Arthroscopic rotator cuff repair in overhead-throwing athletes

Rotator cuff repair and return to sports practice in athletes older than 35 years: Is it possible? A systematic review

INTRODUCTION

Return to sport is an important measure of treatment success for athletes undergoing rotator cuff repair, which can be challenging in older athletes. The purpose of the present study was to systematically review and summarize the literature regarding the return to sport in athletes older than 35 years undergoing rotator cuff repair.

MATERIALS AND METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed, MEDLINE, and Cochrane were used for the literature search. Studies in English evaluating return to sport after repair of partial- or full-thickness rotator cuff tears among athletes older than 35 years of all levels and sports were included.

RESULTS

Four studies of level III and IV were included in this review, with a total of 140 athletes. Both full- and partial-thickness rotator cuff tears were described and managed via acromioplasty combined with open or arthroscopic repair using single or double-row suture. Of the 140 athletes, 122 returned to sports, with 102 returning to equal or higher level pre-injury. The lower mean time to return to sport among the studies included was 6.3 months.

CONCLUSIONS

Although the evidence is limited, rotator cuff tear should not be seen as a mandatory reason for the retirement of older athletes. Of the 140 athletes included in this review, 122 returned to sport, with 102 returning to equal or higher level pre-injury.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

A Comparative Analysis Between Conservative Treatment, Arthroscopic Repair, and Biceps Tenodesis in Superior Labral Anterior-Posterior (SLAP) Lesions

Background "Throwing shoulder" hinders athletes' shoulder functions, causing pain, weakness, and performance reduction due to anatomical, physiological, and biomechanical factors. Anatomical issues include superior labral anterior-posterior (SLAP) injuries, rotator cuff injuries, and glenohumeral instability. Methods This study compared arthroscopic labral repairs in patients under 40 years old with shoulder injuries between 2015 and 2017. Sixty eligible patients were divided into three groups: conservative treatment, arthroscopic repair, and tenodesis. Measures included pain, functional scores, and the range of motion pre-/post-operation. Results At the last follow-up, pain relief and functional improvement were most significant with tenodesis (97% pain relief, 95% functional improvement), followed by repair (85% pain relief, 70% functional improvement), and least in conservative treatment (45% pain relief, 40% functional improvement). While all treatments significantly reduced pain and improved function (p<0.001), tenodesis demonstrated the highest effectiveness, suggesting it as a potentially preferred method. Significant improvements in pain relief and function were observed across all methods; however, surgical options suggested improved outcomes. Conclusion Our study compares conservative treatment, arthroscopic labral repair, and biceps tenodesis (BT) for SLAP lesions, highlighting significant pain relief and functional improvement across all. Conservative treatment suits patients with milder symptoms, while arthroscopic repair addresses larger tears. As the effectiveness of arthroscopic treatment is not inferior to conservative one, BT excels in cases of substantial bicep involvement.

Return to recreational sports participation following rotator cuff repair in adults over 40 Years of age: outcomes and return to play analysis

Background

Despite the high prevalence of rotator cuff (RTC) tears in older adults, there is limited literature evaluating the return to recreational sport after repair. The purpose of this study was (1) to assess the patient-reported outcomes and return to sport rates following rotator cuff repair in patients aged more than 40 years with minimum 2-year follow-up; (2) to compare baseline, preoperative and postoperative outcomes, and level of play following repair of self-reported athletes with nonathletes; and (3) to compare return to sport rates in overhead athletes compared to nonoverhead athletes.

Methods

Patients undergoing arthroscopic rotator cuff repair between January 2016 and January 2019 were screened for inclusion. Inclusion criteria included (1) age more than 40 years at the time of surgery, (2) arthroscopic repair of a full thickness RTC tear, and (3) preoperative American Shoulder and Elbow Surgeons score (ASES) available. Eligible patients were contacted and invited to fill out a custom return to sport and patient-reported outcome survey.

Results

Overall, 375 of the 1141 eligible patients completed the survey instrument. There were 210 self-reported athletes (mean age 59.2 ± 9.55 years) and 165 nonathletes (mean age 62.0 ± 8.27 years) (P = .003). Of the athletes, 193 (91.9%) returned to sport. The average age of athletes was 59.4 ± 9.33 years for those who returned to sport and 57.9 ± 12.0 years for those who did not (P = .631). Athletes reported higher ASES scores than nonathletes both preoperatively (49.8 ± 20.3 vs. 44.8 ± 18.9, P = .015) and postoperatively (87.6 ± 16.7 vs. 84.9 ± 17.5, P = .036), but there was no difference in mean ASES improvement between groups (37.7 ± 23.0 vs. 40.3 ± 24.5, P = .307). There was no difference in postoperative Single Assessment Numeric Evaluation scores when comparing self-reported athletes to nonathletes (85.4 ± 17.5 vs. 85.0 ± 18.7, P = .836). After controlling for age, sex, body mass index, and smoking status using a multivariate analysis, there was no difference in mean ASES improvement when comparing athletes to nonathletes.

Conclusion

There is a high rate of return to sport activities (> 90%) in older adult recreational athletes following arthroscopic repair of full thickness RTC tears and rates of return to sport did not significantly differ for overhead and nonoverhead athletes. Self-reported athletes were noted to have higher baseline, preoperative, and postoperative ASES scores than nonathletes, but the mean ASES improvement following repair did not significantly differ between groups.

Return to Sport after Arthroscopic Rotator Cuff Repair of Full-Thickness Rotator Cuff Tears: A Systematic Review

OBJECTIVE

Perform a systematic literature review regarding return to sport (RTS) outcomes after arthroscopic rotator cuff repair (aRCR) for full-thickness rotator cuff tears (FTRCTs).

DATA SOURCES

Systematic review of all articles in PubMed, Medline, and Excerpta Medica Database (EMBASE) was conducted in April 2022 using a combination of keywords: "rotator cuff repair," "RCR," "complete," "full-thickness," "tear," "RCT," "injury," "shoulder," "arthroscopic," "return to sport," "RTS," "sport," "return to play," and "athlete." Cohorts were included from all articles reporting RTS after aRCR for FTRCTs. Studies that were non-English, failed to distinguish between partial and FTRCT outcomes, or treated FTRCTs by open RCR, mini-open RCR, debridement, or nonsurgical management were excluded. Abstracted data included study design, surgical techniques, concomitant procedures, demographics, FTRCT type and size, patient-reported outcomes, type of sport, competition level, time to return, and reasons for failing to RTS.

MAIN RESULTS

11 studies were reviewed, with inclusion of 463 patients (385 athletes; mean age 47.9). RTS varied considerably in rate and timing, with 50.0% to 100% of patients returning on average between 4.8 to 14 months. In addition, 31 patients returned to a higher level of sport, 107 returned to or near preinjury level, and 36 returned to a lower level of competition or failed to RTS entirely.

CONCLUSIONS

The ability for athletes to RTS after aRCR for FTRCTs is likely multifactorial, demonstrating high variability in return rates and time to RTS. Given the paucity of available literature, future studies are warranted to provide a more definitive consensus.

Return to physical activities after arthroscopic rotator cuff repair: a systematic review and meta-analysis

BACKGROUND

Rotator cuff tear is one of the most common disorders in orthopedic surgery. When conservative treatment fails, arthroscopic rotator cuff repair has become the most common procedure to achieve a functional shoulder.

HYPOTHESIS/PURPOSE

The articles on return to activities following arthroscopic rotator cuff repair have not been collectively analyzed and investigated. We aimed to review systematically and perform a meta-analysis of studies on the return to activities which consist of the return to work, return to sports, and return to daily activities following arthroscopic rotator cuff repair.

STUDY DESIGN

Systematic Review and Meta-Analysis.

METHODS

Articles regarding return to activities were systematically searched using databases of PubMed, MEDLINE via EBSCO, ScienceDirect, and ProQuest. The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. The study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews. Studies with a level of evidence 1-4 that examined the rate of return to activities after arthroscopic rotator cuff repair were included and analyzed.

RESULTS

Fifteen studies published between 2005 and 2021 were included, with 1065 patients (644 male and 421 female). The patient populations are workers and athletes. The meta-analysis on the combined effect of a return to activities using the random-effects model was 88.5% (83.8% on return to work, 88.2% on return to sport, and 97.3% on return to daily activities). The mean duration for return to activities is 6.59 months.

CONCLUSION

As much as 88.5% of patients were able to return to activities after arthroscopic rotator cuff repair with a mean duration of 6.59 months. Preoperative factors (gender, workload, chronicity, tear size, and cholesterol level) may contribute to the rate and duration of return to activities.

Criteria for Return-to-Play (RTP) after Rotator Cuff Surgery: A Systematic Review of Literature

This systematic review of the literature aimed to highlight which criteria are described in the literature to define when a patient, after rotator cuff repair (RCR), is ready for return-to-play (RTP), which includes return to unrestricted activities, return to work, leisure, and sport activities. An online systematic search on the US National Library of Medicine (PubMed/MEDLINE), SCOPUS, Web of Science (WOS), and the Cochrane Database of Systematic Reviews, was performed with no data limit until December 2021. A total of 24 studies that reported at least one criterion after RCR were included. Nine criteria were identified and among these, the most reported criterion was the time from surgery, which was used by 78% of the studies; time from surgery was used as the only criterion by 54% of the studies, and in combination with other criteria, in 24% of the studies. Strength and ROM were the most reported criteria after time (25%). These results are in line with a previous systematic review that aimed to identify RTP criteria after surgical shoulder stabilization and with a recent scoping review that investigated RTP criteria among athletes after RCR and anterior shoulder stabilization. Compared to this latest scoping review, our study adds the methodological strength of being conducted according to the Prisma guidelines; furthermore, our study included both athletes and non-athletes to provide a comprehensive view of the criteria used after RCR; moreover, ten additional recent manuscripts were examined with respect to the scoping review.

The Thrower's Shoulder

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The thrower's shoulder has been a subject of great interest for many decades. Different theories have been proposed to clarify the pathophysiology, clinical presentation, and treatment options for this condition. In this review article, we summarize the relevant anatomy and pathophysiology and how these translate into signs, symptoms, and imaging findings. Also, a historical review of the treatment methodologies in the setting of an evolving concept is presented.

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The initial event in the cascade is thickening and contracture of the posteroinferior capsule resulting from repetitive tensile forces during the deceleration phase of throwing. This is known as "the essential lesion" and is clinically perceived as glenohumeral internal rotation deficit (GIRD), and a Bennett lesion may be found on radiographs.

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Change in the glenohumeral contact point leads to a series of adaptations that are beneficial for the mechanics of throwing, specifically in achieving the so-called "slot," which will maximize throwing performance.

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The complexity of the throwing shoulder is the result of an interplay of the different elements described in the cascade, as well as other factors such as pectoralis minor tightness and scapular dyskinesis. However, it is still unclear which event is the tipping point that breaks the balance between these adaptations and triggers the shift from an asymptomatic shoulder to a painful disabled joint that can jeopardize the career of a throwing athlete. Consequences are rotator cuff impingement and tear, labral injury, and scapular dyskinesis, which are seen both clinically and radiographically.

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A thorough understanding of the pathologic cascade is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common.

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The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures

Background:

Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS).

Purpose:

To describe RTS criteria used after RCS and SSS in athletic populations.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles.

Conclusion:

Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.

Retears and Concomitant Functional Impairments After Rotator Cuff Repair: Shoulder Activity as a Risk Factor

BACKGROUND

Most patients return successfully to shoulder involving sports or activity after rotator cuff repairs. It has not been decided yet whether postoperative participation in shoulder activity adds to the risk of retear.

PURPOSE/HYPOTHESIS

The purpose was to verify whether patients who participate in shoulder activities after rotator cuff repair have a higher risk of structural failure than nonactive patients and to investigate the relationship between postoperative shoulder function and tendon integrity in active and nonactive patients. The hypotheses were that (1) active patients have a higher retear rate than nonactive patients and (2) structural failure is associated with worse functional outcomes in active patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A cohort study was performed using 145 patients who underwent arthroscopic rotator cuff repair from 2015 to 2017. Functional assessments and magnetic resonance imaging were performed at least 24 months postoperatively. Shoulder activities since 6 months after surgery were rated in 4 categories (sports, job, activities of daily life, and weight of general lifting) as sedentary, light, moderate, or strenuous. The activity level of each patient was defined by the highest rated category. Patients who were involved in light, moderate, and strenuous activity were identified as active for the present study, and the rest were defined as sedentary. The proportion of retears between groups and the functional conditions between retorn and intact tendons were compared.

RESULTS

A total of 48 patients were enrolled in the active group, and 97 were enrolled in the sedentary group. The active group demonstrated a significantly higher retear rate than the sedentary group (27.1% vs 11.3%, respectively; P = .016; risk ratio, 2.39 [95% CI, 1.16-4.93]). In the active group, patients with retears showed higher visual analog scale scores for pain, decreased abduction strength, and lower shoulder functional scores (American Shoulder and Elbow Surgeons score, Fudan University Shoulder Score, and Constant-Murley score) than those with healed tendons, whereas in the sedentary group, functional outcomes were generally similar across patients with and without retears.

CONCLUSION

Shoulder activity after the early postoperative period was associated with a high risk of retears in patients who underwent rotator cuff repair. A correlation between inhibited function and structural failure was detected but only in active patients, while sedentary patients with retears retained functional improvements similar to those with intact tendons.

Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a Difference Between the Recreational and the Competitive Athlete?

BACKGROUND

Return to sport (RTS) remains an important challenge and measure of success for athletes undergoing arthroscopic rotator cuff repair (RCR).

PURPOSE

To determine the rate of RTS after RCR and to analyze predictive factors associated with a lower rate of return.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. Study quality was evaluated according to the Coleman Methodology Score. Studies in English evaluating RTS after arthroscopic repair of partial- or full-thickness rotator cuff tears among athletes of all levels, ages, and sports were included. Random effects meta-analysis and metaregression were performed to investigate RTS activity rate after arthroscopic RCR and to explore study heterogeneity, respectively.

RESULTS

Fifteen studies were reviewed, including 486 patients (499 shoulders) who were treated with arthroscopic RCR and who had a mean follow-up of 40.1 months (range, 18-74.4 months). Eighteen patients were lost to follow-up, leaving 468 patients with outcome data; 347 identified themselves as athletes (81 competitive, 266 recreational). The most commonly included sports were baseball (n = 45), golf (n = 38), football (n = 23), and tennis (n = 18). RTS specific to the type of athlete was reported for 299 of 347 athletes. According to the meta-analysis, the overall rate of RTS at a similar level of play or higher was 70.2%, with 73.3% of recreational athletes and 61.5% of competitive athletes able to return. A subset of 43 baseball and softball players across 4 studies yielded a 79% rate of RTS; however, only 38% returned to the same level of play or higher. Subgroup meta-analysis revealed no significant difference in the rate of RTS between competitive and recreational athletes. Metaregression analysis revealed that the mean follow-up time and mean age at surgery were not significantly associated with RTS rate.

CONCLUSION

Most athletes (70.2%) were able to return to a preinjury level of play after arthroscopic RCR. While recreational sports participation (73.3%) was associated with higher return, competitive sports (61.5%) and overhead sports (38%) were associated with lower return. Exactly why all athletes do not return remains uncertain and likely multifactorial.

Return to Sport at 6 Months After Shoulder Surgery

BACKGROUND

Many surgical procedures are intended to return patients to sport early, but it is unknown how realistic these expectations are after shoulder surgery.

PURPOSE

To determine which of the commonly performed surgical interventions in the shoulder best facilitated return to sport, and which did not, by 6 months postoperatively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study was a retrospective analysis of prospectively collected data from patients who underwent shoulder surgery from a single surgeon over 12 years. To be included, at least 20 patients needed to have undergone that procedure and complete a questionnaire evaluating their shoulder's function preoperatively and 6 months postoperatively. The primary outcome was a change in the response to the question, "What is your current level of sport?"

RESULTS

A total of 2261 surgical procedures in 13 categories met the inclusion criteria. Capsular release was the only procedure associated with improved patient-reported sporting level at 6 months (d = 0.18 [95% CI, 0.05-0.30]; P = .009). This represented a mean improvement of 41% from the preoperative sporting level. Bankart repair was associated with the greatest decrease in patient-reported sporting level at 6 months (mean decline of 21%) (d = -0.17 [95% CI, -0.34 to -0.01]; P = .034), followed by rotator cuff repair (mean decline of 13%) (d = -0.06 [95% CI, -0.03 to -0.10]; P = .0004). There were no significant changes in sporting level at 6 months postoperatively for rotator cuff repair with acromioplasty, polytetrafluoroethylene (PTFE) patch repair, acromioplasty, superior labral anterior to posterior (SLAP) repair, total shoulder arthroplasty, reverse total shoulder arthroplasty, rotator cuff repair with capsular release, rotator cuff repair with stabilization, calcific debridement, or hemiarthroplasty.

CONCLUSION

Capsular release was the only surgical procedure that provided a significant improvement in patient-reported sporting level in a relatively short period of time (6 months). Patients who underwent rotator cuff repair and Bankart repair were the only surgical groups that reported a significant decline in sporting level 6 months postoperatively.

Challenges of Medical Care Delivery in Professional Sports: Lessons From Professional Baseball

Team medical management for professional sports teams is a demanding and high-risk activity. Every different sport has unique features and the stresses athletes place on themselves, be it from collisions or repetitive stress, result in specific challenges for the medical team and team organization in general. Injuries in professional sports are costly both to the player and organization. The challenges of managing a professional baseball team exemplify these concerns and correlate well with other professional sports. Multiple strategies exist for improvement of medical care in baseball based on observed deficiencies in player evaluation, injury prevention, and injury treatment, which will require prospective evaluation to determine their success. These include draft strategies, individualized motion and strength analyses, customized in-season and off-season training programs for individuals, and standardized treatment protocols for injuries all based on best practices. Best practices are currently poorly defined in all of these areas.

Does arthroscopic rotator cuff repair improve patients' activity levels?

BACKGROUND

Rotator cuff repair decreases pain, improves range of motion, and increases strength. Whether these improvements translate to an improvement in a patient's activity level postoperatively remains unknown. The Shoulder Activity Level is a valid and reliable outcomes survey that can be used to measure a patient's shoulder-specific activity level. Currently, there are no studies that examine the effect of rotator cuff repair on shoulder activity level.

METHODS

Preoperative patient-determined outcomes scores collected prospectively on patients undergoing rotator cuff repair were compared with postoperative scores at a minimum of 2 years. These scores included the Shoulder Activity Level, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, and simple shoulder test. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair.

RESULTS

Included were 281 shoulders from 273 patients with a mean follow-up of 3.7 years. The postoperative median Western Ontario Rotator Cuff Index (42 vs. 94), American Shoulder and Elbow Surgeons (41 vs. 95), Single Assessment Numeric Evaluation (30 vs. 95), and simple shoulder test (4 vs. 11) scores were statistically significantly improved compared with preoperative scores (P < .0001). The postoperative median Shoulder Activity Level score decreased compared with the preoperative score (12 vs. 11; P < .0001).

CONCLUSIONS

Patients reported a statistically significant deterioration of their Shoulder Activity Level score after rotator cuff repair compared with their preoperative scores, although disease-specific and joint-specific quality of life scores all had statistically significantly improvement. This study suggests that patients generally have (1) significant improvements in their quality of life and (2) small deteriorations in activity level after arthroscopic rotator cuff repair.

Return to Sports and Physical Work After Arthroscopic Superior Capsule Reconstruction Among Patients With Irreparable Rotator Cuff Tears

BACKGROUND

Although sports participation and heavy physical work can contribute to rotator cuff tears, many patients expect to return to these activities after surgery; however, irreparable rotator cuff tears can preclude this outcome. A new surgical treatment-arthroscopic superior capsule reconstruction (SCR)-restores shoulder stability and muscle balance in patients with irreparable rotator cuff tears; consequently, it improves shoulder function and relieves pain.

PURPOSE

To evaluate the rates of return to sports and physical work among patients treated with arthroscopic SCR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2007 to 2014, we performed arthroscopic SCR in 105 patients with irreparable rotator cuff tears, 5 of whom were lost to follow-up. Consequently, 100 patients (mean age, 66.9 years; range, 43-82 years) were enrolled in the study. Before surgery, 26 patients had participated in sports (2 competitive, 24 recreational), and 34 patients had physical work. Rates of return to sports and physical work, the American Shoulder and Elbow Surgeons (ASES) score, active shoulder range of motion, and rate of graft tear were evaluated. The mean time to final follow-up was 48 months (range, 24-88 months).

RESULTS

All 26 patients who played sports before their injuries returned fully to them. In addition, 32 patients returned fully to their previous physical work, whereas the 2 remaining patients returned with reduced hours and workloads. As compared with the nonsports group, the sports group had significantly higher postoperative active elevation (160° ± 32° vs 146° ± 39°; P = .04) and higher postoperative ASES scores (97 ± 7 vs 91 ± 12; P = .02). The shoulder range of motion and ASES scores before and after surgery did not differ significantly between the physical and nonphysical work groups ( P = .11-.99). The rate of graft tear did not differ between the sports group (4%) and nonsports group (5%) ( P = .75) and between the physical work group (6%) and nonphysical work group (5%) ( P = .77).

CONCLUSION

Arthroscopic SCR restored shoulder function and resulted in high rates of return to recreational sports and physical work.

Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes

PURPOSE OF REVIEW

To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears.

RECENT FINDINGS

Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best. Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

Arthroscopic Debridement of the Thrower's Shoulder: Less Is More

The thrower's shoulder has long been a topic of debate among shoulder specialists. The tremendous forces produced during the throwing motion coupled with the compilation of the pathology encountered in the thrower's shoulder have generated a complex treatment algorithm. Simplifying management options has been challenging and recommendations continue to evolve. Treatment of injuries to the thrower's shoulder most commonly involves addressing partial articular-sided rotator cuff tears. These can be isolated or more commonly associated with tearing of the posterior superior labrum. The understanding of the dramatic difference between the surgical treatment of shoulder injuries in overhead athletes and nonoverhead athletes is paramount to positive outcomes after surgery.

Return to recreational sport and clinical outcomes with at least 2years follow-up after arthroscopic repair of rotator cuff tears

INTRODUCTION

The main objective of the study was to assess return to sports in recreational athletes after arthroscopic repair of rotator cuff tear (RCT).

MATERIAL AND METHODS

A retrospective single-center study included all recreational athletes operated between 2008 and 2012 for arthroscopic repair of RCT, with regular sports activity, and aged less than 70 years. All were recontacted at a minimum follow-up of 2 years. The main outcome was return to sports (yes/no). The secondary criteria were return to sports, time to return to sports, number of hours per week of sports activity, and at the last follow-up the subjective assessment of sports level, patient satisfaction, and the Western Ontario Rotator Cuff (WORC) Index.

RESULTS

Seventy-six patients (37 females, 39 males) with a mean age of 57.0±7.3 years were included. Of these 76 patients, 53 (69.7%) patients participated in a sport that specifically involved the upper limb. The mean follow-up was 45±14 months. Postoperatively, 67 of 76 (88.2%) patients returned to a sports activity, the same sport for 52 out of 76 (68.4%). The mean time to return to sports was 6±4.9 months. For patients who had taken up their sport again, the mean number of hours a week was not significantly modified (P=0.58). At the last follow-up, the subjective sports level was judged better or identical to the preoperative level by 52 of 67 (77.6%) patients. The factors significantly associated with absence of return to the previous sport were pain symptoms evolving for more than 9 months before surgery (OR=3.6 [1.01-12.5], P=0.04) and preoperative sports intensity less than 2h/week (OR=4.1 [1.4-12.3], P=0.01). At the last follow-up, the functional improvement evaluated by the WORC Index was strongly significant (P<0.00001) and 73 of 76 (96%) patients were satisfied.

CONCLUSION

The majority of the recreational athletes returned to sports after arthroscopic rotator cuff repair, most often at the same level and with equivalent intensity compared to before surgery.

LEVEL OF EVIDENCE

IV, retrospective study.

Return to Sport After Rotator Cuff Tear Repair: A Systematic Review and Meta-analysis

BACKGROUND

One of the most frequent demands from athletes after rotator cuff tear repair is to return to sport, if possible at the same level of play.

PURPOSE

The main goal of this study was to determine the rate of return to sport after treatment of rotator cuff tears.

STUDY DESIGN

Meta-analysis and systematic review.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature, as well as for the presentation of results. A search of the literature was performed on the electronic databases MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) checklist. Inclusion criteria were studies in English evaluating return to sport after treatment of traumatic, degenerative, partial or full-thickness rotator cuff tears in patients practicing a sport regularly, whatever the level, all ages and sports included. The main judgment criterion was the number of patients who returned to a sports activity after treatment of a rotator cuff tear. The criterion was analyzed in 2 ways: return to sport (yes/no) and the level of play (identical or higher/lower level).

RESULTS

Twenty-five studies were reviewed, including 859 patients (683 athletes), all treated surgically after a mean follow-up of 3.4 years (range, 0.3-13.4 years). The level of sports was recorded in 23 studies or 635 (93%) athletes and included 286 competitive or professional athletes and 349 recreational athletes. The most commonly practiced sports were baseball (224 participants), tennis (104 participants), and golf (54 participants). The overall rate of return to sport was 84.7% (95% CI, 77.6%-89.8%), including 65.9% (95% CI, 54.9%-75.4%) at an equivalent level of play, after 4 to 17 months. Of the professional and competitive athletes, 49.9% (95% CI, 35.3-64.6%) returned to the same level of play.

CONCLUSION

Most recreational athletes return to sports at the same level of play as before their injury, but only half of professional and competitive athletes return to an equivalent level of play.

Arthroscopic Rotator Cuff Repair Using the Undersurface Technique: A 2-Year Comparative Study in 257 Patients

Background:

Arthroscopic rotator cuff repair has traditionally been performed in the subacromial space from the bursal side of the tendon. The undersurface rotator cuff repair technique involves the arthroscope remaining in the glenohumeral joint, thus viewing the tendon from its undersurface during repair without a bursectomy or acromioplasty.

Purpose:

To compare the clinical and structural outcomes of undersurface rotator cuff repair with bursal-side repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was conducted on 2 cohorts of patients who had undergone arthroscopic rotator cuff repair with knotless suture anchors configured in a single-row formation using inverted mattress–style sutures from either the bursal side (n = 100) or undersurface (n = 165) of the supraspinatus tendon. Data were collected preoperatively, intraoperatively, and at 1 week, 6 weeks, 3 months, 6 months, and 2 years postoperatively. At each time point, patients completed a modified L’Insalata questionnaire to assess patient-ranked pain scores and were clinically examined using standardized tests. Ultrasound examination was performed at 6 months and 2 years to assess the integrity of the repair.

Results:

At 2 years postoperatively, patients in both cohorts had significantly less pain and less difficulty with overhead activities compared with preoperative levels (P < .001). The type of repair performed (bursal or undersurface) did not affect the ability to perform overhead activities at 2 years. At 2 years, both groups also had similar retear rates (21% for bursal side, 23% for undersurface). The mean operative time for the arthroscopic rotator cuff repair was 32 minutes when performed from the bursal side and 20 minutes when performed from the undersurface (P < .001).

Conclusion:

Arthroscopic rotator cuff repair, whether performed from the subacromial space or glenohumeral joint, resulted in decreased levels of pain and difficulty with overhead activities at 2 years. The major difference between the 2 techniques was operative time, with the undersurface technique being performed significantly faster than the bursal-side repair technique.

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.

[Rehabilitation concepts and return to sport after interventions on the shoulder]

BACKGROUND

Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport.

OBJECTIVES

The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes.

METHODS

A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration.

RESULTS

This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion.

CONCLUSION

Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

Current concepts: rotator cuff pathology in athletes--a source of pain or adaptive pathology?

Magnetic resonance imaging (MRI) findings are common in patients and athletes with shoulder pain. Historically these anatomic derangements have been thought to be the source of the patient's symptoms, and approaches have been focused on restoring the anatomy. This manuscript will address three objectives: (1) suggest that the approach to rotator cuff disease should be based on the patient's history and physical examination, and not necessarily on the anatomic disorders apparent on imaging; (2) review the data that supports the contention that rotator cuff disease is not the source of pain in the symptomatic shoulder, and (3) describe the concept of adaptive pathology. The findings on the MRI in the thrower's painful shoulder may be adaptive, and these alterations may be required to allow performance at high levels in sport.

Comparisons of retear patterns for 3 arthroscopic rotator cuff repair methods

BACKGROUND

Only a few studies have reported an unusual retear pattern after arthroscopic rotator cuff repair based on the repair method.

PURPOSE

To compare the retear pattern of the arthroscopic single-row technique (SRT), conventional suture-bridge technique (SBT), and knotless suture-bridge technique (K-SBT) for rotator cuff tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study evaluated 65 shoulders with retears revealed on magnetic resonance imaging at least 6 months after arthroscopic repair for a full-thickness rotator cuff tear. A retear was revealed in 21, 22, and 22 shoulders after the SRT, SBT, and K-SBT, respectively. Retears were classified as type 1 (unhealed tendons), type 2 (medially ruptured tendons with a healed footprint), or type 3 (unable to classify). Retear patterns were classified as full- or partial-thickness lesions; partial-thickness retears were further classified as articular- or bursal-side lesions.

RESULTS

A type 1 retear was observed in 71.4%, 40.9%, and 54.5% and a type 2 retear in 23.8%, 59.0%, and 40.9% of patients in the SRT, SBT, and K-SBT groups, respectively. No significant differences were observed among the 3 groups together (P = .195); however, a significant difference was observed between the SRT and SBT groups alone (P = .049). No significant differences were observed for either type 1 (P = .121) or type 2 (including both full- and partial-thickness) retears (P = .064) among the 3 groups together. When respective pairs of groups were compared, a significant difference was noted in both type 1 (P = .044) and type 2 retears (P = .019) between the SRT and SBT groups alone. No significant differences were observed in type 1 (P = .281) or type 2 full-thickness retears (P = .117) among the 3 groups together. When pairs of groups were compared, a significant difference in type 2 full-thickness retears was detected between the SRT and SBT groups alone (P = .037).

CONCLUSION

The SBT has a different retear pattern than that of the SRT. However, the K-SBT retear pattern was not different from that of the SRT.

[Shoulder injuries in golf]

BACKGROUND

Due to its growing popularity golf has now come into the focus of orthopedic sports medicine. With a wide range of age groups and playing levels, orthopedic surgeons will encounter a wide range of musculoskeletal problems which are usually the result of overuse rather than trauma.

ANATOMY

The shoulder joint plays an important role in the golf swing whereby not only the muscles around the glenohumeral joint but also the scapula stabilizing muscles are extremely important for an effective golf swing.

INJURY PATTERNS

Golf is strictly not considered to be an overhead sport; however, the extreme peak positions of the golf swing involve placing the shoulder joint in maximum abduction and adduction positions which can provoke impingement, lesions of the pulley system or even a special form of posterior shoulder instability.

PERSPECTIVES

Even after complex shoulder operations, such as rotator cuff repair or shoulder arthroplasty, a return to the golf course at nearly the same level of play can be expected.

The disabled throwing shoulder: spectrum of pathology-10-year update

In the 10 years since the current concept series entitled "The Disabled Throwing Shoulder: Spectrum of Pathology" was conceived and written, many studies have been reported that add much more information to the understanding of the disabled throwing shoulder (DTS). The editors of Arthroscopy and the authors of the original series believed that an update to the original series would be beneficial to provide an organized overview of current knowledge that could update the thought process regarding this problem, provide better assessment and treatment guidelines, and guide further research. A dedicated meeting, including current published researchers and experienced clinicians in this subject, was organized by the Shoulder Center of Kentucky. The meeting was organized around 5 areas of the DTS that were highlighted in the original series and appear to be key in creating the DTS spectrum and to understanding and treating the DTS: (1) the role of the kinetic chain; (2) the role and clinical evaluation of the scapula; (3) the role of deficits in glenohumeral rotation, glenohumeral internal rotation deficit, and total range-of-motion deficit in the causation of labral injury and DTS; (4) the role of superior labral (SLAP) injuries and rotator cuff injuries; and (5) the composition and progression of rehabilitation protocols for functional restoration of the DTS. The meeting consisted of presentations within each area, followed by discussions, and resulted in summaries regarding what is known in each area, what is not known but thought to be important, and strategies to implement and enlarge the knowledge base.

Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair

BACKGROUND

We evaluated the clinical and imaging outcomes of arthroscopic suture-bridge repair of full-thickness rotator cuff tears.

METHODS

From May 2007 to April 2008, seventy-nine patients with a full-thickness rotator cuff tear consecutively underwent arthroscopic suture-bridge repair. The mean age of the patients was 58.3 years (range, thirty-eight to seventy-eight years), and the mean duration of follow-up was 30.6 months (range, twenty-four to forty-four months). Seventy-three patients underwent postoperative ultrasonography or magnetic resonance imaging; seventy-one underwent the imaging at a minimum of two years postoperatively, and the remaining two did so after the operation because of persistent symptoms. The clinical results of seventy-seven patients (all except two who had undergone revision) were evaluated at a minimum of two years postoperatively. University of California at Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores were used for clinical and functional evaluations before surgery and at the time of final follow-up.

RESULTS

The imaging follow-up rate was 92%, and the follow-up rate for clinical evaluation was 100%. The re-tear rate after suture-bridge repair was 15%. The re-tear rate of the medium, large, and massive tears (as classified according to the anterior-to-posterior diameter of the tear) was 12%, 21%, and 22%, respectively. Massive and large tears tended to show a higher re-tear rate than did medium tears, but the difference was not significant (p = 0.417 and p = 0.964, respectively). The mean UCLA, ASES, and Constant-Murley scores improved from 21.6, 50.4, and 52.7 preoperatively to 30.9, 86.2, and 74.7 at the time of final follow-up (p < 0.001). However, the clinical outcomes after the operation did not differ significantly between the patients who had healing of the tear and those who did not (p = 0.438, p = 0.625, and p = 0.898 for the UCLA, ASES, and Constant-Murley scores, respectively).

CONCLUSIONS

Arthroscopic suture-bridge repair of full-thickness rotator cuff tears was followed by a re-tear rate of 15% as seen with imaging and resulted in significant improvement of functional outcomes and clinical results compared with the preoperative findings.

Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports

PURPOSE

To investigate the outcome of arthroscopic capsular repair for shoulder instability in an active adolescent population participating in overhead or contact sports.

METHODS

We identified 67 patients (aged 13 to 18 years) with post-traumatic recurrent shoulder instability for inclusion in the study from our computer database. Of these patients, 65 (96%) were available for clinical review. There were 44 male and 21 female patients, with a mean age of 16 years at the time of surgery. All patients participated in overhead or contact sports at a competitive level. Arthroscopic capsulolabral repair was performed after at least 6 months of failed nonoperative treatment. The mean follow-up was 63 months. Shoulder range of motion and functional outcomes were measured preoperatively and postoperatively with Single Assessment Numeric Evaluation (SANE), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores. Furthermore, type of sport, time until surgery, and number of dislocations were analyzed from our database to find any correlation with the recurrence rate.

RESULTS

At final follow-up, the mean SANE score was 87.23% (range, 30% to 100%) (preoperative mean, 46.15% [range, 20% to 50%]); the mean Rowe score was 85 (range, 30 to 100) (preoperative mean, 35.9 [range, 30 to 50]); and the mean ASES score was 84.12 (range, 30 to 100) (preoperative mean, 36.92 [range, 30 to 48]). The mean forward flexion and external rotation with the arm at 90° abduction did not change from preoperative values; 81% of the patients returned to their preinjury level of sport, and the rate of failure was 21%. The recurrence rate was not related to the postoperative scores (P = .556 for SANE score, P = .753 for Rowe score, and P = .478 for ASES score), the number of preoperative episodes of instability (P = .59), or the time from the first instability episode to the time of surgery (P = .43). There was a statistically significant relation (P = .0021) between recurrence and the type of sport practiced. Recurrence rate was related to the type of sport practiced.

CONCLUSIONS

Arthroscopic stabilization is a reasonable surgical option even in an adolescent population performing sports activities. However, it must be emphasized to the patients and their relatives that the recurrence rate that could be expected after an arthroscopic procedure is higher than in the adult population.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Repair integrity and functional outcome after arthroscopic rotator cuff repair: double-row versus suture-bridge technique

BACKGROUND

Only a few studies have examined repair integrity and functional outcome after arthroscopic suture-bridge rotator cuff repair procedure. In addition, no reported study has compared outcomes between the suture-bridge and double-row techniques.

PURPOSE

This study compared the functional outcome and repair integrity of arthroscopic double-row and conventional suture-bridge repair in full-thickness rotator cuff tears.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Fifty-two consecutive full-thickness rotator cuff tears with 1 to 4 cm of anterior to posterior dimension that underwent arthroscopic rotator cuff repair were included. A double-row technique was used in the first 26 consecutive shoulders, and a conventional suture-bridge technique was used in the next 26 consecutive shoulders. Fifty shoulders (92.5%) underwent magnetic resonance imaging or ultrasonography postoperatively. Clinical outcomes were evaluated a minimum 2 years (mean, 37.2 months; range, 24-54) postoperatively using the University of California at Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), and Constant scores. The postoperative cuff integrity was evaluated a mean of 33.0 (range, 10-54) months postoperatively.

RESULTS

At the final follow-up, the average UCLA, ASES, and Constant scores improved significantly, to 32.3, 90.5, and 80.7, respectively, in the double-row group and to 30.6, 88.5, and 74.0, respectively, in the suture-bridge group. The UCLA, ASES, and Constant scores improved in both groups postoperatively (all P < .001); however, there was no significant difference between the 2 groups at final follow-up (P = .185, .585, and .053, respectively). The retear rate was 24% in the shoulders that underwent double-row repair and 20% in the shoulders that underwent suture-bridge repair; this difference was not statistically significant (P = .733).

CONCLUSION

The arthroscopic conventional suture-bridge technique resulted in comparable patient satisfaction, functional outcome, and rates of retear compared with the arthroscopic double-row technique in full-thickness rotator cuff tears.

Arthroscopic supraspinatus tendon repair with suture-bridging technique: functional outcome and magnetic resonance imaging

BACKGROUND

The suture-bridging technique is a new arthroscopic technique to repair rotator cuff tears. Biomechanical advantages compared with double-row fixations have been described.

HYPOTHESIS

The authors hypothesized that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty-one consecutive patients, with a median age of 62 years (range, 37-76 years), who had undergone an arthroscopic suture-bridging repair of an isolated supraspinatus tendon tear were evaluated in this prospective study 4, 12, and a median of 24 months postoperatively. Subjective and functional outcome was assessed using the simple shoulder test and Constant score. With magnetic resonance imaging 12 months postoperatively, the tendon integrity and potential predictors of failures were evaluated.

RESULTS

The simple shoulder test scores improved significantly from 9 points (range, 1-12 points) at 4 months, to 12 points (range, 1-12 points) at 12 months, and 12 points (range, 5-12 points) at 24 months postoperatively. The Constant score increased significantly from preoperative 64% (range, 37%-92%) to 82% (range, 36%-100%) at 4 months, 96% (range, 49%-100%) at 12 months, and 96% (range, 64%-100%) at 24 months postoperatively. Magnetic resonance imaging 12 months after surgery showed retears in 28.9%. Two different types of retears could be observed: insufficiently healed and medially retorn supraspinatus tendons. The Constant score did not differ significantly between the groups with retears and intact repairs. A patient age of more than 60 years was found to influence tendon healing significantly.

CONCLUSION

The hypothesis, that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation, could not be confirmed. The functional outcome after the new suture-bridging technique was good and comparable with the reported results after double-row repair from the literature. A structural failure of tendon repair was not identical to clinical failure.