Arthroscopic repair of the rotator cuff: prospective study of tendon healing after 70 years of age in 145 patients

INTRODUCTION

The level of activity of patients older than 70 years is tending to increase, as are their expectations in terms of joint function recuperation. It has not been proven that rotator cuff repair healing is satisfactory in the elderly. The main hypothesis of this study was: repair of supraspinous lesions in patients older than 70 years is reliable in terms of both clinical results and healing. The secondary hypothesis was: tendon healing is significantly correlated with the Constant, ASES, and SST scores as well as with age, tendon retraction, and fatty infiltration.

MATERIAL AND METHODS

Multicenter prospective study on 145 patients older than 70 years, with 135 patients reviewed at 1 year (93%). The mean age was 73.9 years. Full-thickness tears of the supraspinatus extended at most to the upper third of the infraspinatus and retraction limited to Patte stages 1 and 2 were included. Clinical assessment was carried out in accordance with the Constant, ASES, and SST scores. Healing was evaluated with ultrasound.

RESULTS

A significant improvement was noted in the Constant (44/76)+31.5 (P<0.0001), ASES (35/90)+54.4 (P<0.0001), and SST (3.5/10)+6.6 (P>0.0001) scores at 1 year of follow-up. The healing rate was 89% with 15 re-tears, nine of which were stage 1 and six stage 2. The clinical result was not correlated with patient age (Constant, P=0.24; ASES, P=0.38; SST, P=0.83) nor with the retraction stage (Constant, P=0.71; ASES, P=0.35; SST, P=0.69) or the stage of fatty infiltration (P>0.7). Healing was correlated with the quality of the clinical result (Constant, P=0.02; ASES, P=0.03) and age (P=0.01) but was not correlated with retraction or the fatty infiltration stage (P>0.3).

DISCUSSION/CONCLUSION

Arthroscopic repair significantly improves the clinical results, even in patients older than 70 years. The clinical results are not correlated with age (but deterioration of the result was not noted after 75 years) or frontal retraction (but the study only included retractions limited to stages 1 and 2). The healing rate is satisfactory, but this study is limited to small ruptures of the supraspinatus, and the postoperative ultrasound analysis probably inferior to CT imaging with contrast agent injection, often used as the reference. Healing proves to be correlated with the quality of the clinical result and patient age.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis of subscapularis tendon tears: are available diagnostic tests pertinent for a positive diagnosis?

HYPOTHESIS

Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus.

MATERIAL AND METHODS

In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well as their anatomical value. The relationships of the different parameters studied were compared statistically by analysis of variance (ANOVA). This prospective multicenter study was performed from January 2009 to February 2010 and included 208 cases of subscapularis tendon tears, isolated or associated with partial (Ellman 1, 2 or 3) or full thickness (SFA stage 1) supraspinatus tears.

RESULTS

The severity of the subscapularis tear was quantified according to the SFA classification into four stages and according to the level of injury (the lower 1/3 and upper 2/3). The three tests LOT, BPT and BHT were correlated to the severity of observed tears (P<0.05). The more deficient the test results were, the more severe the anatomical damage. The LOT is the test that cannot be performed most often (18%) but when it is positive, it is predictive of very severe tears. The BHT is the most sensitive of all tests (82%). The frequency of biceps involvement was correlated to the severity of subscapularis damage. There was no significant correlation between biceps involvement and subscapularis tests, or between supraspinatus involvement and subscapularis tests. There was no correlation between the Palm-Up test and subscapularis tears with associated supraspinatus involvement however, it was significantly correlated to biceps involvement (P<0.05). The Jobe test was disappointing because it was often positive even for isolated subscapularis tears.

CONCLUSION

Even though all three tests were performed (LOT, BPT, BHT), 24% of the subscapularis tears were only diagnosed during surgery. The role of the Internal Rotation Lag Sign and Belly-Off Sign in improving the diagnosis of tears was not studied in this work.

New endoscopic classification for subscapularis lesions

BACKGROUND

The absence of a coherent classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tendon lesions. In addition, a reliable classification system allows comparisons of epidemiological and therapeutic data. The classification systems used until now fail to incorporate the radiological and intraoperative abnormalities of the bicipital sling, and they do not consider the degree of subscapularis tendon cleavage. Here, we describe a new arthroscopy-based classification system intended for therapeutic and prognostic purposes.

METHODS

A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 150 isolated subscapularis lesions with or without limited anterosuperior involvement. The bicipital sling and insertion of the deep subscapularis layer were routinely investigated by arthroscopy with video recording. Each lesion was classified after a consensus was reached among four surgeons.

RESULTS

We identified four lesion types based on the bicipital sling findings. Type I was defined as partial separation of the subscapularis tendon fibres from the lesser tuberosity with a normal bicipital sling. Type II consisted of a partial subscapularis tear at the lesser tuberosity attachment combined with partial injury to the anterior wall of the bicipital sling, without injury to the superior glenohumeral ligament. Type III was complete separation of the subscapularis fibres from the lesser tuberosity with extensive cleavage of the bicipital sling. Finally, in Type IV, all the subscapularis fibres were detached and, in some cases, conjunction of the subscapularis and supraspinatus fibres produced the comma sign. Nearly all the lesions identified intraoperatively during the study fit one of these four types.

DISCUSSION

A reproducible classification system that allows different surgeons to establish comparable homogeneous patient groups is useful for both therapeutic and prognostic purposes. We defined four types of subscapularis lesions that are easy to identify as either isolated lesions or combined with anterosuperior rotator cuff tears. Long head of biceps tendon abnormalities and fatty degeneration of the shoulder muscles can be added to our classification system. Studies of intraobserver and interobserver reproducibility are needed to complete the process of validating the diagnostic and/or prognostic usefulness of this new classification scheme.

Poor results of the Optetrak™ cemented posterior stabilized knee prosthesis after a mean 25-month follow-up: analysis of 110 prostheses

INTRODUCTION

The introduction of a new knee arthroplasty model, even if it differs from a validated implant by only a few details, should be followed by rigorous assessment. The Optetrak™ cemented posterior stabilized knee prosthesis evolved from the Insall prosthesis with a smaller tibial keel associated with a higher tibial cam and increased femorotibial congruency as well as a more posterior-stabilized trochlea.

HYPOTHESIS

We hypothesized that this implant with only minor modifications to the Insall prosthesis would provide as favorable results as the Insall prosthesis.

MATERIALS AND METHODS

A continuous series of 110 prostheses (106 patients) implanted between 2005 and 2007 was retrospectively analyzed with a mean follow-up of 25 months (range, 12-42 months) by an independent observer. The follow-up was based on the IKS score and the radiological assessment was conducted by three senior surgeons.

RESULTS

The mean IKS score was 83.7 (range, 13-100) points at the last follow-up, the mean function score was 82.6 (range, 30-100 points), and mean flexion was 120° (range, 80-140°). Seventeen patients (15%) were disappointed or dissatisfied, 25 knees (22%) were painful, requiring regular painkillers. The prostheses had a satisfactory mechanical axis, with a mean HKA angle of 177.4 ± 4°, but 25 prostheses (22%) presented rims evolving toward tibial implant loosening, and 24 (21%) developed signs of patellofemoral conflict. With follow-up less than 5 years, nine cases were revised for tibial loosening, three for patellofemoral instability, and one for patellofemoral pain. The cases of tibial loosening were particular because they occurred at the cement-tibial-implant interface. The cumulated survival rate at 36 months was 80.97 ± 9.1% and 76.74 ± 12% at 45 months.

DISCUSSION

This tibial implant with a small keel does not resist the stresses applied by posterior stabilization, with notably a higher level of stress than the Insall prosthesis from which it was derived. In cases of centering defect, the design of the trochlea can lead to impingement between the edges of the patella and the prominent edges of the prosthetic trochlea. We have suspended implantation of this prosthesis and continue to monitor the progression of patients having received these implants.

LEVEL OF EVIDENCE

Level IV, retrospective study.