Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?

Clinical Outcomes and Repair Integrity After Double-Row Modified Mason-Allen Repair Technique With a Single Knot in Small to Medium Supraspinatus Tears

Background

Various arthroscopic rotator cuff repair techniques are being used for the treatment of rotator cuff tears with the development of surgical instruments. However, retears after repair are not completely avoidable, and efforts to reduce retears remain a challenge.

Purpose/Hypothesis

To introduce a new repair technique, the double-row modified Mason-Allen technique with a single knot, and to compare clinical outcomes and retear rates with the single-row modified Mason-Allen technique. It was hypothesized that this new technique would have a better clinical outcome and significantly lower retear rate than the single-row modified Mason-Allen technique.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 110 patients with small- to medium-sized (<1.5 cm) full-thickness supraspinatus tears were enrolled into 2 groups, with 65 patients receiving the single-row modified Mason-Allen technique (group A) and 45 patients receiving the double-row modified Mason-Allen technique with a single knot (group B). The clinical and functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of the Arm, Shoulder and Hand (DASH) score; and visual analog scale (VAS) for pain and satisfaction scores. All patients enrolled in this study were monitored for a minimum of 24 months. Magnetic resonance imaging was performed to analyze the integrity of tendons and retear at 6 months after surgery.

Results

No statistically significant differences between the 2 groups were found regarding the VAS for pain, ASES, and DASH scores. However, retear was found in 9 patients (13.8%) in group A and 1 patient (2.2%) in group B. The difference in the retear rate was statistically significant between the 2 groups (P = .037).

Conclusion

A significantly lower retear rate and comparable clinical outcomes were seen after the double-row modified Mason-Allen repair technique with a single knot when compared with the single-row modified Mason-Allen technique. Based on these findings, the double-row modified Mason-Allen repair technique with a single knot can be considered a surgical treatment option that can provide sufficient stability in small- to medium-sized supraspinatus tears.

Rotator cuff repairs with all-suture tape anchors: no difference in outcomes between with or without all-suture tape anchors

PURPOSE

This study aimed at comparing the outcomes of medium- to large-sized rotator cuff repairs performed using the suture bridge technique either with or without tape-like sutures, and single row techniques with conventional sutures.

METHODS

A total of 135 eligible patients with medium to large rotator cuff tears were identified and analyzed retrospectively, from 2017 to 2019. Only repairs using all-suture anchors were included in the study. Patients were divided into the following three groups: single-row (SR) repair (N = 50), standard double-row suture bridge (DRSB) repair with conventional sutures (N = 35), and DRSB with tape-like sutures (N = 50). The average postoperative follow-up period was 26.3 ± 9.8 months (range, 18-37).

RESULTS

DRSB with tapes had the highest re-tear rate of 16% (8/50), but there was no significant difference with the re-tear rates observed in SR (8%, 4/50) and DRSB with conventional sutures (11.4%, 4/35) (n.s.). DRSB with tapes demonstrated higher rate of type 2 re-tears (10%) compared to type 1 re-tears (6%), but the other two groups showed either similar or higher rates of type 1 re-tears compared to that of type 2. Post-operative functional scores of the three groups improved significantly (all p < 0.05), but the differences between the groups were not statistically significant.

CONCLUSIONS

No clinical difference in functional outcomes and re-tear rates were observed in DRSB with tapes when compared with SR and DRSB using the conventional sutures. Tape-like DRSB suture which was expected to be superior by its biomechanical advantage was clinically non-superior to conventional DRSB suture. There were no significant differences in VAS scores and UCLA scores.

LEVEL OF EVIDENCE

Level III.

Healthcare costs of failed rotator cuff repairs

Background

The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States.

Methods

A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period.

Results

The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure.

Conclusion

The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Clinical Relevance

Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Effect of High-Intensity Interval Training on Fatty Infiltration After Delayed Rotator Cuff Repair in a Mouse Model

Background

Fatty infiltration (FI) of the rotator cuff muscles is correlated with shoulder function and retear rates after rotator cuff repair. High-intensity interval training (HIIT) induces beige adipose tissue to express more uncoupling protein 1 (UCP1) to consume lipids. The beta-3 adrenergic receptor (β3AR) is located on adipocyte membrane and induces thermogenesis.

Purpose

To test the role of HIIT in improving muscle quality and contractility in a delayed rotator cuff repair mouse model via β3AR.

Study Design

Controlled laboratory study.

Methods

Three-month-old C57BL/6J mice underwent a unilateral supraspinatus (SS) tendon transection with a 6-week delayed tendon repair. Mice ran on a treadmill with the HIIT program for 6 weeks after tendon transection or after delayed repair. To study the role of β3AR, SR59230A, a selective β3AR antagonist, was administered to mice 10 minutes before each exercise through intraperitoneal injection. The SS, interscapular brown adipose tissue (iBAT), and subcutaneous inguinal white adipose tissue (ingWAT) were harvested at the end of the 12th week after tendon transection and were analyzed by histology and Western blotting. Tests were performed to assess muscle contractility of the SS.

Results

Histologic analysis of SS showed that HIIT prevented and reversed muscle atrophy and FI. The contractile tests showed higher contractility of the SS in the HIIT groups than in the no-exercise group. In the HIIT groups, SS, iBAT, and ingWAT all showed increased expression of tyrosine hydroxylase, UCP1, and upregulated β3AR thermogenesis pathway. However, SR59230A inhibited HIIT, suggesting that the effect of HIIT depends on β3AR.

Conclusion

HIIT improved SS quality and function after delayed rotator cuff repair through a β3AR-dependent mechanism.

Clinical Relevance

HIIT may serve as a new rehabilitation method for patients with rotator cuff muscle atrophy and FI after rotator cuff repair to improve postoperative clinical outcomes.

Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique

Background

We have tried to create hematoma over the footprint site at the end of arthroscopic rotator cuff repair (ARCR) surgery, expecting to apply biochemical effects of the platelet-related factors. The purpose of this study was to investigate the presence of hematoma-like tissue (HLT) on postoperative magnetic resonance imaging, and to evaluate the relationship between the HLT and the structural outcomes of ARCR.

Materials and methods

Twenty-five patients were reviewed with a mean age at surgery of 69.8 years (range, 52-85 years). Postoperative magnetic resonance imaging was performed at 1 week, 6-8 weeks, and >6 months postoperatively. Structural outcomes for the repaired cuff and thickness of HLT were evaluated on coronal T2-weighted images. Signal intensity of HLT was evaluated on coronal T2-weighted fat-suppressed images as the ratio compared to supraspinatus tendon intensity (HLT/SSP ratio).

Results

Structural outcomes showed Sugaya type 1 in 12 shoulders, type 2 in 4, and type 3 in 9. HLT thickness was significantly thicker at 1 week and 6-8 weeks postoperatively in Sugaya type 1 patients than in type 3 patients (1 week; P = .014, 6-8 weeks; P < .001). HLT/SSP ratio gradually decreased (at 1 week; 1.9 ± 0.7, 6-8 weeks; 1.6 ± 0.6, >6 months; 1.2 ± 0.5), and differed significantly between >6 months and both 1 week and 6-8 weeks (P < .001 each).

Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged <65 years

Background

Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.

Methods

We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years.

Results

There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P = .0001 and P = .25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P = .0009 and P = .1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P = .0003 and P = .1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another.

Discussion

Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Postoperative MRI signal intensity correlates functional outcomes after superior capsular reconstruction

PURPOSE

Superior capsular reconstruction (SCR) using fascia lata autograft has been performed for irreparable rotator cuff tear recently. The signal-to-noise quotient (SNQ) of the graft on magnetic resonance imaging (MRI) may reflect the degree of graft maturity and healing. However, how SNQ changes with graft remodelling and time and whether this change correlates with postoperative clinical outcomes after SCR remain unknown. This study aimed to explore the correlation between SNQ of the fascia lata autograft and clinical functional outcomes after SCR.

METHODS

Patients with irreparable posterosuperior rotator cuff tear undergoing SCR using fascia lata autograft between 2013 and 2017 were retrospectively analysed. For clinical outcomes, the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) for pain and range of motion (ROM; forward flexion and external rotation) were evaluated at postoperative 6 and 12 months. Signal intensity of the humeral, mid-substance, and glenoid sites and background were measured to calculate the SNQ values on follow-up MRI at 3 and 12 months. The correlations between clinical outcomes and SNQ at different time points were then analysed.

RESULTS

A total of 15 patients were enrolled in the study. The mean postoperative VAS score significantly increased at postoperative 6 months and significantly decreased at postoperative 12 months. Except for forward flexion, all other functional outcomes were improved at postoperative 6 months. Analysis of MRI showed SNQ at the humeral (SNQh), mid-substance, and glenoid sites decreased from postoperative 3 to 12 months with a statistical significance detected in SNQh (P < 0.01). Correlation analyses showed that the SNQh values negatively correlated with VAS, ASES, Constant-Murley score, SANE, ROM (forward flexion), and ROM (external rotation) (all P < 0.05).

CONCLUSION

SNQ of the fascia lata autograft decreased with time in patients receiving SCR. SNQ at the humeral site was negatively correlated with clinical outcomes.

LEVEL OF EVIDENCE

III.

Satisfactory functional and structural outcomes of anterior cable reconstruction using the proximal biceps tendon for large retracted rotator cuff tears

PURPOSE

Large retracted anterior L-shaped tear characterized by a retracted supraspinatus tendon to the glenoid level combined with a relatively preserved infraspinatus tendon is one of the challenging tear patterns in achieving complete repair to the anatomic footprint. The purpose of this study was to evaluate clinical outcomes and tendon integrity of rotator cuff repair combined with anterior cable reconstruction using the proximal biceps tendon in patients with large retracted anterior L-shaped rotator cuff tear.

METHODS

This study prospectively enrolled patients who underwent arthroscopic anterior cable reconstruction using the proximal biceps tendon for large retracted anterior L-shaped rotator cuff tears between 2018 and 2020 with a minimum 2-year follow-up. The anterior portion of the rotator cable was reconstructed using tenotomized proximal biceps tendon fixed with two suture anchors at the footprint. The retracted supraspinatus tendon was repaired on the biceps tendon without undue tension. The proximal portion of the infraspinatus tendon was repaired with the biceps tendon-supraspinatus tendon complex. Clinical outcomes was assessed during the follow-up period. Tendon integrity and retear size were evaluated by postoperative MRI.

RESULTS

A total of 32 consecutive patients were included. The ASES score was significantly improved from 66.6 ± 16.6 preoperatively to 94.1 ± 6.1 postoperatively (P < 0.001), and the VAS for pain was significantly relieved from 2.8 ± 1.9 preoperatively to 0.5 ± 0.4 postoperatively (P < 0.001). All patients were satisfied postoperatively regardless of tendon integrity (P = 0.015). Postoperative ROM was increased continuously during the follow-up period (P < 0.001). The Popeye sign was found in 4 patients (12.5%). Six patients (18.7%) had rotator cuff retears. However, the ASES score of patients with retear was significantly improved from 72.8 ± 13.3 preoperatively to 91.1 ± 6.7 postoperatively (P < 0.001). Relative changes in the retear size compared with the primary tear size were -56.8 ± 14.4% for the anteroposterior diameter and - 70.6 ± 6.1% for the mediolateral diameter.

CONCLUSIONS

Rotator cuff repair combined with anterior cable reconstruction using the proximal biceps tendon provided satisfactory clinical and radiological outcomes for large retracted anterior L-shaped tears. Anterior cable reconstruction using the proximal biceps tendon is a sound surgical option for the patients with large retracted anterior rotator cuff tear.

LEVEL OF EVIDENCE

IV.

Association between functional outcome scores and MRI-based structural integrity after rotator cuff repair: a prospective cohort study

PURPOSE

Natural history of rotator cuff tears is poorly understood. Repair of rotator cuff tears has shown to improve functional outcomes in full-thickness tears. However, high re-tear rates have been reported in literature, which does not correlate with poorer outcomes. Primary aim of this study was to explore association between functional outcome scores and structural integrity of rotator cuff, using magnetic resonance imaging (MRI)-based grading.

METHODS

Patients with MRI-proven full-thickness rotator cuff tears, undergoing mini-open rotator cuff repair, were assessed for shoulder abduction strength and functional outcome scores before the surgery and 2 years after the procedure. Association between functional outcome scores and MRI grading for rotator cuff healing (Sugaya grading) was analyzed.

RESULTS

A total of 38 patients (18 females and 20 males), with a mean age of 50.6 years (SD: 10.9), were included in the study. Mean duration of symptoms was 6.05 months (SD: 4.2). On postoperative MRI, healing of the cuff was categorized as Sugaya grade 1 in 12 patients, grade 2 in 20 patients and grade 3 in 6 patients. Higher Sugaya grades (T: 13.48, p: 0.001) and grades of fatty degeneration (T: 14.05, p: 0.001) were found to be associated with longer duration of symptoms. Improvement in shoulder abduction strength correlated negatively with the duration of symptoms (r: -0.39, p: 0.01). There was a significant improvement in functional outcome scores after the surgery. There was no association between postoperative structural integrity of the repaired tendon (Sugaya grading) and functional outcome scores.

CONCLUSION

Early repair of rotator cuff results in better functional outcomes and shoulder strength. The findings from this study suggest there is a dissociation between MRI-based grades of healing of repaired rotator cuff and function of the shoulder.

STUDY DESIGN

Level II, Prospective cohort study.

Periimplant osteolysis does not affect the outcome of rotator cuff repair: a systematic review and meta-analysis

PURPOSE

The goal of this study was to perform a systematic review and meta-analysis to compare the clinical and radiologic outcomes of rotator cuff repair, depending on the presence of developed periimplant osteolysis (PIO) after using suture anchors.

METHODS

The electronic databases of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for articles published up until October 2019 to find relevant articles comparing the outcomes of rotator cuff repair between the periimplant osteolysis group and non-periimplant osteolysis group. Data searching, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines. The results are presented as risk ratio (RR) for binary outcomes and standardised mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI).

RESULTS

Six clinical studies were included. No significant differences were found between the group with periimplant osteolysis and the group without periimplant osteolysis regarding retear rate (RR = 1.34; 95% CI 0.93-1.94; I² = 28%), postoperative clinical scores (SMD = 0.29; 95% CI - 0.26 to 0.83; I² = 80%) and range of motion (ROM); forward flexion (SMD = 0.39; 95% CI - 0.16 to 0.93; I² = 0%), external rotation (SMD = - 0.10; 95% CI - 0.64 to 0.45; I² = 0%) and internal rotation (SMD = - 0.37; 95% CI - 0.92 to 0.17; I² = 0%).

CONCLUSION

The presence of periimplant osteolysis after rotator cuff repair with suture anchor does not affect the clinical outcomes such as retear rate, clinical scoring, and ROM. However, as there was no standard consensus on the criteria for evaluating periimplant osteolysis, this result may not fully reflect the effect of periimplant osteolysis depending on its severity.

LEVEL OF EVIDENCE

Level IV.

Safety and Efficacy of Autologous Dermal Fibroblast Injection to Enhance Healing After Full-Thickness Rotator Cuff Repair: First-in-Human Pilot Study

Background:

There is growing interest in various biological supplements to improve tendon healing in patients after arthroscopic rotator cuff repair. The ideal biological supplement to strengthen rotator cuff remains unknown.

Purpose:

To assess the safety and efficacy of autologous cultured dermal fibroblast (ADF) injection on tendon-to-bone healing in patients after arthroscopic rotator cuff repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 6 patients who underwent arthroscopic rotator cuff repair between June 2018 and March 2020; all patients had a full-thickness rotator cuff tear (>2 cm) involving the supraspinatus and infraspinatus tendons. The patients were injected with ADF between the repaired tendon and footprint during arthroscopic rotator cuff repair using the suture bridge technique. The safety of ADFs and the procedure was evaluated at 5 weeks postoperatively, and the anatomical healing of the repaired tendon was accessed at 6 months postoperatively using magnetic resonance imaging and at 12 months using ultrasonography. Outcomes including shoulder range of motion (ROM), visual analog scale (VAS) for pain, and functional scores were measured at 6 and 12 months postoperatively.

Results:

Adverse reactions to ADF injection were not observed at 6 months after surgery. VAS and functional scores at 6 and 12 months postoperatively were significantly improved compared with preoperative scores (all P < .05). However, there was no significant difference on any ROM variable between preoperative and postoperative measurements at 6 and 12 months (all P > .05). No healing failure was found at 6 and 12 months postoperatively.

Conclusion:

There was no adverse reaction to ADF injection, and all patients had successful healing after rotator cuff repair. A simple and easily accessible ADF injection may be a novel treatment option for increasing the healing capacity of torn rotator cuff tendons. Further clinical research is needed to verify the study results.

Nontendinous healing after repairing of retracted rotator cuff tear: an imaging study

BACKGROUND

Follow-up magnetic resonance imaging (MRI) after rotator cuff repair can sometimes demonstrate healing with nontendinous tissue that extends from the footprint to the retracted tendon end, which is inferred as fibrous tissue formation. The aim was to investigate this particular finding and its significance.

METHODS

There were 494 eligible cases of healed supero-posterior medium-sized to massive rotator cuff repairs, after the exclusion of retears. A retrospective review was performed for the 3 groups that were divided according to their MRI appearances of healing: type I described the direct healing of the tendon to the footprint, whereas type II demonstrated the distinctive continuity of nontendinous tissue from the footprint to the retracted tendinous portion, and type III also showed a similar appearance but with obvious thinning of the tissue, without any evidence of defect confirmed on the routine outpatient ultrasonograph.

RESULTS

Only 108 of 494 patients (21.9%) demonstrated type I healing, whereas the signs of nontendinous healing were evident for the rest, with the 116 patients (23.5%) being classified as type III with attenuation. Comparing the preoperative tendon retraction, 34.8% and 37.2% of the Patte stages 2 and 3, respectively, resulted in type III healing, which were significantly higher compared with that of stage 1 (15.3%, P < .001). Type III healing had the highest average preoperative Goutallier grades. The average postoperative visual analog scale and the American Shoulder and Elbow Surgeons (ASES) scores have improved significantly for all 3 groups (P < .05), with the ASES score being 86.1±15.9 for type I, 93.7±36.1 for type II, and 87.8±15.1 for type III without significant differences between the groups (P = .3).

CONCLUSIONS

Only a fifth of the rotator cuff repairs led to a direct healing to the footprint, and the rest healed with MRI appearance of nontendinous tissue formation bridging the retracted tendinous portion and the footprint. These MRI appearances did not represent the true tendinous tissue formation between the torn end of the tendon and the bone after healing. Such appearances did not seem to affect the clinical outcomes.

Transtendon Suture Bridge Repair of Both-Sided Partial-Thickness Rotator Cuff Tears: Midterm Outcomes

BACKGROUND

Among symptomatic partial-thickness rotator cuff tears (PTRCT) indicated for surgery, both-sided (concurrent articular and bursal side) PTRCT are rarely reported and discussed in the literature. Without clinical data on and definite guidelines for treating these rare partial tears, appropriate management cannot be expected.

PURPOSE

To calculate the prevalence of both-sided PTRCT and to evaluate clinical outcomes after arthroscopic transtendon suture bridge repair of both-sided PTRCT at a minimum 3-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Among symptomatic PTRCT that required arthroscopic surgery (765 patients) between March 2008 and December 2014, 178 both-sided partial tears were confirmed arthroscopically, and arthroscopic transtendon suture bridge repair was performed in 100 patients enrolled in our study after exclusion criteria were applied. The presence of concurrent articular and bursal side partial tears was confirmed via arthroscopy, with Ellman grade >2 on either the bursal or the articular side of these both-sided partial tears. Without tear completion, transtendon suture bridge repair was performed in all cases. Clinical outcomes including clinical scores and range of motion were evaluated at a mean of 5.3 ± 1.4 years (range, 3-8 years). Follow-up magnetic resonance imaging (MRI) was performed at 6 to 12 months (mean ± SD, 11 ± 5.20 months) after surgery to evaluate the tendon integrity (Sugaya classification) of the repaired rotator cuff.

RESULTS

The mean age was 57.5 ± 7.8 years, and 65% of patients were women. Mean preoperative American Shoulder and Elbow Surgeons, University of California Los Angeles, Simple Shoulder Test, and Constant-Murley outcome scores of 52 ± 14, 19 ± 4, 6 ± 2, and 69 ± 10 significantly improved postoperatively to 94 ± 5, 33 ± 2, 11 ± 1, and 93 ± 5, respectively (P < .001). Mean forward flexion, abduction, external rotation, and internal rotation improved significantly from 148°± 31°, 134°± 39°, 22°± 13°, and L2 preoperatively to 154°± 17°, 151°± 60°, 29°± 14°, and T10 postoperatively, respectively (P < .001). The retear rate on follow-up MRI scans was 2%. As per Sugaya classification on postoperative MRI scans, type 1 healing was found in 29%; type 2, in 60%; type 3, in 9%; and type 4, in 2%.

CONCLUSION

Among all symptomatic PTRCT that required surgery, both-sided PTRCT were more common than expected. Arthroscopic transtendon suture bridge repair of these both-sided PTRCT showed satisfactory clinical outcomes at a minimum 3-year follow-up.

Arthroscopic-assisted latissimus dorsi transfer for irreparable posterosuperior cuff tears: Clinical outcome of 15 patients

OBJECTIVE

We analyzed the clinical and functional results of patients with irreparable posterosuperior rotator cuff tears treated with arthroscopic-assisted latissimus dorsi transfer and the clinical relevance of the addition of partial repair of the remaining cuff to the transfer.

METHODS

This was a prospective cohort study that included patients diagnosed with irreparable massive rotator cuff tears treated by arthroscopic-assisted latissimus dorsi transfer between 2015 and 2018. Demographic characteristics, clinical and functional outcomes (Constant-Murley (CS) score and subjective shoulder value (SSV)), and the incidence of complications were evaluated. Clinical outcomes were compared between patients treated with transfer alone and transfer with partial cuff repair.

RESULTS

Fifteen patients were included, with an average follow-up of 37 ± 16 months. The median duration of symptoms before surgery was 66 weeks (24-208). A significant increase in forward elevation of 52° (p < 0.003) and abduction of 48° (p < 0.001) was obtained. The CS score increased by 48 points (p < 0.001), and the SSV changed from 29% preoperatively to 70% postoperatively (p < 0.001), with a significant decrease in the visual analog pain score from 7 to 1 (p < 0.001). In 10 patients, partial repair of the rotator cuff was also performed. No statistically significant differences were found in these patients compared with patients treated with transfer alone. Two patients presented complications, including transient sensitive neuropraxia of the axillary nerve and seroma, which were managed conservatively and did not affect the outcomes.

CONCLUSION

Arthroscopic-assisted latissimus dorsi transfer is a safe technique that significantly improves clinical and functional outcomes in selected patients. Longer follow-up and comparison with other treatment options are needed to confirm these excellent results in this group of difficult-to-treat patients.

LEVEL OF EVIDENCE IV

Nil.

Quantitative T2 mapping-based tendon healing is related to the clinical outcomes during the first year after arthroscopic rotator cuff repair

PURPOSE

The objective of this study was to determine the correlation between quantitative T2 mapping-based tendon healing and clinical outcomes during the first year after arthroscopic rotator cuff repair.

METHODS

Twenty-two patients with rotator cuff tear were prospectively recruited. Serial clinical and MRI follow-up assessments were carried out at 1 month, 6 months and 12 months after surgery. Twenty healthy volunteers were involved and were examined with clinical and MRI assessments. Clinical assessments included Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES), the modified University of California, Los Angles (UCLA) scores and Visual Analog Scale (VAS). The region of interest of tendon healing was defined directly over the medial suture anchor on T2 mapping. Spearman correlation coefficient was used to analyze the correlations between MRI measurements and clinical outcomes.

RESULTS

All clinical scores indicated significant improvements over the postoperative observation period compared with the initial preoperative values (all P < 0.001). At 12 months, all of the patients returned to their daily life activities. The T2 values of the healing site significantly decreased over time (P < 0.001) and were comparable to those of healthy tendons at 12 months (n.s.). Additionally, the T2 values were negatively correlated with CS (r = - 0.5, P < 0.001), ASES (r = - 0.5, P < 0.001), and UCLA (r = - 0.5, P < 0.001); and positively correlated with VAS score (r = 0.4, P < 0.001). No significant correlations were found between Sugaya classification and clinical scores (all n.s.).

CONCLUSIONS

With regard to tendon healing during the first follow-up year, the T2 values of the healing site decreased with the improvement of clinical outcomes over time.

LEVEL OF EVIDENCE

II.

Clinical Outcomes of Nonoperative Treatment for Rotator Cuff Retears and Analysis of Factors That Affect Outcomes

Background

Patients who sustain a rotator cuff retear after arthroscopic rotator cuff repair are generally considered to have worse clinical outcomes compared with patients with an intact rotator cuff. However, some patients have good clinical outcomes, even with a retorn rotator cuff.

Purpose

To report the clinical outcomes of nonoperative treatment for rotator cuff retears and analyze the factors affecting clinical outcomes after a retear.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2011 and 2017 were reviewed, and those with a full-thickness retear on postoperative magnetic resonance imaging (MRI) were included in this study. According to their pre- and postoperative scores on the pain visual analog scale (pVAS) and functional visual analog scale (fVAS), the patients were divided into 3 groups: (1) mild group (pVAS ≤ 1 and fVAS ≥ 8), (2) moderate group (pVAS ≤ 1 and fVAS ≤ 7 or pVAS 2-3 and fVAS ≥ 8), and (3) severe group (pVAS ≥ 3 and fVAS ≤ 7). Preoperative data (dominant hand involvement, heavy labor) and tear size on 6-month postoperative MRI were analyzed as factors affecting clinical outcomes.

Results

A total of 712 patients were reviewed, and a retear was observed in 62 patients (8.7%). Of the patients with retears, 52 were included in this study: 25 men and 27 women with a mean age of 62.6 years (range, 49-80 years) and mean follow-up period of 40 months (range, 24-88 months). According to the pVAS and fVAS scores, 25 patients (48.1%) were classified into the mild group, 9 (17.3%) into the moderate group, and 18 (34.6%) into the severe group. There were no significant differences in preoperative data among the 3 groups. The tear size in the coronal and sagittal planes decreased by 5.1 and 6.6 mm, respectively, in the mild group but increased by 2.8 and 1.4 mm, respectively, in the severe group.

Conclusion

In patients with retears, 48.1% had only mild symptoms at a mean of 40 months postoperatively. Patients with severe symptoms tended to have an increased tear size on postoperative MRI.

Quantitative Magnetic Resonance Imaging UTE-T2* Mapping of Tendon Healing After Arthroscopic Rotator Cuff Repair: A Longitudinal Study

BACKGROUND

Quantitative ultrashort echo time-T2* (UTE-T2*) mapping shows promise for the detection of potential tendon biochemical conditions, while validation against established clinical studies in the shoulder is needed.

PURPOSE

To evaluate and characterize the healing process of the repaired rotator cuff based on longitudinal changes in UTE-T2* values, clinical outcomes, and repair status in patients after arthroscopic rotator cuff repair (ARCR).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients with ARCR (n = 25) underwent quantitative MRI and clinical examinations at serial follow-up time points: 3, 6, 12, and 24 months postoperatively. Age-matched healthy controls (n = 15) were evaluated at 3 and 12 months after enrollment. Clinical scores included the Constant, American Shoulder and Elbow Surgeons, and Fudan University Shoulder score, and visual analog scale for pain. The MRI examination included UTE-T2*mapping. UTE-T2* maps were generated for T2* values at the healing site. Sugaya classification was adopted to evaluate the repair status. Longitudinal analyses of clinical outcomes, UTE-T2* changes, and Sugaya classification were conducted.

RESULTS

The overall retear rate was 8% (2/25, all Sugaya type IV). All patients (including the ones with retear) achieved satisfactory outcomes at 12 months that lasted to 24 months on the basis of clinical scores. The mean UTE-T2* values at the healing site showed an increase from 3 to 6 months (P = .03) and then decreased to a level similar to that observed in age-matched healthy tendons at 12 months (P = .1). No significant differences were found between UTE-T2* values at 12 and 24 months (P = .6). UTE-T2* values at the healing site significantly varied with the repair status according to Sugaya classification (P < .05). Moreover, significant correlations were noted between clinical scores and UTE-T2* values at 6 months (r = -0.6 to -0.3; all P < .05) and 12 months (r = -0.6 to -0.2; all P < .05).

CONCLUSION

This study indicated a healing-related relationship between clinical outcomes and quantitative UTE-T2* values, which highlights the potential of using UTE-T2* mapping to track the tendon-healing process noninvasively. Moreover, the repaired tendon was comparable to age-matched healthy controls at 12-month follow-up based on UTE-T2* values.

Shoulder stiffness after rotator cuff repair: the fate of stiff shoulders up to 9 years after rotator cuff repair

BACKGROUND

Stiffness and retear are 2 common complications of rotator cuff repair. McNamara et al found that postoperative stiffness was associated with lower retear rates at 6 months. This study aimed to determine if stiffness after rotator cuff repair protects the individual from retear up to 9 years after surgery.

MATERIALS AND METHODS

Two groups of patients, 69 with stiff and 63 with nonstiff shoulder, who underwent arthroscopic rotator cuff repair were created based on external rotation measurements at 6 weeks postoperatively. Patients had regular follow-up assessments at 6, 12, and 24 weeks and were instructed to return for a follow-up at least 2 years after surgery. Patients were assessed for range of motion, shoulder function, strength, and rotator cuff integrity using ultrasound.

RESULTS

For patients with postoperative stiffness at 6 weeks, the retear rate at 6 months was 3%, whereas the rate for nonstiff patients was 19% (P = .004). This protective effect of postoperative stiffness persisted up to 9 years after surgery (P = .002). Postoperative stiffness resolved by 5 years after surgery for all measurements except external rotation (50° vs. 61°) (P = .006). Patients with postoperative stiffness had continued improvements in abduction (P < .001), internal rotation (P = .020), and all patient-ranked measurements from the 6-month follow-up to 5 years after surgery. Patients with stiff shoulder had greater overall satisfaction by the final follow-up (P = .028).

CONCLUSIONS

In patients experiencing stiffness after rotator cuff surgery, the repair is less likely to fail at 6 months. Although the stiffness generally resolves by 5 years, this protective effect still persists at 9 years after surgery.

Does the Dog-Ear or Bird-Beak Deformity Remodel After Rotator Cuff Repair?

BACKGROUND

Dog-ear and bird-beak deformities are common after transosseous-equivalent repair (suture bridge technique). The natural course of deformities after rotator cuff (RC) repair using the suture bridge technique is unclear. The remodeling potential of these deformities has not been investigated.

PURPOSE

To evaluate remodeling and retear rates associated with deformities after RC repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between November 2011 and February 2012, we studied 99 consecutive shoulders. All patients underwent arthroscopic RC repair via the suture bridge technique with or without additional sutures. Two groups were formed: no deformity (n= 46) and deformity (n = 53). Deformity was defined as marginal detachment and protrusion of the RC after repair, involving inappropriate compression of the suture limbs from the anchors. Tendon height was measured from the highest point of the most protruding portion of the cuff to the cortex on semi-coronal magnetic resonance imaging (MRI) scan. Change in tendon height was evaluated on MRI scan at 1 week and 6 months postoperatively. Clinical assessment at every patient visit included the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and visual analog scale for pain (pVAS) score.

RESULTS

No significant differences were found in age, sex, symptom duration, tear size, and preoperative ASES, Constant, and pVAS scores (P > .05) between the 2 groups. The initial tendon height was 7.4 ± 1.5 mm in the no-deformity group and 9.3 ± 2.0 mm in the deformity group. Follow-up height was 6.3 ± 2.1 mm in the no-deformity group and 6.4 ± 1.6 mm in the deformity group. Mean postoperative tendon heights were 90.1% ± 23.8% of the initial height in the no-deformity group and 73.2% ± 15.1% in the deformity group. Clinical scores (ASES, Constant, and pVAS) were not significantly different between the groups at 6 months. There were 4 shoulders in each group that experienced retearing (types 4 and 5 according to the Sugaya classification) at 6 months postoperatively. There was no difference in retear rate (P > .999).

CONCLUSION

Most deformities after RC repair were remodeled with no effect on retears. Clinical outcomes were not affected by deformities.

Tendon Healing Progression Evaluated With Magnetic Resonance Imaging Signal Intensity and Its Correlation With Clinical Outcomes Within 1 Year After Rotator Cuff Repair With the Suture-Bridge Technique

BACKGROUND

After a rotator cuff (RC) is repaired, its signal intensity (SI) on magnetic resonance imaging (MRI) gradually changes to normal and could reflect the degree of RC healing. Nevertheless, it remains unclear how long it takes for SI to recover to normal and whether the SI progression correlates with clinical outcomes after RC repair (RCR).

PURPOSE

To serially evaluate the SIs of the repaired RC tendon on MRI and the postoperative clinical outcomes and then analyze the correlation between them.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study prospectively included 25 patients who underwent arthroscopic RCR with the suture-bridge technique between June 2016 and July 2017. Twenty-three patients accepted full follow-ups at 1, 3, 6, 9, and 12 months. Before surgery and at each follow-up, visual analog scale (VAS) for pain and 4 functional scores were evaluated: Constant-Murley score, American Shoulder and Elbow Surgeons shoulder evaluation form, modified University of California at Los Angeles score, and Fudan University shoulder score. The patients underwent MRI examinations at every follow-up. The values of the signal/noise quotient at the distal (SNQd) and proximal (SNQp) areas were calculated to evaluate the SI of the repaired tendon. The correlations of clinical outcomes with SNQd and SNQp values were analyzed, and subgroup analyses were performed.

RESULTS

Overall, the mean postoperative VAS score significantly decreased at postoperative 1 month (P < .001), and the functional scores were all significantly higher than the preoperative values at 6 months (all P < .001). SNQd and SNQp values were both significantly higher than normal at 1 and 3 months (all P < .001) and reduced to normal after 9 and 6 months, respectively. Correlation analyses showed that the SNQp value significantly correlated with VAS score (positive) and all functional scores (negative) at 1 and 3 months postoperatively. Further comparison indicated that the patients with VAS score >3 had higher SNQp values than patients with VAS score ≤3 at 1 and 3 months postoperatively (both P = .01).

CONCLUSION

After RCR with the suture-bridge technique, it took longer for SI to become relatively normal than it did to have a significant clinical improvement. Early after surgery (1-3 months), worse clinical outcome correlated with higher SI on proximal cuff tendon.

Trans-tendon suture bridge rotator cuff repair with tenotomized pathologic biceps tendon augmentation in high-grade PASTA lesions

PURPOSE

The purpose of this study was to evaluate whether trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation improves mid-term clinical outcomes for high-grade partial articular-sided supraspinatus tendon avulsion (PASTA) lesions or not.

METHODS

A retrospective review of a consecutive series of arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation was conducted. Total 115 patients (44 men and 71 women) with minimum 2 years follow-up were enrolled in our study. Their mean age was 59.7 ± 7.6 (38-77) years and mean follow-up were 6.9 ± 2.5 (2 ~ 10) years. Clinical assessment and radiological outcomes using post-operative MRI were evaluated at last follow-up.

RESULTS

All these tears were high-grade PASTA lesions in which mean cuff tear size (exposed footprint) was anteroposterior length 15.7 ± 6.3 mm (5-25 mm) and mediolateral width 10.1 ± 3.6 mm 6.4 mm (5-16 mm). At last follow-up, mean pain VAS, ASES, UCLA, and SST scores were improved from pre-operative values of 5, 59, 21, and 7 to post-operative values of 1, 84.4, 29.5, and 9.4, respectively (p value < 0.001). ROM such as forward flexion, abduction, and internal rotation to the back were improved from a pre-operative mean of 148° (±24), 144° (±24), L2 (Buttock-T7) to a post-operative mean of 161° (±10), 160.0° (±12), and T12 (L3-T5), respectively (p value < 0.001). Follow-up MRI showed Sugaya classification type I in 24 patients (20.9%), type II in 78 patients (67.8%), type III in 11 patients (9.6%) and type 4 in 2 patients (1.7%) were found. As complications, shoulder stiffness was found in five patients, Popeye deformity in two patients and retear in two patients. Revision surgery of the retear was performed in 2 patients. At the last follow-up, 17% (20/115 patients) reported occasional discomfort at the extremes of range of motion during a heavy work or sports activities.

CONCLUSIONS

In high-grade PASTA lesions, arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation could be a useful treatment modality capable of preserving rotator cuff footprint, providing simultaneous biceps tenodesis, inducing better tendon healing and possibly preventing tendon buckling and residual pain of the conventional trans-tendon repair methods. These specific methods showed satisfactory outcomes and decreased residual shoulder discomfort (17%) at mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, Retrospective case study.

All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium Rotator Cuff Tears

BACKGROUND

All-suture anchors are increasingly being used in rotator cuff repair. However, there are debates on the micromotion of all-suture anchors.

PURPOSE

To perform rotator cuff repair on patients with rotator cuff tears and different shoulder bone mineral densities (BMDs) and investigate (1) where the anchor is located under the cortex, (2) if there is any anchor migration settling during follow-up, and (3) if structural outcome differs according to shoulder BMD.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively investigated 88 patients who underwent arthroscopic single-row repair for small- to medium-sized rotator cuff tears (age [mean ± SD], 58.8 ± 7.1 years) from 712 cases of rotator cuff tendon repair between November 2015 and February 2018. Inclusion criteria were as follows: use of an all-suture anchor; preoperative shoulder BMD; and magnetic resonance imaging (MRI) conducted preoperatively, 2 days after surgery, and 10 months after surgery. Patients were excluded from the study if they underwent open rotator cuff repair (n = 118), got surgery with a double-row technique (n = 178), underwent surgery with anchors other than the all-suture type (n = 273), received anchor insertion in sites other than the greater tuberosity owing to concomitant procedures such as biceps tenodesis and subscapularis repair (n = 29), did not take preoperative shoulder BMD (n = 15), had more than a large-size tear (n = 6), and were lost to follow-up (n = 5). After compression of the all-suture anchor during surgery, the strands were pulled multiple times to ensure that the anchor was fixed onto the bone with appropriate tension. BMD was measured before surgery. Depth to anchor (DA), anchor settling, and repaired rotator cuff integrity were measured with MRI. Patients were categorized into 3 groups: group A (BMD, <0.4 g/cm²; n = 31), group B (BMD, 0.4-0.6 g/cm²; n = 32), and group C (BMD, >0.6 g/cm²; n = 25). A total of 65 patients had follow-up MRI. On the basis of rotator cuff tendon integrity, patients were categorized into either a sufficient thickness group (group S, Sugaya classification grade II or lower; n = 44) or an insufficient thickness group (group I, Sugaya classification grade III or higher; n = 21).

RESULTS

On time-zero MRI, the DA differed significantly among groups (group A, 3.62 ± 2.02 mm; group B, 5.18 ± 2.13 mm; group C, 6.30 ± 3.34 mm) (P = .001). The DA was deeper in patients with a higher BMD at time zero (r = 0.374; P = .001), but the DA did not differ at follow-up MRI (mean, 10.3 months after surgery). On follow-up MRI, anchor settling tended to increase with deeper time-zero DA (r = 0.769; P < .001). Anchor settling was significantly different among groups (group A, 1.33 ± 1.08 mm; group B, 2.78 ± 1.99 mm; group C, 3.81 ± 2.19 mm) (P = .001). The proportion of patients with sufficient thickness in each group did not show a statistical difference (group A, 70.8%; group B, 72.7%; group C, 57.9%) (P = .550).

CONCLUSION

In conclusion, this study confirmed that the postoperative site of anchor insertion in arthroscopic single-row rotator cuff repair with all-suture anchors was located farther from the cortex in patients with higher shoulder BMD and closer to the subcortical bone in patients with lower BMD. On follow-up MRI, no further settling occurred past a certain distance from the cortex, and there was no significant difference in anchor depth or integrity of the rotator cuff tendon based on shoulder BMD. Therefore, minimal settling in the all-suture anchor did not show clinical significance.

Arthroscopic rotator cuff repair: magnetic resonance arthrogram assessment of tendon healing

BACKGROUND

Many poor outcomes after arthroscopic rotator cuff (RC) repair relate to failure of tendon healing. The purposes of this study were to provide a better understanding of the magnetic resonance arthrography (MRA) characteristics of the RC tendon repair site after arthroscopic RC repair and to examine how these findings influence patient-reported outcome measures (PROMs) and the presence of persistent symptoms.

METHODS

We reviewed 48 shoulders (13 female and 35 male patients; average age, 53.8 years) at a minimum of 6 months (average, 11.4 months) after arthroscopic RC repair (average tear size, 2.2 cm). All patients completed PROMs and underwent MRA assessment. Detailed analysis of the RC repair site was undertaken, with findings correlated with clinical outcomes and PROMs.

RESULTS

The average preoperative American Shoulder and Elbow Surgeons (ASES) score of 39.5 improved to 92.8 (P < .001). All but 6 patients (87.5%) had increased signal intensity of the involved tendon, with interstitial splits and/or delamination in 65.6%. These changes had no effect on PROMs or patient satisfaction. Significant partial-thickness tears (>50%) were observed in 7 patients (14.6%), with no effect on outcomes (average ASES score of 95.2 and satisfaction score of 9). There were 2 recurrent full-thickness tears (4.2%), and 4 patients (8.3%) had a failure in continuity. The average ASES score in these 6 cases of failure was 76 (P < .001).

CONCLUSIONS

Structural abnormalities on MRA are common after RC repair but do not always result in clinical failure. However, our results suggest that an ASES score of less than 80 may be useful when considering postoperative imaging, especially in a patient with ongoing pain more than 6 months after surgery.

Perianchor Cyst Formation After Arthroscopic Rotator Cuff Repair Using All-Suture-Type, Bioabsorbable-Type, and PEEK-Type Anchors

PURPOSE

This study aimed to identify the difference in postoperative perianchor bone reactions in different groups of patients who underwent rotator cuff tear repairs with all-suture-, bioabsorbable screw-, and PEEK (polyether ether ketone)-type suture anchors. Furthermore, the rate of rotator cuff retear and its association with perianchor bone reactions based on the different anchors used were investigated. Moreover, their impact on the clinical outcome of patients was examined.

METHODS

The study included 213 patients who underwent arthroscopic single-row repair and were divided into 3 groups according to the suture anchor used: all-suture (n = 137), biodegradable (n = 36), and PEEK (n = 40) anchor groups. The clinical outcomes and magnetic resonance imaging findings were evaluated at a mean follow-up of 9.6 months. The perianchor bone reaction at the anchor site was categorized according to grades. Patients were classified based on repair integrity into the healed and retear groups with Sugaya type I to III and Sugaya type IV to V, respectively.

RESULTS

No statistically significant differences in Constant scores and retear rates were observed between the groups (P = .934 and P = .548, respectively). Magnetic resonance imaging showed that the total number of perianchor cysts formed postoperatively was 23 (10.8% [23 of 213 patients]). Moreover, the proportions of perianchor cysts were 8.8%, 16.7%, and 12.5% in the all-suture-type, bioabsorbable-, and PEEK-type anchor groups, respectively (P = .485). In the retear group, the incidence rate was significantly increased with higher grades of perianchor bone reaction (P = .001). The tear size and perianchor bone reaction were found to be independent factors that affected the incidence of retear.

CONCLUSIONS

Perianchor cyst formation was observed in 10.8% of cases after the use of suture anchors for arthroscopic rotator cuff repair. No significant differences were observed among all-suture-type, bioabsorbable-type, and PEEK-type anchors in terms of visual analog scale and Constant scores, retear rates, and perianchor bone reactions. However, the retear rate was associated with a greater perianchor cystic reaction and larger tear size.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Arthroscopic treatment for intratendinous rotator cuff tear results in satisfactory clinical outcomes and structural integrity

PURPOSE

This study aimed to evaluate the clinical outcomes and structural integrity of arthroscopic repair of intratendinous rotator cuff tear.

METHODS

Patients who were diagnosed with an intratendinous tear but in whom conservative treatment failed were selected and underwent arthroscopic repair. Between 2008 and 2014, a total of 30 patients (6 men, 24 women; mean age, 59 ± 3.7 years) met the inclusion criteria and were followed up. The mean follow-up period was 26.3 ± 0.7 months. The results were evaluated using the University of California at Los Angeles (UCLA) score, the Society of the American Shoulder and Elbow Surgeons rating scale (ASES) questionnaire, and the visual analog scale (VAS) and range of motion (ROM) were measured preoperatively and at final follow-up. Magnetic resonance imaging (MRI) was performed preoperatively and at 6.7 ± 0.2 months postoperatively. Postoperative MRI was performed on 27 out of 30 patients and analysed using the Sugaya classification.

RESULTS

Corresponding to the preoperative MRI findings, arthroscopic findings of intratendinous tears were observed in all 30 patients. The mean active forward elevation ROM was 137.3° ± 15.4° before surgery and 168.8° ± 15.2° at the final follow-up. The internal and external rotations at abduction were 31.7° ± 5.1° and 63.0° ± 11.6° before surgery, respectively, and 60.5° ± 8.0° and 75.2° ± 10.8° after surgery, respectively. The UCLA score improved from of 20.1 ± 7.4 points preoperative to 28.4 ± 5.5 points at the final follow-up. The ASES score improved from 55.7 ± 15.3 points preoperative to 82.6 ± 9.7 points postoperatively. The VAS for pain score decreased from 6.4 ± 1.2 points preoperative to 1.6 ± 0.9 points postoperative. Satisfactory outcomes (excellent/good) in terms of UCLA and ASES scores were observed in 29 of 30 patients. Based on Sugaya classification, grades I, II, and III structural integrities were observed in 9, 14, and 4 patients, respectively.

CONCLUSIONS

Successful clinical outcomes and structural integrity can be achieved with arthroscopic repair of intratendinous rotator cuff tears involving more than half thickness (> 50%). Therefore, arthroscopic repair is a practical next treatment option for patients with intratendinous rotator cuff tears in whom conservative treatment fails.

LEVEL OF EVIDENCE

IV.

The Role of Tendon Transfers for Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

This review aims to describe the tendon transfer options for treating irreparable rotator cuff tears (RCTs). Options for transfer include latissimus dorsi and lower trapezius transfers for posterior-superior RCTs and pectoralis major and latissimus dorsi transfer for anterior-superior RCTs.

RECENT FINDINGS

While the latissimus dorsi tendon transfer has historically been performed for posterosuperior RCTs, the lower trapezius transfer is a more anatomic option and has demonstrated promising results in recent studies. Similarly, the pectoralis major transfer has historically been the tendon transfer of choice for anterosuperior RCTs. However, the latissimus dorsi tendon transfer has recently been shown to be a safe and anatomic tendon transfer for subscapularis insufficiency. The treatment of irreparable RCTs involves complex decision making. Tendon transfer procedures can restore the glenohumeral joint force couples, allowing restoration of near-normal shoulder kinematics. Benefits include reliable pain relief, increased function, and increased strength. Proper selection of donor tendon is crucial, and the principles of tendon transfer procedures must be adhered to for maximal benefit.

Does Additional Biceps Augmentation Improve Rotator Cuff Healing and Clinical Outcomes in Anterior L-Shaped Rotator Cuff Tears? Clinical Comparisons With Arthroscopic Partial Repair

BACKGROUND

The repair of anterior L-shaped tears is usually difficult because of the lack of anterior rotator cuff tendon to cover the footprint. The biceps tendon is usually exposed from the retracted anterolateral corner of the torn tendon and can be easily used to augment rotator cuff repair. Hypothesis/Purpose: This study compared the clinical outcomes of the biceps augmentation technique with those of partial tendon repair for the arthroscopic treatment of large anterior L-shaped rotator cuff tears to evaluate the role of additional biceps augmentation in tendon healing. We hypothesized that the biceps augmentation technique would lead to a lower rotator cuff tendon retear rate and provide satisfactory functional outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 64 patients with anterior L-shaped rotator cuff tears who underwent arthroscopic repair. Patients were divided into 2 groups: group A (31 patients) underwent repair of an anterior L-shaped tear combined with biceps augmentation, and group B (33 patients) had a partially repaired tendon whose footprint was exposed after repair without undue tension on the retracted tendon. Clinical evaluations were performed using the American Shoulder and Elbow Surgeons (ASES) score, Constant score, muscle strength, visual analog scale for pain, and patient satisfaction. Magnetic resonance imaging (MRI) was performed for tendon integrity at 6 months postoperatively.

RESULTS

The mean period of follow-up was 29.1 ± 3.5 months (range, 24-40 months). The mean ASES and Constant scores significantly improved from 52.8 ± 10.6 and 43.2 ± 9.9 preoperatively to 88.2 ± 6.9 and 86.8 ± 6.2 at final follow-up in group A ( P < .001) and from 53.0 ± 11.8 and 44.3 ± 11.3 preoperatively to 87.4 ± 7.2 and 87.9 ± 7.3 at final follow-up in group B ( P < .001). Overall muscle strength (given as % of the other side's strength) significantly increased from preoperatively to final follow-up in group A (forward flexion [FF]: 62.0 ± 8.2 to 89.0 ± 8.6; external rotation [ER]: 57.5 ± 9.9 to 86.8 ± 9.3; internal rotation [IR]: 68.1 ± 10.8 to 88.1 ± 8.4; P < .001) and group B (FF: 59.9 ± 9.6 to 87.7 ± 9.0; ER: 58.6 ± 9.3 to 86.2 ± 7.5; IR: 70.0 ± 9.3 to 87.0 ± 8.4; P < .001). Twenty-one patients (67.7%) in group A and 20 patients (60.6%) in group B showed a healed rotator cuff tendon on postoperative MRI. The retear rate between the 2 groups showed no significant difference ( P = .552). Regarding clinical outcomes, both groups had no significant difference in the ASES score ( P = .901), Constant score ( P = .742), and muscle strength.

CONCLUSION

There was no significant difference in the clinical outcomes and retear rate of anterior L-shaped tears between biceps augmentation and partial tendon repair. Additional biceps augmentation proved to have no enhancement in tendon healing. A precise method such as only partial tendon repair for reducing the footprint exposure without undue tension may be considered as one of the treatment options for large anterior L-shaped rotator cuff tears.

Serial clinical and MRI examinations after arthroscopic rotator cuff reconstruction using double-row technique

PURPOSE

Rotator cuff reconstruction using arthroscopic double-row technique enables a better repair of the anatomical footprint at the tendon insertion. Objective of this serial study was to illustrate structural and functional results during recovery following double-row reconstruction.

METHODS

Forty-five patients with mid-sized ruptures of the supraspinatus tendon were assessed prospectively and underwent arthroscopic surgery using the double-row technique. Rupture localization, size, form, and extent of retraction were recorded intraoperatively. Clinical and MRI follow-up examinations were carried out for all patients after 6, 12, 26, and 52 weeks. A A standard protocol was used during the follow-up examinations to determine tendon integration, signal changes in the tendon, extent of bone marrow edema near the enclosed absorbable suture anchors, muscle changes. The clinical results were correlated with the MRI appearance.

RESULTS

After 26 weeks, the Constant score (CS) showed a highly significant increase for the first time with a value of 78 (p < 0.001). Tendon integration according to Sugaya showed a left shift over time, with higher CS-values for lower Sugaya classifications. Significant improvements in strength were first measured between the 26-week and 52-week follow-ups (9->19/p < 0.001). Highly significant improvement (p < 0.001) of the tendon signal and the fatty infiltration was found in the same time interval. The hypotrophy showed slight improvement, while a highly significant reduction of the bone marrow edema was found between weeks 12 and 26 (p < 0.001). There were no re-ruptures after week 26.

CONCLUSIONS

The present serial study showed that it took 26 weeks to reach a significant clinical improvement concerning CS. With regard to tendon healing, no further deterioration of the structural results occurred between week 26 and week 52 postoperative. There were slightly but not significant better clinical results according to the the Sugaya classification. However, parameter "strength" was significantly increased between weeks 26 and 52. This was consistent with a significant decrease in the signal intensity at the repaired tendon site, an additional improvement in the fatty infiltration, and the atrophy according to Thomazeau in the same time interval.

LEVEL OF EVIDENCE

I.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Efficacy of a Subacromial Corticosteroid Injection for Persistent Pain After Arthroscopic Rotator Cuff Repair

BACKGROUND

Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase.

PURPOSE

To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively.

RESULTS

In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04).

CONCLUSION

A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Tendon transfers for irreparable rotator cuff tears: An update

Shoulder dysfunction in the setting of irreparable rotator cuff tears (RCTs) can be treated successfully with different types of tendon transfer: Latissimus dorsi transfer for irreparable posterosuperior RCTs works best for young, active patients with an intact subscapularis, no pseudoparalysis or previous surgery, and a functioning teres minor.A more anatomical transfer for irreparable posterosuperior RCTs is a lower trapezius transfer, and early results are promising.Isolated irreparable tears of the subscapularis can be successfully managed with pectoralis major tendon transfer with a concentric humeral head. However, restricted external rotation (ER) may occur, depending on technique.Pectoralis minor transfer can successfully address combination irreparable tears of the upper border subscapularis and the supraspinatus without significant loss of ER.Rotator cuff arthropathy with ER lag benefits most from a reverse total shoulder arthroplasty and a combination latissimus dorsi and teres major transfer (LDTMT) regardless of patient age. Cite this article: Axe JM. Tendon transfers for irreparable rotator cuff tears: An update. EFORT Open Rev 2016;1:18-24. doi: 10.1302/2058-5241.1.000003.

Arthroscopic Rotator Cuff Repair With Absorbable Sutures in the Medial-Row Anchors

PURPOSE

To report the retear rate and retear pattern after double-row arthroscopic rotator cuff repair (DR-ARCR) with the use of absorbable sutures as medial anchor sutures and to address the advantage of the use of absorbable sutures in medial-row anchors.

METHODS

Fifty-seven shoulders (22 male and 35 female patients; mean age, 66.1 years) with complete rotator cuff tears treated with DR-ARCR using absorbable mattress sutures as medial-row anchor sutures were included in the study. They included 35 medium, 17 large, and 5 massive tears. For the medial row, medial anchor sutures were replaced with absorbable mattress sutures. High-strength simple sutures were used for the lateral anchors. We evaluated retear patterns by magnetic resonance imaging examinations performed at 1 month, 3 months, 6 months, and 1 year postoperatively. The clinical conditions of all patients preoperatively and 2 years postoperatively were assessed by the University of California, Los Angeles rating scale and the American Shoulder and Elbow Surgeons shoulder index.

RESULTS

A complete retear of the tendon at the footprint was observed in 5 shoulders. Complete discontinuity at the middle of the tendon around the medial-row anchors with a footprint remnant was observed in 1 shoulder. A thinned repaired rotator cuff was observed in 2 shoulders because of a partial retear of the deep layer. The overall retear rate was 14%. From before to after surgery, the University of California, Los Angeles score significantly improved from 18.4 to 32.9 (P < .0001) and the American Shoulder and Elbow Surgeons index improved from 55.1 to 87.7 (P < .0001). No complications were observed.

CONCLUSIONS

The retear rates after DR-ARCR with absorbable sutures as medial-row anchors were 8.8% for complete retears of the tendon at the footprint and 1.7% for complete discontinuity of tendon around the medial-row anchors. This procedure provided a low retear rate around the medial-row anchors.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Assessment of the Postoperative Appearance of the Rotator Cuff Tendon Using Serial Sonography After Arthroscopic Repair of a Rotator Cuff Tear

OBJECTIVES

The purpose of this study was to evaluate serial changes in sonographic findings of a rotator cuff tendon after rotator cuff repair.

METHODS

Sixty-five arthroscopically repaired rotator cuff tears (43 full-thickness tears and 22 partial-thickness tears) were retrospectively included in this study. Serial sonographic examinations were performed at 5 weeks, 3 months, and 6 months after surgery. The sonographic findings of the repaired tendon were assessed for a recurrent tear, tendon thickness, morphologic tendon characteristics, vascularity, and bursitis at each time point.

RESULTS

Four recurrent tears occurred within 3 months of surgery. The postoperative tendon thickness decreased from 5 weeks to 6 months after surgery (P = .001). There were significant changes in the morphologic tendon characteristics, including the echo texture, fibrillar pattern, and surface irregularity of the repaired tendon, from 5 weeks to 6 months after surgery (P < .001). Additionally, subacromial-subdeltoid bursitis and the vascularity of the repaired tendon decreased postoperatively over time.

CONCLUSIONS

Serial sonography after arthroscopic rotator cuff repair was useful for monitoring the postoperative changes in a repaired tendon. The morphologic appearance of the repaired tendon and peritendinous soft tissue changes improved over time and nearly normalized within 6 months of surgery.

Prospective evaluation of clinical and radiologic factors predicting return to activity within 6 months after arthroscopic rotator cuff repair

BACKGROUND

This study aimed to report the outcome of patients who underwent arthroscopic rotator cuff repair (ARCR) and to determine the factors associated with return to work and activity.

MATERIALS

Three hundred sixty-five patients who underwent ARCR were prospectively evaluated. The cohort was divided into 2 groups based on clinical results at 6 months. Group A consisted of patients who were considered to have a satisfactory outcome based on return to their previous professional or spare-time activities. Group B consisted of patients with an unsatisfactory outcome based on a lack of return to normal work or activities.

RESULTS

Of the patients, 305 had a satisfactory outcome (group A) and 60 were categorized as having an unsatisfactory outcome (group B). On multivariate analysis, preoperative factors associated with group B included female gender and heavy manual labor. Postoperative bursitis on ultrasound at 6 months was associated with being in group B. Lack of tendon healing was not associated with group B. However, if a patient without healing had persistent pain at 6 months, the pain persisted at 9 months.

CONCLUSION

ARCR is an effective procedure that leads to significant improvement in pain, function, and tendon healing in most cases. However, in 1 of 5 cases, patients were unable to resume normal activity at 6 months postoperatively. Persistent limitation at 6 months was associated with female gender, heavy manual workers, and the presence of postoperative persistent bursitis.

Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients

BACKGROUND

Symptomatic rotator cuff tears are often treated surgically. However, there is a paucity of information regarding the outcomes of revision arthroscopic rotator cuff repairs.

PURPOSE

To evaluate the outcome of revision arthroscopic rotator cuff surgery when compared with primary arthroscopic rotator cuff surgery in a large cohort of patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

A consecutive series of 50 revision arthroscopic rotator cuff repairs performed by a single surgeon, with minimum 2-year follow-up, were retrospectively reviewed using prospectively collected data. As a comparison, 3 primary arthroscopic rotator cuff repair cases (primary group; n = 310) were chosen immediately before each revision case, and 3 were chosen after. Standardized patient-ranked outcomes, examiner-determined assessments, and ultrasound-determined rotator cuff integrity were assessed preoperatively at 6 months and at a minimum of 2 years after surgery.

RESULTS

The revision group was older (mean age, 63 years; range, 43-80 years) compared with the primary group (mean age, 60 years; range, 18-88 years) (P < .05) and had larger tear size (mean ± SEM) (4.1 ± 0.5 cm(2)) compared with the primary group (3.0 ± 0.2 cm(2)) (P < .05). Two years after surgery, the primary group reported less pain at rest (P < .02), during sleep (P < .05), and with overhead activity (P < .01) compared with the revision group. The primary group had better passive forward flexion (+13°; P < .05), abduction (+18°; P < .01), internal rotation (+2 vertebral levels; P < .001) and also significantly greater supraspinatus strength (+15 N; P < .001), lift-off strength (+9.3 N; P < .05), and adduction strength (+20 N; P < .01) compared with the revision group at 2 years. When compared with the primary group, the revision group was more satisfied with the overall shoulder function before surgery but was less satisfied with their shoulder function than the primary group at 2 years (P < .005). The retear rate for primary rotator cuff repair was 16% at 6 months and 21% at 2 years, while the retear rate for revision rotator cuff repair was 28% at 6 months and deteriorated to 40% at 2 years (P < .05).

CONCLUSION

The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. However, these results did not persist, and by 2 years patients who had revision rotator cuff repair were twice as likely to have retorn compared with those undergoing primary repair. The increase in retear rate in the revision group at 2 years was associated with increased pain, impaired overhead function, less passive motion, weaker strength, and less overall satisfaction with shoulder function.

Management of rotator cuff tears

Every year approximately 18 million Americans report shoulder pain, a large percentage of which are a result of rotator cuff disease. Rotator cuff tear progression can be difficult to predict. Factors associated with tear enlargement include increasing symptoms, advanced age, involvement of 2 or more tendons, and rotator cable lesion. Nonsurgical treatment can be effective for patients with full-thickness tears. When conservative treatment fails, surgical repair provides a reliable treatment alternative. Recurrent tears after surgery can compromise outcomes, particularly for younger patients with physically demanding occupations. Revision surgery provides satisfactory results for those with symptomatic re-tears. If the tear is deemed irreparable, addressing concomitant biceps pathology or performing partial repairs can reliably improve pain and potentially reverse pseudoparalysis. The reverse shoulder arthroplasty has limited indications in the setting of rotator cuff tears and should be reserved for patients with painful pseudoparalysis and associated arthropathy.

Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review

PURPOSE

The purpose of this systematic review was to detect the reliability of the currently available magnetic resonance imaging measurements used in the evaluation of repaired rotator cuff.

METHODS

Search was performed using major electronic databases from their inception to February 2014. All studies reporting post-operative magnetic resonance assessment after rotator cuff repair were included. After the identification of available magnetic resonance criteria, reliability studies were further analysed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

One hundred and twenty studies were included in the review. Twenty-six different criteria were identified. Ten studies reported inter-observer reliability, and only two assessed intra-observer reliability of some of the identified criteria. Structural integrity was the most investigated criterion. The dichotomized Sugaya's classification showed the highest reliability (k = 0.80-0.91). All other criteria showed moderate to low inter-observer reliability. Tendon signal intensity and footprint coverage showed a complete discordance. Intra-observer reliability was high for the presence of structural integrity, and moderate to low for all other criteria. Methodological quality was high only for one study and moderate for three studies.

CONCLUSIONS

Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. Reliability of most of them has not been analysed yet. With the data available, only the presence of structural integrity showed good intra- and inter-observer agreement.

LEVEL OF EVIDENCE

Systematic review of descriptive and qualitative studies, Level IV.

Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome

BACKGROUND

Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.

PURPOSE

To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.

STUDY DESIGN

Systematic review and meta-analysis of articles with evidence levels 1-4.

METHODS

A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.

RESULTS

While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. The inconsistent and incomplete data in the published articles limited the meta-analysis of factors affecting the outcome of rotator cuff repair.

CONCLUSION

In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient. To accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patient's condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function.

Intratendinous rotator cuff tears: prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears at midterm follow-up

BACKGROUND

Intratendinous tears of the rotator cuff are rare, and little has been written about them.

PURPOSE

To investigate the prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Included in the study were 33 patients (16 male, 17 female; mean age, 53.4 years) with arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair from March 2006 to July 2012. A history of trauma was found in 10 cases (30.3%). The dominant arm was involved in 26 cases (78.8%). The mean follow-up duration was 56 months. Preoperatively, a thorough physical examination was performed; at final follow-up, shoulder range of motion (ROM) in forward flexion, abduction, external rotation (ER) at the side, and internal rotation (IR) at the back was noted, and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analog scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded and compared with the preoperative data. Postoperative magnetic resonance imaging (MRI) was performed at 6 months to investigate rotator cuff healing status and repair integrity.

RESULTS

The prevalence of arthroscopically confirmed intratendinous tears was 4.7% among all arthroscopically treated partial-thickness rotator cuff tears. Impingement signs were positive in most of the patients (positive Hawkins-Kennedy test result in 78.8%, positive Neer sign in 66.7%, and either positive Hawkins-Kennedy test result or Neer sign in 84.8%). At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from a preoperative mean of 51.4, 18.9, 6.0, and 5.4, respectively, to a postoperative mean of 90.6, 32.9, 1.4, and 10.8, respectively (P < .001). According to the UCLA rating scale, outcomes were excellent in 17, good in 13, and fair in 3 cases. Shoulder ROM in forward flexion, abduction, ER at the side, and IR at the back improved from a preoperative mean of 135°, 129°, 25°, and L2, respectively, to a postoperative mean of 161°, 160°, 29°, and T10, respectively (P < .001 for all except ER). As per the Sugaya classification, on postoperative MRI, type I healing status was found in 10 (30.3%), type II in 18 (54.5%), and type III in 2 (6.1%) cases. None of the patients showed any evidence of retears.

CONCLUSION

Transtendon suture bridge repair yielded satisfactory clinical and radiological outcomes in patients with intratendinous rotator cuff tears.

Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears

BACKGROUND

This study was conducted to evaluate clinical outcomes, maintenance of repair integrity, and retear rate after arthroscopic rotator cuff repair by a suture bridge technique among patients with medium, large, and massive rotator cuff tears.

METHODS

We evaluated 147 patients who had undergone arthroscopic rotator cuff repair. Clinical and functional evaluations were performed with the Constant and University of California-Los Angeles scores. All patients were confirmed to have magnetic resonance imaging evidence of tendon healing at least 12 months postoperatively.

RESULTS

The average postoperative time to follow-up magnetic resonance imaging was 23.4 months (range, 12-48 months). A total of 25 (17.0%) retears were observed. All clinical outcome scores were improved significantly at follow-up. Larger intraoperative tear sizes were correlated with higher retear rates. The incidence of retear was also higher in cases in which the preoperative fatty degeneration grade was higher. The incidence of retear increased with age and in the heavy worker group (e.g., farmers, carriers, car mechanics) but was not statistically significant.

CONCLUSIONS

Arthroscopic rotator cuff repair by a suture bridge technique yields improvements in clinical outcome measures and a relatively high degree of patient satisfaction despite the fact that repair integrity is not maintained in many cases.

Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study

BACKGROUND

The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs.

PURPOSE

To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively.

RESULTS

Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness.

CONCLUSION

Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.

Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis

BACKGROUND

The correlation between the structural integrity of rotator cuff repair and the clinical outcome for the patient remains controversial. The purpose of this study was to assess the relationship between patient function and structural integrity of the rotator cuff after repair.

METHODS

A systematic review and a meta-analysis were conducted for Level-I and Level-II studies showing outcome measures after rotator cuff repair and an imaging assessment of the structural integrity of the repair. Data extracted included patient demographics, tear size, repair type, clinical outcome measures, and repair integrity. Statistical analysis was performed to compare outcomes in patients on the basis of the structural integrity of repair at the time of the latest follow-up.

RESULTS

Fourteen studies met inclusion criteria and were included in the latest analysis. Of the 861 patients who underwent rotator cuff repair with a minimum of a one-year follow-up, 674 patients (78.3%) had intact repairs at the time of latest follow-up. There was no difference in tear size between patients with intact repairs and those with retears (p = 0.866). The University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score increased and the visual analog scale score decreased in patients regardless of the structural integrity of the repair. Patients with intact repairs had higher Constant scores by 8.93 points (p < 0.0001) and higher University of California Los Angeles shoulder scores by 2.95 points (p = 0.0004). Postoperative American Shoulder and Elbow Surgeons scores were no different in patients with intact repairs or retears (p = 0.15). Postoperative visual analog scale scores were 0.93 points lower in patients with intact repairs (p = 0.01). Patients with intact repairs had increased strength in forward elevation by 2.40 kilograms (5.29 pounds) (p < 0.00001) and had a trend toward increased strength in shoulder external rotation (p = 0.06). Although these results are significant, the differences are not clinically important on the basis of the validation of these outcome measures.

CONCLUSIONS

The results of this study suggest that there is not a clinically important difference in validated functional outcome scores or pain for patients who have undergone rotator cuff repair regardless of the structural integrity of the repair. Patients with intact repairs do have significantly greater strength than those with retears.

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity

BACKGROUND

Few studies of large-to-massive contracted rotator cuff tears have examined the arthroscopic complete repair obtained by a posterior interval slide and whether the clinical outcomes or structural integrity achieved are better than those after partial repair without the posterior interval slide.

METHOD

The study included forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. The patients underwent either arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge (twenty-two patients; Group P) or partial repair with margin convergence (nineteen patients; Group M). The patient assignment was not randomized. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and range of motion were used to compare the functional outcomes. Preoperative and six-month postoperative magnetic resonance arthrography (MRA) images were compared within or between groups.

RESULTS

At the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. However, no significant differences were detected between groups. Even though the difference in preoperative tear size on MRA images was not significant, follow-up MRA images identified a retear in twenty patients (91%) in Group P and a significant difference in tear size between groups (p = 0.007).

CONCLUSIONS

The complete repair group with an aggressive release had no better clinical or structural outcomes compared with the partial repair group with margin convergence alone for large-to-massive contracted rotator cuff tears. In addition, the complete repair group had a 91% retear rate and a greater defect on follow-up MRA images. Even though this study had a relatively short-term follow-up, a complete repair of large-to-massive contracted rotator cuff tears, with an aggressive release such as posterior interval slide, may not have an increased benefit compared with partial repair without posterior interval slide.

Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study

PURPOSE

To evaluate the efficacy of a marrow-stimulating technique with microfractures of the greater tuberosity during arthroscopic rotator cuff repair.

METHODS

Eighty patients with a full-thickness rotator cuff tear underwent an arthroscopic single-row repair. Patients were divided into 2 groups of 40 cases each. In group 1, standard repair was performed; in group 2, microfractures of the greater tuberosity were performed to enhance tendon repair. Clinical outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score and normalized Constant score. Tendon integrity was assessed with magnetic resonance imaging. Multivariate analysis was performed to determine which predictors were independently associated with the outcome. Significance was set at P < .05.

RESULTS

The mean follow-up was 28.1 ± 3 months. Seven patients were lost to follow-up (2 in group 1 and 5 in group 2). Comparison between groups did not show significant differences for baseline characteristics. The mean DASH score was 28.6 ± 21.3 points in group 1 and 23.3 ± 20.1 points in group 2. Although the difference was not statistically significant, the confidence interval included a 10-point value (minimal clinically important difference) in favor of the microfracture group. The difference in the Constant score between groups was not significant. The tendon healing rate was 52.6% in group 1 and 65.7% in group 2, without a significant difference between groups. Subgroup analysis for tear size showed that group 2 had a significantly greater healing rate than group 1 for large tears (P = .040). Multivariate analysis showed that age, timing of symptoms, tear location, tendon retraction, and fatty infiltration significantly affected the outcomes.

CONCLUSIONS

Postoperative magnetic resonance imaging did not show any significant difference between groups in structural integrity. However, subgroup analysis showed a significantly greater healing rate in the microfracture group for large tears involving the supraspinatus and infraspinatus.

LEVEL OF EVIDENCE

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

Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair

BACKGROUND

Recurrent or persistent defects in the rotator cuff after its repair are common. Short- and medium-term surveys have revealed, after open repair, patients with an intact rotator cuff have increased function and ROM. However, no long-term studies have verified cuff integrity on MR arthrography or correlated it with clinical and functional outcomes.

QUESTIONS/PURPOSES

We evaluated long-term cuff integrity and fatty infiltration after open repair using MR arthrography and determined whether these findings correlated with clinical and functional results.

METHODS

Using MR arthrography, we retrospectively evaluated 67 patients (48 men, 19 women) who underwent open rotator cuff repair between 1980 and 1989. Their mean age at surgery was 52 years. Minimum followup was 16 years (mean, 20 years; range, 16-25 years).

RESULTS

The retear rate was 94%, and mean size of rerupture was 3.5 × 3.6 cm (ranges, 0.5-5.0 cm × 0.5-5.2 cm; median, 4 × 4 cm). The remaining four patients had a partial supraspinatus tendon tear. Fatty infiltration was marked in the supraspinatus and infraspinatus tendons. Cuff integrity correlated with clinical results: active external rotation and forward flexion, and flexion, abduction, and external rotation strengths, were better in patients with an intact rotator cuff or a small retear of 4 cm(2) or less than in patients with larger tears. Cuff integrity also correlated with functional results.

CONCLUSIONS

Rotator cuff integrity was lost in 94% of patients after a minimum followup of 16 years. Cuff integrity correlates well with clinical and functional results even several years postoperatively. A large retear seems to be the most important factor in deteriorating long-term clinical and functional results after open rotator cuff repair.

LEVEL OF EVIDENCE

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