Rotator cuff repair techniques: Current concepts

Arthroscopic rotator cuff repair is being performed by an ever-increasing number of surgeons. With an ageing population and growing patient expectations it is crucial that clinical outcomes are optimised. Anatomical reduction of the tendon back to its footprint with minimal tension contributes to this, but this can only be achieved if key biomechanical factors are taken into consideration. In this review of the technical aspects of a rotator cuff repair, we focus on: (1) patient positioning, (2) biomechanical principles, (3) optimal visualisation, and (4) repair techniques for both anterior and postero-superior tears.     

Superior capsular reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report

BackgroundRecent evidence continues to confirm the effectiveness of arthroscopic superior capsular reconstruction (SCR) in relieving pain and improving function in an irreparable cuff deficient shoulder. This paper presents an up-to-date literature review on SCRand a tertiary referral unit experience in the United Kingdom.MethodsData was prospectively collected on patients undergoing SCR for irreparable rotator cuff tears using a dermal allograft. Patients with already established arthritis were excluded. The first 49 consecutive cases performed by 3 surgeons over 3 years (including their learning curve) with average follow-up of 19 months (range 3–37 months) were analysed. The outcomes assessed were re-operation rates, patient satisfaction and complications. The study group was analysed to identify the factors predicting outcomes.ResultsThe average age of the cohort was 56 years. The re-operation rate in this group was 12.2% with each of these 6 patients subsequently undergoing a reverse total shoulder arthroplasty. Forty (82%) patients were satisfied with the outcome of the procedure with 35 (72%) of them showing complete pain relief, 5 (10%) having dull aches and clicks and the remaining 9 (18%) unsatisfied due to pain. There was no difference in satisfaction rates between different age groups (p > 0.05). The pre-operative factors associated with poor outcomes included patients with multiple previous surgeries on the same shoulder (p = 0.02) and teres minor atrophy or tear (p = 0.03). The other factors that showed a trend towards inferior outcomes (but not statistically significant) included patients with degenerative tears, symptoms of longer duration (>24 months) and subscapularis tear/atrophy. No serious adverse effects such as graft rejection, infection or neuro-vascular injury were observed.ConclusionEarly results of superior capsular reconstruction are promising and may offer an answer to a challenging group of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery.     

Factors affecting healing after arthroscopic rotator cuff repair

Rotator cuff repair has been shown to have good long-term results. Unfortunately, a significant proportion of repairs still fail to heal. Many factors, both patient and surgeon related, can influence healing after repair. Older age, larger tear size, worse muscle quality, greater muscle-tendon unit retraction, smoking, osteoporosis, diabetes and hypercholesterolemia have all shown to negatively influence tendon healing. Surgeon related factors that can influence healing include repair construct-single vs double row, rehabilitation, and biologics including platelet rich plasma and mesenchymal stem cells. Double-row repairs are biomechanically stronger and have better healing rates compared with single-row repairs although clinical outcomes are equivalent between both constructs. Slower, less aggressive rehabilitation programs have demonstrated improved healing with no negative effect on final range of motion and are therefore recommended after repair of most full thickness tears. Additionally no definitive evidence supports the use of platelet rich plasma or mesenchymal stem cells regarding improvement of healing rates and clinical outcomes. Further research is needed to identify effective biologically directed augmentations that will improve healing rates and clinical outcomes after rotator cuff repair.     

肩袖修补术后再撕裂危险因素的研究进展

肩袖再撕裂是肩袖修复术后主要的并发症,其严重影响了手术疗效。肩袖再发撕裂的影响因素包括术前年龄、糖尿病、高脂血症、症状持续时间、撕裂大小、肩袖脂肪浸润及回缩、手术方式的选择、生物制剂的应用、术后康复锻炼方案等。本文对关于肩袖修复术后再发撕裂危险因素进行了综述和分析,加深对再撕裂的认识,以期减少肩袖修补术后再次撕裂的发生,促进患者术后功能恢复和满意度。     

Treatment of massive irreparable rotator cuff tears without arthritis: a comparison of superior capsular reconstruction,partial rotator cuff repair,and reverse total shoulder arthroplasty

BackgroundTo compare outcomes of superior capsular reconstruction (SCR), partial rotator cuff repair (PR), and reverse total shoulder arthroplasty (rTSA) for massive irreparable rotator cuff tear (MIRCT) without arthritis at more than 2 years follow-up.MethodsA retrospective analysis of prospectively collected data of consecutive patients undergoing surgical treatment for intraoperatively confirmed MIRCT without arthritis using SCR, PR, or rTSA. Preoperative and postoperative data were collected and multivariate analysis performed.ResultsThirty two patients met inclusion criteria for SCR, 24 for PR, and 42 for rTSA (mean follow-up years: SCR 3.2; PR 4.0; rTSA 3.5; P = .02). The rTSA patients were older (66.2 years; SCR 57.3; PR 59.0; P = .0001) and more likely to be female (61.9%; SCR 12.5%; PR 25.0%; P < .001). Intraoperative evaluation demonstrated full thickness subscapularis tear in 37.5% for SCR, 4.2% for PR, and 21.4% for rTSA (P = .01). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (P = .08). All groups saw postoperative improvement in strength and patient-reported outcomes (P < .036). SCR and rTSA demonstrated an improved forward elevation range of motion (ROM) postoperatively while PR did not (P = .96). No group experienced improvement in rotation ROM (P > .12). rTSA had worse postoperative ROM in all planes compared to SCR and PR (P < .003). There were no differences between groups in postoperative strength (P > .16) or patient-reported outcomes (American Shoulder and Elbow Surgeons P = .14; visual analog scale P = .86; single assessment numeric evaluation P = .61). Patients were satisfied in 81.2% of SCR cases, 87.5% of PR, and 95.3% of rTSA (P = .33). Three of 32 (9.4%) SCR patients required conversion to rTSA, while 3 of 24 (12.5%) PR patients required reoperation (2 revision repairs; 1 conversion to rTSA). There were 3 additional surgical complications among 42 rTSA patients (7.1%). There were 4 nonsurgical complications in the SCR group and 1 in the rTSA group. One SCR patient and 3 rTSA patients were deceased. Multivariate analysis demonstrated no independent predictors of revision surgery. An increased acromiohumeral interval distance was an independent predictor of improved postoperative strength for all groups (P < .02).ConclusionSCR, PR, and rTSA for the treatment of MIRCT without arthritis all significantly improved postoperative strength and outcomes scores with >80% patient satisfaction but with rTSA having worse postoperative motion and a higher complication rate. There were no independent predictors for revision surgery. SCR, PR and rTSA are all viable operations for MIRCT without arthritis with satisfactory results maintained at 2 years postoperatively.     

Trends in rotator cuff surgery: Research through the decades

IntroductionThe aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigationMethodsJournal Citation Index was searched to find articles using the search terms pertaining to “rotator cuff repair”. All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade.ResultsAll the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade’s most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade.ConclusionThere are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.     

Functional evaluation of patient after arthroscopic repair of rotator cuff tear

BackgroundRotator cuff tear is a common problem either after trauma or after degenerative tear in old age group. Arthroscopic repair is the current concept of rotator cuff repair. Here, we are trying to evaluate the functional outcome after arthroscopic repair of full thickness rotator cuff tear (single row) in Indian population.Materials and methodsTwenty five patients (14 males and 11 females) who underwent arthroscopic repair of full thickness rotator cuff tear at a single institution were included in the study. Postoperatively patient's shoulder was rated according to UCLA score, pain was graded according to the visual analog score. The range of motion was analysed and documented.ResultsThe mean age of the patients were 50.48 years. The preoperative VAS score mode was 7 and post operative VAS was 1 (p value <0.001). The UCLA grading was good in 80% (n = 20), fair in 12% (n = 3), excellent in 8% (n = 2) and poor results were seen in none of the patients.The mean UCLA improved from a score of 15.84 to 30.28 with a p value <0.001. Mean postoperative forward flexion was 161.6°, mean abduction was 147.6° and mean external rotation was 45.4°.ConclusionArthroscopic repair is a good procedure for full thickness rotator cuff tear with minimal complications. The newer double row repair claims to be biomechanically superior with faster healing rates without functional advantages, hence we used a single row repair considering the Indian population and the cost effectiveness of the surgery with good to excellent results.     

Traumatic rotator cuff tears - Current concepts in diagnosis and management

Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms “acute” and “traumatic” used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management.We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.     

肩袖损伤的关节镜下治疗

目的探讨肩关节镜手术治疗肩袖损伤的适应证选择、手术技巧和疗效。方法2002年3月至2005年5月对68例患者行关节镜下肩袖重建,其中40例获得随访,以其为研究对象。年龄30~81岁,平均年龄56岁,其中29例发生于主力侧。根据Gerber分型,其中部分肩袖损伤8例,中小型肩袖损伤27例,巨大肩袖损伤5例。手术均采用金属缝合锚(Super-Revo)进行肩袖重建。分别在术前及最终随访时采用美国肩肘医师协会评分(ASES)、Constant-Murley评分以及简易肩关节评分(SST)问卷进行功能评估。结果40例患者获得随访,随访时间12~40个月,平均20.6个月。40例患者手术前及终末随访时ASES平均分为72.6对92.3(P<0.001),其中VAS疼痛评分平均为6.2对1.8(P<0.001),肩关节平均前屈上举为74.5°对146.0°(P<0.001),平均外旋为27.8°对38.3°(P<0.01),ASES评分为优和良所占的比例为92.5%(37/40),平均Constant-Murley评分为69.6对90.4(P<0.001),Constant-Murley评分为优和良所占的比例为90.0%(36/40)。结论肩关节镜下肩袖重建手术具有损伤小、肩关节功能恢复快等特点,尤其在保护三角肌方面具有独到的优势,是治疗肩袖损伤的有效方法之一。正确的适应证选择、熟练的关节镜下操作技术以及术后严格的功能康复锻炼是手术成功的关键。     

肩袖损伤患者术前焦虑状况与肩关节镜术后疼痛的相关性分析

目的 分析肩袖损伤行关节镜下肩袖修复手术的患者术前各因素对术后疼痛的影响.方法 本研究回顾性分析了2018年1月至2019年12月本科室收治的肩袖损伤患者的基本资料,所有患者术前进行视觉模拟评分(visual analogue scale,VAS)、美国肩肘外科协会评分(American shoulder and el...     

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis

BACKGROUNDRotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA.AIMTo evaluate if a relationship exists between outcomes of RCR in the setting of GHOA.METHODSThis was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected.RESULTSA total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes.CONCLUSIONPatients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.     

肩袖撕裂修补术后腱骨愈合的研究进展

肩袖撕裂是导致肩关节疼痛和活动受限的常见疾病,随着手术技术的进步,关节镜下修补成为主流方式。尽管如此,术后依旧有很高的再撕裂率,而腱骨界面的愈合不佳主要原因是腱骨界面未能形成正常组织结构反而形成瘢痕化,因腱骨界面的组织学改变导致其生物力学性能下降,易再次发生撕裂。近年来,越来越多的学者致力于生物学、生物力学的研究,希望能够加速腱骨愈合的进程,恢复腱骨界面的正常组织结构,本文就影响腱骨愈合常见4个因素(炎症反应、缓慢而有限的骨长入、不当的机械刺激、不足的干细胞)及物理治疗的研究进展进行综述。     

关节镜下肩袖缝合术治疗肩袖全层撕裂的中期疗效观察

目的 探讨关节镜下肩袖缝合术治疗肩袖全层撕裂的手术方法和中期效果.方法 2002年12月至2007年5月对35例肩袖全层撕裂患者行关节镜下肩袖缝合术,30例获得随访,其中男性15例,女性15例;年龄31～74岁,平均55.6岁.左肩3例,右肩27例.全部病例行肩峰下滑囊切除及肩峰成形术.肩袖修复方式:19例应用缝合锚钉行肩袖止点重建,11例联合应用断端缝合及缝合锚钉技术.16例行单排缝合,14例行双排缝合.2012年6月对所有患者进行随访,分别在术前和随访时采用UCLA肩关节评分标准进行评价,评分结果行配对t检验.结果 小型撕裂3例,中型撕裂22例,大型撕裂3例,巨大撕裂2例,随访时间5 ～ 10年,平均78.5个月.UCLA评分从术前的(14.2±3.1)分增至术后(33.6±2.1)分(t=-37.154,P=0.000).其中疼痛评分平均为(2.5±0.9)分比(9.5±1.0)分(t=-24.466,P=0.000),功能评分平均为(4.5±1.5)分比(9.4±1.1)分(t=-18.500,P=0.000),主动前屈角度评分平均为(3.3±1.6)分比(4.9±0.2)分(t=-5.614,P=0.000),前屈肌力评分平均为(3.9±0.5)分比(4.7±0.4)分(t=-6.591,P=0.000),差异均有统计学意义.根据术后随访UCLA评分,优19例,良11例.单排缝合患者术前平均(13.0±3.2)分,术后平均(33.6±1.7)分.双排缝合患者术前平均(15.6±2.4)分,术后平均(33.6±2.6)分,两组患者手术前后评分差异均有统计学意义(t=-33.071和-26.455,P＜0.05).所有患者对手术效果表示满意.结论 关节镜下肩袖缝合治疗肩袖全层撕裂创伤小、恢复快,中期效果令人满意.单排缝合与双排缝合的效果均令人满意.术中应正确识别撕裂的形状,充分松解粘连并采用恰当的缝合方式.     

关节镜下肩袖缝合术治疗肩袖撕裂

目的探讨关节镜下肩袖缝合术治疗肩袖撕裂的手术方法和临床效果。方法2002年12月至2005年10月，对27例肩袖撕裂患者行关节镜下肩袖缝合术，25例获得1年以上随访，其中男12例，女13例；年龄35～67岁，平均54．3岁；左肩6例，右肩19例，涉及优势侧19例。10例滑囊侧部分撕裂，1例滑囊侧及关节侧均有部分撕裂，14例全层撕裂。术前均拍摄肩关节正位和冈上肌出口位X线片，21例行B超检查，23例行MR或MRA检查。全部病例行肩峰下滑囊切除及前肩峰成形术。肩袖修复方式：1例直接行断端缝合，15例应用缝合锚钉行肩袖止点重建，9例联合应用断端缝合及缝合锚钉技术。分别在术前和最终随访时采用UCLA肩关节评分标准进行评价。结果随访时间1～3年，平均23个月。术后平均UCLA评分为（32．3±t2．3）分。手术前后疼痛评分平均为（2．6±t0．9）分和（8．6±1．4）分（P=0．000），功能评分平均为（5．0±1．8）分和（9．1±1．0）分（P=0．000），肩关节主动前屈评分平均为（3．6±1.5）分和（4．9±10.3）分（P=0．000），前屈肌力评分平均为（4．0±0．6）分和（4．7±0．5）分（P=0．000），差异均有统计学意义。优8例、良17例，所有患者均对手术效果表示满意。结论关节镜下肩袖缝合术是治疗肩袖撕裂的有效方法。术中应有效地控制出血，适度进行肩峰成形，正确识别撕裂的形状，充分松解粘连并采用恰当的缝合方式。手术创伤小、恢复快，其疗效可达到切开手术水平。     

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis

BackgroundAn all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques.Material and methodsThe main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants.ResultsA total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0–56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5).ConclusionArthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.     

关节镜下修复类风湿关节炎病人肩袖损伤的疗效分析

目的 探讨关节镜下修复类风湿关节炎病人肩袖损伤的疗效。方法 回顾性分析2015年3月至2018年7月的17例（20肩）类风湿关节炎病人的病例资料,均行关节镜下肩袖修复术,其中肩袖部分撕裂6例（7肩）,完全撕裂11例（13肩）。收集并比较病人术前及术后1年的疼痛视觉模拟量表（visual analogue scale, VAS）评分。分析病人术前、术后6个月及1年的Constant-Murley肩关节功能评分和美国加利福尼亚大学洛杉矶分校（University of California at Los Angeles, UCLA）肩关节评分。分析病人术前、术后1年的外展、外旋、内旋等肩关节活动度。结果 17例病人术后均随访1年以上。本组术后6个月和1年的UCLA评分分别为（27.15±2.85）分、（30.55±2.11）分,Constant-Murley评分分别为（73.20±4.07）分、（83.35±3.84）分,与术前相比逐步提升,各个时间点的评分比较,差异均有统计学意义（P均＜0.05）。静息和活动状态下的VAS评分由术前的（5.95±2.37）分、（7.35±2.13）分改善至术后的（2.20±1.23）分和（2.40±1.43）分,术前肩关节外展、外旋及内旋活动度由术前的77.30°±18.20°、37.25°±10.03°、35.25°±12.74°改善至术后的131.80°±20.22°、47.85°±7.66°和59.40°±12.12°,差异均有统计学意义（P均＜0.05）。无论是肩袖完全撕裂还是部分撕裂的类风湿关节炎病人,通过关节镜下肩袖修复术后,病人动、静态疼痛及内旋活动度恢复良好;但在肩袖完全撕裂的病人中,术后外展活动度及病人满意度均未见明显改善（P均＞0.05）。结论 关节镜下修复类风湿关节炎病人肩袖损伤能较好地缓解病人疼痛,对于肩袖部分撕裂的病人也能较好地改善肩关节的活动度和术后满意度。     

关节镜辅助下小切口修复肩袖损伤

目的　探讨关节镜辅助下小切口修复肩袖损伤的方法与疗效。方法　 1999年 5月至 2 0 0 3年 10月 ,采用关节镜辅助下小切口修复肩袖损伤 3 2例。术前 3 2例行肩关节X线片和肩关节MRI检查 ,其中 15例行肩关节造影检查 ,结果均证实为肩袖损伤。关节镜下发现肩袖附着处撕脱伤 5例 ,肩袖损伤2 7例。关节镜下行肩峰成形术 3 0例 ,小切口作肩峰成形术 2例。肩袖全层损伤在关节镜辅助下小切口行肩袖缝合术 2 2例 ,肩袖不完全性损伤在关节镜下作射频清理术 10例。结果　 3 2例术后随访 6～ 3 2个月 ,平均 10个月。根据美国UCLA肩关节评分标准评估 ,优 2 2例 ,良 5例 ,可 5例 ,优良率达 84.3 7%。结论　关节镜辅助下肩峰成形和小切口修复肩袖损伤具有操作安全简便、创伤小、有利于早期功能练习和康复。     

Current concepts in the rehabilitation of rotator cuff related disorders

Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.