Arthroscopic repair of large to massive rotator cuff tears in patients younger than 60 years

BackgroundThe incidence of rotator cuff tears in young patients has increased recently with the increase in sports and recreation activities, however, few studies have reported clinical outcomes after arthroscopic repair of large to massive rotator cuff tears in young patients. This study aimed to evaluate preoperative characteristics and postoperative outcomes after arthroscopic repair of large to massive rotator cuff tears in patients younger than 60 years, and to compare these results with those of tear size-matched patients older than 60 years.MethodsForty-eight patients who underwent arthroscopic repair for large to massive rotator cuff tears were included. Group I (n = 24) consisted of patients younger than 60 years, while tear size-matched patients older than 60 years were assigned to group II (n = 24). Clinical outcomes were evaluated preoperatively and at 3, 6, and 12 months postoperatively, and at the final visit. All patients underwent magnetic resonance imaging (MRI) preoperatively and at 3 and 12 months postoperatively to evaluate repair integrity.ResultsThe mean patient age was 53.4 ± 4.2 years in group I and 67.4 ± 4.5 in group II (P = 0.001). At the last visit, there were no significant differences in postoperative clinical scores or passive range of motion between two groups. However, young patients complained of shoulder pain less frequently than elderly patients (visual analog scale for pain at last visit: 0.8 ± 0.3 in group I, 2.4 ± 1.9 in group II, P = 0.04). Elderly patients showed more advanced fatty infiltration preoperatively than young patients and advanced fatty infiltration was correlated with postoperative repair integrity (r = 0.83, P = 0.001). Postoperative re-tear rate was 12.5% in group I, and 33.3% in group II (P = 0.08).ConclusionMore satisfactory clinical and structural outcomes followed by less advanced preoperative fatty infiltration can be expected in younger patients compared with patients older than 60 years, based on large to massive rotator cuff tear treatment outcomes.     

The Correlation between Various Shoulder Anatomical Indices on X-Ray and Subacromial Impingement and Morphology of Rotator Cuff Tears

Objectives

Rotator cuff injury caused by subacromial impingement presents different morphologies. This study aims to investigate the correlation between various shoulder anatomical indexes on X-ray with subacromial impingement and morphology of rotator cuff tears to facilitate surgical management.

Method

This retrospective study was carried out between January 2020 and May 2022. Patients who were diagnosed as sub-acromial impingement associated with rotator cuff tears (without tendon retraction) and received arthroscopic surgery were enrolled in this study. The radiographic indexes of acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), acromial Index (AI), and sub-acromial distance (SAD) were measured on preoperative true AP view and outlet view. The location of rotator cuff tear (anterior, middle, posterior, medial, and lateral) and morphology of tear (horizontal, longitudinal, L-shaped, and irregular shaped) were evaluated by arthroscopy. Groups were set up due to different tear location and tear morphologies, by comparing the various radiographic indices between each group (one-way analysis of variance and t-test), the correlation between radiographic indices and tear characteristics was investigated.

Results

We analyzed 92 shoulders from 92 patients with a mean age of 57.23 ± 8.45 years. The AS in anterior tear group (29.32 ± 6.91°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.000) and posterior tear group (24.01 ± 7.69°) (p = 0.041). The AS in posterior tear group (24.01 ± 7.69°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.029). The LAA in middle tear group (67.41 ± 6.54°) was significantly smaller than that in posterior group (72.74 ± 8.78°) (p = 0.046). The AS in longitudinal tear group (26.86 ± 8.41°) was significantly larger than that in horizontal tear group (22.05 ± 9.47°) (p = 0.035) and L-shaped group (21.56 ± 6.62°) (p = 0.032). The LAA in horizontal group (70.60 ± 6.50°) was significantly larger than that in L-shaped group (66.39 ± 7.31°) (p = 0.033). The AI in L-shaped tear group (0.832 ± 0.074) was significantly larger than that in horizontal tear group (0.780 ± 0.084) (p = 0.019) and irregular tear group (0.781 ± 0.068) (p = 0.047).

Conclusion

Acromion with a larger AS and a smaller LAA tend to cause anterior or posterior rotator cuff tears rather than middle tears in sub-acromial impingement. Meanwhile acromion with a larger AS tends to cause a longitudinal tear, a larger LAA tends to cause horizontal tears and a larger AI tends to cause L-shaped tears.     

Technique for Margin Convergence in Rotator Cuff Repair

The purpose of the present study is to describe the technique of margin convergence for U-shaped rotator cuff tears and report the clinical outcomes and ultrasonography with a minimum of 2 years follow-up. Three hundred eleven patients with a rotator cuff tear were prospectively enrolled in a registry at one institution. Inclusion criteria included any patient undergoing arthroscopic margin convergence for a rotator cuff tear. Exclusion criteria included open or mini-open rotator cuff repairs or suture anchor fixation to the cuff insertion without margin convergence. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. Nineteen patients met the study criteria and 13 were available for 2-year follow-up (68.4%). The mean age of this cohort was 62.2 ± 7.5 years with a mean pre-operative rotator cuff tear size of 4.0 ± 1.6 cm. The ASES score increased significantly from 50.0 ± 17.7 before surgery to 83.3 ± 19.5 at 2 years (P = 0.01). The active forward elevation also improved from 156.2 ± 11.9° before surgery to 168.0 ± 12.1 at 2 years (P = 0.03). The active external rotation 54.4 ± 14.5 at baseline and improved to 57.1 ± 19.1 at 2 years (P = 0.04). The strength also increased significantly from 6.7 ± 6.4 to 10.6 ± 4.9 lb at 1 year (P = 0.048). The post-operative ultrasound demonstrated that 46.2% of rotator cuff tears were healed at 2 years. In conclusion, margin convergence is a useful technique for U-shaped tears that are difficult to mobilize.     

Modified load sharing rip-stop technique in patients with traumatic transtendinous rotator cuff tear: Surgical technique and clinical outcomes

BackgroundTranstendinous rotator cuff tear is likely to occur due to trauma in sports activities, with a frequency of <2% of total rotator cuff tears. These tears are difficult to treat because of limited tendon tissue in the proximal stump, and standard repair techniques are sometimes ineffective. Few studies have reported on the repair technique and clinical outcomes for transtendinous rotator cuff tear, and an appropriate repair technique has, therefore, not been established. The purpose of this study was to use our modified load sharing rip-stop technique to repair transtendinous rotator cuff tear and to clarify the clinical effectiveness of this technique.MethodsThis was a retrospective case series review of eight patients who underwent the modified load sharing rip-stop technique for repairing traumatic transtendinous rotator cuff tear between January 2013 and June 2017. The eight patients were followed up for at least 2 years (range: 24–41 months). Cuff integrity was evaluated using magnetic resonance imaging at 12 months after surgery using the Sugaya classification. We evaluated the pre- and postoperative ranges of motion, American Shoulder and Elbow Surgeons score, Constant Shoulder Score, and muscle strength at 90° abduction. Data were analyzed using the Mann–Whitney U test and Fisher's exact tests. P < .05 was considered to indicate statistical significance.ResultsSix patients were classified as Sugaya I and two as Sugaya II. ASES score (38.5–90.2, P = .0008), Constant shoulder score (36.5–79, P = .002), flexion (85°–158.1°, P = .002), abduction (85°–157.5°, P = .001), external rotation (38.8°–55°, P = .024), and muscle strength at 90° abduction (2.95–5.39 kg, P = .028) improved significantly. Six patients were able to return to their previous sports activity.ConclusionUsing our modified load sharing rip-stop technique for repair of transtendinous rotator cuff tear, patients obtained good clinical outcomes and could return to sports activities.     

经皮超声造影对肩袖撕裂亚型的诊断价值

目的:探讨肩袖撕裂亚型的超声造影(contrast-enhanced ultrasound,CEUS)图像特征及其对肩袖撕裂亚型的诊断价值。方法:自2019年1月至2022年3月,采用经皮超声引导下肩峰下滑囊造影(percutaneous ultrasoundguided subacromial bursography,PUSB)联合经皮超声引导下肌腱造影(persutaneous ultrasound-guide tendon lesionography,PUTL)评估疑似肩袖损伤的患者114例,其中男54例,女60例;年龄35～75 (58.8±8.7)岁;右侧76例,左侧38例。采用美国GE LOGIQ E9彩色多普勒超声诊断仪线阵探头,探头频率6～12 MHz,对患者进行超声造影检查。以肩关节镜为金标准,采用受试者工作特征(receiver operating characteristic,ROC)曲线评估超声(ultrasound,US),MRI及CEUS对肩袖损伤的诊断效能,并计算敏感度、特异性、阳性预测值、阴性预测值和准确度,采用Kappa检验比较US、MRI及CEUS诊...     

Which patients are less likely to improve after arthroscopic rotator cuff repair?

ObjectiveThe aim of this study was to evaluate which specific factors influence the improvement in function and to estimate the time to obtain pain relief following arthroscopic rotator cuff repair.MethodsA total of 97 patients (57 men and 40 women; mean age: 55.5 ± 9.3 years) who had arthroscopic rotator cuff repair between 2013 and 2016 were included into the study. Multivariable stepwise analysis included preoperative variables (age, gender, body mass index, comorbidities, occupation and participation in sports, Oxford shoulder score at baseline, preceding injury and duration of preoperative symptoms) and arthroscopic findings (size of rotator cuff tear, pathology of the long head of the biceps and cartilage lesions). The change in the Oxford shoulder score at the last follow-up was modeled as a function of the above predictor variables. The time to regain a visual analogue scale (VAS) under two points following surgery was considered the time to regain substantial pain relief.ResultsThe mean follow-up time was 33.2 ± 14.4 months. Twenty three patients had partial thickness and seventy four had full thickness supraspinatus tears. In third of the patients the tears were defined as large full thickness. At the last follow-up the mean Oxford shoulder score improved from 13.8 ± 4.8 to 42.1 ± 7.2 points (P < 0.001). The mean VAS improved from a preoperative score of 6.7 ± 1.3 points to 1.5 ± 0.6 points postoperatively (P < 0.001) and 80 (83%) patients declared they were satisfied to have had the operation. The mean time interval for substantial pain relief was 4.9 ± 3.6 months. Patients with higher preoperative Oxford shoulder score and larger tear size were correlated with lesser improvement in Oxford shoulder score (R = 0.5, P = 0.001).ConclusionArthroscopic rotator cuff repair improved pain and function at an average follow-up of three years. A substantial pain relief was regained within five months from surgery. Larger rotator cuff tear size and more favorable preoperative function were predictors of worse postoperative function.Level of evidenceLevel IV, Therapeutic study.     

Partial-thickness Articular Surface Rotator Cuff Tears: An All-inside Repair Technique

Background  

Treatment of partial-thickness articular surface rotator cuff tears varies from simple débridement with or without an acromioplasty to various repair techniques. These repair techniques have included in situ transtendinous methods, as well as completion of the tear and repairing the full-thickness defect. The transtendinous techniques can be associated with stiffness and completing the tear takes down normal intact tissue. Therefore, a technique was developed that repairs the articular-side partial- thickness rotator cuff tears with an all-inside approach that does not violate the intact bursal tissue and does not complete the tear.     

Functional and MRI Outcomes After In Situ Repair Versus Tear Completion Before Repair of Bursal-Side Partial-Thickness Rotator Cuff Tears

Objective

The optimal repair method for bursal-side partial-thickness rotator cuff tears (PTRCTs) involving >50% of the thickness remains a controversial topic. The study was aimed to compare the functional and magnetic resonance imaging (MRI) outcomes after in situ repair or tear completion before repair of bursal-side PTRCTs.

Methods

A retrospective clinical study was conducted involving 58 patients who underwent in situ repair or tear completion before repair of bursal-side PTRCTs between January 2019 and December 2020. These patients were divided into two groups: the in situ repair group and the tear completion before repair group. Functional assessment consisted of active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Constant–Murley score. The percentages of patients in each group achieving the minimal clinical important difference (MCID) of the functional scores were determined. The healing status of the rotator cuff was assessed by postoperative MRI.

Results

There were no statistically significant differences between the two groups in terms of demographic data. The mean follow-up period was 14.53 ± 2.64 months in the in situ repair group and 15.40 ± 2.66 months in the tear completion before repair group. At the final follow-up, the forward elevation, external rotation, and internal rotation improved significantly in both groups. The VAS, ASES score, and Constant–Murley score improved significantly in the in situ repair group (5.17 ± 2.00 points to 0.11 ± 0.41 points, p = 0.001; 44.04 ± 17.40 points to 95.47 ± 4.32 points, p = 0.001; 49.50 ± 14.38 points to 93.50 ± 3.49 points, p = 0.001) and in the tear completion before repair group (5.43 ± 3.32 points to 0.03 ± 0.18 points, p = 0.001; 41.50 ± 19.59 points to 95.94 ± 2.68 points, p = 0.001; 47.54 ± 17.13 points to 93.97 ± 2.61 points, p = 0.001). Postoperative MRI revealed that the re-tear rate was 7.1% (2/28) in the in situ repair group and 3.3% (1/30) in the tear completion before repair group. No significant differences were observed in terms of the functional scores, the percentages of patients achieving the MCID of the functional scores, and the re-tear rate between the two groups (p > 0.05).

Conclusions

Both in situ repair and tear completion before repair yielded satisfactory clinical outcomes for patients with bursal-side PTRCTs. No significant differences were observed in the functional and MRI outcomes between the two groups.     

Classification and Clinical Significance of Acromial Spur in Rotator Cuff Tear: Heel-type Spur and Rotator Cuff Tear

Acromial spurs reportedly relate to the impingement syndrome and rotator cuff tears. We classified the morphologic characteristics of the acromion (shape and thickness) and acromial spurs and determined whether they correlated with rotator cuff tears. We measured acromial shape and thickness using simple radiography and MR arthrography or CT arthrography in 106 patients with full-thickness rotator cuff tears and in 102 patients without tears. Acromial spurs could be classified morphologically into six types: heel, lateral/anterior traction, lateral/anterior bird beak, and medial. We found acromial spurs in 142 of the 208 patients (68%), and their incidence increased with age. The acromial spur was more common in the cuff tear group. The heel type was most common and detected in 59 patients (56%) in the cuff tear group and in 36 patients (35%) in the control group. The flat acromion was more common (60%) than curved and hooked acromion; however, there was no major difference between acromial shape and cuff tear. The mean acromial thickness was 8.0 mm, and the cuff tear group had thicker acromion. These data suggest acromial spurs can be classified according to the distinct morphology, and the most common heel-type spur might be a risk factor for full-thickness rotator cuff tears.     

Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging

We studied magnetic resonance images of rotator cuff tears to determine whether it was possible to establish preoperatively the feasibility or infeasibility of primary repair. The study comprised 27 shoulders in 26 patients who underwent magnetic resonance imaging before surgery because of complete tears of the rotator cuff and who were treated with primary repair or by the patch graft technique because primary repair was not feasible. The length and width of each tear, the thickness of the supraspinatus muscle at the superior margin of the glenoid, and the presence or absence of a high signal intensity in the infraspinatus muscle were statistically analyzed. Primary repair was often not feasible when both the length and width of the tear exceeded 40 mm on a preoperative magnetic resonance image, when the supraspinatus muscle was thin at the superior margin of the glenoid, and when a high signal intensity was observed in the infraspinatus muscle.     

Influence of a nerve injury proximal to the suprascapular nerve on healing of repaired rotator cuff tear

BackgroundMassive rotator cuff tears have a high rate of re-injury because of severe fatty infiltration. Our data showed that injuries proximal to the suprascapular nerve may be one cause of massive rotator cuff tears. The purpose of this study was to evaluate, using a rat model, how brachial plexus injury associated with a massive rotator cuff tear influences healing of the rotator cuff repair.MethodsSeventy Sprague–Dawley rats were divided into three groups: rotator cuff tear with BP injury (DT group) (n = 28), rotator cuff tear without brachial plexus injury (T group) (n = 28), and a sham-operated group (n = 14). In the DT group, the rotator cuff tear was made and repaired 4 weeks after brachial plexus ligation. The gross assessment (evaluated the wet weight), biomechanical testing (evaluated the yield stress and the Young's modulus) and histological analyses (using the Bonar scale) were performed at baseline in the sham group, and at 4 and 12 weeks postoperatively in the DT and T groups (n = 7/group/time).ResultsMean wet weight and yield stress were significantly lower in the DT group than in the T group. Additionally, the mean Young's modulus was significantly higher in the DT group than in the T group. Histologically, greater tendon degeneration was observed around the musculotendinous junction in the DT group than in the T group.ConclusionThe gross, biomechanical and histological data show that the repaired rotator cuff tendon with brachial plexus injury in rats does not heal as well as a repaired tendon without an accompanying brachial plexus injury. This suggests that more proximal neuropathy is one risk factor for re-tear of a repaired rotator cuff tendon.     

The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears

This study investigated whether a relationship exists between greater tuberosity osteopenia and chronicity of rotator cuff tears. In a retrospective study, anteroposterior radiographs of 28 shoulders in 27 patients who had undergone surgical repair for rotator cuff tears were reviewed. Greater tuberosity osteopenia scores were created using National Institutes of Health digital image software. There was no significant difference in the mean age between patients with minimal to mild rotator cuff tear retraction (63.1 +/- 6.14 years) and patients with moderate to severe rotator cuff tear retraction (63.4 +/- 9.76 years; P = .77). Of the 13 patients with minimal to mild rotator cuff tear retraction, 10 (77%) were women and 3 (23%) were men. Of 14 patients (50%) with moderate to severe rotator cuff tear retraction, 7 were men and 7 were women. The mean greater tuberosity osteopenia score in the 15 patients with moderate to severe retraction (0.48 +/- 0.095) was significantly less than the greater tuberosity osteopenia score in the 13 patients with minimal to mild retraction (0.58 +/- 0.135; P < .05). Furthermore, the mean greater tuberosity osteopenia score in 6 patients with chronic retracted rotator cuff tears (0.48 +/- 0.125) was significantly less than in the 6 patients with acute minimally retracted tears (0.64 +/- 0.119, P < .05). There were significantly greater osteopenic changes in the greater tuberosity in patients with chronic retracted rotator cuff tears. The greater tuberosity osteopenia may affect anchor pullout strength and the healing biology that influences overall rotator cuff repair healing rates.     

A comparison of clinical estimation,ultrasonography, magnetic resonance imaging,and arthroscopy in determining the size of rotator cuff tears

This prospective study was undertaken to compare the ability of clinical estimation, diagnostic ultrasonography, magnetic resonance imaging, and arthroscopy to estimate the size of rotator cuff tears. Estimates of rotator cuff tear size were compared with the findings at open operation in 33 consecutive patients with a presumptive diagnosis of rotator cuff tear. Arthroscopy estimates of rotator cuff tear size correlated best with actual tear size (Pearson correlation coefficient r = 0.92; P <.001). Magnetic resonance imaging (r = 0.74; P <.001) was similar to ultrasonography (r = 0.73; P <.001). Estimates of rotator cuff tear size after clinical assessment alone had weaker correlation coefficients (r = 0.41; P =.02) than the other methods. Each method underestimated rotator cuff tear size by 12%, 30%, 33%, and 38%, respectively. No method was able to determine the size of partial-thickness rotator cuff tears (r < 0.02).     

Rotator cuff muscle degeneration and tear severity related to myogenic,adipogenic, and atrophy genes in human muscle

Large rotator cuff tear size and advanced muscle degeneration can affect reparability of tears and compromise tendon healing. Clinicians often rely on direct measures of rotator cuff tear size and muscle degeneration from magnetic resonance imaging (MRI) to determine whether the rotator cuff tear is repairable. The objective of this study was to identify the relationship between gene expression changes in rotator cuff muscle degeneration to standard data available to clinicians. Radiographic assessment of preoperative rotator cuff tear severity was completed for 25 patients with varying magnitudes of rotator cuff tears. Tear width and retraction were measured using MRI, and Goutallier grade, tangent (tan) sign, and Thomazeau grade were determined. Expression of myogenic‐, adipogenic‐, atrophy‐, and metabolism‐related genes in biopsied muscles were correlated with tear width, tear retraction, Goutallier grade, tan sign, and Thomazeau grade. Tear width positively correlated with Goutallier grade in both the supraspinatus (r = 0.73) and infraspinatus (r = 0.77), along with tan sign (r = 0.71) and Thomazeau grade (r = 0.68). Decreased myogenesis (Myf5), increased adipogenesis (CEBPα, Lep, Wnt10b), and decreased metabolism (PPARα) correlated with radiographic assessments. Gene expression changes suggest that rotator cuff tears lead to a dramatic molecular response in an attempt to maintain normal muscle tissue, increase adipogenesis, and decrease metabolism. Fat accumulation and muscle atrophy appear to stem from endogenous changes rather than from changes mediated by infiltrating cells. Results suggest that chronic unloading of muscle, induced by rotator cuff tear, disrupts muscle homeostasis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2808–2814, 2017.

     

Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears

Background:

Rotator cuff problems are frequently seen by orthopedic surgeons and accurate diagnosis is essential for appropriate management. Value of the clinical assessment of a shoulder is often limited, therefore, imaging studies have important implications in the management of rotator cuff pathologies.

Aim:

The purpose of this retrospective study is to compare the accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for detection of full-thickness rotator cuff tears.

Materials and Methods:

We reviewed 91 consecutive cases of shoulder arthroscopy and open rotator cuff repair, who had undergone preoperative investigation in the form of either an ultrasound or MRI. Thirty-six patients had an ultrasound and 55 had an MRI for their affected shoulders. We compared the accuracy of US and MRI for detection of full-thickness rotator cuff tears, using the operative findings as the ‘gold standard’. Data regarding a supraspinatus tear was assessed for the purpose of this study.

Results:

Ultrasonography correctly diagnosed 15 out of 17 tears (sensitivity of 0.88). There were 17 true-negative and two false-positive ultrasounds (specificity of 0.89). MRI accurately identified 33 of the 36 tears (sensitivity of 0.91). There were 16 true-negative and three false-positive tears on MRI (specificity of 0.84). The positive predictive value (PPV) was 88% for US and 92% for MRI. The negative predictive value (NPV) was 89% for US and 84% for MRI. The overall accuracy of the ultrasound was 88.89% (95% confidence interval (CI) = 74.09 to 96.18) as compared to 89.09% (95% CI = 77.82% to 95.26%) for the MRI.

Conclusion:

Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. US being a dynamic study and better tolerated by the patient, can therefore be used as the first-line investigation for rotator cuff tear, where appropriate skills are available to reduce the waiting time and cost of investigation.     

Arthroscopic treatment of massive rotator cuff tears

In the past 10 years, arthroscopic surgeons have gone from being unable to repair any rotator cuff tears arthroscopically to being able to repair virtually all rotator cuff tears, even complex massive tears, arthroscopically. The factors responsible for this rapid evolution have been: (1) recognition of the mechanical principles responsible for a secure repair (margin convergence, knot security, loop security); (2) recognition of major tear patterns that require different techniques of repair; and (3) development of instrumentation and arthroscopic portals that predictably accomplish secure repair of the rotator cuff and direct access to the pathologic areas. In the current study, the author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair. In the author's series of arthroscopic repair of rotator cuff tears, the results have been gratifying, with massive tears achieving final results equivalent to those of smaller tears.     

关节镜下改良Mason-Allen与缝线桥缝合治疗中型肩袖撕裂的疗效对比

目的:观察并比较关节镜下改良Mason-Allen与缝线桥缝合治疗中型肩袖撕裂的术后疗效.方法:自2017年1月至2018年1月,采用关节镜下改良Mason-Allen缝合治疗中型肩袖撕裂患者22例,年龄40～81(57.14±10.26)岁;男9例,女13例.2018年2月至2019年1月,采用缝线桥缝合治疗中型肩袖...     

Combined tears of the subscapularis and supraspinatus tendon: clinical outcome,rotator cuff strength and structural integrity following open repair

Background  

Anterosuperior rotator cuff tears involving the subscapularis and supraspinatus tendons are less common than other tears of the rotator cuff. The purpose of this study was to report the clinical outcome, rotator cuff strength and structural integrity of open repair of combined anterosuperior rotator cuff tears.     

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

Background

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

Questions/purposes

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, therapeutic study.

     

Editorial Commentary: Monitoring Tendon and Muscle Recovery After Rotator Cuff Repair Using Diagnostic Ultrasound Demonstrates that Early Repair is Beneficial for Many Patients With Reparable Tears

Rotator cuff repair is performed to effect healing of the enthesis; to restore shoulder comfort, strength, and function; to prevent tear propagation; and to prevent progression of atrophic muscle changes (fatty degeneration, fatty infiltration, and fatty atrophy) that eventually occur. Non-retracted and moderately retracted rotator cuff tears usually heal after repair, and muscle atrophy may recover over time. It follows that early rotator cuff repair is beneficial for many patients with chronic but reparable rotator cuff tears. Diagnostic ultrasound can provide quantitative information about the recovery of both muscle and tendon and represents a viable alternative to magnetic resonance imaging for evaluating healing after rotator cuff repair.