Long-term outcome and structural integrity following open repair of massive rotator cuff tears

Background:

Surgical repair of massive rotator cuff tears is associated with less favorable clinical results and a higher retear rate than repair of smaller tears, which is attributed to irreversible degenerative changes of the musculotendinous unit.

Materials and Methods:

During the study period, 25 consecutive patients with a massive rotator cuff tear were enrolled in the study and the tears were repaired with an open suture anchor repair technique. Preoperative and postoperative clinical assessments were performed with the Constant score, the simple shoulder test (SST) and a pain visual analog scale (VAS). At the final follow-up, rotator cuff strength measurement was evaluated and assessment of tendon integrity, fatty degeneration and muscle atrophy was done using a standardized magnetic resonance imaging protocol.

Results:

The mean follow-up period was 70 months. The mean constant score improved significantly from 42.3 to 73.1 points at the final follow-up. Both the SST and the pain VAS improved significantly from 5.3 to 10.2 points and from 6.3 to 2.1, respectively. The overall retear rate was 44% after 6 years. Patients with an intact repair had better shoulder scores and rotator cuff strength than those with a failed repair, and also the retear group showed a significant clinical improvement (each P<0.05). Rotator cuff strength in all testing positions was significantly reduced for the operated compared to the contralateral shoulder. Muscle atrophy and fatty infiltration of the rotator cuff muscles did not recover in intact repairs, whereas both parameters progressed in retorn cuffs.

Conclusions:

Open repair of massive rotator tears achieved high patient satisfaction and a good clinical outcome at the long-term follow-up despite a high retear rate. Also, shoulders with retorn cuffs were significantly improved by the procedure. Muscle atrophy and fatty muscle degeneration could not be reversed after repair and rotator cuff strength still did not equal that of the contralateral shoulder after 6 years.

Level of evidence:

Level IV     

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.     

Deltoid detachment consequent to open surgical repair of massive rotator cuff tears

Deltoid detachment is one of the complications in open rotator cuff repair. Although it is often described, the actual prevalence, time at which it occurs and the predisposing causes are still unknown. We prospectively studied 112 patients with massive rotator cuff tears with a mean age of 67. The surgical approach was performed with a lateral para-acromial incision. Clinical assessment was performed with Constant's method. Of the 112 patients, 9 (8%) had deltoid detachment. It occurred about 3 months after surgery. Of the nine patients, two underwent revision surgery for the deltoid trans-bone reattachment. At the follow-up, the patients with deltoid detachment had a mean increase of only 5.5 points in the Constant score compared to that of 16.9 obtained by the control group. Deltoid reattachment, performed on the two patients, provided a mean increase of 7 points only with respect to the post-operative control at the 4th month. Considering the unsatisfactory functional result consequent to deltoid detachment and the slight improvement obtained with the reattachment, we recommend the following: use suture thread thicker than #2, do not use a simple stitch and avoid extending acromioplasty to the lateral margin of the acromion.     

Rotator cuff strength following open subscapularis tendon repair

The purpose of this study was to evaluate supraspinatus and subscapularis strength following repair of either isolated or anterosuperior subscapularis tears associated with a supraspinatus tear. Open subscapularis repairs were done in 24 patients, 12 isolated and 12 anterosuperior. At an average follow-up of 40 months, UCLA, ASES, and Constant scores were recorded. Subscapularis and supraspinatus strengths were tested using a spring gauge. Ultrasound scanning was performed in 20 patients. Average scores were 27 UCLA, 77 ASES and 90 relative Constant. Subscapularis strength was 92% of the non-operated shoulder. Supraspinatus strength was 90%. Statistical analysis showed a significant decrease in supraspinatus strength in the anterosuperior group. No other significant differences were noted. Ultrasound scanning showed an intact subscapularis tendon in all. Full thickness supraspinatus tears were found in 5 and partial thickness in 1. Not the subscapularis, but the supraspinatus determines the outcome of anterosuperior repairs, with more re-tears and decreased strength.     

Massive rotator cuff tears: the result of partial rotator cuff repair

Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P<.001). Active elevation improved from 114 degrees to 154 degrees , and no patient lost strength after surgery. The ability to raise the arm to at least 135 degrees improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears.     

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.     

Arthroscopic repair of partial-thickness tears of the rotator cuff

Management of partial-thickness tears of the rotator cuff should include consideration of tear size, tear depth, patient age and activity level, and tear etiology. We present an arthroscopic technique for repair of articular surface partial-thickness tears that may promote healing by closing the tendon side-to-side, placing the debrided tendon end in contact with an abraded humeral surface. By repairing selected partial-thickness tears, progression of the tear and the need for subsequent repair may be prevented. Our preliminary results in 28 patients are encouraging and suggest that this technique is a useful adjunct to tendon debridement for articular surface partial-thickness tears of the rotator cuff.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 219–223     

大型及巨大肩袖撕裂的肩关节镜下治疗

目的 探讨全关节镜下手术对大型及巨大肩袖撕裂进行治疗的手术技巧与临床疗效.方法 2004年3月至2008年9月对13例大型或巨大肩袖撕裂患者行肩关节镜下手术治疗,男3例,女10例;年龄45～72岁,平均58.3岁.4例有肩关节摔伤病史,3例有搬抬重物致伤史,其余患者无明显外伤史.肩关节疼痛、无力病史4个月～7年,平均10.6个月.关节镜下11例患者行肩峰成形术,8例行肩袖组织缝合锚修复,5例行单纯肩袖组织清理等.采用视觉模拟法(VAS)疼痛评分和加州大学洛杉矶分校(UCLA)肩关节功能评分进行疗效评估.结果 所有患者术后随访16～32个月,平均18.2个月.术前VAS评分为(6.6±1.3)分,末次随访时为(1.5±1.1)分.术前UCLA肩关节评分为(11.2±2.2)分,末次随访时为(29.5±2.2)分.术前与末次随访时各项评分差异均有统计学意义(P＜0.05).结论 肩关节镜下手术治疗大型及巨大肩袖撕裂是一种微创、有效、安全的治疗方式.     

Arthroscopic repair of partial-thickness tears of the rotator cuff

This study prospectively evaluated the clinical outcome of 41 patients who underwent arthroscopic repair of a significant (>50% thickness) partial-thickness supraspinatus tear. Tears were converted to full-thickness lesions and repaired with suture anchors and simple sutures. Of the tears, 80% (33/41) involved the articular surface. The mean age of the patients was 49 years (range, 23-70 years), and the mean follow-up was 38 months (range, 24-50 months). All patients had improvements in range of motion and strength. Postoperative isometric strength measurements revealed no significant difference between the operative and asymptomatic shoulder. Significant improvements were demonstrated for American Shoulder and Elbow Surgeons scores (from 42 to 93 points, P < .001), pain relief (from 6.5 to 0.8 points, P < .001), and satisfaction (from 3.0 to 9.2 points, P < .001). Of the 41 patients, 40 (98%) were satisfied with their outcome. This study documented the successful clinical outcome of arthroscopic repair of significant partial-thickness rotator cuff tears.     

Shoulder strength following surgical rotator cuff repair: a comparative analysis using isokinetic testing

Although previous studies have been conducted to ascertain the outcome of rotator cuff repair, the greatest majority have utilized subjective evaluation. The purpose of this study was to objectively compare the strength, as determined isokinetically, of the muscles around the shoulder complex a minimum of 1 year following surgical rotator cuff repair. Twenty-four subjects from two geographically separate university centers participated. Bilateral isokinetic comparisons were made of the subjects' ability to perform flexion/extension, abduction/adduction, and internal/external rotation. Paired t-tests were used to analyze the deficiencies encountered for the shoulder flexors, abductors, and external rotators, while the sign test was used to analyze the comparisons for the remaining movement patterns. Significant deficits were only found in the shoulder flexors and external rotators. All other movement patterns were not significant. It was interesting to note that although objective differences were found across the shoulders, no complaints or weakness were expressed by the patients. This is explained by a lessening of intensity among these elderly patients. J Orthop Sports Phys Ther 1992;15(5):215-222.