Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination

A Comparison of the Results of Two Different Double-Row Repair Techniques in Arthroscopic Repair of Rotator Cuff Tears

Background and Objectives: Shoulder pain, mainly involving rotator cuff tears, is a common type of musculoskeletal pain that significantly impairs quality of life. Arthroscopic rotator cuff repair has become the gold standard for treating symptomatic, full-thickness rotator cuff tears. Double-row repair techniques are widely used because of their superior fixation and healing results. However, fewer implants may reduce treatment costs and raise questions about the impact on clinical outcomes and re-tear rates. This study compares the functional outcomes and re-tear rates of two transosseous-like double-row repair techniques: one anchor and one push lock (Group 1), and two anchors and two push locks (Group 2). Materials and Methods: A prospective, randomized, single-blind study was conducted on 53 patients undergoing arthroscopic repair for crescent-shaped rotator cuff tears (3-5 cm). Before surgery and 24 months after surgery, patients were evaluated for shoulder function using Constant-Murley scores and shoulder abduction angles. MRI was used to assess re-tear rates. Results: Both groups showed significant postoperative improvement in Constant scores (Group 1: 84.1; Group 2: 84.0; p > 0.05). Re-tear rates were slightly higher in Group 1 (23.1%) than in Group 2 (18.5%), but this was not statistically significant (p > 0.05). Shoulder abduction angles improved similarly between groups, with no significant difference in outcome. Despite higher costs and longer operative times, the two-anchor technique provided more stable fixation, but its functional outcomes were comparable to the single-anchor method. Conclusions: Using fewer implants in a double-row repair provides comparable functional outcomes and re-tear rates, and offers surgeons a cost-effective alternative, especially at the beginning of their learning curve. However, the two-anchor technique may be more beneficial in cases requiring improved mechanical stability. These findings provide valuable information to balance cost and effectiveness in rotator cuff repair.

Long head of biceps tendon augmentation in rotator cuff repair enhances tendon healing, shoulder function and patient-reported outcomes one-year post-surgery

Purpose

The aim is to determine the effect on healing and functionality of patients after 1 year of biceps augmentation of a rotator cuff repair (RCR) compared to RCR plus long head of the biceps (LHB) tenotomy. In addition, to analyse the main factors involved in the recovery after the surgery.

Methods

A prospective, comparative, non-randomized study (Level of Evidence III) was conducted. Patients with repairable rotator cuff tears were allocated to either the control group, with a double row transosseous equivalent RCR with LHB tenotomy, or the RCR+augmentation with LHB group. Patients were evaluated for radiological (MRI), clinical (cuff size, Patte and Goutallier scales) and functional variables (Constant and American Shoulder and Elbow Surgeons [ASES] scales) before the intervention. At 1-year follow-up cuff healing was confirmed through MRI and functional evaluation with Constant, ASES, simple shoulder test [SST] and Disabilities of the Arm, Shoulder and Hand scales.

Results

Seventy-seven patients underwent control or RCR+augmentation with LHB, there were no preoperative differences between the groups. After 1 year of the surgery, re-rupture occurred in 38.5% and 16% of the patients in control and RCR+augmentation with LHB groups, respectively (p = .026). Total functionality was higher (p < .05) in RCR+augmentation with LHB than in the control group: Constant, SST and ASES scales. Among the explored factors involved in healing, re-rupture occurred in 100% of the cases with high fatty degeneration. Besides, higher initial functionality (Constant scale) and RCR+augmentation with LHB increased the odds of healing (odds ratio [OR] = 1.12 [1.04-1.21]; OR = 5 [1, 61], respectively), while higher cuff length had a detrimental effect (OR = 0.92 [0.85-0.99]).

Conclusion

RCR+augmentation with LHB achieves a higher healing percentage and a better functional evolution than RCR+LHB tenotomy, 1 year after cuff repair. Fatty degeneration, cuff length and initial functionality are the main factors involved in cuff healing.

Level of Evidence

Level III randomized controlled trial.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair

BACKGROUND

This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed.

METHODS

A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios.

RESULTS

Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%.

CONCLUSIONS

This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

Factors affecting satisfaction in patients with a rotator cuff retear: CT arthrography-based study

PURPOSE

The relationship between retear that may occur after rotator cuff repair and patient satisfaction is not well established. This study aimed to determine whether the types and size of the retear evaluated by computed tomography arthrography (CTA) influenced patient satisfaction. We also analyzed the patient factors that could affect patient satisfaction.

PATIENTS AND METHODS

A total of 50 patients who were diagnosed with rotator cuff retear after undergoing arthroscopic rotator cuff repair were included in this study. All the patients were dichotomously classified into the satisfactory or dissatisfactory groups according to the patients' self-classifications. CTA was used to assess the attachment status of the footprint, detect retear on the medial side of the footprint of the repaired cuff, and determine the retear size. Demographic factors, including sex, age, occupation, dominant upper extremity, duration of pain, presence of diabetes mellitus, trauma history, history of ipsilateral shoulder surgery, repair technique, worker's compensation status, and functional shoulder score, were investigated.

RESULTS

Thirty-nine patients were classified into the satisfactory group and 11 patients were classified into the dissatisfactory group. There were no differences in age, sex, occupation, dominant hand, duration of pain, presence of diabetes mellitus, trauma history, history of ipsilateral shoulder surgery, repair technique, worker's compensation, and duration of follow-up between the two groups. However, the postoperative American Shoulder and Elbow Surgeon (ASES) score (P < 0.01), visual analog scale (VAS) pain level (P < 0.01), anteroposterior (AP) length (P < 0.01), and area of the retear site (P < 0.01) were significantly different.

CONCLUSION

The AP length and area of the retear site estimated using CTA were confirmed as the significant risk factors for dissatisfaction. However, the type of repaired rotator cuff judged by the attachment status of the footprint did not correlate with patient satisfaction. In addition, the postoperative VAS pain scale and ASES score was correlated with patient satisfaction.

Patch augmentation does not provide better clinical outcomes than arthroscopic rotator cuff repair for large to massive rotator cuff tears

PURPOSE

Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes.

METHODS

Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed.

RESULTS

This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups.

CONCLUSION

The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR.

LEVEL OF EVIDENCE

III.

Clinical outcomes in patients with retear after arthroscopic rotator cuff repair: A meta-analysis

BACKGROUND

Rotator cuff retear is a major concern after arthroscopic rotator cuff repair (ARCR); however, the effects of retear remain unclear. Therefore, the purpose of this study was to assess the clinical outcomes of postoperative retear and intact tendons after ARCR.

METHODS

We searched PubMed, Cochrane Library, Scopus, and PEDro databases for studies performed from January 2000 to June 2020. Clinical outcomes included the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles shoulder (UCLA) score, pain score, range of motion, and muscle strength. Meta-analysis using random-effects models was performed on the pooled results to determine significance.

RESULTS

The initial database search yielded 3141 records. After removal of duplicates, 26 of which met the inclusion criteria. Patients in the retear group had significantly lower Constant score [- 8.51 points (95% CI, - 10.29 to - 6.73); P < 0.001], ASES score [- 12.53 points (95% CI, - 16.27 to - 8.79); P < 0.001], UCLA score [- 3.77 points (95% CI, - 4.72 to - 2.82); P < 0.001], and significantly higher pain score [0.56 cm (95% CI, 0.10 to 1.01); P = 0.02] than the intact group. In addition, the retear group had significantly lower flexion [- 10.46° (95% CI, - 19.86 to - 1.07); P = 0.03], abduction [- 14.84° (95% CI, - 28.55 to - 1.14); P = 0.03], and external rotation [- 7.22° (95% CI, - 13.71 to - 0.74); P = 0.03] range of motion, and flexion [- 1.65 kg·f (95% CI, - 2.29 to - 1.01); P < 0.001], abduction [- 1.87 kg·f (95% CI, - 3.02 to - 0.72); P = 0.001], and external rotation [- 1.66 kg·f (95% CI, - 3.25 to - 0.07); P = 0.04] muscle strength.

CONCLUSION

Our results suggest that retear after ARCR leads to poor clinical outcomes after surgery.

Histologic and biomechanical evaluation of the thoracolumbar fascia graft for massive rotator cuff tears in a rat model

BACKGROUND

Fascial autografts, which are easily available grafts, have provided a promising option in patients with massive rotator cuff tears. However, no fascial autografts other than the fascia lata have been reported, and the exact healing process of the fascia-to-bone interface is not well understood. The objective of this study is to histologically and biomechanically evaluate the effect of the thoracolumbar fascia (TLF) on fascia-to-bone healing.

METHODS

A total of 88 rats were used in this study. Eight rats were killed at the beginning to form an intact control group, and the other rats were divided randomly into 2 groups (40 rats per group): the TLF augmentation group (TLF group) and the repair group (R group). The right supraspinatus was detached, and a 3 × 5 mm defect of the supraspinatus was created. The TLF was used to augment the torn supraspinatus in the TLF group, whereas in the R group, the torn supraspinatus was repaired in only a transosseous manner. Histology and biomechanics were assessed at 1, 2, 4, 8, and 16 weeks postoperatively.

RESULTS

The modified tendon maturation score of the TLF group was higher than that of the R group at 8 weeks (23.00 ± 0.71 vs. 24.40 ± 0.89, P = .025) and 16 weeks (24.60 ± 0.55 vs. 26.40 ± 0.55, P ≤ .001). The TLF group showed a rapid vascular reaction, and the peak value appeared at 1 week. Later, the capillary density decreased, and almost no angiogenesis was observed at 8 weeks postoperatively. Immunohistochemistry results demonstrated a significantly higher percentage of collagen I in the TLF group at 4, 8, and 16 weeks (24.78% ± 2.76% vs. 20.67% ± 2.11% at 4 weeks, P = .046; 25.46% ± 1.77% vs. 21.49% ± 2.33% at 8 weeks, P = .026; 34.77% ± 2.25% vs. 30.01% ± 3.17% at 16 weeks, P = .040) postoperatively. Biomechanical tests revealed that the ultimate failure force in the TLF group was significantly higher than that in the R group at the final evaluation (29.13 ± 2.49 N vs. 23.10 ± 3.47 N, P = .022).

CONCLUSIONS

The TLF autograft can promote a faster biological healing process and a better fixation strength. It could be used as an alternative reinforcement or bridging patch when the fascia lata is not appropriate or available for superior capsule reconstruction (SCR).

Modified double-pulley suture-bridge techniques with or without medial knot tying show comparable clinical and radiological outcomes in arthroscopic rotator cuff repair

PURPOSE

The optimal technique for arthroscopic rotator cuff repair is still controversial. The aim of this study was to compare modified arthroscopic double-pulley suture-bridge (DPSB) technique with medial knot tying to those without tying, considering clinical and radiological outcomes.

METHODS

This study included 292 patients with large full-thickness rotator cuff tears treated with modified DPSB technique. The patients were divided into 158 cases with medial knot tying (knot-tying group) and 134 without tying (knotless group). At follow-up, clinical outcome was assessed by the Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Shoulder Rating Scale of the University of California at Los Angeles (UCLA) score. The assessment of tendon healing was performed with magnetic resonance imaging (MRI) at a minimum of 12 months postoperatively.

RESULTS

The Constant score, ASES score and UCLA score in the knot-tying and knotless groups all improved significantly from before surgery to 12 months postoperatively (P < 0.05, respectively). No significant differences were observed between groups for each phase evaluated (n.s.). Tendon healing was categorised according to Sugaya's classification. The retearing rate was 27/158 (17.0%) in the knot-tying group and 20/134 (14.9%) in the knotless group, with no statistically significant difference between groups (n.s.). Additionally, the retear was classified using the Cho's classification. When comparing the retear rates of different types independently, no statistically significant differences were found between groups (n.s.).

CONCLUSIONS

The knotless modified DPSB technique showed comparable short-term functional outcomes to those of the knot tying method in large full-thickness rotator cuff tears. Additionally, no significant differences in repair integrity were observed between the two methods. Both techniques can be considered effective treatments for patients with large-sized full-thickness rotator cuff tears.

LEVEL OF EVIDENCE

III.

Shoulder outcome scoring systems have substantial ceiling effects 2 years after arthroscopic rotator cuff repair

PURPOSE

Previous studies show no difference in clinical outcomes between patients with healed and structurally failed rotator cuff repairs. The objective of this study was to assess ceiling effects when reporting surgical outcomes of arthroscopic rotator cuff repair using four of the currently most popular clinical shoulder outcome scoring systems.

METHODS

Ninety-two patients who underwent arthroscopic rotator cuff repair were examined. The simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder rating scale, and Constant-Murley shoulder score were completed 2 years postoperatively. Demographic data of the subjects were analysed using descriptive statistics. The ceiling effects in the outcome data assessed for each scale were estimated based on two previously reported definitions.

RESULTS

The number of patients with the maximum possible score was 31 (33.7%) with the SST, 26 (28.3%) with the ASES score, 28 (30.4%) with the UCLA scale, and 18 (19.6%) with the Constant-Murley score. The standardised distance of the outcome data assessed by the SST, ASES score, UCLA scale, and Constant-Murley scores were 0.92, 0.97, 0.96, and 1.18, respectively.

CONCLUSION

The SST, ASES score, and UCLA scale evaluated at 2 years postoperatively have substantial ceiling effects showing that the proportion of patients with the maximum possible score is > 20%, and the standardised distance is < 1.0. Researchers should be aware of possible biases due to ceiling effects when interpreting the results of studies investigating the surgical outcomes of arthroscopic rotator cuff repair. It could increase the likelihood of a type II error.

LEVEL OF EVIDENCE

IV.

Outcomes Following Double-Row and Medial Double-Pulley Rotator Cuff Repair

Multiple arthroscopic double-row repair techniques have been developed to treat full-thickness rotator cuff tears. However, healing rates and functional outcomes vary among these repair methods. A suture tape and medial double-pulley (STDP) technique that incorporated 2-mm suture tape for a knotless double-row with a broad double-mattress suture medially was developed as an alternative method to other double-row repair techniques. This prospective study reviewed the functional outcomes and healing rates of full-thickness supraspinatus tendon tears repaired using an STDP technique. Of 33 consecutive patients who underwent arthroscopic rotator cuff repair with an STDP construct, 24 patients with a minimum of 1 year of follow-up were included in the study. Preoperative fatty atrophy was recorded. Ultrasound imaging was used to assess rotator cuff healing at a minimum of 6 months postoperatively. Range of motion and functional outcome scores were evaluated at final follow-up. Mean active forward elevation improved from 124° preoperatively to 160° postoperatively. Comparing preoperative and postoperative values, the American Shoulder and Elbow Surgeons score improved from 45.9 to 90.8, the Single Assessment Numeric Evaluation score improved from 34.6 to 87.1, and the visual analog scale score decreased from 5.3 to 1.3. Twenty-one of 24 patients (88%) were satisfied with their outcomes. Ultrasound evaluation demonstrated complete healing in 88% of the cohort. The STDP technique is a technically efficient method of obtaining medial fixation in a double-row repair and appears to demonstrate clinically acceptable results. Healing was observed in 88% of cases, and functional outcome showed a statistically significant improvement. [Orthopedics. 2021;44(1):e125-e130.].

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes

Background:

Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs.

Purpose:

To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05.

Results:

A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up.

Conclusion:

Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

Background:

Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique.

Hypothesis:

Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

Results:

The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative).

Conclusion:

Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.

Graft use in the treatment of large and massive rotator cuff tears: an overview of techniques and modes of failure with MRI correlation

Despite technical advances, repair of large or massive rotator cuff tears continues to demonstrate a relatively high rate of failure. Rotator cuff repair or superior capsular reconstruction (SCR) using a variety of commercially available grafts provides a promising option in patients with tears that may be at high risk for failure or otherwise considered irreparable. There are three major graft constructs that exist when utilizing graft in rotator cuff repair or reconstruction: augmentation at the rotator cuff footprint, bridging, and SCR. Each construct has a unique appearance when evaluated using postoperative magnetic resonance imaging (MRI), and each construct has unique sites that are predisposed to failure. Understanding the basic principles of these constructs can help the radiologist better evaluate the postoperative MRI appearance of these increasingly utilized procedures.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV.

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity

BACKGROUND

The rationale for rotator cuff repair surgery is that better integrity of the cuff should be associated with better comfort and function. However, in patients with cuff disease, there is not good evidence that the degree of rotator cuff integrity is closely associated with the shoulder's comfort, function, or active motion. The goal of this study was to explore these relationships in shoulders with surgically documented cuff disease.

METHODS

In 55 shoulders having surgery for cuff-related symptoms, we correlated the preoperative Simple Shoulder Test score with the objectively measured preoperative active shoulder motion and with the integrity of the cuff observed at surgery.

RESULTS

The 16 shoulders with tendinosis or partial-thickness tears had an average Simple Shoulder Test score of 3.7 ± 3.3, active abduction of 111° ± 38°, and active flexion of 115° ± 36°. The corresponding values were 3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and 3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.

CONCLUSION

In this study, surgically observed cuff integrity was not strongly associated with the shoulder's comfort or function. Whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.

Ten-year clinical and anatomic follow-up after repair of anterosuperior rotator cuff tears: influence of the subscapularis

BACKGROUND

Anterosuperior rotator cuff tears are more frequent than expected. We report the results of a 10-year follow-up study after repair. Our hypothesis was that the extent of the subscapularis tear influenced the prognosis.

MATERIALS AND METHODS

The study population consisted of all 138 patients who underwent surgery in 14 participating centers in 2003 for full-thickness tears of the rotator cuff with lesions in the subscapularis and supraspinatus tendons. The patients were divided into 2 groups, depending on whether the subscapularis lesion affected only the superior half of the tendon (group A) or extended into the lower half (group B). Ninety-two patients (56 ± 7 years; 71 in group A and 21 in group B) were available for follow-up after 10 years (127 ± 16 months) with magnetic resonance imaging to evaluate tendon healing and muscle condition.

RESULTS

The mean Constant scores were 59 ± 16 before surgery and 77 ± 14 at follow-up (P = 1.7 × 10^-12). The retear rates were 25% for the supraspinatus and 13.5% for the subscapularis tendon. The clinical results for group A patients were better than those for group B. Severe fatty infiltration was observed more frequently in the subscapularis than in the supraspinatus muscle (27% vs. 12% of cases). Supraspinatus healing influenced subscapularis healing and fatty infiltration.

CONCLUSIONS

Repair of anterosuperior rotator cuff tears is satisfactory at 10 years, particularly if the subscapularis tear is not extensive. An extensive subscapularis tear is a negative prognosis factor. Postoperatively, fatty infiltration of the subscapularis muscle was frequently observed despite tendon healing.

Knotless Transosseous-Equivalent Rotator Cuff Repair Improves Biomechanical Self-reinforcement Without Diminishing Footprint Contact Compared With Medial Knotted Repair

PURPOSE

To assess the effect of medial-row knots on self-reinforcement and footprint contact characteristics for transosseous-equivalent repair compared with the same construct without knots.

METHODS

In 8 fresh-frozen human shoulders, transosseous-equivalent repairs with and without medial-row mattress knots were performed in each specimen. A pressure sensor was fixed at the tendon-footprint interface for all repairs. Parameters measured included footprint contact area, force, and pressure. The supraspinatus tendon was loaded sequentially from 0 to 60 N at 0° and 30° of abduction.

RESULTS

Both repairs provided a linear progression (slope) of footprint force and pressure as increasing tendon loads were applied. However, the knotless repair had a significantly higher progression ("self-reinforcement" effect) than the knotted repair at both abduction angles (P = .006 at 0° and P = .021 at 30°). The addition of medial-row knots did not significantly change the footprint contact area (in square millimeters), contact force (in newtons), contact pressure (in kilopascals), or peak pressure (in kilopascals) at each load tested, as well as at both abduction angles. For a given repair, only the knotless repair had significant decreases in contact area, contact force, contact pressure, and peak pressure with increasing abduction angles from 0° to 30° (P = .004 and P = .048).

CONCLUSIONS

Knotless transosseous-equivalent repair shows an improved self-reinforcement effect, without diminishing footprint contact, compared with the same repair with medial knots. Although knotless repair itself can show diminished footprint contact with abduction, medial knots show an adverse biomechanical effect by inhibiting self-reinforcement, without improving contact characteristics compared with knotless repair at each abduction angle tested. Clinical outcomes with specific indications, on the basis of these findings, require further investigation.

CLINICAL RELEVANCE

This study biomechanically helps to validate studies that have shown clinical success with knotless transosseous-equivalent repair. The inhibition of self-reinforcement may provide a quantified biomechanical rationale for medial tear patterns seen with knotted repairs.

The Clinical Effect of a Rotator Cuff Retear: A Meta-analysis of Arthroscopic Single-Row and Double-Row Repairs

BACKGROUND

The clinical effect of a retear after rotator cuff repair remains unclear. While some studies have indicated clinical deficits due to a retear, others have stated that a retear does not detrimentally affect outcomes.

PURPOSE

To conduct a meta-analysis comparing clinical outcomes between intact and retorn rotator cuffs after arthroscopic repair.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search using the terms "arthroscopic," "rotator cuff," "repair," "retear," "re-tear," "defect," "single-row," "double-row," "clinical outcomes," and "functional outcomes" was conducted. Article inclusion criteria were an adequate description of the surgical technique, stratification of outcomes by intact rotator cuff versus retear with a minimum of 1 year of follow-up, and documentation of the presence/absence of a full-thickness retear using imaging. Exclusion criteria were isolated subscapularis tears/repairs, labral repairs, infections, postoperative fractures, insufficient data or statistical indications, and postoperative data not stratified by retear versus intact rotator cuff. A meta-analysis was performed using a random-effects model on variables that had comparisons from at least 3 studies. Single-row (SR) and double-row (DR) studies were analyzed both separately and together in an "all arthroscopic repairs" (AAR) comparison. The calculated effect was considered significant at a P value <.05.

RESULTS

Within the SR group, patients with a rotator cuff retear had a significantly lower Constant score (mean difference [95% CI], -6.79 [-8.94 to -4.65]; P < .001) and lower University of California, Los Angeles (UCLA) score (-3.21 [-5.27 to -1.15]; P = .002) but not higher pain (0.071 [-0.34 to 0.49]; P = .739). Within the DR group, patients with a rotator cuff retear had a significantly lower Constant score (mean difference [95% CI], -9.35 [-12.2 to -6.50]; P < .001), lower American Shoulder and Elbow Surgeons (ASES) score (-12.1 [-17.1 to -7.26]; P < .001), lower UCLA score (-3.07 [-4.85 to -1.29]; P < .001), higher pain (0.622 [0.19 to 1.05]; P = .005), and lower abduction strength ( P < .001). In the AAR comparison, patients with a retear had a significantly lower Constant score (mean difference [95% CI], -7.56 [-9.55 to -5.57]; P < .001), lower ASES score (-10.1 [-15.5 to -4.64]; P < .001), lower UCLA score (-3.00 [-4.47 to -1.53]; P < .001), and lower abduction strength (in kg·f) (-3.32 [-4.53 to -2.12]; P < .001) but not higher pain (0.332 [-0.014 to 0.680]; P = .060).

CONCLUSION

Patients with a full-thickness rotator cuff retear exhibited significantly lower clinical outcome scores and strength compared with patients with an intact or partially torn rotator cuff.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study

BACKGROUND

Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. Mechanical stresses to failure of repaired tendons have been reported. While optimal immobilization postures were proposed to minimize this stress, post-operative rehabilitation protocols have never been assessed with respect to these values. Purpose was to use musculoskeletal simulation to predict when the stress in repaired tendons exceeds safety limits during passive movements. Hence, guidelines could be provided towards safer post-operative exercises.

METHODS

Sixteen healthy participants volunteered in passive three-dimensional shoulder range-of-motion and passive rehabilitation exercises assessment. Stress in all rotator cuff tendons was predicted during each movement by means of a musculoskeletal model using simulations with different type and size of tears. Safety stress thresholds were defined based on repaired tendon loads to failure reported in the literature and used to discriminate safe from unsafe ranges-of-motion.

FINDINGS

Increased tear size and multiple tendons tear decreased safe range-of-motion. Mostly, glenohumeral elevations below 38°, above 65°, or performed with the arm held in internal rotation cause excessive stresses in most types and sizes of injury during abduction, scaption or flexion. Larger safe amplitudes of elevation are found in scapular plane for supraspinatus alone, supraspinatus plus infraspinatus, and supraspinatus plus subscapularis tears.

INTERPRETATION

This study reinforces that passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.

Open side-to-side repair for non-repairable tendon-to-bone rotator cuff tear. Clinical and anatomic outcome at a mean 5 years' follow-up

INTRODUCTION

Anatomical tendon-to-bone repair of retracted rotator cuff tear is a difficult challenge given the high rate of recurrence.

HYPOTHESIS

The study hypothesis was that side-to-side repair of U-shaped retracted tear allows tendon healing with satisfactory medium-term clinical results.

MATERIALS AND METHODS

Between 1999 and 2007, 35 patients (mean age 53.5 years) were operated on with this open technique. On the De Orio and Cofield classification, tendon lesions were medium in 5 cases, large in 25 and massive in 5. Subacromial space was in all cases greater than 7 mm. Fatty infiltration grade was less than or equal to 2 on Goutallier's classification in all cases except for 1 grade3 (supraspinatus only). At last follow-up, patients were assessed clinically (Constant score) and radiographically. Tendon healing was assessed by ultrasound (31 cases) or CT-arthrography (4 cases).

RESULTS

Mean follow-up was 60 months. Constant score improved significantly, from 64.7 ± 10 preoperatively to 77.1 ± 14 postoperatively (P < 0.05). Recurrence rate was 17.1%. Subacromial space was < 6 mm postoperatively in 2 cases.

DISCUSSION

Side-to-side repair, bringing the posterior cuff onto the anterior edge of the tear, allowed tension-free repair of retracted tear if the preoperative reparability criteria are met: subacromial space equal to or greater than 7 mm, and absence of fatty infiltration significantly greater than grade 2 on the Goutallier classification. Under these conditions, clinical and anatomical results were satisfactory at a mean 5 years' follow-up.

LEVEL OF EVIDENCE

IV, retrospective.

The double-pulley technique for anatomical double-bundled medial patellofemoral ligament reconstruction

INTRODUCTION

Majority of the current medial patellofemoral ligament (MPFL) reconstruction techniques vary with respect to methods of fixation on the patella. In an effort to maximise the area of patellar footprint coverage and minimise the complication of patellar fracture, we developed a procedure that implemented the double-pulley suture anchors technique.

DESIGN

Prospective case series.

SETTING

A primary medical centre in Kaohsiung, Taiwan.

PATIENTS AND METHODS

Eighteen consecutive patients (18 knees) who met the inclusion criteria underwent the aforementioned operation between January 2010 and March 2012. Patients were evaluated using functional scores (Kujala and Tegner-Lysholm scores), apprehension test, and radiographic examination (congruence angle and patellar tilting angle) preoperatively and at the follow-up.

RESULTS

The mean follow-up was 35 months. A firm endpoint to lateral patellar translation was noted in all patients at the last follow-up with a mean lateral translation quadrant of 1.5 (improved from 3.5 preoperatively, p<0.001). Both clinical and radiographic assessment improved significantly (p<0.001); the mean Kujala score improved from 55.3±6.8 preoperatively to 95.2±3.5 at the last follow-up; TegnerLysholm from 43.6±8.1 to 93.6±6.8; the mean congruence angle improved from 20.6°±2.1° preoperatively to -5.2°±2.4° at the last follow-up; and the patellar tilting angle from 23.8°±2.3° to 9.6°±1.3°.

CONCLUSION

The double-pulley patellar fixation technique, by having a result that is comparable with those of other studies that used aperture fixation techniques, can be a promising surgical option for anatomically reconstructing the medial petellofemoral ligament.

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.

Surface-holding repair: an original arthroscopic rotator cuff repair technique

BACKGROUND

Arthroscopic rotator cuff repair provides satisfactory results; however, there is still a high rate of re-tear. The objective of this study was to present a surface-holding technique that we recently developed for arthroscopic rotator cuff repair in detail and to evaluate the clinical outcome as well as cuff repair integrity with this new method.

MATERIALS AND METHODS

A consecutive series of 116 patients with full-thickness rotator cuff tears underwent arthroscopic surface-holding repair and were monitored with the Japanese Orthopaedic Association, Constant-Murley, and University of California-Los Angeles scores to assess the clinical outcome. The mean follow-up period was 17.9 months (range, 12-40 months). Cuff repair integrity was evaluated by magnetic resonance imaging.

RESULTS

All 3 rating systems at the time of final follow-up reflected a significant improvement in functional recovery of the shoulder compared with the preoperative scores. The overall rate of rotator cuff retear was 19.0% (22 of 116 shoulders), and the rates were 13.6% (9 of 66 shoulders) for small and medium-sized tears and 26% (13 of 50 shoulders) for large and massive tears. The rate for large and massive tears was much higher in patients older than 70 years (58.3%) compared with those younger than 70 years (36.3%), whereas the retear rates were similar in these 2 groups (22.2% and 17.5%, respectively).

CONCLUSIONS

Arthroscopic surface-holding repair technique with medial suture and transosseous fixation improved rotator cuff healing. This method may be useful both for young patients and for elderly patients, who frequently have chronic large and massive tears, including osteoporotic bones.