The influence of the acromial coverage index in rotator cuff tears

Several intrinsic and extrinsic factors have been advocated in the pathogenesis of rotator cuff tears, but it is still unclear whether the origin of the tear is related to tendon degeneration itself or induced by several morphologic changes. The purpose of this study is to determine the relationship between the acromial coverage of the humeral head and the presence of a cuff tear. We evaluated 148 shoulders, including 45 that underwent surgical rotator cuff repair (group I), 26 with documented rotator cuff tears treated conservatively (group II), and 77 with no cuff pathology as a control group (group III). The mean acromial coverage index was 0.68 in group I, 0.72 in group II, and 0.59 in group III, giving a highly significant difference (P < .0001) between the control group and both cuff tear groups. Patients with a cuff tear have a significantly higher acromial coverage index than the control group.     

Management of failed arthroscopic rotator cuff repair

Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.     

Reoperation for failed rotator cuff repair: Analysis of fifty cases

Fifty patients who underwent reoperation for failure of previous repair of rotator cuff rupture were evaluated 24 to 84 months after final repair (mean 30 months). Forty-eight of these patients had undergone all previous attempts at repair elsewhere. Most patients had had one or two earlier attempts, but four patients had had three, and three patients had had four. Forty-six (92%) patients reported pain improvement, and four were unchanged. Twenty-six patients showed an average increase in elevation of 50° (range 10° to 130°). Twenty-two retained their preoperative motion, and two lost motion (mean 45°) but still had more than 90°. Overall mean elevation increased from 92° to 137°. Compared with 17 patients before surgery, only six had less than 90° motion after surgery-and all six had deltoid abnormalities. The size of the rupture, the number of previous operations, and dysfunction of the biceps did not affect the result. The following factors were associated with success: adequate decompression, closure of all defects with tendon-to-bone junctures (by direct repair, interpositional grafting, or local tendon transfers), avoiding use of weights or resistive exercises during the early (first 3 months) postoperative rehabilitation period, and an intact, functioning deltoid.     

Clinical and biomechanical performance of patients with failed rotator cuff repair

Purpose

The purpose of the study was clinical and advanced biomechanical evaluation of shoulder function with respect to rotator cuff (RC) integrity following repair.

Methods

This was a retrospective study of 111 cases with solid single row rotator cuff repair and a minimal one-year follow-up. The RC repair was performed as an open procedure in 42 patients, arthroscopically assisted in 34 and fully arthroscopic in 48 cases. Evaluation protocol included ultrasound evaluation of the RC integrity, clinical evaluation using shoulder scores and advanced biomechanical evaluation (isometric and the isokinetic strength testing).

Results

Ultrasound evaluation revealed complete retear in 16 %, partial retear in 10 % and intact repair in 74 % of the cases. Isometric testing of flexion and abduction had shown that shoulders with complete retear were weaker by 45 % compared to those with full tendon healing. Isokinetic testing revealed 29–43 % deficits in peak external rotation torque comparing complete retear vs. normal healing. Patients’ ability to generate shoulder power and withstand a load proved to be lower in circumstances of a complete lack of healing (40–43 % and 34–55 %, respectively). Partial retears did not have a negative impact on the biomechanical properties of shoulders. Surprisingly, there were no significant differences in the shoulder scores related to the quality of healing. In terms of patient satisfaction the results were good and the patients declared themselves better in all cases, no matter what quality of healing had been recorded ultimately.

Conclusions

According to the results of this research rotator cuff integrity after open or arthroscopic repair does not seem to affect clinical scores. Recurrent tears may result in lower muscle performance in terms of active motion, strength and endurance. Advanced shoulder testing may be essential in assessing the patients’ ability to return to sports or heavy labour.     

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。     

Mini-open rotator cuff repair

Open shoulder procedures require a deltoid release for proper exposure. Arthroscopic techniques have progressed so that minimally invasive techniques give similar outcomes as more formal open procedures with less risk of morbidity. Arthroscopically assisted open rotator cuff repair offers advantages over open procedures with some diagnostic and decompression performed with the arthroscope. The mini-open technique has more aspects of a cuff repair performed through the arthroscope leaving a few steps to be done open. The modern use of arthroscopic techniques for minimally invasive rotator cuff surgery coupled with advances in rehabilitation is discussed.     

Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is being performed by an increasing number of orthopaedic surgeons. The principles, techniques, and instrumentation have evolved to the extent that all patterns and sizes of rotator cuff tear, including massive tears, can now be repaired arthroscopically. Achieving a biomechanically stable construct is critical to biologic healing. The ideal repair construct must optimize suture-to-bone fixation, suture-to-tendon fixation, abrasion resistance of suture, suture strength, knot security, loop security, and restoration of the anatomic rotator cuff footprint (the surface area of bone to which the cuff tendons attach). By achieving optimized repair constructs, experienced arthroscopic surgeons are reporting results equal to those of open rotator cuff repair. As surgeons' arthroscopic skill levels increase through attendance at surgical skills courses and greater experience gained in the operating room, there will be an increasing trend toward arthroscopic repair of most rotator cuff pathology.     

Arthroscopic rotator cuff repair

The arthroscopic operation for repair of full-thickness rotator cuff tears is successful and has the advantages of glenohumeral joint inspection, treatment of intraarticular lesions, smaller incisions, no deltoid detachment, less soft tissue dissection, less pain, and more rapid rehabilitation. However, these advantages must be balanced against the technical difficulty of the method, which limits its application to surgeons skilled in open and arthroscopic shoulder operations.     

Technique for arthroscopic rotator cuff repair

Modern arthroscopic tools and techniques have allowed surgeons to operate on a wide variety of injuries using procedures less invasive than traditional open methods. For shoulder surgery in general, and rotator cuff repairs specifically, methods now yield a similar footprint as open procedures with several advantages, including reduced tissue trauma, postoperative pain, swelling, and concern about the deltoid attachment, which should lead to good outcomes.     

LactoSorb plates for rotator cuff repair

Purpose: We present our preliminary studies using LactoSorb plates (Lorenz/Biomet, Warsaw, IN) for rotator cuff repair in humans. The use and application of this plate are described as an adjunct to prevent hole migration in trough-tunnel repairs of rotator cuff tears. Methods: Fifty patients with rotator cuff tears documented by magnetic resonance imaging underwent arthroscopic subacromial decompression followed by a mini-open repair of the rotator cuff. Tears were repaired using a trough and tunnel technique, horizontal mattress sutures, and a standard LactoSorb plate. Follow-up was obtained on 45 patients, 26 male and 19 female, with an average age of 61.6 years. The patients were followed-up and evaluated at 5 days, 1 month, 3 months, 6 months, and a minimum of 1 year postoperatively. All surgeries were performed by the same surgeon and followed a similar rehabilitation protocol. Results: There were 89% excellent results, 9% good results, and 2% fair results. There were no poor results. No significant swelling, tenderness, or erythema was noted at the operative site, and there were no infections. Postoperative radiographs at 3, 6, and 12 months did not show any bone erosion. No repeat surgical procedures were necessary. Conclusion: The results of our study support the use of LactoSorb bioabsorbable plates in the repair of rotator cuff tears to prevent hole migration and potentially poor results or failures of repairs. The LactoSorb plate appears to maintain its strength during the healing period of the repair and does not elicit any clinically noticeable inflammatory process.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 279–283     

Results of surgery after failed attempt at repair of irreparable rotator cuff tear

Twelve patients who had surgery to repair a rotator cuff tear, which could not be repaired because the residual tendon tissue was of poor quality, insufficient, or both, were followed up for a mean of 33 months. At surgery, the deltoid was detached from the acromion for 4 to 6 cm and an acromioplasty was done. Preoperatively, all patients except one had mild to severe pain. The mean active forward flexion, abduction, and external rotation were 75 degrees, 61 degrees, and 22 degrees, respectively. After surgery, of the 11 patients who had shoulder pain preoperatively, 10 reported partial relief of pain and one was pain-free. However, shoulder function deteriorated in 11 patients and remained unchanged in one patient who had a pseudoparalytic shoulder before and after surgery. The mean postoperative values of forward flexion, abduction, and external rotation were 49 degrees, 43 degrees, and 16 degrees, respectively. Only one patient was satisfied with the result of surgery because of pain relief. Two patients had repeat surgery (total shoulder replacement or latissimus dorsi transfer) 6 and 4 months after the index surgery because of unsatisfactory functional results. Attempts at open repair of an irreparable cuff tear should be avoided because functional results generally are poor. When there is a risk that an irreparable tear will be found, open surgery should not be done or alternative procedures should be planned before surgery.     

Mini-open rotator cuff repair does not result in intractable stiffness

We conducted a study to determine whether intractable postoperative stiffness or deltoid damage results from primary arthroscopic anterior acromioplasty and mini-open repair of full-thickness tears of the superior rotator cuff. Eighty-three repairs (80 patients) were available for follow-up at a mean (range) of 57.2 (12-98) months. Range of motion at presentation and motion in contralateral shoulder at final follow-up were used for comparison. Significant improvements were seen in active forward elevation, passive forward elevation, and active external rotation at 90° abduction. Final motion in the operative and contralateral shoulders was similar. American Shoulder and Elbow Surgeons shoulder index improved significantly (P<.0001) from 50.0 before surgery to 88.3 after surgery. Although 1 patient had a symptomatic retear that required revision surgery, there were no cases of intractable stiffness, and there were no cases of deltoid damage.     

Infection after rotator cuff repair

Sixteen patients (15 men and 1 woman) were treated for infection complicating rotator cuff repair during the period 1975 through 1994. Eight of the 16 patients had their initial procedure performed elsewhere. The remaining 8 procedures were performed at our institution with the known incidence of this complication being 0.27%. In addition to intravenous antibiotic therapy, an average of 3.5 (range 2 to 8) operative procedures were required to eradicate the infections. Micro-organisms cultured were Propionibacter in 6, coagulase negative Staphylococcus in 4, Staphylococcus aureus in 4, Peptostreptococcus magnus in 1, and both Propionibacter and coagulase-negative Staphylococcus in 1. The deltoid was restored in all patients; the rotator cuff was reparable in 11. In the 12 shoulders with greater than 1 year of follow-up (average 51 months, range 14 to 165 months), active elevation averaged 110 degrees and external rotation 50 degrees. Four patients had no pain, 4 had minimal pain, and the remaining 4 had moderate pain. Satisfactory final results, which were determined by the patients' opinion or with the use of either the University of California, Los Angeles score or the modified Neer system, were obtained in 5 (42%) of the shoulders.