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Encalada-Diaz I, Cole BJ, MacGillivray JD, Ruiz-Suarez M, Kercher JS, Friel NA, Valero-Gonzalez F. Rotator cuff repair augmentation using a novel polycarbonate polyurethane patch: preliminary results at 12 months' follow-up. J Shoulder Elbow Surg 2011; 20:788-94. [PMID: 21106404 PMCID: PMC3872973 DOI: 10.1016/j.jse.2010.08.013] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 07/26/2010] [Accepted: 08/07/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preventing anatomic failure after rotator cuff repair (RCR) remains a challenge. Augmentation with a surgical mesh may permanently reinforce the repair and decrease failure rates. The purpose of this study is to assess the postoperative outcomes of open RCR augmented with a novel reticulated polycarbonate polyurethane patch. MATERIALS AND METHODS Ten patients with supraspinatus tendon tears underwent open RCR augmented with a polycarbonate polyurethane patch secured in a 6-point fixation construct placed over the repaired tendon. Patients were evaluated with preoperative and postoperative outcome measures, including the Simple Shoulder Test, visual analog pain scale, American Shoulder and Elbow Surgeons shoulder score, Cumulative Activities of Daily Living score, and University of California, Los Angeles shoulder scale, as well as range of motion. Postoperative magnetic resonance imaging was used to evaluate repair status. RESULTS Patients showed significant improvements in visual analog pain scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons shoulder scores at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). The University of California, Los Angeles postoperative score was good to excellent in 7 patients at 6 months and in 8 patients at 12 months. Range of motion in forward flexion, abduction, internal rotation, and external rotation was significantly improved at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). Magnetic resonance imaging at 12 months showed healing in 90%; one patient had a definitive persistent tear. We found no adverse events associated with the patch, including the absence of fibrosis, mechanical symptoms, or visible subacromial adhesions. DISCUSSION The polycarbonate polyurethane patch was designed to support tissue in growth and enhance healing as shown by preclinical animal studies. Clinically, the patch is well tolerated and shows promising efficacy, with a 10% retear rate at the 12-month time point.
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Affiliation(s)
- Ivan Encalada-Diaz
- Shoulder and Elbow Department, National Institute for Rehabilitation, Mexico City, Mexico
| | - Brian J. Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA,Reprint requests: Brian J. Cole, MD, MBA, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St, Ste 300, Chicago, IL 60612. (B.J. Cole)
| | | | - Michell Ruiz-Suarez
- Shoulder and Elbow Department, National Institute for Rehabilitation, Mexico City, Mexico
| | - James S. Kercher
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nicole A. Friel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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102
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Open repair for massive rotator cuff tear with a modified transosseous-equivalent procedure: preliminary results at short-term follow-up. J Orthop Sci 2011; 16:398-404. [PMID: 21584743 DOI: 10.1007/s00776-011-0092-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 04/15/2011] [Indexed: 02/09/2023]
Abstract
BACKGROUND Many surgical procedures have been reported for rotator cuff tears. We adopted the modified transosseous-equivalent procedure, also termed "surface-holding repair with transosseous sutures," and demonstrated that this procedure has a biomechanical advantage regarding the concentration of stress on the tendon stump. This study aimed to evaluate the clinical and structural outcomes of this technique, which has been demonstrated by postoperative magnetic resonance imaging (MRI) to produce high intact rates. METHODS Twenty-nine massive rotator cuff tears involving at least two tendons were treated by open repair using this procedure. Twenty-four patients were evaluated at an average of 43.2 months (range 24-71) postoperatively (the follow-up rate was 83.8%). The pre- and postoperative clinical outcomes were examined using the scoring system of the Japanese Orthopedic Association (JOA score). In an A-P radiograph, the presence of osteoarthritis (OA) of the glenohumeral joint and upward migration of the humeral head were compared pre- and postoperatively. The repair integrity of the cuff tendon was evaluated by applying Sugaya's classification to the postoperative MRIs. RESULTS The JOA score improved from 42.8 points preoperatively to 89.3 points at final follow-up. Radiographic examination showed that OA progressed in 16.7% and upward migration of the humeral head progressed in 20.8%. Postoperative MRI scans revealed 14 shoulders with type 1 repair based on Sugaya's classification, 4 shoulders with type 2, 4 shoulders with type 3, 2 shoulders with type 4, and no shoulders with a type 5 repair. CONCLUSIONS Although osteoarthritis of the glenohumeral joint and upward migration of the humeral head had both progressed postoperatively in some cases, postoperative MRI scans revealed that 91.7% of the repairs resulted in a continuous rotator cuff. Therefore, this technique produces a high healing rate.
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Toussaint B, Schnaser E, Bosley J, Lefebvre Y, Gobezie R. Early structural and functional outcomes for arthroscopic double-row transosseous-equivalent rotator cuff repair. Am J Sports Med 2011; 39:1217-25. [PMID: 21427446 DOI: 10.1177/0363546510397725] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair is growing in popularity. The current body of literature supports this technique; however, the number of patients in these studies is relatively small. The authors conducted this study to learn more about the natural history of this construct in a large sample of patients. HYPOTHESIS The double-row TOE rotator cuff repair will have an acceptable structural failure rate with improved clinical outcomes at 1-year follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between June 2006 and October 2007, 225 patients underwent an all-arthroscopic rotator cuff repair at 2 surgical centers. A total of 155 TOE primary rotator cuff repairs were performed, and 154 of these patients met the inclusion criteria. Assessment of structural integrity was based on evaluation of postoperative magnetic resonance imaging or computed tomography arthrogram at a minimum of 12 months after surgery. The Constant scores, visual analog pain scale, range of motion, strength, and complications were the clinical outcomes analyzed for the study. Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. RESULTS The 154 patients were clinically and radiologically evaluated at a mean of 15 months postoperatively (range, 12-26.1 months). The study included 47 small (30.5%), 89 large (57.1%), and 19 massive (12.3%) rotator cuff tears. Analysis of postoperative imaging demonstrated that 92%, 83%, and 84% of the small, large, and massive rotator cuff tears, respectively, were intact. The mean Constant score improved from 44.42 points preoperatively to 80.47 points postoperatively (P < .001). The mean preoperative pain score improved from 3.83 to 12.77 (P < .001) postoperatively. The mean forward flexion improved from 123.06° preoperatively to 162.39° postoperatively (P < .001). Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. CONCLUSION The short-term results of this study indicate that the clinical outcomes and structural integrity of TOE double-row rotator cuff repair (the suture-bridge technique) have results that compare favorably with those reported for other double-row suture anchor techniques employed in rotator cuff repairs. Long-term follow-up will be necessary to determine if the durability of these repairs and the structural integrity of these constructs maintain their performance over time.
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Affiliation(s)
- Bruno Toussaint
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, OH 44106, USA
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104
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Gulotta LV, Kovacevic D, Packer JD, Deng XH, Rodeo SA. Bone marrow-derived mesenchymal stem cells transduced with scleraxis improve rotator cuff healing in a rat model. Am J Sports Med 2011; 39:1282-9. [PMID: 21335341 DOI: 10.1177/0363546510395485] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuffs heal through a scar tissue interface after repair that makes them prone to failure. Scleraxis (Scx) is a basic helix-loop-helix transcription factor that is thought to direct tendon development during embryogenesis. The purpose of this study was to determine if the application of mesenchymal stem cells (MSCs) transduced with adenoviral-mediated scleraxis (Ad-Scx) could improve regeneration of the tendon-bone insertion site in a rat rotator cuff repair model. HYPOTHESIS Bone marrow-derived cells transduced with Scx would improve the structure of the healing tendon-bone interface and result in increased tendon attachment strength. STUDY DESIGN Controlled laboratory study. METHODS Sixty Lewis rats underwent unilateral detachment and repair of the supraspinatus tendon. Thirty animals received MSCs in a fibrin glue carrier, and 30 received Ad-Scx-transduced MSCs. Animals were sacrificed at 2 weeks and 4 weeks and evaluated for the presence of fibrocartilage and collagen fiber organization at the insertion. Biomechanical testing was performed to determine the structural and material properties of the repaired tissue. Statistical analysis was performed with a Wilcoxon rank sum test with significance set at P = .05. RESULTS There were no differences between the Scx and MSC groups in terms of histologic appearance at 2 weeks. However, the Scx group had higher ultimate stress-to-failure (2.6 ± 0.9 vs 1.7 ± 0.3 MPa; P = .03) and stiffness (8.4 ± 2.9 vs 5.0 ± 1.9 N/mm; P = .01) compared with the MSC group. At 4 weeks, the Scx group had more fibrocartilage (728.7 ± 50.4 vs 342.6 ± 217.0 mm(2); P = .04), higher ultimate load to failure (26.7 ± 4.6 vs 20.8 ± 4.4 N; P = .01), higher ultimate stress to failure (4.7 ± 1.3 vs 3.5 ± 1.0 MPa; P < .04), and higher stiffness values (15.3 ± 3.4 vs 9.3 ± 2.2 N/mm; P < .001) as compared with the MSC group. CONCLUSION Mesenchymal stem cells genetically modified with Scx can augment rotator cuff healing at early time points. CLINICAL RELEVANCE Biologic augmentation of acutely injured rotator cuffs with Scx-transduced MSCs may improve rotator cuff tendon healing and reduce the incidence of re-tears. However, further studies are needed to determine if this remains safe and effective in larger models.
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105
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Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011; 20:518-28. [PMID: 21570659 DOI: 10.1016/j.jse.2011.02.008] [Citation(s) in RCA: 327] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/15/2011] [Indexed: 02/06/2023]
Abstract
HYPOTHESIS Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. STUDY DESIGN Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. MATERIALS AND METHODS Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. RESULTS The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). CONCLUSION The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.
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106
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Koh KH, Kang KC, Lim TK, Shon MS, Yoo JC. Prospective randomized clinical trial of single- versus double-row suture anchor repair in 2- to 4-cm rotator cuff tears: clinical and magnetic resonance imaging results. Arthroscopy 2011; 27:453-62. [PMID: 21444007 DOI: 10.1016/j.arthro.2010.11.059] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 11/18/2010] [Accepted: 11/18/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to compare the clinical outcomes and the retear rates of arthroscopic single-row (SR) and double-row (DR) suture anchor repair in 2- to 4-cm rotator cuff tears. METHODS From 2005 to 2007, 71 patients with a 2- to 4-cm rotator cuff tear (proven by arthroscopy) were prospectively randomized to SR and DR repair groups. Of these patients, 62 (31 in each group) were available for evaluation at final follow-up. Demographic data, clinical scores, mean surgical times, and patient satisfaction were compared. Retear rates and clinical scores were also analyzed for 47 patients who underwent follow-up magnetic resonance imaging. RESULTS Comparisons of demographic data, tear size on preoperative magnetic resonance imaging, global fatty degeneration index, and concomitant procedures showed no differences between the SR and DR groups. Preoperative clinical scores were significantly improved postoperatively in both groups. No intergroup differences in pain visual analog scale, American Shoulder and Elbow Surgeons, Constant, or University of California, Los Angeles scores were found at final follow-up. Only mean surgical time was significantly different between the 2 groups. In the SR group, there were 4 full-thickness retears and 11 partial-thickness retears, whereas in the DR group, there were 6 full-thickness retears and 1 partial-thickness retear. However, despite numerical differences, these differences were not statistically different. Statistically, there were no significant differences both in full-thickness retear (P = .999) and retear including partial-thickness tear between the 2 groups (P = .124). CONCLUSIONS This study indicates that the clinical results and retear rates of DR repair with 1 additional medial suture anchor were not significantly different from those of SR repairs with 2 lateral suture anchors in patients with medium to large rotator cuff tear. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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107
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Abstract
When designing a study, it is important to select appropriate instruments to measure health outcomes. An investigator must have a comprehensive understanding of the disease and its effects on patient health to inform instrument selection. We provide a brief introduction of different ways that health is defined and the properties of a good measurement tool (reliability, validity, sensitivity to change). We describe patient-reported outcomes (PROs) and methods to improve their interpretability, and we include strategies to reduce bias in health measurement and considerations that may improve the feasibility of measuring outcomes in a research study.
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108
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Kowalsky MS, Keener JD. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome: surgical technique. J Bone Joint Surg Am 2011; 93 Suppl 1:62-74. [PMID: 21411687 DOI: 10.2106/jbjs.j.01173] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Literature regarding the outcomes of revision rotator cuff repair is limited. The purposes of the present study were to report the tendon repair integrity and clinical outcomes for a cohort of patients following revision arthroscopic rotator cuff repair and to examine factors related to tendon healing and the influence of healing on clinical outcomes. METHODS Twenty-one of twenty-nine consecutive revision arthroscopic rotator cuff repairs with a minimum of two years of postoperative follow-up were retrospectively reviewed. Outcomes were evaluated on the basis of a visual analog pain scale, the range of motion of the shoulder, the Simple Shoulder Test, the American Shoulder and Elbow Surgeons score, and the Constant score. Ultrasonography was used to examine repair integrity at a minimum of one year following surgery. Ten shoulders underwent arthroscopic repair of a recurrent single-tendon posterior rotator cuff tear, whereas eleven shoulders had repair of both the supraspinatus and infraspinatus. RESULTS The mean age of the twenty-one subjects was 55.6 years; thirteen subjects were male and eight were female. Complete preoperative and postoperative clinical data were available for nineteen subjects after an average duration of follow-up of thirty-three months. Significant improvements were seen in terms of postoperative pain (p < 0.05), the Simple Shoulder Test score (p < 0.05), the American Shoulder and Elbow Surgeons function (p < 0.05) and total scores (p < 0.05), active forward elevation (p < 0.05), and active external rotation (p < 0.05). Postoperative ultrasound data were available for all twenty-one shoulders after a mean duration of follow-up of twenty-five months. Ten (48%) of the twenty-one shoulders had an intact repair. Seven (70%) of the ten single-tendon repairs were intact, compared with three (27%) of the eleven supraspinatus/infraspinatus repairs (p = 0.05). Patient age (p < 0.05) and the number of torn tendons (p = 0.05) had significant effects on postoperative tendon repair integrity. Shoulders with an intact repair had better postoperative Constant scores (p < 0.05) and scapular plane elevation strength (p < 0.05) in comparison with those with a recurrent tear. CONCLUSIONS Revision arthroscopic rotator cuff repair results in reliable pain relief and improvement in shoulder function in selected cases. Approximately half of the revision repairs can be expected to be intact at a minimum of one year following surgery. Patient age and the number of torn tendons are related to postoperative tendon integrity. The postoperative integrity of the rotator cuff can have a significant influence on shoulder abduction strength and the Constant score.
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Affiliation(s)
- Marc S Kowalsky
- Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri 63110, USA
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109
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Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: a 3-5 year follow-up study. J Shoulder Elbow Surg 2011; 20:131-7. [PMID: 20621524 DOI: 10.1016/j.jse.2010.05.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 05/14/2010] [Accepted: 05/25/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mini-open approach has been considered for years the gold standard for rotator cuff repairs. Nevertheless, the rate of tendon-to-bone healing, and that of cuff re-tear, still remains unclear. METHODS Between 2001 and 2004, 37 shoulders (32 patients) with a mean age of 54.8 years (range, 34-72) and a large or massive cuff tear were repaired with a mini-open procedure. At a minimum of 3 years postoperatively (range, 36-60 months), 27 shoulders (23 patients) underwent functional evaluation and US investigation of cuff integrity. RESULTS The rotator cuff was completely healed and watertight in 13 cases (48.1%), while recurrent defects were detected in the remaining 14 shoulders (51.9%). In 12 cases (92.5%), the recurrent tears were smaller and in 2 (7.5%) larger than the initial tear. Despite the high re-tear rate, the overall Constant and UCLA scores improved from of 38.4 to 72.1 and 11.2 to 29.4, respectively. However, only "large" re-tears were correlated with a worse functional outcome (P < .005). The preoperative tear size was negatively associated with tendon healing. Patients with an intact rotator cuff repair were, on average, 15 years younger (49.9) than those who sustained a tear recurrence (64.14) (P < .005). DISCUSSION Our results suggest that large and massive rotator cuff tears treated with mini-open technique using a tendon-grasping suture have a very satisfactory clinical outcome, despite a significant re-tear rate. Patient age, the size of the initial tear, as well as the size of a potential re-tear are factors affecting the final clinical outcome.
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110
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El-Azab H, Buchmann S, Beitzel K, Waldt S, Imhoff AB. Clinical and structural evaluation of arthroscopic double-row suture-bridge rotator cuff repair: early results of a novel technique. Knee Surg Sports Traumatol Arthrosc 2010; 18:1730-7. [PMID: 20824269 DOI: 10.1007/s00167-010-1257-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 08/16/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE Assessment of repair integrity and clinical outcome after arthroscopic repair of rotator cuff tears in double-row suture-bridge technique with the use of a new knotless suture-anchor system. METHODS The first treated 25 patients with arthroscopic rotator cuff repair in the suture-bridge technique using a novel knotless anchor and chain-link suture system were evaluated. Patients with isolated full-thickness supraspinatus tears were selected. They were followed clinically with functional scores (Constant score, ASES index), visual analog scale (VAS), and instrumentally with Isobex digital strength analyzer preoperatively, at 6 and 14 months postoperatively. The repair integrity was evaluated with MRI at an average of 14 months postoperatively. RESULTS Significant improvement of pain, strength, range of motion, and functional scores occurred (P < 0.05). There was a re-tear rate of 20%. The subjective parameters (VAS and ASES Index) showed non-significant (n.s.) differences between the re-tear and intact repair groups, whereas the objective parameters (Constant score, muscle power and active ROM) showed significant differences between both groups (P < 0.05). CONCLUSION The functional outcome has improved significantly with this new knotless anchor-chain system and was more superior in shoulders with intact repair, whereas the resulted repair integrity was not better than other types of double-row repair techniques mentioned in the recent literature. However, this early report of the novel technique may show limited power for comparison due to the relatively small sample size.
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Affiliation(s)
- H El-Azab
- Department of Orthopaedic Sports Medicine, Technical University Munich, Connolly Street 32, 80809 Munich, Germany
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111
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Temporal Evolution of MRI Findings After Arthroscopic Rotator Cuff Repair. AJR Am J Roentgenol 2010; 195:1361-6. [DOI: 10.2214/ajr.10.4436] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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112
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Funakoshi T, Iwasaki N, Kamishima T, Nishida M, Ito Y, Kondo M, Minami A. In vivo visualization of vascular patterns of rotator cuff tears using contrast-enhanced ultrasound. Am J Sports Med 2010; 38:2464-71. [PMID: 20829415 DOI: 10.1177/0363546510375536] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hypoxia and decreased blood supply have been proposed as risks for tendon rupture. Visualization of the vascularity of intact and torn rotator cuffs would be useful for improving treatments for rotator cuff tear. PURPOSE To assess vascularity inside a tendon or an adjacent rotator cuff insertion point in patients differing in age and extent of damage to the tendon. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Ten volunteers (all men) and 15 patients (10 men, 5 women) consented to participate in the study. Contrast agent for enhanced ultrasound was injected intravenously. Enhanced ultrasound images of the torn cuff and the contralateral shoulder were recorded for 1 minute. Four small regions of interest, the articular and bursal sides of the tendon and the medial and lateral sides of the bursa, were studied in all shoulders. RESULTS There was a significant decrease in blood flow in the intratendinous region in elderly subjects compared with young subjects, but age had no effect on blood flow in bursal tissue. Blood flow in ruptured rotator cuffs did not differ from that in intact rotator cuffs. The intraclass correlation coefficient for intraobserver reproducibility was 0.82 (95% confidence interval: 0.77-0.86). CONCLUSIONS The findings of this investigation were the hypovascular pattern in intratendinous tissue compared with the subacromial bursa, the age-related decrease in intratendinous vascularity, and the hypovascular pattern in the tendon, regardless of rupture of the tendon. Clarification of vascular patterns inside or around the torn ends of a rotator cuff will assist in the development of successful treatments for torn rotator cuffs.
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Affiliation(s)
- Tadanao Funakoshi
- Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Japan.
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113
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Mazzocca AD, McCarthy MBR, Chowaniec DM, Cote MP, Arciero RA, Drissi H. Rapid isolation of human stem cells (connective tissue progenitor cells) from the proximal humerus during arthroscopic rotator cuff surgery. Am J Sports Med 2010; 38:1438-47. [PMID: 20375368 DOI: 10.1177/0363546509360924] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone-to-tendon healing in the shoulder can be unpredictable. Biologic augmentation, through the implementation of adult mesenchymal stem cells, may improve this healing process. PURPOSE The purpose of this study was to (1) arthroscopically obtain bone marrow aspirates from the proximal humerus during rotator cuff repair, (2) purify and concentrate the connective tissue progenitor cells (CTPs) in the operating room efficiently, and (3)confirm these are stem cells through their ability to differentiate into bone cells. We hypothesize that CTPs can be quickly and efficiently isolated from bone marrow during arthroscopic surgery and that these cells are capable of osteogenesis. STUDY DESIGN Cohort study; Level of evidence, 3; and Descriptive laboratory study. METHODS Bone marrow aspirates were harvested through the anchor tunnel of the humeral head during arthroscopic rotator cuff repair in 23 patients. Twenty-three matched controls were selected from a clinical registry to evaluate for increased incidence of complication. Connective tissue progenitor cells were isolated using 2 accepted methods and compared with a novel, rapid method designed for use in the operating room. Osteogenic potential was assessed by cytochemical and molecular analysis. RESULTS Reverse transcription polymerase chain reaction analysis and cellular staining confirmed the osteogenic potential of these CTPs. There was no statistical significant difference in the Single Assessment Numeric Evaluation score (aspirate, 86.3 +/- 10.5; control, 83.6 +/- 15.1; P = .54), range of motion measures (postoperative external rotation: aspirate, 65.0 degrees +/- 20.4 degrees ; control, 62.5 degrees +/- 17.1 degrees ; P = .67; postoperative forward elevation: aspirate, 163.0 degrees +/- 30.6 degrees ; control, 145.7 degrees +/- 41.4 degrees ; P = .12), or postoperative strength measures between groups (median, 5; range, 4-5 in the aspirate group compared with median, 5; range, 4-5 in the control group; P > .05). CONCLUSION Connective tissue progenitor cells can be safely and efficiently aspirated from the proximal humerus using the anchor tunnel created during arthroscopic rotator cuff surgery. These cells may play an important role in cell-based therapies involving rotator cuff repair. CLINICAL RELEVANCE We have established a reliable, reproducible protocol for isolating CTPs in the operating room. These cells may have the potential to enhance the healing process after rotator cuff repair.
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Affiliation(s)
- Augustus D Mazzocca
- University of Connecticut, Department of Orthopaedic Surgery, Farmington, CT 06034, USA.
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114
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Gulotta LV, Kovacevic D, Montgomery S, Ehteshami JR, Packer JD, Rodeo SA. Stem cells genetically modified with the developmental gene MT1-MMP improve regeneration of the supraspinatus tendon-to-bone insertion site. Am J Sports Med 2010; 38:1429-37. [PMID: 20400753 DOI: 10.1177/0363546510361235] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuffs heal through a scar tissue interface after repair, which makes them prone to failure. Membrane type 1 matrix metalloproteinase (MT1-MMP) is upregulated during embryogenesis in areas that develop into tendon-bone insertion sites. HYPOTHESIS Bone marrow-derived stem cells in the presence of the developmental signal from MT1-MMP will drive the healing process toward regeneration and away from scar formation. STUDY DESIGN Controlled laboratory study. METHODS Sixty Lewis rats underwent unilateral detachment and repair of the supraspinatus tendon. Thirty animals received mesenchymal stem cells (MSCs) in a fibrin glue carrier, and 30 received adenoviral MT1-MMP (Ad-MT1-MMP)-transduced MSCs. Animals were sacrificed at 2 weeks and 4 weeks and evaluated for the presence of fibrocartilage and collagen fiber organization at the insertion. Biomechanical testing was performed to determine the structural and material properties of the repaired tissue. Statistical analysis was performed with a Wilcoxon rank-sum test with significance set at P = .05. RESULTS There were no differences between the Ad-MT1-MMP and MSC groups in any outcome variable at 2 weeks. At 4 weeks, the Ad-MT1-MMP group had more fibrocartilage (P = .05), higher ultimate load to failure (P = .01), higher ultimate stress to failure (P = .005), and higher stiffness values (P = .02) as compared with the MSC group. CONCLUSION Mesenchymal stem cells genetically modified to overexpress the developmental gene MT1-MMP can augment rotator cuff healing at 4 weeks by the presence of more fibrocartilage at the insertion and improved biomechanical strength. CLINICAL RELEVANCE Biologic augmentation of repaired rotator cuffs with MT1-MMP-transduced MSCs may reduce the incidence of retears. However, further studies are needed to determine if this remains safe and effective in larger models.
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Affiliation(s)
- Lawrence V Gulotta
- Hospital for Special Surgery, Sports Medicine/Shoulder Service, 535 E 70th Street, New York, NY 10021, USA.
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Yi JW, Cho NS, Cho SH, Rhee YG. Arthroscopic suture bridge repair technique for full thickness rotator cuff tear. Clin Orthop Surg 2010; 2:105-11. [PMID: 20514268 PMCID: PMC2867195 DOI: 10.4055/cios.2010.2.2.105] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 05/12/2009] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of our study is to evaluate the clinical results of arthroscopic suture bridge repair for patients with rotator cuff tears. Methods Between January 2007 and July 2007, fifty-one shoulders underwent arthroscopic suture bridge repair for full thickness rotator cuff tears. The average age at the time of surgery was 57.1 years old, and the mean follow-up period was 15.4 months. Results At the last follow-up, the pain at rest improved from 2.2 preoperatively to 0.23 postoperatively and the pain during motion improved from 6.3 preoperatively to 1.8 postoperatively (p < 0.001 and p < 0.001, respectively). The range of active forward flexion improved from 138.4° to 154.6°, and the muscle power improved from 4.9 kg to 6.0 kg (p = 0.04 and 0.019, respectively). The clinical results showed no significant difference according to the preoperative tear size and the extent of fatty degeneration, but imaging study showed a statistical relation between retear and fatty degeneration. The average Constant score improved from 73.2 to 83.79, and the average University of California at Los Angeles score changed from 18.2 to 29.6 with 7 excellent, 41 good and 3 poor results (p < 0.001 and p = 0.003, respectively). Conclusions The arthroscopic suture bridge repair technique for rotator cuff tears may be an operative method for which a patient can expect to achieve clinical improvement regardless of the preoperative tear size and the extent of fatty degeneration.
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Affiliation(s)
- Jin Woong Yi
- Department of Orthopaedic Surgery, Konyang University College of Medicine, Daejeon, Korea
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Mazzocca AD, Bollier MJ, Ciminiello AM, Obopilwe E, DeAngelis JP, Burkhart SS, Warren RF, Arciero RA. Biomechanical evaluation of arthroscopic rotator cuff repairs over time. Arthroscopy 2010; 26:592-9. [PMID: 20434655 DOI: 10.1016/j.arthro.2010.02.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 02/19/2010] [Accepted: 02/19/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to assess the contact pressure, force, and area over time for 4 common arthroscopic rotator cuff repair techniques. METHODS The transosseous-equivalent, single-row, triangle double-row, and suture-chain transosseous repair techniques were used to repair a full-thickness tear of the supraspinatus in 16 cadaveric shoulders. Continuous data points were collected immediately after repair and for 160 minutes at set time intervals by use of a custom thin film pressure sensor. RESULTS Each of the 4 rotator cuff repair techniques showed decreased contact force, pressure, and area 160 minutes after the repair was performed. The transosseous-equivalent construct had the highest contact pressure and force initially and at all time points up to 160 minutes. Although the 3 double-row constructs had greater pressure and force at all time points compared with the single-row repair, only the transosseous-equivalent group showed a statistically greater pressure and force when compared with single-row repair (P < .05). CONCLUSIONS Contact pressure, force, and pressurized footprint area decrease 160 minutes after repair regardless of repair technique. The transosseous-equivalent group had the highest contact pressure and force at all time points. CLINICAL RELEVANCE The decrease in contact pressure and force after rotator cuff repair may have important implications in evaluating tendon-to-bone healing and determining the optimal rehabilitation protocol.
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Affiliation(s)
- Augustus D Mazzocca
- University of Connecticut Medical Center, Farmington, Connecticut 06030, USA
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117
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Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med 2010; 38:664-71. [PMID: 20040768 DOI: 10.1177/0363546509350081] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A subset of patients is often seen with an unusual pattern of tendon failure after arthroscopic rotator cuff repair using a suture bridge technique. PURPOSE To evaluate retear patterns in cases with structural failure after arthroscopic primary repairs of rotator cuff tears. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Forty-six cases revealing retear on magnetic resonance imaging performed at least 6 months after arthroscopic repair for the treatment of full-thickness rotator cuff tear were evaluated. A single-row technique had been performed in 19 cases and a suture bridge in 27 cases. According to retear patterns on postoperative magnetic resonance imaging, cases were divided into type 1 (cuff tissue repaired at the insertion site of rotator cuff was not observed remaining on the greater tuberosity) and type 2 (remnant cuff tissue remained at the insertion site in spite of retear). RESULTS In the single-row group, 14 cases (73.7%) had type 1 and 5 cases (26.3%) type 2 retear. In the suture bridge group, 7 cases (25.9%) had type 1 and 20 cases (74.1%) type 2. There were statistically significant differences between groups (P = .049). Extent of fatty degeneration of the rotator cuff did not affect retear patterns in the single-row group (P = .160). In the suture bridge group, the percentage of type 1 retear increased with severity of fatty degeneration (P = .030). Extent of muscle atrophy did not affect retear patterns of the single-row group; in the suture bridge group, the percentage of type 1 retear increased with severity of muscle atrophy (P = .904 vs .029). CONCLUSION The suture bridge technique tended to better preserve the cuff tissue repaired to the insertion site of the rotator cuff than a single-row technique did; the retear in cases with a suture bridge technique was mainly in the musculotendinous junction. Direct retear at the footprint of the rotator cuff increased with severity of fatty degeneration or muscle atrophy in cases with a suture bridge technique.
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Affiliation(s)
- Nam Su Cho
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Dongdaemun-gu, Seoul 130-702, Korea.
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Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med 2010; 38:835-41. [PMID: 20357403 DOI: 10.1177/0363546509359679] [Citation(s) in RCA: 257] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery. HYPOTHESES We hypothesized that (1) the rotator cuff repair method will not affect retear rate, and (2) the surgical approach will not affect the retear rate for a given repair method. STUDY DESIGN Systematic review of the literature. METHODS The literature was systematically searched to find articles reporting imaging study assessment of structural healing rates after rotator cuff repair, with data stratified according to tear size. Retear rates were compared for transosseous (TO), single-row suture anchor (SA), double-row suture anchor (DA), and suture bridge (SB) repair methods, as well as for open (O), miniopen (MO), and arthroscopic (A) approaches. RESULTS Retear rates were available for 1252 repairs collected from 23 studies. Retear rates were significantly lower for double-row repairs when compared with TO or SA for all tears greater than 1 cm and ranged from 7% for tears less than 1 cm to 41% for tears greater than 5 cm, in comparison with retear rates for single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than 5 cm, respectively. There was no significant difference in retear rates between TO and SA repair methods or between arthroscopic and nonarthroscopic approaches for any tear size. CONCLUSION Double-row repair methods lead to significantly lower retear rates when compared with single-row methods for tears greater than 1 cm. Surgical approach has no significant effect on retear rate.
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Affiliation(s)
- Thomas R Duquin
- Department of Orthopaedic Surgery, University at Buffalo, Buffalo, NY, USA
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Slabaugh MA, Nho SJ, Grumet RC, Wilson JB, Seroyer ST, Frank RM, Romeo AA, Provencher MT, Verma NN. Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair? Arthroscopy 2010; 26:393-403. [PMID: 20206051 DOI: 10.1016/j.arthro.2009.07.023] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 07/19/2009] [Accepted: 07/28/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. METHODS Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. RESULTS Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. CONCLUSIONS The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. LEVEL OF EVIDENCE Level IV, systematic review.
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Affiliation(s)
- Mark A Slabaugh
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois 60612, USA
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Keener JD, Wei AS, Kim HM, Paxton ES, Teefey SA, Galatz LM, Yamaguchi K. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome. J Bone Joint Surg Am 2010; 92:590-8. [PMID: 20194317 DOI: 10.2106/jbjs.i.00267] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Literature regarding the outcomes of revision rotator cuff repair is limited. The purposes of the present study were to report the tendon repair integrity and clinical outcomes for a cohort of patients following revision arthroscopic rotator cuff repair and to examine factors related to tendon healing and the influence of healing on clinical outcomes. METHODS Twenty-one of twenty-nine consecutive revision arthroscopic rotator cuff repairs with a minimum of two years of postoperative follow-up were retrospectively reviewed. Outcomes were evaluated on the basis of a visual analog pain scale, the range of motion of the shoulder, the Simple Shoulder Test, the American Shoulder and Elbow Surgeons score, and the Constant score. Ultrasonography was used to examine repair integrity at a minimum of one year following surgery. Ten shoulders underwent arthroscopic repair of a recurrent single-tendon posterior rotator cuff tear, whereas eleven shoulders had repair of both the supraspinatus and infraspinatus. RESULTS The mean age of the twenty-one subjects was 55.6 years; thirteen subjects were male and eight were female. Complete preoperative and postoperative clinical data were available for nineteen subjects after an average duration of follow-up of thirty-three months. Significant improvements were seen in terms of postoperative pain (p < 0.05), the Simple Shoulder Test score (p < 0.05), the American Shoulder and Elbow Surgeons function (p < 0.05) and total scores (p < 0.05), active forward elevation (p < 0.05), and active external rotation (p < 0.05). Postoperative ultrasound data were available for all twenty-one shoulders after a mean duration of follow-up of twenty-five months. Ten (48%) of the twenty-one shoulders had an intact repair. Seven (70%) of the ten single-tendon repairs were intact, compared with three (27%) of the eleven supraspinatus/infraspinatus repairs (p = 0.05). Patient age (p < 0.05) and the number of torn tendons (p = 0.05) had significant effects on postoperative tendon repair integrity. Shoulders with an intact repair had better postoperative Constant scores (p < 0.05) and scapular plane elevation strength (p < 0.05) in comparison with those with a recurrent tear. CONCLUSIONS Revision arthroscopic rotator cuff repair results in reliable pain relief and improvement in shoulder function in selected cases. Approximately half of the revision repairs can be expected to be intact at a minimum of one year following surgery. Patient age and the number of torn tendons are related to postoperative tendon integrity. The postoperative integrity of the rotator cuff can have a significant influence on shoulder abduction strength and the Constant score.
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Affiliation(s)
- Jay D Keener
- Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington University, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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Vaishnav S, Millett PJ. Arthroscopic rotator cuff repair: scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system. J Shoulder Elbow Surg 2010; 19:83-90. [PMID: 20188272 DOI: 10.1016/j.jse.2009.12.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/21/2009] [Accepted: 12/27/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotator cuff repair has shown to improve shoulder function and reduce pain experienced by patients. Successful repairs should have high fixation strength, allow minimal gap formation, maintain stability, and restore normal anatomy and function of the supraspinatus footprint. The purpose of this study is to describe our preferred method for rotator cuff repair using a knotless self-reinforcing double-row system, and to cite biomechanical data rationalizing its use. METHODS AND MATERIAL Seventeen of 22 patients were identified as undergoing primary rotator cuff repair with minimum follow-up of 1 year (mean, 535 days; range, 370-939). The average age was 63 (range, 43-79). Data collected included average pain today, average worst pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction. RESULTS For all patients, average pain today and average worst pain decreased and functional scores (SANE) increased. Patient satisfaction was 9.8 out of 10 (range, 7-9). The patients also began rehabilitation earlier and returned to full activities at 4 months. CONCLUSION These results indicate that the knotless self-reinforcing double-row repair system is a viable option in treating rotator cuff tears. This system provides improved contact area and restores the native footprint of the tendon leading to better outcomes.
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123
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Dodson CC, Kitay A, Verma NN, Adler RS, Nguyen J, Cordasco FA, Altchek DW. The long-term outcome of recurrent defects after rotator cuff repair. Am J Sports Med 2010; 38:35-9. [PMID: 19752204 DOI: 10.1177/0363546509341654] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Retears of the rotator cuff are not uncommon after arthroscopic and mini-open rotator cuff repairs. In most studies, the clinical results in patients with persistent defects demonstrated significantly less pain and better function and strength compared with their preoperative state at an early follow-up. HYPOTHESIS The clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS This study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L'Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound. RESULTS At the 7.9 year follow-up the average scores were 95 (American Shoulder and Elbow Surgeons), 95 (L'Insalata), 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (P < .001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm(2) to 467 mm(2) (P < .001). Finally, the size of the defect increased in all patients, and no defects healed structurally. CONCLUSION At an average of 7.9 years, patients with recurrent defects after rotator cuff repair still had an improvement in terms of pain, function, and satisfaction. However, the rotator cuff defect significantly increased in size, and there was a progression of strength deficits. These findings suggest that patients with recurrent defects can remain asymptomatic over the long term but will predictably lose strength in the involved extremity. Furthermore, the study demonstrated that defects after rotator cuff repair increase in size but often remain asymptomatic.
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Affiliation(s)
- Christopher C Dodson
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY 10021, USA.
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Jo CH, Kim JK, Yoon KS, Lee JH, Kang SB, Lee JH, Han HS, Rhee SW. Clinical Outcomes After Arthroscopic Double-Row Rotator Cuff Repair and Evaluation of Cuff Integrity by CT Arthrography. Clin Shoulder Elb 2009. [DOI: 10.5397/cise.2009.12.2.199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Gumina S, Patti AM, Vulcano A, Della Rocca C, Postacchini F. Culture of human rotator cuff cells on orthobiologic support (porcine small intestinal submucosa). Musculoskelet Surg 2009; 93 Suppl 1:S65-70. [PMID: 19711172 DOI: 10.1007/s12306-009-0005-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Outcomes obtained in patients with two-tendon rotator cuff tear submitted to repair reinforced with porcine small intestinal submucosa (SIS) have not been as encouraging as those observed in animal models. We verify the capacity of SIS to be used as a physical support for a culture of cuff cells. During arthroscopic repairs of large rotator cuff tears, we removed a fragment of supraspinatus tendon. Samples were treated for obtaining a cuff cell culture. Daily microscopic analysis, to observe adhesion to substrate, replication and cell shape was performed. A confluent monolayer was obtained in 1 week. Cells at the second passage were collected and seeded onto scaffold and cultured for 7-30 days. A morphological and immunohistochemical evaluation was performed. After 1 week, a monolayer of tendinous-like cells lay along the surface of the SIS. Within two weeks, a multicellular layer was observable in many foci of the scaffold. After a month, the cells completely invaded the numerous splits of the SIS and were positive to monoclonal anti-type I collagen antibody. Our experimental study has proved that a cuff cell culture can be performed using SIS as substrate. The culture covers the SIS surface, therefore it may reduce immune or non-specific inflammatory reactions.
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Affiliation(s)
- Stefano Gumina
- Department of Orthopaedic Surgery, University La Sapienza, Piazzale A. Moro 6, 00185, Rome, Italy.
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Gulotta LV, Kovacevic D, Ehteshami JR, Dagher E, Packer JD, Rodeo SA. Application of bone marrow-derived mesenchymal stem cells in a rotator cuff repair model. Am J Sports Med 2009; 37:2126-33. [PMID: 19684297 DOI: 10.1177/0363546509339582] [Citation(s) in RCA: 222] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tendons heal to bone with interposed scar tissue, which makes repairs prone to failure. The purpose of this study was to determine if the application of bone marrow-derived mesenchymal stem cells (MSCs) can improve rotator cuff healing after repair. HYPOTHESIS Application of MSCs to the repair site will result in superior results compared with controls on histologic and biomechanical testing. STUDY DESIGN Controlled laboratory study. METHODS Ninety-eight Lewis rats underwent unilateral detachment and repair of the supraspinatus tendon; 10 rats were used for MSC harvest. Eight animals were used for cell tracking with Ad-LacZ. The remaining animals received either 10(6) MSCs in a fibrin carrier, the carrier alone, or nothing at the repair site. Animals were sacrificed at 2 and 4 weeks for histologic analysis to determine the amount of fibrocartilage formation and the collagen organization at the insertion. Biomechanical testing was also performed. RESULTS Specimens treated with Ad-LacZ-transduced MSCs exhibited more beta-galactosidase activity at the repair site compared with controls at both 2 and 4 weeks, although activity at 4 weeks was less than that at 2 weeks. There were no differences in the amount of new cartilage formation or collagen fiber organization between groups at either time point. There were also no differences in the biomechanical strength of the repairs, the cross-sectional area, peak stress to failure, or stiffness. CONCLUSION The addition of MSCs to the healing rotator cuff insertion site did not improve the structure, composition, or strength of the healing tendon attachment site despite evidence that they are present and metabolically active. CLINICAL RELEVANCE A biologic solution to the problem of tendon-to-bone healing in the rotator cuff remains elusive. The repair site may lack the cellular and/or molecular signals necessary to induce appropriate differentiation of transplanted cells. Further studies are needed to determine if cell-based strategies need to be combined with growth and differentiation factors to be effective.
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Cho NS, Rhee YG. The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder. Clin Orthop Surg 2009; 1:96-104. [PMID: 19885061 PMCID: PMC2766755 DOI: 10.4055/cios.2009.1.2.96] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 08/16/2008] [Indexed: 12/15/2022] Open
Abstract
Background The purpose of this study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repair, and to analyze the factors affecting the integrity of arthroscopically repaired rotator cuff tears of the shoulder. Methods One hundred sixty-nine consecutive shoulders that underwent arthroscopic rotator cuff repair, had a postoperative MRI evaluation and were followed for at least two years were enrolled in this study. The mean age was 57.6 years (range, 38 to 74 years) and the mean follow-up period was 39 months (range, 24 to 83 months). Results The rotator cuff was completely healed in 131 (77.5%) out of 169 shoulders and recurrent tears occurred in 38 shoulders (22.5%). At the last follow-up visit, the mean score for pain during motion was 1.53 (range, 0 to 4) in the completely healed group and 1.59 (range, 0 to 4) in the group with recurrent tears (p = 0.092). The average elevation strength was 7.87 kg (range, 4.96 to 11.62 kg) and 5.25 kg (range, 4.15 to 8.13 kg) and the mean University of California at Los Angeles score was 30.96 (range, 26 to 35) and 30.64 (range, 23 to 34), respectively (p < 0.001, p = 0.798). The complete healing rate was 87.8% in the group less than 50 years of age (49 shoulders), 79.4% in the group over 51 years but less than 60 years of age (68 shoulders), and 65.4% in the group over 61 years of age (52 shoulders, p = 0.049); it was 96.7% in the group with small-sized tears (30 shoulders), 87.3% in the group with medium-sized tears (71 shoulders), and 58.8% in the group with large-sized or massive tears (68 shoulders, p = 0.009). All of the rotator cuffs with a global fatty degeneration index of greater than two preoperatively had recurrent tears. Conclusions Arthroscopic repair of full-thickness rotator cuff tears led to a relatively high rate of recurrent defects. However, the minimum two-year follow up demonstrated excellent pain relief and improvement in the ability to perform the activities of daily living, despite the structural failures. The factors affecting tendon healing were the patient's age, the size and extent of the tear, and the presence of fatty degeneration in the rotator cuff muscle.
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Affiliation(s)
- Nam Su Cho
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009; 91:1055-62. [PMID: 19411453 DOI: 10.2106/jbjs.g.00118] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Partial-thickness rotator cuff tears are a common cause of shoulder pain, yet the appropriate surgical treatment is controversial. In particular, very little information is available regarding rotator cuff integrity after operative repair. The purpose of this study was to evaluate the functional outcome and anatomic healing rate after arthroscopic repair of high-grade partial (>50%) thickness tears of the supraspinatus tendon. METHODS Forty-one consecutive patients (forty-two shoulders) who had undergone arthroscopic conversion of a partial-thickness rotator cuff tear to a full-thickness tear and subsequent repair were evaluated with ultrasound for evidence of rotator cuff healing. Clinical outcomes were assessed with use of validated outcomes measures, and all patients were reexamined by an independent observer. RESULTS The average patient age was fifty-three years. Thirty-seven (88%) of the forty-two shoulders had an intact rotator cuff repair seen on ultrasound at an average of eleven months postoperatively. The remaining five patients had a full-thickness defect in the tendon. The mean American Shoulder and Elbow Surgeons (ASES) score improved from 46.1 points preoperatively to 82.1 points at the time of follow-up. The overall rate of patient satisfaction was 93%. The average age of the patients with an intact rotator cuff was 51.8 years compared with 62.6 years for those with a persistent defect (p = 0.02). CONCLUSIONS Arthroscopic repair of high-grade partial-thickness rotator cuff tears results in a high rate of tendon healing. Patient age is an important factor in tendon healing.
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Affiliation(s)
- Ganesh Kamath
- Department of Orthopaedic Surgery, Shoulder and Elbow Service, Washington University, St Louis, MO 63110, USA
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130
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Burks RT, Crim J, Brown N, Fink B, Greis PE. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: magnetic resonance imaging and early clinical evaluation. Am J Sports Med 2009; 37:674-82. [PMID: 19204365 DOI: 10.1177/0363546508328115] [Citation(s) in RCA: 197] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Double-row arthroscopic rotator cuff repair has become more popular, and some studies have shown better footprint coverage and improved biomechanics of the repair. HYPOTHESIS Double-row rotator cuff repair leads to superior cuff integrity and early clinical results compared with single-row repair. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Forty patients were randomized to either single-row or double-row rotator cuff repair at the time of surgical intervention. Patients were followed with clinical measures (UCLA, Constant, WORC, SANE, ASES, as well as range of motion, internal rotation strength, and external rotation strength). Magnetic resonance imaging (MRI) studies were performed on each shoulder preoperatively, 6 weeks, 3 months, and 1 year after repair. RESULTS Mean anteroposterior tear size by MRI was 1.8 cm. A mean of 2.25 anchors for single row (SR) and 3.2 for double row (DR) were used. There were 2 retears at 1 year in each group. There were 2 additional cases that had severe thinning in the DR repair group at 1 year. The MRI measurements of footprint coverage, tendon thickness, and tendon signal showed no significant differences between the 2 repair groups. At 1 year, there were no differences in any of the postoperative measures of motion or strength. At 1 year, mean WORC (SR, 84.8; DR, 87.9), Constant (SR, 77.8; DR, 74.4), ASES (SR, 85.9; DR, 85.5), UCLA (SR, 28.6; DR, 29.5), and SANE (SR, 90.9; DR, 89.9) scores showed no significant differences between groups. CONCLUSIONS No clinical or MRI differences were seen between patients repaired with a SR or DR technique.
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Affiliation(s)
- Robert T Burks
- University of Utah Orthopaedic Center, Salt Lake City, 84108, USA.
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131
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Nho SJ, Shindle MK, Adler RS, Warren RF, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: subgroup analysis. J Shoulder Elbow Surg 2009; 18:697-704. [PMID: 19269861 DOI: 10.1016/j.jse.2008.11.018] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Revised: 11/28/2008] [Accepted: 11/30/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome. METHODS A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. RESULTS The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P < .0001) and 92.65 +/- 11.36 at 2 years (P < 0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity. CONCLUSION Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.
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Affiliation(s)
- Shane J Nho
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.
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132
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Bigoni M, Gorla M, Guerrasio S, Brignoli A, Cossio A, Grillo P, Marinoni EC. Shoulder evaluation with isokinetic strength testing after arthroscopic rotator cuff repairs. J Shoulder Elbow Surg 2008; 18:178-83. [PMID: 19111477 DOI: 10.1016/j.jse.2008.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 08/21/2008] [Accepted: 09/03/2008] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study was to evaluate, with isokinetic testing, the recovery of strength in patients with rotator cuff tears treated with two different arthroscopic repair techniques. MATERIALS AND METHODS From September 2004 to September 2006, patients with a full-thickness supraspinatus tear were randomized to two different groups. Patients in group 1 underwent side-to-side repair with permanent sutures, whereas those in group 2 underwent tendon-to-bone fixation with 1 metal suture anchor loaded with double sutures. The same independent examiner evaluated the outcomes using the Constant score and isokinetic strength testing preoperatively and at 3, 6, and 12 months postoperatively. Data analysis was also performed in three subgroups: small, medium, and large tears. RESULTS Constant scores improved from preoperatively to 12 months postoperatively. In group 1, the mean Constant score was 32 points before surgery and 78 points at 12 months postoperatively. In group 2, the mean Constant score was 30 points before surgery and 88 points at 12 months after surgery. Strength increased gradually during the first postoperative year. In group 1, preoperative mean peak torque was 34% and 39% in internal rotation and external rotation, respectively. After repair, it decreased to 17% and 21%, respectively, at 12 months. In group 2, preoperative mean peak torque was 32% and 37% in internal rotation and external rotation, respectively; after surgery, it decreased to 9% and 12%, respectively, at 12 months. Data analysis showed that the difference in improvement in Constant scores and in strength recovery from preoperatively to postoperatively in groups 1 and 2 was statistically significant (p < .05). CONCLUSION We showed a strength difference between patients with side-to-side repairs and those with tendon-to-bone repairs. LEVEL OF EVIDENCE Level 1; Prospective randomized study.
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Affiliation(s)
- Marco Bigoni
- Clinica Ortopedica-Azienda Ospedaliera San Gerardo, Università degli studi Milano-Bicocca, Monza, Italy
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133
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Balyk R, Luciak-Corea C, Otto D, Baysal D, Beaupre L. Do outcomes differ after rotator cuff repair for patients receiving workers' compensation? Clin Orthop Relat Res 2008; 466:3025-33. [PMID: 18784971 PMCID: PMC2628237 DOI: 10.1007/s11999-008-0475-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 08/08/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Comparisons of outcomes after rotator cuff repair between Worker's Compensation Board (WCB) recipients and nonrecipients generally do not consider patient, injury, and shoulder characteristics. We compared preoperative differences between WCB recipients and nonrecipients and determined the impact on their 6-month postoperative outcome. We evaluated a prospective cohort of 141 patients with full-thickness rotator cuff tears, 36 of whom (26%) were WCB recipients, preoperatively and 3 and 6 months after rotator cuff repair. Their mean age was 54.0 +/- 10.4 years (standard deviation) and 102 (72%) patients were male. Shoulder range of motion, Western Ontario Rotator Cuff (WORC) index, and American Shoulder and Elbow Surgeons' score were used to evaluate outcomes. We performed regression analyses to control for baseline differences in age, baseline scores, smoking status, symptom duration, injury type, and associated biceps disorder between WCB recipients and nonrecipients. WCB recipients were younger and more likely to smoke, have a traumatic injury, and undergo surgery within 6 months of injury. WCB recipients had lower recovery for all outcomes when these differences were not considered but when differences were accounted for, only 6-month WORC scores were lower in WCB recipients. Clinicians should consider preoperative characteristics before concluding WCB recipients experience less recovery after surgical repair. LEVEL OF EVIDENCE Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- R. Balyk
- Department of Surgery, Caritas Health Group, Edmonton, AB Canada ,Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - C. Luciak-Corea
- Department of Rehabilitation Medicine, Caritas Health Group, Edmonton, AB Canada
| | - D. Otto
- Department of Surgery, Caritas Health Group, Edmonton, AB Canada ,Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - D. Baysal
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - L. Beaupre
- Department of Surgery, University of Alberta, Edmonton, AB Canada ,Department of Physical Therapy, University of Alberta, Edmonton, AB Canada ,1F1.52 WMC, 8440-112 ST, Edmonton, AB Canada T6G 2B7
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134
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Funakoshi T, Suenaga N, Sano H, Oizumi N, Minami A. In vitro and finite element analysis of a novel rotator cuff fixation technique. J Shoulder Elbow Surg 2008; 17:986-92. [PMID: 18823800 DOI: 10.1016/j.jse.2008.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 04/21/2008] [Accepted: 06/09/2008] [Indexed: 02/01/2023]
Abstract
The purpose of this investigation was to assess the biomechanic strength and stress dispersion at the repair site of surface-holding repair techniques for rotator cuff repair compared to the double-row technique. Eighteen bovine infraspinatus tendons were repaired using 3 different repair techniques: double-row repair, surface-holding repair with transosseous sutures, and surface-holding repair with knotless anchors. Biomechanical testing and two-dimensional finite element analysis were performed. The surface-holding repair with transosseous sutures provided 87.9% more stiffness than the double-row repair. The number of tendon-suture site failures of the surface-holding repair with transosseous sutures was smaller than the other 2 techniques. The finite element analysis showed that the surface-holding repair model had a more dispersing stress pattern compared to a double-row repair model. It suggests that these repair techniques can prevent high stress concentration compared to the double-row repair.
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Affiliation(s)
- Tadanao Funakoshi
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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135
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Nho SJ, Brown BS, Lyman S, Adler RS, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome. J Shoulder Elbow Surg 2008; 18:13-20. [PMID: 18799326 DOI: 10.1016/j.jse.2008.05.045] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 04/20/2008] [Accepted: 05/16/2008] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to identify potential predictors of function and tendon healing after arthroscopic rotator cuff repair that will enable the orthopaedic surgeon to determine which patients can expect a successful outcome. Between 2003 and 2005, the Arthroscopic Rotator Cuff Registry was established to collect demographic, intraoperative, functional outcome, and ultrasound data prospectively on all patients who underwent primary arthroscopic rotator cuff repair. At total of 193 patients met the study criteria, and 127 (65.8%) completed the 2-year follow-up. The most significant independent factors affecting ultrasound outcome were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.14; P = .006) and tear size (OR, 2.29; 95% CI, 1.55-3.38; P < .001). After adjustment for age and tear size, the intraoperative factors found to be significantly associated with a tendon defect were concomitant biceps procedures (OR, 11.39; 95% CI, 2.90-44.69; P < .001) and acromioclavicular joint procedures (OR, 3.85; 95% CI, 1.46-10.12; P = .006). In contrast to the ultrasound data, the functional outcome variables, such as satisfaction (OR, 3.92; 95% CI, 2.00-7.68; P < .001) and strength (OR, 10.05; 95% CI, 1.61-62.77; P = .01), had a greater role in predicting an American Shoulder and Elbow Surgeons score greater than 90. The progression from a single-tendon rotator cuff tear to a multiple-tendon tear with associated pathology increased the likelihood of tendon defect by at least 9 times, and therefore, earlier surgical intervention for isolated, single-tendon rotator cuff tears could optimize the likelihood of ultrasound healing and an excellent functional outcome.
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Affiliation(s)
- Shane J Nho
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.
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136
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Frank JB, ElAttrache NS, Dines JS, Blackburn A, Crues J, Tibone JE. Repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair. Am J Sports Med 2008; 36:1496-503. [PMID: 18658021 DOI: 10.1177/0363546507313574] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Successful healing after arthroscopic rotator cuff repair remains a challenge. Earlier studies have shown a relatively high rate of failure. New surgical techniques may improve healing potential. The purpose of this study was to provide an objective evaluation of repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair. HYPOTHESIS Rotator cuff tears repaired using the transosseous-equivalent suture-bridge technique will show a higher intact rate on postoperative magnetic resonance imaging (MRI) evaluation. STUDY DESIGN Case series; Level of evidence, 4. METHODS The first 25 patients who underwent arthroscopic rotator cuff repair using the transosseous-equivalent suture-bridge technique underwent MRI evaluation of the postoperative shoulder. Minimum follow-up was 1 year. Demographic, clinical, and surgical factors, including tear size, were evaluated. RESULTS Postoperative MRI demonstrated intact surgical repair sites in 22 of 25 patients (88%). Tears limited to the supraspinatus tendon were intact in 16 of 18 patients (89%). Tears of the supraspinatus involving part or all of the infraspinatus showed an 86% intact rate (6 of 7 patients). Of these tears, 3 were considered massive (complete 2-tendon or greater). These demonstrated an intact cuff on MRI. CONCLUSIONS The transosseous-equivalent suture-bridge technique demonstrates a high healing rate on imaging studies at 1 year. Of the first 25 patients repaired with the technique, 88% had an intact rotator cuff repair on MRI evaluation. This indicates excellent cuff healing, as judged by the intact repair sites, compared with most standard arthroscopic rotator cuff repair series. In this early report of the technique, a persistent tear could not be correlated with age or initial tear size; however, this may be due to the relatively small sample size.
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Affiliation(s)
- Joshua B Frank
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, USA.
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137
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Chun JM, Song JS, Sohn DW. Clinical Outcome and Causative Factor in Patients of Structural Failure after Rotator Cuff Repair. ACTA ACUST UNITED AC 2008. [DOI: 10.5397/cise.2008.11.1.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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138
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Mini-open versus all-arthroscopic rotator cuff repair: comparison of the operative costs and the clinical outcomes. Adv Ther 2008; 25:249-59. [PMID: 18363045 DOI: 10.1007/s12325-008-0031-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Rotator cuff injury is one of the most frequently encountered problems of the shoulder in the daily practice of orthopaedic surgeons. This study compared all-arthroscopic cuff repair (ARCR) and mini-open rotator cuff repair (MORCR) methods in regard to clinical outcomes and costs. METHODS Fifty patient charts and operative repairs were analysed (25 ARCR and 25 MORCR). Pre-and postoperative Constant-Murley and UCLA scores along with factors such as tear size, tear type, pre-operative physical therapy, motion and satisfaction levels were compared for the two procedures. Cost-benefit analysis was also performed for comparison between procedures. The duration of follow-up was 31.20 and 21.56 months for MORCR and ARCR groups, respectively. RESULTS Tear sizes (P=0.68), pre-and postoperative Constant-Murley and UCLA scores (P=0.254) and satisfaction levels were not significantly different between groups. However, the differences between pre-and postoperative Constant-Murley and UCLA scores were statistically significant within both groups (P<0.01). The MORCR group stayed 1 day longer in hospital than the ARCR group, which was statistically significant (P=0.036). The differences regarding mean pain scores, abductions, internal and external rotations in Constant-Murley scores and forward flexion scores in UCLA scores were not significant. The ARCR group cost more, leaving less profit. CONCLUSION Results suggest that ARCR yields similar clinical results but at a higher cost compared with MORCR.
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139
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Arthroscopic repair of full-thickness tears of the rotator cuff in patients younger than 40 years. Arthroscopy 2008; 24:324-8. [PMID: 18308185 DOI: 10.1016/j.arthro.2007.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2005] [Revised: 09/11/2007] [Accepted: 09/12/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE Recent reports document excellent outcomes with arthroscopic repair of rotator cuff tears (RCT). However, full-thickness RCT are uncommon in patients younger than 40 years, and few reports document results after repair in this population. The purpose of this study is to retrospectively report results of arthroscopic repair of full-thickness RCT in patients younger than 40 years. METHODS Twenty-three consecutive patients younger than 40 years with full-thickness RCT underwent arthroscopic repair with suture anchors. Mean age was 37 years (range, 21 to 39). The mean size of RCT was 2.4 cm in the largest dimension (range, 1 to 4 cm). The mean number of anchors used was 2.5 (range, 1 to 4). Concomitant procedures included subacromial decompression (22), distal clavicle resection (13), SLAP repair (2), biceps tenodesis (2), anterior capsulorraphy (1), and capsular releases (1), and were performed at the discretion of the surgeon. Twenty-two patients (95%) recalled a single incipient trauma; two patients sustained a dislocation. Ten patients (43%) claimed Workers' Compensation (WC). Minimum follow-up was 24 months, and mean follow-up was 26 months (range, 24 to 29). RESULTS Mean preoperative American Shoulder and Elbow Surgeon's (ASES) self-report score was 42 (range, 22 to 60); the mean postoperative score was 92 (range, 65 to 100; P < .01). Twenty-one patients (90%) returned to their previous level of activity and employment, including 9 (90%) with WC claims. All patients (100%) reported diminished pain, and 22 (95%) reported improvement with activities of daily living. Complications included superficial wound infection (1) and axillary nerve palsy after initial dislocation (1). Given the choice, 22 patients (95%) would have same procedure again. CONCLUSIONS Excellent outcomes were observed following arthroscopic rotator cuff repair both with and without concomitant procedures in patients younger than 40 years. Full-thickness RCT in patients younger than 40 years appeared to be traumatic in etiology. Successful repair returns patients to their pre-injury level of function. These results support arthroscopic rotator cuff repair in young, active patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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140
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Mellado JM, Calmet J. [The postsurgical rotator cuff: surgical techniques, clinical outcome, and MRI evaluation]. RADIOLOGIA 2008; 50:11-27. [PMID: 18275784 DOI: 10.1016/s0033-8338(08)71925-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Surgical treatment of rotator cuff tears significantly reduces painful symptoms and improves functional capacity in many patients. However, despite recent advances, up to 25% of patients remain symptomatic after surgery. This has led to research into the reasons for these poor outcomes, including how to identify them with imaging methods and how to avoid them through new therapeutic approaches. Based on our clinical experience, we review the available treatment alternatives for rotator cuff tears, analyzing the main areas of controversy and the possible causes of unsatisfactory outcome after surgery. Furthermore, we review the expectations, difficulties, and requirements of diagnostic imaging in the follow-up of surgically treated rotator cuffs, with special emphasis on the MRI findings and their clinical impact.
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Affiliation(s)
- J M Mellado
- Sección de Radiología. Hospital Reina Sofía. Tudela. Navarra. España.
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141
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Milano G, Grasso A, Zarelli D, Deriu L, Cillo M, Fabbriciani C. Comparison between single-row and double-row rotator cuff repair: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 2008; 16:75-80. [PMID: 17684730 DOI: 10.1007/s00167-007-0382-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Accepted: 06/21/2007] [Indexed: 10/23/2022]
Abstract
The aim of this study was to compare the mechanical behavior under cyclic loading test of single-row and double-row rotator cuff repair with suture anchors in an ex-vivo animal model. For the present study, 50 fresh porcine shoulders were used. On each shoulder, a crescent-shaped full-thickness tear of the infraspinatus was performed. Width of the tendon tear was 2 cm. The lesion was repaired using metal suture anchors. Shoulders were divided in four groups, according the type of repair: single-row tension-free repair (Group 1); single-row tension repair (Group 2); double-row tension-free repair (Group 3); double-row tension repair (Group 4); and a control group. Specimens were subjected to a cyclic loading test. Number of cycles at 5 mm of elongation and at failure, and total elongation were calculated. Single-row tension repair showed significantly poorest results for all the variables considered, when compared with the other groups. Regarding the mean number of cycles at 5 mm of elongation and at failure, there was a nonsignificant difference between Groups 3 and 4, and both of them were significantly greater than Group 1. For mean total elongation, the difference between Groups 1, 3, and 4 was not significant, but all of them were significantly lower than the control group. A single-row repair is particularly weak when performed under tension. Double-row repair is significantly more resistant to cyclic displacement than single-row repair in both tension-free and tension repair. Double-row repair technique can be primarily considered for large, unstable rotator cuff tears to improve mechanical strength of primary fixation of tendons to bone.
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Affiliation(s)
- Giuseppe Milano
- Department of Orthopaedics and Traumatology, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy.
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142
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Abstract
This study examined the technique and outcome of arthroscopically assisted mini-deltopectoral rotator cuff repair. The mini-deltopectoral approach enables the repair of large or massive rotator cuff tears while preventing injury to the deltoid muscle and axillary nerve often caused by splitting and excessive traction during conventional mini-open repair. This technique also is useful in the repair of subscapularis tears and thus could extend the indications for mini-open repair.
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Affiliation(s)
- Jae-Myeung Chun
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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143
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Pearsall AW, Ibrahim KA, Madanagopal SG. The results of arthroscopic versus mini-open repair for rotator cuff tears at mid-term follow-up. J Orthop Surg Res 2007; 2:24. [PMID: 18053153 PMCID: PMC2216003 DOI: 10.1186/1749-799x-2-24] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 12/01/2007] [Indexed: 12/13/2022] Open
Abstract
Background To prospectively evaluate patients who underwent a "mini-open" repair versus a completely arthroscopic technique for small to large size rotator cuff tears. Methods Fifty-two patients underwent "mini-open" or all arthroscopic repair of a full thickness tear of the rotator cuff. Patients who complained of shoulder pain and/or weakness and who had failed a minimum of 6 weeks of physical therapy and had at least one sub-acromial injection were surgical candidates. Pre and post-operative clinical evaluations included the following: 1) demographics; 2) Simple Shoulder Test (SST); 3) University of California, Los Angeles (UCLA) rating scale; 4) visual analog pain assessment (VAS); and 5) pre-op SF12 assessment. Descriptive analysis was performed for patient demographics and for all variables. Pre and post outcome scores, range of motion and pain scale were compared using paired t-tests. Analysis of variance (ANOVA) was used to evaluate any effect between dependent and independent variables. Significance was set at p is less than or equal to 0.05. Results There were 31 females and 21 males. The average follow-up was 50.6 months (27 – 84 months). The average age was similar between the two groups [arthroscopic x = 55 years/mini-open x = 58 years, p = 0.7]. Twenty-seven patients underwent arthroscopic repair and 25 underwent repair with a mini-open incision. The average rotator cuff tear size was 3.1 cm (range: 1–5 centimeters). There was no significant difference in tear size between the two groups (arthroscopic group = 2.9 cm/mini-open group = 3.2 cm, p = 0.3). Overall, there was a significant improvement from pre-operative status in shoulder pain, shoulder function as measured on the Simple Shoulder test and UCLA Shoulder Form. Visual analog pain improved, on average, 4.4 points and the most recent Short Shoulder Form and UCLA scores were 8 and 26 respectively. Both active and passive glenohumeral joint range of motion improved significantly from pre-operatively. Conclusion Based upon the number available, we found no statistical difference in outcome between the two groups, indicating that either procedure is efficacious in the treatment of small and medium size rotator cuff tears. Level of Evidence Type III
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Affiliation(s)
- Albert W Pearsall
- Department of Orthopaedic Surgery, University of South Alabama, Mobile, Alabama, USA.
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Ammon JT, Nyland J, Chang HC, Burden R, Caborn DNM. Evaluation of BioCorkscrew and Bioknotless RC suture anchor rotator cuff repair fixation: an in vitro biomechanical study. Knee Surg Sports Traumatol Arthrosc 2007; 15:1375-81. [PMID: 17437085 DOI: 10.1007/s00167-007-0321-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Accepted: 02/20/2007] [Indexed: 11/28/2022]
Abstract
This in vitro biomechanical study used cadaveric specimens to compare the rotator cuff repair fixation provided by BioCorkscrew and Bioknotless RC suture anchors. Three cm wide by 1-cm long full-thickness supraspinatus defects were repaired using either two BioCorkscrew suture anchors with combined vertical and horizontal mattress sutures (n = 7) or three Bioknotless RC suture anchors with simple sutures (n = 7). Therefore, the BioCorkscrew suture anchor group had two sutures per anchor (four total sutures), while the Bioknotless RC suture anchor group had one suture per anchor (three total sutures). Two-phase cyclic (5-100 N, 1,000 cycles and 5-180 N, 2,000 cycles) and load to failure tests (31 mm/s) were performed. Non-parametric statistics were used to compare group differences (P < 0.05). All of the BioCorkscrew group specimens (seven of seven) completed the two phase cyclic test regimen without failure or gapping >/= 5 mm, compared to only three of seven of the Bioknotless RC group (Fisher's Exact test = 0.03). Groups did not differ for repair site gapping during the 5-100 N cyclic test phase (Fisher's Exact test = 0.77), however more of the Bioknotless RC group displayed gapping >/= 5 mm during the 5-180 N cyclic test phase than the BioCorkscrew group (P = 0.02). The BioCorkscrew group also displayed greater yield load during load to failure testing (492.2 +/- 204 N vs. 296.4 +/- 155 N, P = 0.03). In this in vitro biomechanical study, the BioCorkscrew group with combined vertical and horizontal mattress sutures displayed greater cyclic test survival, less repair site gapping, and superior yield load compared to the Bioknotless RC group with simple sutures. These results in human cadaveric rotator cuff-humerus specimens suggest better immediate post-operative repair site strength and a reduced need for post-operative restrictions. Clinical studies are needed to determine how these rotator cuff repair modes withstand the forces of early rehabilitation and activities of daily living that potentially influence patient outcomes.
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Affiliation(s)
- Jennifer Tucker Ammon
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Suite 1003, Louisville, KY 40202, USA
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145
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Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am 2007; 89 Suppl 3:127-36. [PMID: 17908878 DOI: 10.2106/jbjs.g.00583] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Shane J Nho
- The Hospital for Special Surgery, New York, NY 10021, USA.
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146
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Charousset C, Grimberg J, Duranthon LD, Bellaiche L, Petrover D. Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair?: A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment. Am J Sports Med 2007; 35:1247-53. [PMID: 17452513 DOI: 10.1177/0363546507301661] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Increasing the rate of watertight tendon healing has been suggested as an important criterion for optimizing clinical results in rotator cuff arthroscopic repair. HYPOTHESIS A double-row anchorage technique for rotator cuff repair will produce better clinical results and a better rate of tendon healing than a single-row technique. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS We compared 31 patients undergoing surgery with a double-row anchorage technique using Panalok anchors and Cuff Tack anchors and 35 patients with rotator cuff tear undergoing surgery with a single-row anchorage arthroscopic technique using Panalok anchors. We compared pre- and postoperative Constant score and tendon healing, as evaluated by computed tomographic arthrography 6 months after surgery, in these 2 groups. RESULTS The Constant score increased significantly in both groups, with no difference between the 2 groups (P = .4). Rotator cuff healing was judged anatomic in 19 patients with double-row anchorage and in 14 patients with single-row anchorage; this difference between the groups was significant (P = .03). CONCLUSION In this first study comparing double- and single-row anchorage techniques, we found no significant difference in clinical results, but tendon healing rates were better with the double-row anchorage. Improvements in the double-row technique might lead to better clinical and tendon healing results.
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Affiliation(s)
- Christophe Charousset
- Association Francilienne de Traumatologie du Sport, 60, rue de Courcelles, 75008 Paris, France.
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147
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Bales C, Anderson K. Arthroscopic Double-Row Repair of Full-Thickness Rotator Cuff Tears Using a Suture Bridge Technique. OPER TECHN SPORT MED 2007. [DOI: 10.1053/j.otsm.2007.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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148
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Lafosse L, Brozska R, Toussaint B, Gobezie R. The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique. J Bone Joint Surg Am 2007. [DOI: 10.2106/00004623-200707000-00018] [Citation(s) in RCA: 177] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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149
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Kim JM, Kim YS, Kwon YJ, Yoo JS, Jung HW. The Thickness of Normal and Repaired Rotator-cuff Measured in MRI. Clin Shoulder Elb 2007. [DOI: 10.5397/cise.2007.10.1.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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150
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Noh HK, Wang JH, Kim DH, Park JW, Kim JG, Park JH. Correlation of Clinical Outcome and Cuff Integrity after Open Repair in Large and Massive Rotator Cuff Tears. Clin Shoulder Elb 2007. [DOI: 10.5397/cise.2007.10.1.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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