 10.1 points in group 2; the mean Work-DASH scores were 16.0 +/- 22.0 points and 9.6 +/- 13.3 points, respectively; and the mean Constant scores were 100.5 +/- 17.8 points and 104.9 +/- 21.8 points, respectively. Muscle strength was 12.7 +/- 5.7 lb in group 1 and 12.9 +/- 7.0 lb in group 2. Univariate and multivariate analysis showed that only age, gender, and baseline strength significantly and independently influenced the outcome. Differences between groups 1 and 2 were not significant.

CONCLUSIONS

At short-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with no statistically significant differences but narrow confidence intervals.

Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome

PURPOSE

To analyze the relationship between functional outcomes and postoperative cuff integrity (anatomic outcome), and to reveal the factors affecting outcomes of rotator cuff repair.

METHODS

Seventy-eight patients who had undergone repair of full-thickness rotator cuff tear received both computed tomographic arthrography (CTA) and functional evaluation a minimum of 1 year after surgery. The mean follow-up period was 19.6 months (range, 12 to 39 months). Anatomic outcome was evaluated by CTA. Functional outcomes were evaluated by visual analogue scale (VAS) for pain and satisfaction with the operation, Constant score, simple shoulder test (SST), and American Shoulder and Elbow Surgeons (ASES) score. Various clinical and structural factors were included for statistical analysis.

RESULTS

All patients displayed significant improvement in all functional evaluations at the final visit. Functional outcome did not correlate with anatomic outcome (P > .05). A few variables did relate to functional outcome: female or old age statistically correlated with the score of SST, and the size of the tear correlated with the ASES score (P < .05). The retear was influenced by age, fatty degeneration of the cuff muscles, and the size of tear. Fatty degeneration of the infraspinatus was the most independent predictor of anatomic outcome on multivariate regression analysis.

CONCLUSIONS

Rotator cuff repair brought significant functional improvement. However, the functional outcome did not correlate with the anatomic outcome. The fatty degeneration of the infraspinatus muscle served as an independent predictor of the postoperative integrity of the rotator cuff.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

An in vitro analysis of the mechanical properties of 16 arthroscopic knots

The purpose of this study was to determine the biomechanical characteristics of 16 arthroscopic knots and to determine if locking knots have superior loop security compared to non-locking knots. Sixteen knot types were tied in arthroscopic fashion and tested on a materials testing system. Knots were cyclically loaded to 30 Newtons (N) for 20 cycles and then loaded to failure at 1.25 mm/s. Ten samples of each knot were tied using both #2 Ethibond and #1 PDS II. Load to ultimate failure, load to clinical failure, post-cyclic stiffness, cyclical elongation, ultimate displacement, loop security, and mode of failure were determined for each knot. Nicky's Knot and the French Knot were most consistently ranked within the top five knot types for each of the biomechanical parameters. Locking knots did not improve loop security over non-locking knots.

Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome

The purpose of this study was to identify potential predictors of function and tendon healing after arthroscopic rotator cuff repair that will enable the orthopaedic surgeon to determine which patients can expect a successful outcome. Between 2003 and 2005, the Arthroscopic Rotator Cuff Registry was established to collect demographic, intraoperative, functional outcome, and ultrasound data prospectively on all patients who underwent primary arthroscopic rotator cuff repair. At total of 193 patients met the study criteria, and 127 (65.8%) completed the 2-year follow-up. The most significant independent factors affecting ultrasound outcome were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.14; P = .006) and tear size (OR, 2.29; 95% CI, 1.55-3.38; P < .001). After adjustment for age and tear size, the intraoperative factors found to be significantly associated with a tendon defect were concomitant biceps procedures (OR, 11.39; 95% CI, 2.90-44.69; P < .001) and acromioclavicular joint procedures (OR, 3.85; 95% CI, 1.46-10.12; P = .006). In contrast to the ultrasound data, the functional outcome variables, such as satisfaction (OR, 3.92; 95% CI, 2.00-7.68; P < .001) and strength (OR, 10.05; 95% CI, 1.61-62.77; P = .01), had a greater role in predicting an American Shoulder and Elbow Surgeons score greater than 90. The progression from a single-tendon rotator cuff tear to a multiple-tendon tear with associated pathology increased the likelihood of tendon defect by at least 9 times, and therefore, earlier surgical intervention for isolated, single-tendon rotator cuff tears could optimize the likelihood of ultrasound healing and an excellent functional outcome.

Repair integrity and clinical outcome after arthroscopic rotator cuff repair using single-row anchor fixation: a prospective study of single-tendon and two-tendon tears

This prospective study determined whether single-row anchor fixation would reliably improve clinical outcome and maintain structural integrity after arthroscopic repair of single-tendon and 2-tendon rotator cuff tears. In 39 patients, 21 shoulders had single-tendon tears and 18 had 2-tendon tears. Mean follow-up was 38 months (minimum, 24 months). A standardized assessment was done preoperatively and postoperatively at yearly intervals. Postoperative magnetic resonance imaging (MRI) was performed at a minimum 1-year follow-up. Mean forward elevation, pain, satisfaction, and American Shoulder and Elbow Surgeons scores significantly improved for both groups (P < .01). Postoperative MRI examinations showed 19 cuffs (90%) were intact for single-tendon tears and 15 (83%) were intact for 2-tendon tears. A recurrent tear on postoperative MRI was significantly correlated with the intraoperative finding of asymmetric retraction. Arthroscopic rotator cuff repair using single-row anchor fixation resulted in significant improvements in clinical outcome and reliable repair integrity for both single-tendon and 2-tendon tears.