Does Suture Technique Affect Re-Rupture in Arthroscopic Rotator Cuff Repair? A Meta-analysis

Editorial Commentary: Improved Suture Configurations Can Enhance Shoulder Rotator Cuff Healing: The Cuff Doesn't Always Heal-But We Can Nudge It in the Right Direction

The success of rotator cuff repair is often measured by patient-reported outcomes or structural healing on magnetic resonance imaging. Ideally, we can achieve both a satisfied patient and a healed tendon. Various technical modifications and stitch patterns have been presented in an effort to achieve the perfect rotator cuff repair. It appears the independently popular suture bridge technique and Mason-Allen stitch may do their best work when combined together. First, double-row repair "anchors down" the tendon to its footprint, and suture bridge adds to this concept with double-row compressive interlinking suture. Second, the Mason-Allen stitch, combining a horizontal stich and a simple stitch that passes around the horizontal, leverages the rip-stop concept where an "anchor suture" is included as a suture is passed around friable tendon like steel rebar rods strengthening concrete. In the midst of many factors out of the surgeon's control during the healing process, we are compelled to listen when a change in our technique might actually make a difference.

Morbidity of long head of the triceps motor branch neurotization to the axillary nerve: Retrospective subjective and objective assessment of triceps brachii strength after transfer

INTRODUCTION

Morbidity is considered to be negligible in Leechavengvongs transfer (LT) of the long head of the triceps onto the axillary nerve, but the assessment methods used may lack reproducibility. We assessed triceps strength after LT objectively by the isokinetic technique, addressing the following questions: Is strength lowered after LT compared to the healthy limb? And 2) is there a good correlation between isokinetic dynamometry and subjective assessment?

HYPOTHESIS

Isokinetic measurement shows a decrease in triceps strength at peak torque after LT compared to the healthy limb, and this morbidity is underestimated on subjective assessment.

MATERIAL AND METHODS

This single-center retrospective study included patients undergoing LT for axillary nerve trunk palsy between 2008 and 2020, with M5 triceps preoperatively on the British Medical Research Council (BMRC) scale. Twenty patients, with a mean age of 25±9years (range, 15-48years) were assessed at a mean 58±47months (range, 6-174months). Elbow extension strength was assessed on a standardized questionnaire, BMRC isometric test and isokinetic test on an angular course of 90° at 60°/sec and 180°/sec concentrically and 30°/sec excentrically.

RESULTS

Strength at 60°/sec and 180°/sec concentrically and 30°/sec excentrically was significantly lower than in the healthy limb: respectively, -17Nm, -15Nm, and -16Nm, (p<0.001) for a mean -23%. Loss of strength was mainly severe on isokinetic testing and mild on isometric testing. Seven patients reported contracture (35%), 12 fatigue (60%), and 3 weakness (15%). Satisfaction with extension strength was excellent or good for respectively 12 (60%) and 8 patients (40%). Triceps strength was graded BMRC M4 in 9 triceps (11%) and M5 in 11 (55%).

DISCUSSION

After LT, isokinetic measurement found generally severe loss of triceps strength, but without subjective impact on everyday life.

LEVEL OF EVIDENCE

IV; retrospective study.

Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective

PURPOSE

The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis.

METHODS

A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY.

RESULTS

On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921.

CONCLUSION

Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective.

LEVEL OF EVIDENCE

Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.

A Biomechanical Comparison of High-Tensile Strength Tape Versus High-Tensile Strength Suture for Tendon Fixation Under Cyclic Loading

PURPOSE

To compare the biomechanical properties of high-tensile strength tape and high-tensile strength suture across 2 selected stitch techniques, the Krackow and whip stitch, in securing tendinous tissue during 5,000 cycles of nondestructive loading followed by a load to failure.

METHODS

Fourteen matched pairs each of cadaveric Achilles, quadriceps, and patellar tendons (n = 84) were randomly assigned to either Krackow or whip stitch and sutured with either 2-mm high-tensile strength tape or No. 2 high-tensile strength suture. Specimens were preloaded to 20 N, cyclically loaded from 20 to 200 N for 5,000 cycles at 2 Hz, and then loaded to failure at 200 mm/min. Linear mixed models evaluated the effects of suture material and stitch technique on cyclic normalized tendon-suture elongation, total normalized tendon-suture elongation at 5,000 cycles, and maximum load at failure.

RESULTS

Across all suture constructs, normalized elongation was greater during the initial 10 cycles, compared with all subsequent cycling intervals (all P < .001). There was less total normalized elongation (β = -0.239; P = .007) and greater maximum load at failure in tape (β = 163.71; P = .014) when used in the Krackow stitch compared with the whip stitch.

CONCLUSIONS

Our findings indicate that tape used in the Krackow stitch maintains the most favorable fixation strength after enduring cyclic loading, with greater maximum load at failure. In addition, overall normalized elongation during long-term cyclic loading was predominately affected by the stitch technique used, regardless of the suture material; however, tape allowed less normalized elongation during the initial loading cycles, especially when placed in the whip stitch.

CLINICAL RELEVANCE

Understanding the potential short- and long-term outcomes of suture material and stitch technique on securing tendinous tissue under repetitive stresses can help inform clinicians on optimal tendon fixation techniques for early postoperative activities.

Intratendinous Strain Variations of the Supraspinatus Tendon Depending on Repair Technique: A Biomechanical Analysis Regarding the Cause of Medial Cuff Failure

BACKGROUND

Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far.

PURPOSE

To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions-(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction-using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair.

RESULTS

The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N (P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N (P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group (P≤ .029).

CONCLUSION

While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon.

CLINICAL RELEVANCE

DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Double Row Knotted "Trident": 1 Suture Technique for Superior to Posterosuperior Small Cuff Tear

Many arthroscopy suture techniques have been described for small rotator cuff tears, but there is no consensus. The aim of this study is to describe a double-row knot technique, which we call a "trident point," for the superior and posterosuperior small cuff tear that is easily reproducible and has a fast learning curve. This knot takes into account the excess of tendon tissue on the foot print after a cuff suture, called a "dog-ear deformity." However clinical, ultrasound, and biomechanical evaluation with follow-up remains necessary to validate the sustainability of this arthroscopy technique.

Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents

PURPOSE

The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents.

METHODS

This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity.

RESULTS

A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon.

CONCLUSIONS

Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series.

Supraspinatus tendon transosseous vs anchor repair surgery: a comparative study of mechanical recovery in the rabbit

BACKGROUND

Supraspinatus (SSP) tendon ruptures requiring surgical repair are common. Arthroscopic suture anchor fixation has gradually replaced transosseous repair in supraspinatus tendon tear. Our objective was to compare mechanical properties between transosseous and anchor supraspinatus repair in the first 6 postoperative weeks in a rabbit model.

METHODS

One hundred and fifty-two rabbits had one supraspinatus tendon repaired either with an anchor suture 1 week after detachment or with transosseous sutures. Rabbits were euthanized at 0, 1, 2, 4 or 6 postoperative weeks. Experimental and contralateral tendons (304 tendons) were mechanically tested to failure. Data are expressed as percent of contralateral.

RESULTS

Anchor repair had higher loads to failure compared to transosseous repair, at immediate repair (week 0, 52 ± 21% vs 25 ± 17%, respectively; p = 0.004) and at 1 postoperative week (64 ± 32% vs 28 ± 10%; p = 0.003) with no difference after 2 weeks. There was no difference in stiffness. Transosseous repairs showed higher rates of midsubstance failures compared to anchor repairs at 1 (p = 0.004) and 2 postoperative weeks (p < 0.001). Both transosseous and anchor repairs restored supraspinatus mechanical properties after 4 postoperative weeks.

CONCLUSION

Anchor repair provided better initial tensile strength while transosseous repair led to a faster normalization (namely, midsubstance) of the mode of failure. Research to optimize supraspinatus repair may need to consider the advantages from both surgical approaches.

TGF-β1-containing exosomes derived from bone marrow mesenchymal stem cells promote proliferation, migration and fibrotic activity in rotator cuff tenocytes

Objective

This study aimed to investigate effects of TGF-β1-containing exosomes derived from bone marrow mesenchymal stem cells (BMSC) on cell function of rotator cuff tenocytes and its implication to rotator cuff tear.

Methods

The primary BMSC and rotator cuff tenocytes were extracted and cultured. Identification of BMSC were performed by observing cell morphology and measurement of surface biomarkers by flow cytometry. BMSC-derived exosomes were extracted and identified by using electron microscopy, nanoparticle-tracking analysis (NTA) and western blotting. Cell proliferation and cell cycle were measured by CCK-8 assay and flow cytometry assay, respectively. Transwell assay was used for detection of tenocytes migration. The fibrotic activity of tenocytes was determined via qPCR and western blotting assays.

Results

BMSC and BMSC-derived exosomes were successfully extracted. Treatment of BMSC-derived exosomes or TGF-β1 promoted cell proliferation, migration and increased cell ratio of (S + G2/M) phases in tenocytes, as well as enhanced the expression levels of fibrotic activity associated proteins. However, inhibition of TGF-β1 by transfection of sh-TGF-β1 or treatment of TGFβR I/II inhibitor partially reversed the impact of BMSC-derived exosomes on tenocytes function.

Conclusion

Taken together, TGF-β1-containing exosomes derived from BMSC promoted proliferation, migration and fibrotic activity in rotator cuff tenocytes, providing a new direction for treatment of rotator cuff tendon healing.

Application of a new polyester patch in arthroscopic massive rotator cuff repair-a prospective cohort study

BACKGROUND

Massive rotator cuff (RC) tears still present a clinically challenging problem, with reported rerupture rates in up to 94%. The study objective was to determine the impact of synthetic patch augmentation for massive RC tears.

METHODS

Between June 2012 and 2014, we performed 50 arthroscopic RC reconstructions augmented with a synthetic polyester patch. Pre- and postoperative imaging methods included arthrographic magnetic resonance imaging, arthrographic computed tomography, and ultrasound examination to determine tendon integrity or rerupture. Clinical outcome was evaluated using the Constant-Murley score and the subjective shoulder value. Mean clinical midterm and final follow-up was 22 months (9-35 months) and 52 months (25-74 months), respectively.

RESULTS

The mean Constant-Murley score increased significantly from 36.5 (±16.4 standard deviation [SD]) preoperatively to a midterm value of 81.2 (±9.6 SD; P < .0001) and further improved to a mean of 83.4 (±10.8 SD) at final follow-up. The mean subjective shoulder value increased from 40.3 (±24.3 SD) to 89.2 (±12.9 SD; P < .0001) at midterm and to 89.6 (±15.2 SD) at final follow-up. We observed 7 complete reruptures (14%). However, reruptures did not correlate with revision surgery, which was performed in 8 patients. The main reason for revision was frozen shoulder or arthrofibrosis with an intact reconstruction and patch, which was performed in 6 cases.

CONCLUSIONS

The retear rate of 14% compared favorably with nonaugmented RC repairs in the literature. Therefore, we conclude that patch augmentation in massive RC tears is feasible to reduce retears and to improve clinical outcome.

Adipocyte hyperplasia: the primary mechanism of supraspinatus intramuscular fat accumulation after a complete rotator cuff tendon tear: a study in the rabbit

Intramuscular fat (IMF) accumulates in muscles of the rotator cuff after tendon tear. The number and cross-sectional area of fat clumps and of adipocytes were quantified on osmium tetroxide stained sections of the proximal, middle and distal quarters of SSP muscles 4, 8 and 12 weeks after SSP tendon division in a rabbit model. Linear mixed-effects models were fitted to the data and statistical significance was evaluated by ANOVA. Both the number (P<0.001) and cross-sectional area (P<0.0005) of fat clumps increased after tendon detachment while time had no significant effect (both at P>0.01). IMF accumulation was more important in the distal quarter of detached SSP muscle near tendon sectioning and characterized by increases of the number (P<0.0005) and cross-sectional area of fat clumps (P<0.0005) compared to the proximal quarter. Adipocyte number increased after tendon detachment (P<0.0005) and over time (P<0.01). The cross-sectional area of adipocytes increased in the detached group compared to controls (P<0.01) while time had no significant effect (P>0.01). Interestingly, the number of adipocytes in the distal quarter increased (P<0.0005) but the cross-sectional area was smaller (P<0.0005) compared to adipocytes in the proximal quarter. Adipocyte hyperplasia localized near tendon sectioning was the main contributor to fat accumulation in the detached SSP muscles.

Rotator Cuff Repair With Knotless Technique Is Quicker and More Cost-Effective Than Knotted Technique

Purpose

To determine the cost-effectiveness of knotted (KT) versus knotless (KL) methods for rotator cuff surgical repair and to assess differences in patients' outcomes.

Methods

We retrospectively identified all patients who underwent arthroscopic rotator cuff repair at 1 institution by 1 surgeon over 2 6-month periods of time (KT technique from August 1, 2013, through January 31, 2014; and KL technique from December 1, 2014, through May 31, 2015) to calculate the direct and indirect costs associated with arthroscopic KT or KL suture bridge rotator cuff repair. Patient demographics, number of anchors used, tendons repaired, procedure time, operative time, and clinical results were also evaluated. We used univariate generalized linear models with a Gaussian distribution for assessment scores and total and implant cost data.

Results

We identified 87 patients for inclusion during the 2 time frames (35 KT, 54 KL). After excluding patients for tear size < 4 cm² (n = 42), ≤ 3 anchors (n = 5), revision surgery (n = 1), and those in whom additional procedures were performed (n = 2), 37 eligible subjects remained (n_KT = 15, n_KL = 22). Median implant costs were statistically significantly higher in the KL group than in the KT group (M_KL = $2,127, M_KT = $1,520, β = 413.7, 95% CI: 242.8, 584.6, P < .01), and more anchors were used in the KL group, with KT requiring a median of 4 anchors (IQR: 4, 5) and KL requiring a median of 5 anchors (IQR: 5, 5, P = .02). Procedure time was cut in half with KL repair (estimated 43.5 minutes) versus KT repair (80 minutes) (β = 0.5, 95% CI: 0.4, 0.6, P < .001). Operating room time also was reduced by approximately 40% (79.5 minutes for KL; 121 minutes for KT [β = 0.6, CI: 0.6, 0.7, P < .001]). Once operating room costs were considered, median costs were found to be significantly lower in the KL group (M_KL = $3788.40, M_KT = $4262.90, β = -492.1, 95% CI: -840.0, -144.1, P < .01). No statistically significant differences were found between groups in mean preoperative, postoperative or postpreoperative differences in the visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or University of California at Los Angeles scores (P > 0.05 for all).

Conclusions

Despite using more anchors and incurring higher implant costs, the KL technique for rotator cuff repair required less surgical procedure time and cost less overall than the KT technique and resulted in equivalent clinical results.

Level of Evidence

Level IV Economic and Decision Analyses.

A Prospective Randomized Trial Comparing Suture Bridge and Medially Based Single-Row Rotator Cuff Repair in Medium-Sized Supraspinatus Tears

PURPOSE

To compare the clinical and imaging outcomes between the suture bridge technique (SB) and the medially based single-row technique (medSR) in patients with 1- to 3-cm tear sizes.

METHODS

All patients were evaluated preoperatively and postoperatively (at 12 and 24 months) using the modified University of California, Los Angeles scoring system; active range of motion (flexion and external rotation); and a visual analog scale for pain. Healing status was examined by postoperative magnetic resonance imaging.

RESULTS

Clinical and imaging evaluations were completed by 92 patients at 1-year follow-up and by 74 patients at 2 years. No significant differences were found between the 2 groups across all measures at final follow-up: The University of California, Los Angeles scores were 33.4 points in SB patients and 33.0 points in medSR patients (P = .58); the visual analog scale scores were 6 mm and 7 mm, respectively (P = .38); the active flexion angles were 161° and 159°, respectively (P = .34); and the external rotation angles were 49° and 52°, respectively (P = .37). Retears were observed in 6.5% of SB patients and 2.1% of medSR patients (P = .31). Medial cuff failure was observed only in SB patients (4.3%, 2 cases), whereas incomplete healing (deep-layer retraction pattern) was observed only in medSR patients (8.7%, 4 cases). Neo-tendon regeneration in the medSR group was observed in 93% of patients.

CONCLUSIONS

This study did not show any significant differences in the clinical outcomes and cuff integrity between the 2 treatment groups at final follow-up; however, medial cuff failure was observed only in the SB group, and incomplete healing was more frequent in the medSR group. One should consider the risk of medial cuff failure and incomplete healing of the repaired cuff before choosing the repair technique for medium-sized supraspinatus tears.

LEVEL OF EVIDENCE

Level I, therapeutic, prospective, randomized trial.

Current Concepts in Rotator Cuff Repair Techniques: Biomechanical, Functional, and Structural Outcomes

There is substantial evidence indicating that double-row (DR) repair restores more of the anatomic rotator cuff footprint and is biomechanically superior to single-row (SR) repair. Transosseous-equivalent (TOE) techniques have shown biomechanical advantages when compared with traditional DR, including increased contact at the rotator cuff footprint, higher pressure at the tendon-bone interface, and increased failure strength. Several meta-analyses of evidence level 1 and 2 studies have shown a lower rate of failed/incomplete healing when DR repair was compared with SR repair types. There is some limited evidence that TOE techniques improve healing rates in large and massive tears as compared with SR and DR. Overall, most level 1 and 2 studies have failed to prove a significant difference between SR and DR repairs in terms of clinical outcomes. However, most studies include only short-term follow-up, minimizing the impact that the higher rate of retears/failed healing seen with SR repairs can have in the long term. There are no high-quality clinical studies comparing different DR configurations, and there are currently not enough clinical data to determine the functional advantages of various DR technique modifications over one another. Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance. It is essential for the orthopaedic surgeon to know in detail the available literature to be able to apply the most appropriate and cost-effective technique in terms of healing and functional outcomes. This review provides a critical analysis of the comparative biomechanical and clinical studies among SR, DR, and TOE techniques reported in the literature in the past decade.

Comparison of arthroscopic suture-bridge technique and double-row technique for treating rotator cuff tears: A PRISMA meta-analysis

BACKGROUND

Rotator cuff tear is a common shoulder disorder in the elderly. Either arthroscopic double-row (DR) or suture-bridge (SB) technique for rotator cuff tear patients is needed to choose. We conducted this systematic review and meta-analysis to compare the clinical outcomes of arthroscopic SB versus DR intervention.

METHODS

The 7 studies were acquired from PubMed, Medline, Embase, CNKI, Google, and Cochrane Library. The data were extracted by 2 of the co-authors independently and were analyzed by RevMan5.3. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa scale were used to assess risk of bias.

RESULTS

Seven studies including 1 randomized controlled trial and 6 observational studies were assessed. The methodological quality of the trials ranged from low to moderate. The pooled results of American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score, and range of motion showed that the differences were not statistically significant between the 2 interventions. The difference of University of California at Los Angeles (UCLA) score was statistically significant between SB and DR intervention, and SB treatment was more effective (MD = -0.95, 95% CI = -1.70 to -0.20, P = .01). The difference of re-tear rate was statistically significant and SB treatment achieved better result than DR treatment (OR = 0.31, 95% CI = 0.15-0.64, P = .001). Sensitivity analysis proved the stability of the pooled results and the publication bias was not apparent.

CONCLUSIONS

Both arthroscopic SB and DR interventions had benefits in rotator cuff tear. SB treatment was more effective in UCLA score and had lower re-tear rate than DR treatment. The arthroscopic SB technique is recommended as the optical choice for rotator cuff tear.

Clinical outcomes of arthroscopic rotator cuff repair: a retrospective comparison of double-layer, double-row and suture bridge methods

BACKGROUND

The suture-bridge (SB) method has recently become the mainstream means of repairing full-thickness rotator cuff tears. However, in some patients the deep and superficial layers have moved in different directions because of delamination of their rotator cuffs. In such cases, a simple suture (double-layer, double-row [DD] method) is used to repair the superficial and deep layers separately. The purpose of this study was to analyze the clinical outcomes and re-tear rates of the DD and SB methods, with patients selected according to the condition of their torn cuffs.

METHODS

We retrospectively registered 74 patients with full-thickness rotator cuff tears that had been repaired arthroscopically, 35 shoulders by the DD and 39 by the SB method. Mean ages were 66.1 years in the DD and 62.9 years in the SB group. We evaluated clinical status before and after surgery (Japanese Orthopedic Association [JOA] scores) and re-tear rate. The Wilcoxon signed-ranks test was used to compare JOA scores and active ROM between before and after surgery in each group. Mann-Whitney's U test was used for comparing JOA scores, active ROM, re-tear rates, size of tear, duration of follow-up, sex, and presence of subscapular muscle repair between the DD and SB groups. A hazard ratio of less than 5% was considered to denote significance.

RESULTS

JOA scores improved significantly in the DD and SB groups from preoperative means of 63.4 and 63.3 points, respectively, to postoperative means of 91.8 and 92.1 points, respectively. The active flexural ROM improved significantly from means of 110.1° and 100.0°, respectively, to postoperative means of 142.3° and 142.7°, respectively; the differences between groups were not significant. Re-tear occurred in 5.9% of the DD (two of 34 shoulders) and 7.9% of the SB group (three of 38 shoulders); its incidence did not differ significantly between the two groups.

CONCLUSIONS

Both the DD and SB methods achieve satisfactory clinical outcomes that do not differ significantly. Our results suggest that careful selection of operative method on the basis of the delamination pattern in patients undergoing RCT may reduce the re-tear rate after utilizing the SB method.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and meta-analysis study

PURPOSE

The purpose of this study is to perform a systematic review and meta-analysis of all available level I prospective randomized controlled trials comparing arthroscopic single-row (SR) with double-row (DR) rotator cuff repairs by both clinical outcomes and radiological re-tear rates.

METHODS

PubMed, EMBASE, Google Scholar, and Cochrane databases search was done for level I RCTs comparing clinical and radiological outcomes after SR versus DR rotator cuff repair. Clinical outcomes included UCLA, ASES, Constant, WORC, and SANE scores; structural outcomes included MRI, MRA, or US.

RESULTS

Seven level I studies were included (5 mid-term and 2 short-term). Postoperative ASES, Constant, WORC, and SANE scores showed nonsignificant slightly better function of DR groups. Only, UCLA score showed significantly better scores with DR repair (p = 0.007). Full-thickness re-tear incidence was reported in 15/174 (8.6%) in DR group and 20/175 (11.4%) in SR group (p = 0.44). Partial-thickness re-tear rate was reported in 18/174 patients (10.3%) in DR group and 41/175 patients (23.4%) in SR group (p = 0.009).

CONCLUSION

Within the domain of level I mid-term and short-term studies, DR repair showed significant better UCLA score only. (ASES, Constant, WORC, and SANE scores showed no significance.) This may correlate weakly with the significant lower partial-thickness re-tear rates of DR repairs. In contrary, long-term level III studies showed a direct correlation of both functional outcomes and cuff structural integrity, with significant superiority of DR over SR repair techniques.

LEVEL OF EVIDENCE

Level 1, systematic review and meta-analysis.

Critical period and risk factors for retear following arthroscopic repair of the rotator cuff

PURPOSE

The incidence of retear following rotator cuff repair remains a major concern, and the cause and timing of retear remain unclear. The aim of this study was to prospectively investigate the timing of retears following rotator cuff repair at multiple time intervals. The hypothesis was that the 'critical period' for retears extends beyond the first three post-operative months.

METHODS

The authors prospectively studied 206 shoulders that underwent arthroscopic double-row (without suture bridge) suture anchor repair for rotator cuff tears. Patients were recalled to three follow-up visits at the following post-operative time intervals: 3, 6, and 12 months or longer. Ultrasonography was performed at each visit, and Constant score was collected during the last visit.

RESULTS

A total of 176 shoulders attended all required follow-up visits with mean age 56.0 years. Ultrasonography revealed retears in 16 shoulders (9.1 %) at 3 months, in 6 shoulders (3.4 %) at 6 months, and in 5 others (2.8 %) at the last follow-up, while it confirmed intact rotator cuffs in 149 shoulders (84.7 %) at the last follow-up (median 35.5; range 12-61). The incidence of retears was significantly associated with tear size (p = 0.001) and tendon degeneration (p = 0.003).

CONCLUSION

The 'critical period' for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months. The risk of retear is greatest for massive 3-tendon tears, which may require longer periods of protection. The clinical relevance of this study is the identification of patients at risk of retear and the adjustment of their rehabilitation strategy and time for return to work.

LEVEL OF EVIDENCE

III.

Longitudinal Long-term Magnetic Resonance Imaging and Clinical Follow-up After Single-Row Arthroscopic Rotator Cuff Repair: Clinical Superiority of Structural Tendon Integrity

BACKGROUND

The number of arthroscopic rotator cuff surgeries is consistently increasing. Although generally considered successful, the reported number of retears after rotator cuff repair is substantial. Short-term clinical outcomes are reported to be rarely impaired by tendon retears, whereas to our knowledge, there is no study documenting long-term clinical outcomes and tendon integrity after arthroscopic rotator cuff repair.

PURPOSE

To investigate longitudinal long-term repair integrity and clinical outcomes after arthroscopic rotator cuff reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty patients who underwent arthroscopic rotator cuff repair with suture anchors for a full-tendon full-thickness tear of the supraspinatus or a partial-tendon full-thickness tear of the infraspinatus were included. Two and 10 years after initial arthroscopic surgery, tendon integrity was analyzed using magnetic resonance imaging (MRI). The University of California, Los Angeles (UCLA) score and Constant score as well as subjective questions regarding satisfaction with the procedure and return to normal activity were used to evaluate short- and long-term outcomes.

RESULTS

At the early MRI follow-up, 42% of patients showed a full-thickness rerupture, while 25% had a partial rerupture, and 33% of tendons remained intact. The 10-year MRI follow-up (129 ± 11 months) showed 50% with a total rerupture, while the other half of the tendons were partially reruptured (25%) or intact (25%). The UCLA and Constant scores significantly improved from preoperatively (UCLA total: 50.6% ± 20.2%; Constant total: 44.7 ± 10.5 points) to 2 years (UCLA total: 91.4% ± 16.0% [ P < .001]; Constant total: 87.8 ± 15.3 points [ P < .001]) and remained significantly higher after 10 years (UCLA total: 89.7% ± 15.9% [ P < .001]; Constant total: 77.5 ± 15.6 points [ P < .001]). The Constant total score and Constant strength subscore, but not the UCLA score, were also significantly better at 10 years postoperatively in patients with intact tendons compared with patients with retorn tendons (Constant total: 89.0 ± 7.8 points vs 75.7 ± 14.1 points, respectively [ P = .034]; Constant strength: 18.0 ± 4.9 points vs 9.2 ± 5.2 points, respectively [ P = .006]). The majority of patients rated their satisfaction with the procedure as "excellent" (83.3%), and 87.5% returned to their normal daily activities.

CONCLUSION

Arthroscopic rotator cuff repair showed good clinical long-term results despite a high rate of retears. Nonetheless, intact tendons provided significantly superior clinical long-term outcomes, making the improvement of tendon healing and repair integrity important goals of future research efforts.

All-Suture Repair for Compressive Rotator Cuff Tears: Reducing the Traction of the Tissue

Tears of the rotator cuff are a frequent pathology, but the best surgical procedure remains unclear. The arthroscopic approach has become the gold standard, but there are many different suture configurations that can be used. We describe an all-suture repair system with which the anatomical reduction of the rotator cuff is achieved performing traction from the anchor of the lateral row to subsequently performing a suture bridge suture from the medial row. The major advantage of this technique is that it creates compression forces and minimizing tensioning of the tissue.

The Rotator Cuff Organ: Integrating Developmental Biology, Tissue Engineering, and Surgical Considerations to Treat Chronic Massive Rotator Cuff Tears

The torn rotator cuff remains a persistent orthopedic challenge, with poor outcomes disproportionately associated with chronic, massive tears. Degenerative changes in the tissues that comprise the rotator cuff organ, including muscle, tendon, and bone, contribute to the poor healing capacity of chronic tears, resulting in poor function and an increased risk for repair failure. Tissue engineering strategies to augment rotator cuff repair have been developed in an effort to improve rotator cuff healing and have focused on three principal aims: (1) immediate mechanical augmentation of the surgical repair, (2) restoration of muscle quality and contractility, and (3) regeneration of native enthesis structure. Work in these areas will be reviewed in sequence, highlighting the relevant pathophysiology, developmental biology, and biomechanics, which must be considered when designing therapeutic applications. While the independent use of these strategies has shown promise, synergistic benefits may emerge from their combined application given the interdependence of the tissues that constitute the rotator cuff organ. Furthermore, controlled mobilization of augmented rotator cuff repairs during postoperative rehabilitation may provide mechanotransductive cues capable of guiding tissue regeneration and restoration of rotator cuff function. Present challenges and future possibilities will be identified, which if realized, may provide solutions to the vexing condition of chronic massive rotator cuff tears.

Could Disruption of the Shoulder Superior Capsule Be the "Essential Lesion" of Rotator Cuff Disease? Possibly, but Questions Remain…

Rotator cuff disease remains a complex clinical problem with significant variation in pathology, clinical presentation, and management options. Functionally, humeral head depression is critical in restoring or maintaining arm elevation, and the shoulder superior capsule serves in this important function. Could disruption of the shoulder superior capsule be the "essential lesion" of rotator cuff disease? Possibly, but many questions remain unanswered, and substantial scientific evidence is required before we can assert with certainty that disruption of the superior capsule with resultant superior instability of the humeral head is the essential lesion of rotator cuff disease.

Tendon Collagen Crosslinking Offers Potential to Improve Suture Pullout in Rotator Cuff Repair: An Ex Vivo Sheep Study

BACKGROUND

The suture-tendon interface is often the weakest link in tendon to bone repair of massive rotator cuff tears. Genipin is a low-toxicity collagen crosslinker derived from the gardenia fruit that has been shown to augment collagen tissue strength and mechanically arrest tendon-tear progression.

QUESTION/PURPOSE

The purpose of the current study was to evaluate whether genipin crosslinking can sufficiently augment the suture-tendon interface to improve suture pullout strength using simple single-loop sutures and the modified Mason-Allen technique. The study also aimed to assess whether time of genipin treatment is a relevant factor in efficacy.

METHODS

In an ex vivo (cadaveric) sheep rotator cuff tendon model, a total of 142 suture pullout tests were performed on 32 infraspinatus tendons. Each tendon was prepared with three single-loop stitches. Two groups were pretreated by incubation in genipin solution for either 4 hours or 24 hours. Two corresponding control groups were incubated in phosphate buffered saline for the same periods. The same test protocol was applied to tendons using modified Mason-Allen technique stitch patterns. Each suture was loaded to failure on a universal materials testing machine. Suture pullout force, stiffness, and work to failure were calculated from force-displacement data, and then compared among the groups.

RESULTS

Median single-loop pullout force on tendons incubated for 24 hours in genipin yielded an approximately 30% increase in maximum pullout force for single-loop stitches with a median of 73 N (range, 56-114 N) compared with 56 N (range, 40-69 N; difference of medians = 17 N; p = 0.028), with corresponding increases in the required work to failure but not stiffness. Genipin treatment for 4 hours showed no added benefit for suture-pullout behavior (46 N, [range, 35-95 N] versus 45 N, [range, 28-63 N]; difference of medians, 1 N; p = 1). No tested genipin crosslinking conditions indicated benefit for tendons grasped using the modified Mason-Allen technique after 4 hours (162 N, [range, 143-193 N] versus 140 N, [range, 129-151 N]; difference of medians, 22 N; p = 0.114) or after 24 hours of crosslinking (172 N, [range, 42-183 N] versus 164 N [range, 151-180 N]; difference of medians, 8 N; p = 0.886).

CONCLUSION

Exogenous collagen crosslinking in genipin can markedly improve resistance to pullout at the tendon-suture interface for simple stitch patterns while the modified Mason-Allen stitch showed no benefit in an ex vivo animal model.

CLINICAL RELEVANCE

Tendon strength augmentation by genipin pretreatment offers the potential to improve suture retention properties. Future studies are warranted for the development of clinically viable intraoperative delivery strategies and in vivo testing for safety and efficacy.

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.

Summary of Meta-Analyses Dealing with Single-Row versus Double-Row Repair Techniques for Rotator Cuff Tears

Background:

Several meta-analyses of randomized clinical trials have been performed to analyze whether double-row (DR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing compared to single-row (SR) repair. The purpose of this study was to sum up the results of meta-analysis comparing SR and DR repair with respect on clinical outcomes and re-tear rates.

Methods:

A literature search was undertaken to identify all meta-analyses dealing with randomized controlled trials comparing clinical und structural outcomes after SR versus DR RCR.

Results:

Eight meta-analyses met the eligibility criteria: two including Level I studies only, five including both Level I and Level II studies, and one including additional Level III studies. Four meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas four favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas six found DR repair to be superior for tears greater than 3 cm tears.

Conclusion:

No clinical differences are seen between single-row and double-row repair for small and medium rotator cuff tears after a short-term follow-up period with a higher re-tear rate following single-row repairs. There seems to be a trend to superior results with double-row repair in large to massive tear sizes.

Triple-Loaded Single-Row Versus Suture-Bridge Double-Row Rotator Cuff Tendon Repair With Platelet-Rich Plasma Fibrin Membrane: A Randomized Controlled Trial

PURPOSE

To compare the structural healing and clinical outcomes of triple-loaded single-row with suture-bridging double-row repairs of full-thickness rotator cuff tendons when both repair constructs are augmented with platelet-rich plasma fibrin membrane.

METHODS

A prospective, randomized, consecutive series of patients diagnosed with full-thickness rotator cuff tears no greater than 3 cm in anteroposterior length were treated with a triple-loaded single-row (20) or suture-bridging double-row (20) repair augmented with platelet-rich plasma fibrin membrane. The primary outcome measure was cuff integrity by magnetic resonance imaging (MRI) at 12 months postoperatively. Secondary clinical outcome measures were American Shoulder and Elbow Surgeons, Rowe, Simple Shoulder Test, Constant, and Single Assessment Numeric Evaluation scores.

RESULTS

The mean MRI interval was 12.6 months (range, 12-17 months). A total of 3 of 20 single-row repairs and 3 of 20 double-row repairs (15%) had tears at follow-up MRI. The single-row group had re-tears in 1 single tendon repair and 2 double tendon repairs. All 3 tears failed at the original attachment site (Cho type 1). In the double-row group, re-tears were found in 3 double tendon repairs. All 3 tears failed medial to the medial row near the musculotendinous junction (Cho type 2). All clinical outcome measures were significantly improved from the preoperative level (P < .0001), but there was no statistical difference between groups postoperatively.

CONCLUSIONS

There is no MRI difference in rotator cuff tendon re-tear rate at 12 months postsurgery between a triple-loaded single-row repair or a suture-bridging double-row repair when both are augmented with platelet-rich plasma fibrin membrane. No difference could be demonstrated between these repairs on clinical outcome scores.

LEVEL OF EVIDENCE

I, Prospective randomized study.

Editorial Commentary: Meta-analyses Are on the Rise, but Are We Learning More?

The number of published meta-analyses in the arthroscopy literature is clearly on the rise. As this increase occurs, it is important to step back and refresh ourselves on the key features of meta-analyses.

High-Tensile Strength Tape Versus High-Tensile Strength Suture: A Biomechanical Study

PURPOSE

To determine which suture design, high-tensile strength tape or high-tensile strength suture, performed better at securing human tissue across 4 selected suture techniques commonly used in tendinous repair, by comparing the total load at failure measured during a fixed-rate longitudinal single load to failure using a biomechanical testing machine.

METHODS

Matched sets of tendon specimens with bony attachments were dissected from 15 human cadaveric lower extremities in a manner allowing for direct comparison testing. With the use of selected techniques (simple Mason-Allen in the patellar tendon specimens, whip stitch in the quadriceps tendon specimens, and Krackow stitch in the Achilles tendon specimens), 1 sample of each set was sutured with a 2-mm braided, nonabsorbable, high-tensile strength tape and the other with a No. 2 braided, nonabsorbable, high-tensile strength suture. A total of 120 specimens were tested. Each model was loaded to failure at a fixed longitudinal traction rate of 100 mm/min. The maximum load and failure method were recorded.

RESULTS

In the whip stitch and the Krackow-stitch models, the high-tensile strength tape had a significantly greater mean load at failure with a difference of 181 N (P = .001) and 94 N (P = .015) respectively. No significant difference was found in the Mason-Allen and simple stitch models. Pull-through remained the most common method of failure at an overall rate of 56.7% (suture = 55%; tape = 58.3%).

CONCLUSIONS

In biomechanical testing during a single load to failure, high-tensile strength tape performs more favorably than high-tensile strength suture, with a greater mean load to failure, in both the whip- and Krackow-stitch models. Although suture pull-through remains the most common method of failure, high-tensile strength tape requires a significantly greater load to pull-through in a whip-stitch and Krakow-stitch model.

CLINICAL RELEVANCE

The biomechanical data obtained in the current study indicates that high-tensile strength tape may provide better repair strength compared with high-tensile strength suture at time-zero simulated testing.

Editorial Commentary: Biomechanical Data Does Not Translate to Clinical Rerupture Rates After Shoulder Rotator Cuff Repair Using Different Suture Techniques

Biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size. Explanations include reporting and selection bias.