Transtendon arthroscopic repair of high grade partial-thickness articular surface tears of the rotator cuff with biceps tendon augmentation: technical note and preliminary results

Introduction  

Partial articular surface of the rotator cuff tendon tears has been recognized as a source of treatable shoulder pain and a precursory pathology for full-thickness tendon tears. Arthroscopic rotator cuff repair is a possible surgical method of treatment. Recent data have shown that the treating partial-thickness rotator cuff repairs with transtendon technique shows good clinical outcome. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact bursal part. In cases of high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff, subsequently revision surgery in these patients will be demanding.     

Chondrogenic differentiation and lubricin expression of caprine infraspinatus tendon cells

Reparative strategies for the treatment of injuries to tendons, including those of the rotator cuff of the shoulder, need to address the formation of the cartilage which serves as the attachment apparatus to bone and which forms at regions undergoing compressive loading. Moreover, recent work indicates that cells employed for rotator cuff repair may need to synthesize a lubricating glycoprotein, lubricin, which has recently been found to play a role in tendon tribology. The objective of the present study was to investigate the chondrogenic differentiation and lubricin expression of caprine infraspinatus tendon cells in monolayer and three‐dimensional culture, and to compare the behavior with bone marrow‐derived mesenchymal stem cells (MSCs). The results demonstrated that while tendon cells in various media, including chondrogenic medium, expressed lubricin, virtually none of the MSCs synthesized this important lubricating molecule. Also of interest was that the cartilage formation capacity of the tendon cells grown in pellet culture in chondrogenic medium was comparable with MSCs. These data inform the use of tendon cells for rotator cuff repair, including for fibrocartilaginous zones. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 28:716–725, 2010     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

The low-profile Roman bridge technique for knotless double-row repair of the rotator cuff

With advances in arthroscopic surgery, many techniques have been developed to increase the tendon–bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. We present a low-profile arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon–footprint contact area and mean pressure. A 5.5 mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL, USA), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL, USA), is placed in the anteromedial aspect of the footprint. Two suture limbs from a single suture are both passed through a single anterior point in the rotator cuff. One suture limb is retrieved from the cannula. The second suture limb is passed through a single posterior point in the rotator cuff producing two points of fixation in the tendon, with a tendon bridge between them. The same suture limb is retrieved through the lateral portal, and then inserted into the bone by means of a Pushlock (Arthrex, Naples, FL, USA), placed approximately 1.5–2 cm posterior to the first anchor. This second suture is passed again in the posterior aspect of the cuff. The limbs of the first suture are pulled to compress the tendon in the medial aspect of the footprint. The two free suture limbs are used to produce suture bridges over the tendon by means of a Pushlock (Arthrex, Naples, FL, USA), placed 1 cm distal to the lateral edge of the footprint relative to the medially placed suture anchors anterior to posterior. This technique allows us to perform a low-profile (single pulley–suture bridges) repair for knotless double-row repair of the rotator cuff.     

Single Row Rotator Cuff Repair with Triple Loaded Suture Anchors: The SCOI Row Technique

Since the introduction of rotator cuff repair in the beginning of the 20th century, there have been significant advances in the surgical techniques and improvement in patient outcomes. However, controversy remains regarding the best method for tendon repair, including implant choice, ideal suture construct, and the potential benefits of supplemental biologic additives in order to achieve repair with the best opportunity for healing. The “SCOI Row” technique has been refined over three decades with extensive application and consistently good outcomes. Our technique uses a single row of anchors, triple loaded with a high-strength suture maximizing the number of sutures passed through the tendon to repair the rotator cuff arthroscopically. These anchors are placed 3-4 millimeters from the articular cartilage, providing strong anchorage and a low-tension repair. Debridement of devitalized tendon and only incorporating healthy tendon into the repair is imperative. The biology of the repair is enhanced with bone marrow vents created via microfracture of the greater tuberosity, forming the “Crimson Duvet” or bone marrow super-clot that will envelope the repair site. The bone marrow vents deliver marrow elements, including growth factors and mesenchymal cells that will help to regenerate the footprint of the rotator cuff. This repair construct has been evaluated biomechanically by other investigators and is favorable, as compared to dual row repairs. Our outcomes show greater than 90 % healing rate on postoperative magnetic resonance imaging and excellent patient-reported outcomes.     

Arthroscopic vs mini-open rotator cuff repair. A quality of life impairment study

We compared the clinical and quality of life related outcome of rotator cuff repair performed using either a mini-open or an arthroscopic technique for rotator cuff tears of less than 3 cm. The records of 64 patients who underwent rotator cuff repair between September 2003 and September 2005 were evaluated. Thirty-two patients underwent a mini-open rotator cuff repair, and 32 patients underwent an arthroscopic rotator cuff repair. The mean follow-up period was 31 months in the mini-open group and 30.6 months in the arthroscopic group (P > 0.05). The UCLA rating system, range of motion examination and the self-administered SF-36 used for postoperative evaluation showed a statistically significant improvement from the preoperative to the final score for both groups (P < 0.05). No statistically significant difference in the total UCLA scores was found when comparing the two repair techniques (P > 0.05). This study suggests that there is no difference in terms of subjective and objective outcomes between the two surgical procedures studied if patients have rotator cuff tears of less than 3 cm.     

促进肩袖止点腱骨愈合的研究进展

肩袖修补术是肩袖撕裂常用的治疗方式,能有效缓解肩关节疼痛,改善肩关节的活动,但肩袖修补术后肩袖再撕裂的发生率依然很高,主要原因在于肩袖修补术后肩袖止点处腱—骨愈合差,不能恢复原有的组织学结构和生物力学性能。因此,如何有效提高肩袖止点处腱骨愈合是解决此类问题的关键。目前随着人们对于肩袖止点研究的不断深入,各类治疗方法在改善肩袖止点腱骨愈合方面取得了较大的进展。本文将从影响肩袖止点处腱骨愈合的因素、肩袖止点处腱骨界面的恢复以利于肩袖腱骨愈合以及组织工程学在腱骨愈合中的应用3个方面阐述近几年关于肩袖腱骨愈合的研究进展,以期为肩袖撕裂的临床治疗提供一定的指导。     

Mechanical properties of the long‐head of the biceps tendon are altered in the presence of rotator cuff tears in a rat model

Rotator cuff tears are disabling conditions that result in changes in joint loading and functional deficiencies. Clinically, damage to the long‐head of the biceps tendon has been found in conjunction with rotator cuff tears, and this damage is thought to increase with increasing tear size. Despite its importance, controversy exists regarding the optimal treatment for the biceps. An animal model of this condition would allow for controlled studies to investigate the etiology of this problem and potential treatment strategies. We created rotator cuff tears in the rat model by detaching single (supraspinatus) and multiple (supraspinatus + infraspinatus or supraspinatus + subscapularis) rotator cuff tendons and measured the mechanical properties along the length of the long‐head of the biceps tendon 4 and 8 weeks following injury. Cross‐sectional area of the biceps was increased in the presence of a single rotator cuff tendon tear (by ～150%), with a greater increase in the presence of a multiple rotator cuff tendon tear (by up to 220%). Modulus values decreased as much as 43 and 56% with one and two tendon tears, respectively. Also, multiple tendon tear conditions involving the infraspinatus in addition to the supraspinatus affected the biceps tendon more than those involving the subscapularis and supraspinatus. Finally, biceps tendon mechanical properties worsened over time in multiple rotator cuff tendon tears. Therefore, the rat model correlates well with clinical findings of biceps tendon pathology in the presence of rotator cuff tears, and can be used to evaluate etiology and treatment modalities. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:416–420, 2009     

Restoration of anterior–posterior rotator cuff force balance improves shoulder function in a rat model of chronic massive tears

The rotator cuff musculature imparts dynamic stability to the glenohumeral joint. In particular, the balance between the subscapularis anteriorly and the infraspinatus posteriorly, often referred to as the rotator cuff “force couple,” is critical for concavity compression and concentric rotation of the humeral head. Restoration of this anterior–posterior force balance after chronic, massive rotator cuff tears may allow for deltoid compensation, but no in vivo studies have quantitatively demonstrated an improvement in shoulder function. Our goal was to determine if restoring this balance of forces improves shoulder function after two‐tendon rotator cuff tears in a rat model. Forty‐eight rats underwent detachment of the supraspinatus and infraspinatus. After four weeks, rats were randomly assigned to three groups: no repair, infraspinatus repair, and two‐tendon repair. Quantitative ambulatory measures including medial/lateral forces, braking, propulsion, and step width were significantly different between the infraspinatus and no repair group and similar between the infraspinatus and two‐tendon repair groups at almost all time points. These results suggest that repairing the infraspinatus back to its insertion site without repair of the supraspinatus can improve shoulder function to a level similar to repairing both the infraspinatus and supraspinatus tendons. Clinically, a partial repair of the posterior cuff after a two‐tendon tear may be sufficient to restore adequate function. An in vivo model system for two‐tendon repair of massive rotator cuff tears is presented. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1028–1033, 2011     

巨大肩袖撕裂的治疗及研究进展

目的总结巨大肩袖撕裂的治疗及研究进展。方法查阅巨大肩袖撕裂临床治疗及实验研究的相关文献,并进行综合分析。结果巨大肩袖撕裂的治疗方法主要有非手术治疗、清创减压术、直接修复术、肌腱转移术以及各种材料修复,其疗效各异。近年来,出现了许多有关巨大肩袖撕裂治疗的实验研究,如基因治疗、细胞治疗和组织工程技术,有望为临床医生提供新的治疗策略。结论巨大肩袖撕裂的治疗对临床医生是一个挑战,治疗方案的选择需要从多方面考虑;传统手术方法修复断裂肩袖效果有限,巨大肩袖撕裂的研究和治疗技术尚需进行深入研究。     

Biceps tenodesis associated with arthroscopic repair of rotator cuff tears

Associated lesions of the biceps tendon are commonly found during arthroscopic repair of rotator cuff tears. These lesions are treated with tenodesis, classically performed through an open approach. However, it seems reasonable to seek a single approach to correct both lesions; therefore, we have proposed a new arthroscopic technique that allows an exclusive arthroscopic tenodesis by including the biceps tendon in the rotator cuff suture, a surgical technique with a single suture of the rotator cuff that includes the biceps tendon. We treated 97 shoulders in 96 patients arthroscopically for complete rotator cuff tears. Of these shoulders, 15 required tenodesis for treatment of biceps tendon lesions. Through an arthroscopic approach, a subacromial decompression followed by a rotator cuff repair was carried out in association with a biceps tenodesis. In this technique, one limb of the suture was passed through the biceps tendon, and the other was passed through the rotator cuff tear, bringing both tissues together in the final suture. Of the patients, 9 were men and 5 were women. Their mean age was 71 years (range, 41-80 years). The dominant arm was affected in all patients. Postoperative evaluation, by use of the UCLA score, after a mean follow-up period of 32.4 months showed satisfactory results in 93.4% of patients: 11 had excellent results, 3 had good results, and only 1 had an unsatisfactory result. In this case a postoperative magnetic resonance imaging scan showed an intact rotator cuff and biceps tenodesis. The suture involving the rotator cuff and the biceps tendon proved effective to correct both lesions, with the main advantage being that an additional approach was not required.     

Editorial Commentary: Yet Another Arrow in the Quiver for Surgical Treatment of the Rotator Cuff–Deficient Shoulder: Will It Fly Fast and Far or Fall Short Like Other Options Have?

Rotator cuff tears are common. When indicated, surgical repair is a highly successful procedure. There are circumstances when there is not enough tendon to perform an anatomic repair because of tear size, retraction, and/or atrophy. This clinical scenario, massive irreparable rotator cuff tear, has no perfect solution. Many options exist in treating massive irreparable rotator cuff tears: partial tendon repairs, debridement, tuberoplasty, intercalary allograft repairs, tendon transfers, superior capsular reconstruction, hemiarthroplasty, arthrodesis, and reverse total shoulder arthroplasty. No superior technique has been described. Another treatment has been added to this list: inserting a biodegradable balloon within the subacromial space to reduce the articulation of the humeral head on the acromion and aid in recentering the humeral head to restore balance to the remaining rotator cuff and improve deltoid function.     

Homing and reparative effect of intra-articular injection of autologus mesenchymal stem cells in osteoarthritic animal model

Background

The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).

Methods

Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.

Results

In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).

Conclusions

Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.     

关节镜下肩袖缝合固定并肱二头肌长头腱锚钉固定的疗效观察

目的探讨关节镜下肩袖缝合固定并肱二头肌长头腱锚钉固定的临床疗效。方法选择2015年3月-2018年3月收治的肩袖损伤患者60例,按照两种不同的手术方法分为对照组和观察组。其中对照组30例,行单纯肩袖缝合固定;观察组30例,行肩袖缝合固定并肱二头肌长头腱锚钉固定。观察并分析两组术后临床疗效、康复情况。结果治疗前,两组VAS、Constant-Murley评分差异无统计学意义(P>0.05);治疗后,观察组治疗有效率明显高于对照组,且VAS评分更低,Constant-Murley评分更高,两组比较差异有统计学意义(P<0.05)。结论肩袖损伤患者实施关节镜下肩袖缝合固定并肱二头肌长头腱锚钉固定可有效纠正关节损伤,提高治疗效果,减轻患者疼痛应激,具有推广价值。     

MicroRNA Profiling Reveals Distinct Signatures in Degenerative Rotator Cuff Pathologies

MicroRNAs (miRNAs) have emerged as key regulators orchestrating a wide range of inflammatory and fibrotic diseases. However, the role of miRNAs in degenerative shoulder joint disorders is poorly understood. The aim of this explorative case-control study was to identify pathology-related, circulating miRNAs in patients with chronic rotator cuff tendinopathy and degenerative rotator cuff tears (RCT). In 2017, 15 patients were prospectively enrolled and assigned to three groups based on the diagnosed pathology: (i) no shoulder pathology, (ii) chronic rotator cuff tendinopathy, and (iii) degenerative RCTs. In total, 14 patients were included. Venous blood samples (“liquid biopsies”) were collected from each patient and serum levels of 187 miRNAs were determined. Subsequently, the change in expression of nine candidate miRNAs was verified in tendon biopsy samples, collected from patients who underwent arthroscopic shoulder surgery between 2015 and 2018. Overall, we identified several miRNAs to be progressively deregulated in sera from patients with either chronic rotator cuff tendinopathy or degenerative RCTs. Importantly, for the several of these miRNAs candidates repression was also evident in tendon biopsies harvested from patients who were treated for a supraspinatus tendon tear. As similar expression profiles were determined for tendon samples, the newly identified systemic miRNA signature has potential as novel diagnostic or prognostic biomarkers for degenerative rotator cuff pathologies. © 2019 The Authors. Journal of Orthopaedic Research^® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. Inc. J Orthop Res 38:202–211, 2020     

Anatomic Reduction and Next-Generation Fixation Constructs for Arthroscopic Repair of Crescent,L-Shaped,and U-Shaped Rotator Cuff Tears

Emerging techniques and instrumentation have allowed orthopaedic surgeons to achieve rotator cuff repair through an all-arthroscopic technique. The most critical steps in rotator cuff repair consist of proper identification of the cuff tear pattern and anatomic restoration of the torn tendon footprint. With anatomic reduction of the rotator cuff tendons, a sound fixation construct can help restore rotator cuff contact pressure and kinematics, allowing for decreased repair tension and optimal healing potential. We provide surgical methods to recognize tear patterns and present a repair construct that will restore the anatomic footprint of the torn rotator cuff tendon. The key, initial maneuver to restore the anatomic footprint of the cuff includes placement of a suture anchor at the anterolateral corner for L-shaped tears and at the posterolateral corner for reverse L–shaped and U-shaped tears. After insertion of the medial-row anchors, the tendon stitches should be planned by use of a grasper to hold the tendon in a reduced position and guide location of the stitch. The lateral row with suture bridge can be visualized, and the final repair construct should produce an anatomic restoration of the rotator cuff footprint.     

Medial Rotator Cuff Failure After Arthroscopic Double-Row Rotator Cuff Repair

Persistent tendon defects after rotator cuff repair are not uncommon. Recently, the senior author has identified a subset of 5 patients (mean age, 52 years; range, 42 to 59 years) after arthroscopic double-row rotator cuff repair who showed an unusual mechanism of tendon failure. In these patients the tendon footprint appears well fixed to the greater tuberosity with normal thickness. However, medial to the intact footprint, the tendon is torn with full-thickness defects through the rotator cuff. All patients were involved in Workers' Compensation claims. Magnetic resonance arthrography showed an intact cuff footprint but dye leakage in all patients. Revision surgery was performed at a mean of 8.6 months after the index procedure and showed an intact rotator cuff footprint but cuff failure medial to the footprint. Four patients had repair of the defects by tendon-to-tendon side-to-side sutures, whereas one did not undergo repair. Medial-row failure of the rotator cuff is a previously unreported mechanism of failure after double-row rotator cuff repair. Given the small number of patients in this study, it is unclear whether these defects are symptomatic. However, repair of these defects resulted in improvement in pain in 4 of 5 patients.     

Risk Factors for Rotator Cuff Disease: An Experimental Study on Intact Human Subscapularis Tendons

Although several studies revealed a multifactorial pathogenesis of degenerative rotator cuff disorders, the impact and interaction of extrinsic variables is still poorly understood. Thus, this study aimed at uncovering the effect of patient- and pathology-specific risk factors that may contribute to degeneration of the rotator cuff tendons. Between 2015 and 2018, 54 patients who underwent arthroscopic shoulder surgery at three specialized shoulder clinics were prospectively included. Using tendon samples harvested from the macroscopically intact subscapularis (SSC) tendon, targeted messenger RNA expression profile analysis was performed in the first cohort (n = 38). Furthermore, histological analyses were conducted on tendon tissue samples obtained from a second cohort (n = 16). Overall, both study cohorts were comparable concerning patient demographics. Results were then analyzed with respect to specific extrinsic factors, such as patient age, body mass index, current as well as previous professions and sport activities, smoking habit, and systemic metabolic diseases. While patient age, sports-activity level, and preexisting rotator cuff lesions were considered to contribute most strongly to tendinopathogenesis, no further coherences were found. With regards to gene expression analysis, change in expression correlated most strongly with patient age and severity of the rotator cuff pathology. Further, chronic disorders increased overall gene expression variation. Taken together, our study provides further evidence that tendon degeneration is the consequence of a multifactorial process and pathological changes of the supraspinatus tendon affect the quality of SSC tendon and most likely vice versa. Therefore, the rotator cuff tendons need to be considered as a unit when managing rotator cuff pathologies. © 2019 The Authors. Journal of Orthopaedic Research^® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society J Orthop Res 38:182–191, 2020     

Why Repair the Subscapularis? A Logical Rationale

Tears of the subscapularis tendon are now more frequently recognized and are often associated with tears of the posterosuperior rotator cuff tendons. This has been facilitated by arthroscopic approaches, and repair techniques have been developed. In the setting of a rotator cuff repair, when a subscapularis tendon tear is found in continuity with a supraspinatus tendon tear, it is essential to recognize how the repair of both tendon tears can influence the overall security of the entire repair construct. When a repairable subscapularis tendon tear is left unrepaired, the function of the subscapularis muscle will be lost. In addition, the posterosuperior rotator cuff tear will be more difficult to repair, and it will be less securely repaired. When the subscapularis tendon is repaired initially, the posterosuperior rotator cuff repair can be more easily and more reliable achieved.     

Failed surgical management of partial thickness rotator cuff tears

Some authors have recommended that rotator cuff tears <50% of tendon thickness be debrided and those involving >50% of the tendon be treated with miniopen repair. We hypothesize that if indications for selecting between simple debridement and tendon repair were appropriate, then both groups should have comparable outcomes. Thirty-nine patients with partial rotator cuff tears met inclusion criteria and were available for retrospective analysis. Twenty-six percent of patients who underwent debridement and 12.5% of patients who had mini-open repair had unsatisfactory results according to Neer's criteria.