Open repair of massive rotator cuff tears in patients aged sixty-five years or over: is it worthwhile?

Arthroscopic rotator cuff repair in patients over 65 years of age: successful functional outcomes and a high tendon integrity rate can be obtained after surgery

Background

Although interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears.

Methods

A retrospective study was conducted with the following inclusion criteria: (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness posterosuperior tears; (2) age over 65 years at surgery; and (3) participation in 24 months of follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the 12-Item Short Form Survey, the American Shoulder and Elbow Surgeons, and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification.

Results

The final sample consisted of 110 patients with an average age of 69.2 ± 3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all P < .001) after a mean follow-up time of 54.5 ± 22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (P < .001, β = -6.085) and lower age (P = .004, β = -0.533). Higher postoperative American Shoulder and Elbow Surgeons were associated with lower age (P = .020, β = -0.414). Higher postoperative 12-Item Short Form Survey physical component score and mental component score were associated with lower age (P = .013, β = -0.550 and P < .001, β = -0.520, respectively) and shorter preoperative physical therapy period (P = .013, β = -2.075 and P = .006, β = -1.093, respectively).

Conclusion

A significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical, and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears

BACKGROUND

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

METHODS

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

RESULTS

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

CONCLUSION

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Arthroscopic Superior Capsular Reconstruction for Older Patients With Irreparable Rotator Cuff Tears: A Comparative Study With Younger Patients

BACKGROUND

Arthroscopic superior capsular reconstruction (ASCR) is a method for treating irreparable chronic rotator cuff tears. However, the extent to which ASCR can be performed with regard to the patient's age has yet to be determined.

PURPOSE

To compare the surgical outcomes of ASCR for the treatment of irreparable rotator cuff tears (IRCTs) in patients aged <65 years versus patients aged ≥65 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Of 105 patients with IRCTs who underwent ASCR between March 2013 and June 2020, 73 patients were enrolled in this study based on the selection criteria. Polypropylene mesh augmentation to the graft was used in 18 of 36 patients in the younger adults group (age, <65 years) and 20 of 37 patients in the older adults group (age, ≥65 years). The clinical and radiological outcomes were evaluated preoperatively and at the final clinical follow-up. The graft integrity status was evaluated using serial magnetic resonance imaging and set as the primary endpoint. Furthermore, subgroup analysis was performed based on age group and graft type.

RESULTS

The mean age of the patients was 59.2 ± 3.8 years in the younger adults group and 70.5 ± 4.1 years in the older adults group. Both groups showed improvement based on the clinical and radiological outcomes at the final follow-up. The mean American Shoulder and Elbow Surgeons scores improved from 52.3 ± 15.4 to 77.3 ± 13.5 in the younger adults group (P < .001) and from 45.7 ± 16.1 to 76.6 ± 11.4 in the older adults group (P < .001). The mean visual analog scale for pain scores improved from 5.5 ± 1.2 to 2.1 ± 0.9 in the younger adults group (P < .001) and from 5.5 ± 1.4 to 2.1 ± 1.2 in the older adults group (P < .001). The graft healing rate was significantly higher in the younger adults group (81%) than in the older adults group (65%) (P = .049). Subgroup analysis showed that after mesh augmentation, the healing rate in the younger adults group (84%) was similar to that in the older adults group (85%) (P = .299).

CONCLUSION

ASCR resulted in a favorable surgical outcome for both younger and older adult patients with IRCT. The younger patients had lower graft failure rates and superior surgical outcomes. In older patients, ASCR using polypropylene mesh augmentation may reduce graft failure and result in surgical outcomes similar to those in younger patients.

Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re-tear

PURPOSE

To conduct a systematic review of outcomes following primary arthroscopic repair of chronic massive rotator cuff tears (RCTs) and to assess clinical outcomes and rates of repair failure. The authors' preferred treatment algorithm is also provided.

METHODS

Medline, Embase and PubMed were searched identifying articles pertaining to primary arthroscopic repair of chronic massive RCTs without the use of augmentation. Primary outcomes were patient-reported outcomes and the secondary outcome was the rate of repair failure. Outcome data were pooled and presented as well as assessment of study methodological quality. Data from studies reporting similar outcome measures were pooled when possible, and mean differences alongside confidence intervals and p values were reported, where appropriate.

RESULTS

Twenty-six studies (1405 participants) were included, with mean age of 62 years (range 52-69). The mean duration of symptoms pre-operatively was 31 months (range 6-40), and the mean follow-up time was 39 months (range 12-111). Complete repair was performed in 78% of patients and partial repair was performed in 22%. Both complete and partial repairs resulted in significant improvements with respect to pain, range of motion and functional outcome scores. The rate of repair failure for the total cohort was 36% at a mean follow-up of 31 months, and for the complete and partial repair subgroups the failure rate was 35% and 40%, respectively.

CONCLUSIONS

Arthroscopic repairs of chronic, massive RCTs, whether complete or partial, are associated with significant improvements in pain, function and objective outcome scores. The rate of repair failure is lower than previously reported, however, still high at 36%. The present paper finds that arthroscopic repair is still a viable treatment option for massive RCTs.

LEVEL OF EVIDENCE

IV.

Septuagenarians aged 75 years and older do benefit from arthroscopic rotator cuff repair: a propensity matched-pair analysis

Background

Numerous studies show that patients who failed conservative management, benefit from open, mini open and arthroscopic rotator cuff repair (ARCR). However, there is a paucity of literature addressing ARCR and outcomes in patients older than the age of 75 years. The purpose of our study was to compare the outcomes of ARCR in patients older than 75 years and younger than 75 years of age.

Methods

Between January 2010 and December 2016, 397 patients underwent unilateral ARCR; of which, 23 patients were 75 years of age and older. Outcome measures recorded include the Constant Shoulder Score (CSS), University of California, Los Angeles Shoulder Score (UCLASS), Oxford Shoulder Score (OSS), and visual analog scale (VAS) for pain assessment.

Results

There were no statistically significant differences in VAS, CSS, and UCLASS between the two groups at all time points of follow-up (all P > .05). At 2 years after surgery, the OSS was 2 ± 5 points better in the <75 group (P = .012). However, the improvement in OSS was comparable between both groups. The improvement in VAS, CSS, and UCLASS at 2 years after surgery compared with baseline was also similar between the two groups (all P < .05).

Conclusions

The improvement in VAS, CSS, and UCLASS was similar in both groups of patients. We conclude that septuagenarians with symptomatic cuff tears, who have failed conservative management, experience significant improvement in pain, and function after surgery and should not be excluded from the benefits of ARCR.

Prognostische Faktoren der arthroskopischen Rotatorenmanschettenrekonstruktion

Hintergrund

Rupturen der Rotatorenmanschette sind eine der häufigsten Erkrankungen des Bewegungsapparats. Die klinischen und strukturellen Ergebnisse nach einer arthroskopischen Rotatorenmanschettenrekonstruktion (ARCR) sind im Allgemeinen gut, aber hinsichtlich der großen Schwankungsbreite der postoperativen Resultate noch verbesserungsfähig.

Fragestellung

Ziel dieser Literaturübersicht ist es, einen Überblick über prognostische Faktoren zu geben, die das postoperative Ergebnis nach ARCR beeinflussen.

Material und Methoden

Systematische Reviews, welche prognostische Faktoren für das Outcome nach ARCR analysieren, wurden in diese Übersichtsarbeit eingeschlossen. Die Literatursuche erfolgte in den Datenbanken Embase, Medline (Ovid) und Scopus. In die Auswertung wurden nur prognostischen Faktoren eingeschlossen, welche in mindestens zwei Übersichtsarbeiten beschrieben wurden.

Ergebnisse

Sieben systematische Reviews mit insgesamt 332 eingeschlossenen Artikeln wurden ausgewertet. Postoperative Ergebnisse waren Patientenzufriedenheit, Lebensqualität sowie funktionelle und strukturelle Ergebnisse. Sechzehn prognostische Faktoren wurden identifiziert und in patientenbezogene, rupturbezogene und behandlungsbezogene prognostische Faktoren untergliedert.

Schlussfolgerung

Anhand von patienten-, ruptur- und behandlungsbezogenen prognostischen Faktoren soll in Zukunft ein Vorhersagemodell erstellt werden können, um die individuellen Heilungschancen nach ARCR vorherzusagen und dem Patienten eine präzise Therapieempfehlung abgeben zu können.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?

BACKGROUND

This study was conducted to ascertain whether patients aged older than 75 years achieve outcomes after arthroscopic rotator cuff repair comparable to younger patients.

METHODS

Arthroscopic cuff repair was performed in 60 shoulders of 59 patients aged older than 75 years. A control group of 60 younger patients, matched for sex, tear size, and American Society of Anesthesiology Functional Classification grade were included. Surgery occurred from 2006 to 2016. Prospective outcomes were the Constant score (CS), Subjective Shoulder Value, pain, satisfaction, and operative complications. Mean follow-up was 29 months.

RESULTS

The elderly group was a mean age of 78 years compared with 59 years for controls. Tear sizes were 25 massive, 20 large, 12 medium, and 3 small. The CS improved by 25.1 points in elderly patients compared with 23.7 points for controls (P = .742). Pain improved by 7.5 of 15 in elderly patients vs. 6.2 of 15 in controls (P = .055). Fifty-five of 59 older patients were satisfied compared with 52 of 60 controls (P = .378). The overall complication rate did not differ between the groups (P = .509). Both groups had 1 infection and 1 stiffness. An acromioclavicular joint cyst developed in 1 younger patient, and a traumatic retear occurred in 1 patient. Subsequent reverse total shoulder arthroplasty was performed in 4 elderly patients at a mean of 28 months after cuff repair. Massive tears had higher risk for subsequent reverse total shoulder arthroplasty (P = .026).

CONCLUSION

Elderly patients benefit as much from arthroscopic rotator cuff repair as their younger counterparts. Similar improvements in CS, Subjective Shoulder Value, pain, and satisfaction occurred for both elderly and control patients. Arthroscopic repair was safe and effective in both groups. Even elderly patients with massive tears showed clinically significant improvements. Arthroscopic rotator cuff repair should be considered as a valuable treatment irrespective of age.

Current Concepts and Recent Trends in Arthroscopic Treatment of Large to Massive Rotator Cuff Tears: A Review

Rotator cuff tear is a common cause of shoulder pain and disability in adults. Due to the various nature of progression of rotator cuff tears and the complex biomechanics of the shoulder joint, repair and treatment of large-to-massive tears are challenging for many surgeons. Despite the recent popularity of reverse total shoulder arthroplasty as a treatment option for large-to-massive irreparable rotator cuff tears, biological and mechanical repair augmentation has also shown promise as a viable treatment option. The purpose of this study was to briefly summarize and review current studies on the assessment and arthroscopic treatment of large-to-massive rotator cuff tears, whether repairable or irreparable, to aid in developing a consensus on future treatment directions.

Functional outcomes and repair integrity after arthroscopic repair of partial articular supraspinatus tendon avulsion

INTRODUCTION

Partial-thickness rotator cuff tears are a common cause of shoulder pain and disability. Arthroscopic repair is an effective treatment for partial articular supraspinatus tendon avulsion (PASTA) lesions, and transtendon repair and completion of the tear and repair are the surgical techniques commonly used to treat such lesions. Our aim was to retrospectively evaluate the minimum 24-month clinical and radiological results of PASTA.

MATERIALS AND METHODS

Patients suffering from PASTA lesion who underwent arthroscopic repair with a minimum 24-month follow-up were included in this study. The Constant and Murley score (CMS) was used to assess the patients' functionality pre- and postoperatively. The postoperative patient assessment included the simple shoulder test (SST). Postoperative tendon integrity was evaluated by ultrasound examination.

RESULTS

151 patients (153 shoulders) were retrospectively evaluated 73.9 (24-142) months after a completion-repair (94 cases) or transtendon repair (59 cases) of a PASTA lesion. The CMS significantly improved from 47.7 (22-63) preoperatively to 84.2 (62-100) postoperatively (p < 0.001). The mean postoperative SST score was 10.1 (5-12), and 95% of patients were satisfied with the surgery. No significant differences were noted between the two techniques in terms of postoperative CMS, SST score and satisfaction. Seventy-four and 43 cases treated with completion and repair and transtendon repair, respectively, performed ultrasound examination 66.1 (24-142) months after surgery. The overall retear rate was 13.7%, supraspinatus retears were observed in ten shoulder subjected to completion and repair (13.5%) and six shoulders subjected to transtendon repair (13.9%), and no significant differences were noted between the two techniques as for CMS (p = 0.896), SST (p = 0.973), satisfaction (p = 0.621) and retear (p = 0.999). Males and younger patients had a higher postoperative CMS (p values < 0.001), and SST score (p < 0.001 and p = 0.038, respectively).

CONCLUSIONS

Arthroscopic repair of PASTA lesion achieves high rates of repair integrity regardless of repair type and high levels of functional recovery and patient satisfaction 6 years after surgery.

Prognostic Factors for Functional Outcome After Rotator Cuff Repair: A Prospective Cohort Study With 2-Year Follow-up

BACKGROUND

Although shoulder function is reported to be generally good after rotator cuff repair, limited knowledge exists regarding which prognostic factors predict functional outcomes.

PURPOSE

To identify pre- and perioperative predictors of functional outcomes after arthroscopic rotator cuff repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A cohort of 733 consecutive patients treated with rotator cuff repair between 2010 and 2014 in a single orthopaedics unit was included. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariable linear regression analyses were used to predict shoulder function at 2-year follow-up, as measured by the Western Ontario Rotator Cuff Index (WORC).

RESULTS

In total, 647 (88%) patients were followed for 25 ± 5 months (mean ± SD; range, 17-66 months). In the multivariable regression model, the adjusted R² was 0.360, indicating that 36% of the variation in the WORC at final follow-up could be explained by this statistical model. The multivariable linear regression analysis revealed that the strongest positive independent predictors of shoulder function at 2 years were preoperative WORC and Constant-Murley score in the contralateral shoulder. The model also indicated that activities of daily living, age, subacromial decompression, and biceps surgery had independent positive associations with better shoulder function at 2 years. In addition, previous surgery in the ipsilateral or contralateral shoulder, smoking, partial rotator cuff repair, preoperative pain, and atrophy in the infraspinatus were all independent factors negatively associated with shoulder function after 2 years. The overall healing rate of complete repairs per magnetic resonance imaging was 80%.

CONCLUSION

The most important finding of the present study was that the strongest prognostic factors for better WORC at 2-year follow-up were better preoperative WORC and Constant-Murley score in the contralateral shoulder. Although not all the prognostic factors identified in this study are modifiable, they can still be useful for guiding patients in shared decision making with the surgeon. This cohort study shows that if selection of patients is performed properly, it is possible to obtain a successful outcome.

Outcomes of rotator cuff augmentation surgery with autologous fascia lata

OBJECTIVE

To evaluate whether augmentation grafts using autologous fascia lata improve functional results for rotator cuff repairs and reduce the retear rate compared to those without augmentation.

MATERIAL AND METHODS

This is a prospective evaluation comprising 20 patients with a complete symptomatic rotator cuff tear. The operations were carried out from a superior approach performing a total cuff repair, for 10 patients we used a suture augmented with an autologous graft taken from their own fascia lata while unaugmented sutures were used for the other 10 patients. The follow-up period lasted for one year post-intervention. We measured variables for tear type, functionality and pain, both baseline and at 6 and 12-month follow ups. We evaluated retear incidence in each group as well as each group's pain and functionality response.

RESULTS

The improved pain levels in the non-graft group evolved gradually over time. Conversely, in the group with the augmentation grafts, average Constant-Murley shoulder outcome scores at six months were already above 10 and were maintained at 12 months. One retear occurred in the graft group and 2 in the group without grafts, thus presenting no significant differences. There were no significant changes in pain and function values at the one year follow up in either group.

CONCLUSION

Our preliminary results regarding rotator cuff augmentation surgery with autologous fascia lata showed a significant improvement in pain levels after 6 months compared to the patients with no augmentation, who required 12 months to reach the same values. After a year of follow up, there were no differences between the mean Constant and pain scores in either intervention group The number of retears in the non-graft group was greater than that in the group with grafts although the difference was not significant.

Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review

BACKGROUND

Psychosocial factors are key determinants of health and can influence patient-reported outcomes after rotator cuff tears. However, to our knowledge, a systematic review of published studies has not been conducted to determine the degree of consistency and strength of the relationship between psychosocial factors and patient-reported outcomes in this patient population.

QUESTIONS/PURPOSES

(1) Are psychosocial factors associated with patient-reported measures at initial clinical presentation in patients with rotator cuff tears? (2) Are psychosocial factors associated with patient-reported outcomes after treatment in patients with rotator cuff tears?

METHODS

A systematic review of cross-sectional and prospective observational studies was performed in MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science from each database's inception to June 2016. We included studies examining associations between psychosocial factors and patient-reported measures in patients with rotator cuff tears. We excluded studies not reporting on this relationship, involving patients with nonspecific shoulder pain, and written in a language other than English. Two independent reviewers performed the search, extracted information, and assessed methodological quality. Study quality was assessed using the Methodological Items for Non-Randomized Studies (MINORS) criteria. The primary outcomes for the review were associations between each psychosocial factor and patient-reported measures of function or disability, pain, or quality of life. Associations were interpreted based on significance, strength, and direction of the relationship. A total of 10 studies (five cross-sectional and five prospective) in 1410 patients (age range, 46-62 years, 60% [571 of 958] men) were included in the review. Pooling of results for meta-analyses was not possible as a result of study heterogeneity.

RESULTS

Weak to moderate cross-sectional associations were found for emotional or mental health with function or disability and pain in multiple studies. Lower emotional or mental health function was associated with greater pain or disability or lower physical function at initial evaluation. Only one psychosocial factor (patient expectation) was weak to moderately associated with patient-reported outcomes after treatment in more than one study. In the two studies that examined expectations, the higher the expectation of benefit, the greater the perceived benefit after surgical intervention.

CONCLUSIONS

At the initial evaluation of patients with rotator cuff tear, there was an association between self-reported function and pain and emotional or mental health. However, these factors were not associated with patient-reported outcomes after intervention. This finding could be attributed to the lack of large prospective studies in this area or complex phenotypes within this patient population. Preoperative patient expectation is an important predictor of patient-reported outcomes in patients after rotator cuff surgery and may be a modifiable target for enhancing recovery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Tendon Repair Leads to better Long-Term Clinical Outcome than Debridement in Massive Rotator Cuff Tears

Introduction:

Massive tears in the rotator cuff are debilitating pathologies normally associated with loss of function and pain. Tendon reconstruction is seen as the standard treatment in order to preserve shoulder function and to inhibit cuff associated osteoarthritis. However, the effect on longer-term shoulder function and patient satisfaction is unknown.

Material and Methods:

165 consecutive patients with massive tears were included. 57 debridement (mean age 61.9±8.7 years (range 43-77)) and 108 reconstruction (mean age 57.5±8.9 years (range 45-74)) cases could be followed up 2-4 (short-term), 5-6 (mid-term) and 8-10 (long-term) years after surgery. Evaluation was performed with the Constant, a modified ASES and the DASH score. Statistical analysis was done using Sigma-Stat Version 3.5 with a p-value<0.05 indicating statistical significant differences.

Results:

All three scoring systems showed no significant differences in the short-term follow-up for the two groups (mean values: Constant debridement/repair: 70±11.9/66±13.6; ASES debridement/repair: 22.3±3.3/ 23.3±3.3; DASH debridement/repair: 22.3±11.0/ 24.3±10.1). In the mid-term (Constant debridement/repair: 51±2.9/68.3±5.2; ASES debridement/repair: 20.3±1.3/24.3±1.7; DASH debridement/repair: 31.0±6.5/20.3±5.4) and long-term follow-up (Constant debridement/repair: 42.3±3.8 /60.7±2.6, ASES debridement/repair: 17.3±0.5/21.7±0.5, DASH debridement/repair: 41.3±6.2/25.0±1.4), rotator cuff reconstruction revealed better objective results and better patients’ satisfaction.

Conclusion:

Rotator cuff tendon repair leads to better long-term clinical outcome and subjective satisfaction compared to debridement. Tendon reconstruction should be considered as a treatment for patients suffering from massive rotator cuff tears, thus preserving shoulder function and by that means delay indication for reverse arthroplasty.

Prognostic factors influencing the outcome of rotator cuff repair: a systematic review

PURPOSE

To identify prognostic factors significantly associated with rotator cuff repair outcome and define the strength of these associations.

METHODS

Search was performed using electronic databases. Studies reporting prognostic factors affecting rotator cuff repair outcome were included. Primary outcomes were: structural integrity, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, and Constant score. Each other outcome was considered as secondary outcome. Descriptive statistics was used. When possible, meta-analyses were performed. Methodological quality was assessed using the Quality In Prognosis Studies Tool. A best evidence synthesis was performed using the Grading of Recommendations Assessment, Development and Evaluation framework adapted to prognostic studies.

RESULTS

Sixty-four studies were included. Methodological quality was high only for twelve studies. The overall quality of evidence was low to very low. Meta-analyses were possible only for seven studies. Older age and larger tears size were found to affect retear risk. Results were controversial for fatty infiltration, acromioclavicular joint or biceps procedures, acromiohumeral distance, delamination of tendon edges, musculotendinous junction position, number of tendons involved, and tendon length, quality and retraction. Baseline scores and workers compensation claim predicted functional outcomes. Subjective outcome was also affected by patient's expectations.

CONCLUSIONS

Despite the large number of outcomes and prognostic factors evaluated by a relative small number of studies, almost not prognostic in design, it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair. Moreover, the low methodological quality of the included studies and, subsequently, the low quality of evidence, seriously affected the strength of recommendation of the present review. Based on data available, retear risk is mainly affected by older age and larger tears size. Baseline scores and work compensation claim are the most significant predictors for functional outcomes.

LEVEL OF EVIDENCE

Systematic review of level I-IV prognostic studies, Level IV.

Evaluation of the results from arthroscopic surgical treatment of rotator cuff injuries in patients aged 65 years and over

OBJECTIVES

To evaluate the results from arthroscopic surgical treatment of rotator cuff injuries in patients aged 65 years and over.

METHODS

Between 1998 and 2009, 168 patients underwent operations. Five cases were excluded. The remaining 163 patients were stratified according to their age group: 65-69 years (49.1%), 70-74 (26.4%) and 75 years and over (24.5%). Their mean age was 71 years (range: 65-83). There were 63 male patients (38.7%). The mean length of time with pain, from the onset of symptoms to the surgery, was 23 months (range: 2 days to 240 months). Sixty-two patients (38%) reported histories of trauma and 26 (16%) reported that their pain worsened through exertion.

RESULTS

From the UCLA criteria, 80.4% of the results were excellent, 16% good, 1.8% fair and 1.8% poor. Complications occurred in 11%. The final clinical result did not show any correlation with age progression, injury size or tendons affected. However, there was a significant association (p < 0.001) between the presence of trauma and larger injuries. The length of time between the onset of symptoms and the surgical procedure had a significant relationship (p < 0.027) with the postoperative results: the longer this time was, the worse the results were.

CONCLUSION

Arthroscopic treatment of rotator cuff injuries in patients aged 65 years and over presented excellent and good results in 96.4% of the cases, according to the UCLA assessment, with a low complication rate. Advanced age did not show any influence on the postoperative clinical evolution, but the earlier the surgical treatment was instituted, the better the results were.

Anatomic shoulder replacement for primary osteoarthritis in patients over 80 years: outcome is as good as in younger patients

BACKGROUND AND PURPOSE

Anatomic total shoulder arthroplasty (TSA) gives good outcome in the treatment of primary osteoarthritis, but it is not known whether this also applies to patients over 80 years old.

PATIENTS AND METHODS

We retrospectively assessed outcome in patients over the age of 80 after anatomic TSA, performed for primary osteoarthritis with a preoperative intact rotator cuff (group O, n = 32). We compared it with outcome in a group of patients under the age of 70 (group Y, n = 32). Subjective outcome, Constant score, and radiological findings were analyzed.

RESULTS

At a mean follow-up time of 7 years, there were no statistically significant differences between the groups. In group O, 24 patients were very satisfied and in group Y, 23 patients were very satisfied; the subjective shoulder value was 81% in both groups. Mean Constant score was 65 in group O and 67 in group Y. Moderate or severe radiological upper migration of the humeral head was detected in 1 patient in group O and in 3 patients in group Y. One patient in group Y was revised for glenoid loosening.

INTERPRETATION

Good to excellent results can be expected after anatomic TSA in patients over the age of 80. Our findings suggest that they have similar results to those in patients around 70 years of age.

Outcome of open massive rotator cuff repairs with double-row suture knotless anchors: case series

PURPOSE

The aim of the present study was to evaluate functional and quality of life outcomes after transosseous equivalent (TOE) double row suture technique for massive rotator cuff (RTC) tear repair using validated subjective and objective measures. This technique has shown promising preliminary results in RTC repair; however, a paucity of evidence regarding these outcomes in massive RTC (MRTC) tear repair exists.

METHODS

Patients were identified using the Hospital Inpatient Enquiry Scheme. Pre-operative MRI and medical records were reviewed. A massive RTC tear was defined as the detachment of two or more tendons from their point of insertion on the humeral head. The Constant and Oxford Shoulder Scores (OSS) and SF-12 questionnaire were used for evaluation.

RESULTS

Twenty-two patients were studied (72.7 % male; mean age at surgery, 62.6 years). Mean follow up was 14 (range six to 30) months. At six weeks postoperatively, 68 % achieved good or excellent shoulder function as measured by the OSS and Constant score. The cohort's mean SF-12 physical and emotional scores were significantly lower (p = 0.0002 and 0.037) and the vitality and mental health scores were higher (p = 0.005 and 0.006) than the reference norm scores.

CONCLUSIONS

The TOE double row surgical repair for MRTC tears provides good to excellent functional outcomes and is associated with high vitality and mental health scores at a mean of 14 months. Physical and emotional scores were lower than reference norm. These results suggest this repair technique is appropriate for massive rotator cuff tears, and future randomised control studies are warranted.

Specific patient-related prognostic factors for rotator cuff repair: a systematic review

BACKGROUND

Many studies that describe factors affecting outcome in primary rotator cuff repair (RCR) have been published, but so far there is no review that summarizes them. This systematic review was conducted to identify prognostic factors influencing functional (clinical) outcome and radiologically proven cuff integrity after RCR.

METHODS

A literature search was conducted up to July 2013 for prospective studies that describe prognostic factors affecting outcome in primary RCR. Inclusion criteria were open or arthroscopic repair of a full-thickness supraspinatus or infraspinatus tear. Included outcome measures were shoulder function and cuff integrity. Studies describing revision surgery, muscle transpositions, and subscapular or partial-thickness tears and those with retrospectively collected data were excluded, as were studies without linear or multivariate regression. The literature search resulted in 662 hits, and 12 of those studies were included in this review.

RESULTS

Moderate evidence was found for increasing age, larger tear size, and additional biceps or acromioclavicular procedures to have a negative influence on cuff integrity at follow-up as well as for Workers' Compensation Board status to have a negative influence on functional outcome after RCR. There is limited evidence that performance of an additional acromioclavicular procedure has a negative influence on functional outcome. There was insufficient evidence for other described prognostic factors.

CONCLUSION

Several patient-specific factors influencing functional and radiologic outcome after RCR have been identified. These factors can guide orthopedic surgeons in their decision-making process as to whether to operate on their patients.

Rotator cuff tears after 70 years of age: a prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients

INTRODUCTION

Arthroscopic repair of rotator cuff tears leads to better clinical outcomes than subacromial decompression alone; however the former is rarely proposed to patients above 70 years of age. Our hypothesis was that arthroscopic repair would be superior to decompression in patient 70 years or older. The primary goal was to compare the clinical results obtained with each technique. The secondary goal was to analyze the effects of age, tendon retraction and fatty infiltration on the outcome.

METHODS

This was a prospective, comparative, randomized, multicenter study where 154 patients were included who were at least 70 years of age. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 74.6 years. Shoulders had a complete supraspinatus tear with extension limited to the upper-third of the infraspinatus and Patte stage 1 or 2 retraction. Clinical outcomes were evaluated with the Constant, ASES and SST scores.

RESULTS

All scores improved significantly with both techniques: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001). However, repair led to even better results than decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference between repair and decompression was not correlated with age; arthroscopic repair was also better in patients above 75 years of age (Constant, ASES and SST scores P<0.01). There was no significant correlation between the final outcomes and initial retraction: Constant (P=0.14), ASES (P=0.92), SST (P=0.47). The difference between repair and decompression was greater in patients with stages 0 and 1 fatty infiltration (Constant P<0.02) than in patients with stages 2 and 3 fatty infiltration (Constant P<0.05).

CONCLUSION

There was a significant improvement in all-clinical scores for both techniques 1 year after surgery. Repair was significantly better than decompression for all clinical outcomes, even in patients above 75 years of age. The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.

Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function

BACKGROUND

Many patients with an unhealed cuff after repair show functional improvement.

PURPOSE

To evaluate outcomes of arthroscopically repaired massive rotator cuff tears and to identify prognostic factors affecting rotator cuff healing and functional outcome, especially in patients with failed rotator cuff healing.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Among 173 patients who underwent arthroscopic repair of a massive rotator cuff tear, 108 patients with a mean age of 63.7 years were included. Outcome evaluation was completed both anatomically (CT arthrography or ultrasonography) and functionally at a minimum of 1 year postoperatively; mean follow-up period was 31.68 ± 15.81 months. Various factors affecting cuff healing were analyzed, and factors affecting functional outcome were evaluated in patients with failed repairs using both univariate and multivariate analyses.

RESULTS

The anatomic failure rate was 39.8% in arthroscopically repaired massive rotator cuff tears; however, functional status significantly improved regardless of cuff healing (P < .05). Several factors were associated with failure of cuff healing in the univariate analysis, but only fatty infiltration (FI) of the infraspinatus was significantly related to healing failure in the multivariate analysis (P = .04). Among patients with failed rotator cuff healing, only reduced postoperative acromiohumeral distance (AHD) was related to poor functional outcome in the multivariate analysis (P = .01), with a cutoff value of 4.1 mm.

CONCLUSION

Despite a high rate of healing failures, arthroscopic repair can be recommended in patients with massive rotator cuff tears because of the functional gain at midterm follow-up. Higher FI of the infraspinatus was the single most important factor negatively affecting cuff healing. In cases of failed massive rotator cuff repair, no preoperative factor was able to predict poor functional outcome; reduced postoperative AHD was the only relevant functional determinant in the patients' eventual functional outcome and should be considered when ascertaining a prognosis and planning further treatment strategies.

Rotator cuff repair in patients over 70 years of age

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.

Factors that impact rehabilitation strategies after rotator cuff repair

Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.

Rotator cuff: biology and current arthroscopic techniques

The present article summarizes current trends in arthroscopic rotator cuff repairs focusing on the used repair technique, potential influencing factors on the results, and long-term outcome after reconstruction of the rotator cuff. Moreover, different treatment options for the treatment for irreparable rotator cuff ruptures were described, and the results of additional augmentation of the repairs with platelet-rich plasma were critically analyzed. Based on the current literature, double-row repairs did not achieve superior clinical results compared to single-row repairs neither in the clinical results nor in the re-rupture rate. Multiple factors such as age, fatty infiltration, and initial rupture size might influence the results. If the rupture is not repairable, various options were described including cuff debridement, partial repair, tuberoplasty, or tendon transfers. The additional augmentation with platelet-rich plasma did not reveal any significant differences in the healing rate compared to conventional rotator cuff repairs.

LEVEL OF EVIDENCE

IV.

Engaging stem cells for customized tendon regeneration

The need for a consistent therapeutic approach to tendon injury repair is long overdue. Patients with tendon microtears or full ruptures are eligible for a wide range of invasive and non invasive interventions, often subjectively decided by the physician. Surgery produces the best outcomes, and while studies have been conducted to optimize graft constructs and to track outcomes, the data from these studies have been inconclusive on the whole. What has been established is a clear understanding of healthy tendon architecture and the inherent process of healing. With this knowledge, tissue regeneration efforts have achieved immense progress in scaffold design, cell line selection, and, more recently, the appropriate use of cytokines and growth factors. This paper evaluates the plasticity of bone-marrow-derived stem cells and the elasticity of recently developed biomaterials towards tendon regeneration efforts. Mesenchymal stem cells (MSCs), hematopoietic progenitor cells, and poly(1,8-octanediol co-citrate) scaffolds (POC) are discussed in the context of established grafting strategies. With POC scaffolds to cradle the growth of MSCs and hematopoietic progenitor cells, developing a fibroelastic network guided by cytokines and growth factors may contribute towards consistent graft constructs, enhanced functionality, and better patient outcomes.

Open rotator cuff repairs in patients 70 years and older

BACKGROUND

  Symptomatic rotator cuff tear is a commonly diagnosed problem in patients over the age of 70; however, there is controversy regarding the management of this condition. We set out to investigate whether this group has satisfactory results with operative management of their rotator cuff tears.

METHODS

  Retrospective review of one surgeon's patients who have undergone an open rotator cuff repair at age 70 or older. Outcome assessment included history of work and recreational activities, review of medical records, clinical examination, the Simple Shoulder Test (SST) and the Constant Shoulder Score (CSS).

RESULTS

  A total of 96 patients (104 shoulders) underwent open rotator cuff repair during the study period. Sixteen patients (16 shoulders) were lost to follow-up leaving 80 patients (88 shoulders) for review. Mean duration of symptoms was 18.3 months, mean age at surgery was 74.2 years and mean time to follow-up was 40.8 months. The mean SST and CSS scores were 9.8 and 80.1, respectively. In both tests, patients scored best in the pain relief categories and worst in strength-measuring areas. A total of 73 patients (92.7%) reported satisfaction with their surgery. None of these were limited by their shoulders in returning to pre-injury independence, work or recreations. They were either completely pain free or had only mild symptoms.

CONCLUSION

  Patients in our study reflected a high satisfaction rate of 92.7% as well as excellent pain relief and a high level of function when related to their daily activities, independence and recreations or work.

LEVEL OF EVIDENCE

  Level IV (observational study without control - retrospective study).

The management of rotator cuff tears in the elderly

Rotator cuff tears occur commonly in the elderly causing significant pain and disability. In light of new treatment options developed over recent years, this article reviews the diagnosis and operative options available for this condition.

Conventional rotator cuff repair complemented by the aid of mononuclear autologous stem cells

PURPOSE

To investigate the behavior of rotator cuff tears treated with conventional repair technique with the aid of autologous bone marrow mononuclear cells (BMMC).

METHODS

Fourteen consecutive patients (9 women, 5 men, mean age of 59.2 years) with complete rotator cuff tears (mean preoperative UCLA score of 12 ± 3.0) were fixed by transosseous stitches through mini-open incision, with subsequent injection of BMMC into the tendon borders, obtained from the iliac crest just prior to surgery. Magnetic resonance images (MRI) were acquired before and after surgery and evaluated by two musculoskeletal radiologists regarding new postoperative findings of patients treated with BMMC.

RESULTS

After a minimum 12-month follow-up period, the UCLA score increased from 12 ± 3.0 to 31 ± 3.2. Clinical findings remained unaltered in the following year in all but one patient (13/14). MRI analysis after a 12-month follow-up period demonstrated tendon integrity in all cases (14/14), presence of low-signal intensity areas along the supraspinatus tendon and distal muscle belly in 8 cases (8/14), and high-intensity blooming small round artifact at the bursal and tendon topography in 11 cases (11/14). Six patients (6/14) showed formation of a high-signal intensity zone at the critical zone. Clinical findings remained unaltered in the following year in all but one patient, who relapsed into loss of strength and pain, being considered a bad result.

CONCLUSION

Implantation of BMMC in rotator cuff sutures appears to be a safe and promising alternative to other biological approaches currently used to enhance tissue quality in affected tendons.

Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplasty-tenotomy in the short term

INTRODUCTION

The principal study objective was to compare clinical results for arthroscopic repair of rotator cuff tear and acromioplasty-tenotomy in patients aged over 60 years.

HYPOTHESES

Repair provides better clinical results than isolated acromioplasty-tenotomy. Shoulder function is improved when healing is obtained.

PATIENTS AND METHODS

One hundred and forty-two patients aged over 60 years (mean age, 67 years) presenting with reparable supraspinatus tear, extending to a greater or lesser degree to the infraspinatus, agreed to take part in a randomized prospective study. Fifteen were excluded from statistical analysis. All underwent acromioplasty and biceps tenotomy. They were randomly assigned to arthroscopic rotator-cuff repair (CR group) or not (AT group). The principal evaluation criterion was mean weighted Constant score at one year's follow-up. Healing in the CR group was assessed on ultrasound at one year.

RESULTS

The complications rate was 7.9%. Mean weighted Constant score was significantly better in group CR: 75.8%, versus 68.8% in AT. In the CR group, the 1-year healing rate was 67.6%. Healing significantly impacted mean weighted Constant score: 80% with healing, versus 66.9% in iterative tearing. Whatever the size of the tear, mean weighted Constant score was significantly better in patients with than without (no repair or iterative tear) tendon healing.

DISCUSSION

The study demonstrated the interest of arthroscopic rotator cuff repair in patients aged over 60 years. The benefit of repair compared to isolated acromioplasty-tenotomy depended on tendon healing.

LEVEL OF EVIDENCE

Randomized prospective study, level II.

Functional recovery period after arthroscopic rotator cuff repair: is it predictable before surgery?

BACKGROUND

Several studies have reported functional recovery of the shoulder after arthroscopic rotator cuff repair (ARCR). Preoperative estimation of the time required for functional recovery is important for determining surgical indications and for planning timing of the surgery and an appropriate postoperative physical therapy.

QUESTIONS/PURPOSES

We therefore asked: (1) how long it takes to obtain functional recovery after ARCR, and (2) what preoperative factors influence functional recovery time.

PATIENTS AND METHODS

We retrospectively evaluated 201 patients who had undergone ARCR. Using the Japanese Orthopaedic Association (JOA) shoulder scoring system, we defined the functional recovery period as the time required to achieve a score greater than 80% in each component. We evaluated the functional recovery periods and assessed preoperative influencing factors such as age, gender, shoulder stiffness, morphologic features of rotator cuff tears, and rotator cuff tear size.

RESULTS

Sixty-three patients (31%) took less than 3 months, 81 patients (40%) took between 3 and 6 months, and 57 patients (28%) took greater than 6 months to achieve a score greater than 80% in each JOA shoulder assessment component. Younger patients without shoulder stiffness and with smaller rotator cuff tears had shorter functional recovery periods.

CONCLUSIONS

One hundred forty-four patients (72%) obtained functional recovery within 6 months after ARCR. Age, shoulder stiffness, and rotator cuff tear size influenced functional recovery time.

Validation of the Western Ontario Rotator Cuff index in patients with arthroscopic rotator cuff repair: a study protocol

BACKGROUND

Arthroscopic rotator cuff repair is described as being a successful procedure. These results are often derived from clinical general shoulder examinations, which are then classified as 'excellent', 'good', 'fair' or 'poor'. However, the cut-off points for these classifications vary and sometimes modified scores are used.Arthroscopic rotator cuff repair is performed to improve quality of life. Therefore, disease specific health-related quality of life patient-administered questionnaires are needed. The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff. The score is validated for rotator cuff disease, but not for rotator cuff repair specifically. The aim of this study is to investigate reliability, validity and responsiveness of WORC in patients undergoing arthroscopic rotator cuff repair.

METHODS/DESIGN

An approved translation of the WORC into Dutch is used. In this prospective study three groups of patients are used: 1. Arthroscopic rotator cuff repair; 2. Disorders of the rotator cuff without rupture; 3. Shoulder instability. The WORC, SF-36 and the Constant Score are obtained twice before therapy is started to measure reliability and validity. Responsiveness is tested by obtaining the same tests after therapy.

Clinical and radiological outcome of conservative vs. surgical treatment of atraumatic degenerative rotator cuff rupture: design of a randomized controlled trial

Background

Subacromial impingement syndrome is a frequently observed disorder in orthopedic practice. Lasting symptoms and impairment may occur when a subsequent atraumatic rotator cuff rupture is also present. However, degenerative ruptures of the rotator cuff can also be observed in asymptomatic elderly individuals. Treatment of these symptomatic degenerative ruptures may be conservative or surgical. Acceptable results are reported for both treatment modalities. No evidence-based level-1 studies have been conducted so far to compare these treatment modalities. The objective of this study is to determine whether there is a difference in outcome between surgical reconstruction and conservative treatment of a degenerative atraumatic rotator cuff tendon rupture.

Methods/Design

A randomized controlled trial will be conducted. Patients aged between 45 and 75 with a symptomatic atraumatic rotator cuff rupture as diagnosed by MRI will be included. Exclusion criteria are traumatic rotator cuff rupture, frozen shoulder and diabetes mellitus. Patients will be randomized into two groups. Conservative treatment includes physical therapy according to a standardized protocol, NSAIDs and, if indicated, subacromial infiltration with a local anesthetic and corticosteroids. Surgical reconstruction is performed under general anesthesia in combination with an interscalenus plexus block. An acromioplasty with reconstruction of the rotator cuff tendon is performed, as described by Rockwood et al. Measurements take place preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively. The primary outcome measure is the Constant score. Secondary measures include both disease-specific and generic outcome measures, and an economic evaluation. Additionally, one year after inclusion a second MRI will be taken of all patients in order to determine whether extent and localization of the rupture as well as the amount of fatty degeneration are prognostic factors.

Discussion

Both surgical as conservative treatment of a symptomatic atraumatic rotator cuff tendon rupture is used in current practice. There is a lack of level-1 studies comparing surgical vs. conservative treatment. This randomized controlled trial has been designed to determine whether the surgical treatment of a degenerative atraumatic rotator cuff tendon rupture may lead to a better functional and radiological outcome than conservative treatment after one year of follow-up.

Trial registration number

Netherlands Trial Register (NTR): NTRTC2343

Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older

PURPOSE

To evaluate outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older.

METHODS

We identified 44 consecutive patients aged 70 years or older undergoing primary all-arthroscopic repair of symptomatic full-thickness tears of the rotator cuff. A minimum 2-year follow-up was performed by an independent examiner including range of motion and dynamometer strength testing, and shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and pain score on a visual analog scale were determined. Paired t tests were performed to compare preoperative and postoperative measures. Postoperative Constant-Murley scores were normalized with scores from age- and sex-matched healthy individuals.

RESULTS

Of the patients, 39 (88.6%) were available for follow-up evaluation, with a mean age of 75.3 ± 4.2 years (range, 70.1 to 89.8 years) and a mean follow-up of 36.1 ± 9.9 months (range, 24.3 to 59.4 months). The American Shoulder and Elbow Surgeons score improved from 45.8 ± 16.6 (mean ± SD) to 87.5 ± 14.4 at final follow-up (P < .0001). The Simple Shoulder Test score improved from 3.9 ± 2.3 to 9.8 ± 2.5 (P < .0001). The pain score on the visual analog scale improved from 4.6 ± 2.2 to 0.5 ± 0.9 (P < .0001), and forward elevation increased from 114.8° ± 42.0° to 146.2° ± 33.2° (P = .0012). Mean age- and sex-matched normalized Constant-Murley scores ranged from 88.3% to 97.2% of normal in men and 81.7% to 88.8% of normal in women.

CONCLUSIONS

Arthroscopic rotator cuff repair provides significant improvement in pain and function in carefully selected patients aged 70 years or older with symptomatic full-thickness rotator cuff tears and has a low complication rate.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Massive tears of the rotator cuff

Repair of massive rotator cuff tears is technically difficult but often feasible. Technical and biological challenges to a successful repair include inelastic poor-quality tendon tissue, scarring, muscle atrophy, and fatty infiltration. Fatty infiltration of the involved rotator cuff muscles has been identified as an important negative prognostic factor for the outcome after repair of massive rotator cuff tears. Tendon transfer is a good option for young patients and manual laborers with an irreparable massive rotator cuff tear. Arthroplasty can be considered for the treatment of symptomatic massive rotator cuff tears in patients who have glenohumeral arthritis.

Effect of age on functional and structural outcome after rotator cuff repair

BACKGROUND

There are numerous reports on the outcome of rotator cuff repair according to age. However, the results are conflicting and driven by univariate analysis, which is not free of confounding factors.

HYPOTHESIS

Age does not affect the anatomical and functional outcomes of rotator cuff repair.

STUDY DESIGN

Case series; Level of evidence, 4.

MATERIALS AND METHODS

Eighty-one men and 96 women underwent rotator cuff repair at one institution and received computed tomography arthrography and functional evaluations at least 1 year after surgery. Various structural and clinical features according to age were evaluated. The correlation was assessed between age and outcomes, with adjustment for the preoperative score.

RESULTS

Patient mean age was 60.0 +/- 8.7 years. The mean ages were higher in women, nonsmokers, and those with positive paradoxical abduction, lower level of sports activity, the presence of biceps injury, higher fatty degeneration in cuff muscles, inferior isokinetic muscle performance, bigger tear size, more retraction of tear, and symptomatic acromioclavicular arthritis. For the integrity of the repair, the mean age was higher in the retear group (31.1%) than in the intact group (68.9%)-that is, 63.7 +/- 7.5 and 58.4 +/- 8.7 years, respectively (P <.001). Only the Constant score exhibited a positive correlation with age after adjustment (P = .009). Univariate regression analysis revealed that a 0.313-point increment of Constant score could be expected for each year of age.

CONCLUSION

On univariate analysis, older age was related with poor postoperative integrity and better functional improvement in Constant score. Multivariate regression revealed that age was not an independent determinant for anatomical or functional outcome whereas the tear retraction and fatty degeneration of the infraspinatus were independent factors for the integrity of repair and the presence of the paradoxical abduction and abduction torque of the unaffected shoulder for the Constant score.

Biomechanical and biologic augmentation for the treatment of massive rotator cuff tears

Recent studies have reported that massive rotator cuff tears do not heal as predictably as, and may have diminished clinical outcomes compared with, smaller rotator cuff tears. An improved understanding of the biologic degeneration and the biomechanical alterations of massive rotator cuff tears should provide better strategies to optimize outcomes. The approach to patients with massive rotator cuff tears requires careful assessment of the patient and the extent of rotator cuff degeneration to determine the appropriate treatment. For a rotator cuff tear that is repairable, the goal is to produce a tension-free, anatomical repair that restores the footprint using soft tissue releases and various suturing techniques, including double-row, transosseous-equivalent suture bridges or the rip-stop stitch. For irreparable cuff tears, the surgeon may elect to proceed with 1 of 2 approaches: (1) palliative surgical treatment-that is, rotator cuff debridement, synovectomy, biceps tenotomy, tuberoplasty and/or nonanatomical repair with partial repair; or (2) salvage treatment with various tendon transfers. Even though the biomechanical constructs for rotator cuff repairs have been improved, the integrity of the repair still depends on biologic healing at the tendon-to-bone junction. There has been much interest in the development of a scaffold to bridge massive rotator cuff tears and adjuvant biologic modalities including growth factors and tenocyte-seeded scaffolds to augment tendon-to-bone healing. The treatment of rotator cuff disease has improved considerably, but massive rotator cuff tears continue to pose a challenging problem for orthopaedic surgeons.

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.

Indications for surgery in clinical outcome studies of rotator cuff repair

Full-thickness tears of the rotator cuff are common, but there is no clear consensus regarding indications for rotator cuff surgery. Because some patients with full-thickness rotator cuff tears who are asymptomatic or symptomatic can be successfully treated nonoperatively, clinical outcome studies of rotator cuff repair should describe the subjects in detail to allow appropriate interpretation of the results. However, we hypothesized the indications for surgery are poorly described in outcome studies of rotator cuff surgery. We undertook a detailed literature review over 11 years of six major orthopaedic journals to assess whether the indications for surgery were described adequately in studies of rotator cuff repair. Eighty-six papers fit the criteria for the study and were reviewed. Limitations of activities of daily living (31%), failure of nonoperative treatment (52%), duration of nonoperative treatment (26%), and history of nocturnal pain (16%) were reported in a minority of papers overall. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. It is important for these factors to be considered and reported because, without this information, the reasons for and results of rotator cuff repair are difficult to interpret.

LEVEL OF EVIDENCE

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

Large and massive tears of the rotator cuff

The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique.

The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire.

The mean Constant score improved significantly from 36 before to 68 after operation (p < 0.0001) and the mean Oxford Shoulder score from 39 to 20 (p < 0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients (83%). However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair.

The efficacy of conservative treatment in patients with full-thickness rotator cuff tears

Rotator cuff tears are a common cause of shoulder pain and disability. Although many studies have reported about the surgical results of full-thickness tears of the rotator cuff, there are few studies about the efficacy of conservative treatment. The aim of this study was to investigate the efficacy of conservative treatment in patients with full-thickness rotator cuff tears by using objective and subjective measurements. Twenty patients with full-thickness rotator cuff tears were included in the study. Outcome measures were range of motion, pain and function according to the shoulder index of the American Shoulder and Elbow Surgeons (ASES), Constant score, Short-Form 36 Health Survey (SF-36), isokinetic shoulder strength, and patient response. Patients were assessed at baseline and after 6 months. In addition, patients were contacted by telephone at 1 year and at 3 years for functional assessment according to ASES, and patient response. The treatment protocol included activity modification, oral nonsteroidal antiinflammatory medications, physical modalities, and a specific exercise program. Statistically significant improvements were obtained in range of motion, pain and function scores according to ASES, Constant score, SF-36 scores, and isokinetic strength (P < 0.05). At the 6-month evaluation, 11 patients (55%) reported that they were "much better", and 9 patients (45%) "better". Conservative treatment of full-thickness rotator cuff tears yields satisfactory results both subjectively and objectively.