Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: a propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years

What is the Optimal Construct to Reduce Failure in Arthroscopic Four Anchor Rotator Cuff Repair?

Background

Re-tear following rotator cuff repair (RCR) is a concerning complication that can lead to poor patient outcomes and necessitate the need for revision surgery. The purpose of our study was to look at the combined construct of knotted vs. knotless medial row and suture vs. suture tape, focusing primarily on re-tear rates following surgery.

Methods

A retrospective observational study of 343 consecutive patients undergoing arthroscopic double row, 4-anchor rotator cuff repair from February 2014 to March 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities and tear characteristics between patients who experienced a symptomatic re-tear and those who did not.

Results

The overall symptomatic re-tear rate was 7.6%. Patients who had a knotted medial row repair had a significantly lower rate of re-tear (4.7 vs. 11.3%, p = 0.022). Patients that had a knotted medial row and suture tape repair were significantly less likely to experience a re-tear (OR: 0.180, p = 0.001).

Discussion

The use of suture tape and a knotted medial row repair decreases the incidence of symptomatic re-tear following rotator cuff repair. The combined construct of suture tape and a knotted medial row in rotator cuff repair decreases the risk for symptomatic re-tear following surgery.

Midterm Clinical Outcomes After Arthroscopic Rotator Cuff Repair in Olympic Volleyball Players: Return to Sports and Return to Performance

Background

The decision-making process and predicting the time to return to sport (RTS) and return to performance (RTP) after arthroscopic rotator cuff repair (ARCR) in elite volleyball players are difficult issues to address, even among experienced shoulder surgeons.

Purpose/Hypothesis

The purpose of the study was to evaluate the results in Olympic-level volleyball players treated with arthroscopic supraspinatus repair and to report the RTS and the RTP. It was hypothesized that these athletes had higher RTS and faster RTP.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 17 elite volleyball athletes (11 male, 6 female; mean age, 26.2 years) who underwent ARCR for partial- and full-thickness supraspinatus tears that did not improve despite nonoperative treatment. The clinical results were evaluated at 12 months postoperatively. The authors compared the athletes' preoperative, 6-month, and 12-month Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and the visual analog scale (VAS) for pain after competition and conducted 6- and 12-month isometric strength analyses. The athletes' RTS and RTP times were recorded.

Results

All tears were on the dominant side (15 right, 2 left), and 82% were partial tears (14 partial thickness, 3 full thickness). The mean time from the onset of symptoms to surgery was 11.3 ± 6.7 months. While the mean Kerlan-Jobe Orthopaedic Clinic score was 31 preoperatively, it was 89 after 6 months (P < .001 vs preoperative) and 96 after 12 months (P = .003 vs 6 months). The mean VAS for pain was 7.9 preoperatively, 0.4 at 6 months (P < .001 vs preoperative), and 0.1 at 12 months (P = .02 vs 6 months). All athletes were able to reach their preinjury level, with RTS at a mean of 6.9 months and RTP at a mean of 12.4 months.

Conclusion

ARCR appears to be an effective option for Olympic-level volleyball players who do not benefit from nonoperative treatment. All athletes returned to their preinjury level of sports. The surgeon and athlete can plan surgical decision-making and timing based on the mean RTS time of 6.9 months and mean RTP time of 12.4 months.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

BACKGROUND

Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated.

PURPOSE

To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes.

RESULTS

A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05).

CONCLUSION

This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

Comparison of clinical outcomes of arthroscopic rotator cuff repair utilizing suture-bridge procedures with or without medial knots: a meta-analysis

PURPOSE

This investigation aimed to compare the medical efficacy of the knotted and knotless suture-bridge procedures in rotator cuff repair.

METHODS

The Pubmed, Embase, and Cochrane Library datasets were searched for all available publications comparing the medical results of arthroscopic rotator cuff repairs utilizing knotted or knotless suture-bridge procedures. Two researchers utilized Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to evaluate the included studies. Employing Revman 5.3 software, meta-analysis was conducted following the PRISMA reporting guideline.

RESULTS

Eleven investigations with 1083 patients were considered suitable for the final meta-analysis. 522 individuals were assigned to the knotted group, whereas 561 were assigned to the knotless group. No statistical difference was found between the knotted and knotless groups, regarding VAS score (WMD, 0.17; 95% CI, - 0.10 to 0.44; P = 0.21); Constant score (WMD, -1.50; 95% CI, - 3.52 to 0.52; P = 0.14); American Shoulder and Elbow Surgeons Shoulder (WMD, -2.02; 95% CI, - 4.53 to 0.49; P = 0.11); University of California Los Angeles score (WMD, -0.13; 95% CI, - 0.89 to 0.63; P = 0.73); ROM of flexion (WMD, 1.57; 95% CI, - 2.11 to 5.60; P = 0.37), abduction (WMD, 1.08; 95% CI, - 4.53 to 6.70; P = 0.71) and external rotation (WMD, 1.90; 95% CI, - 1.36 to 5.16; P = 0.25); re-tear rate (OR, 0.74; 95% CI, 0.50 to 1.08; P = 0.12), and medical complications (OR, 0.90; 95% CI, 0.37 to 2.20; P = 0.82).

CONCLUSION

For arthroscopic rotator cuff repairs, there were no statistical differences in medical results among knotted and knotless suture-bridge procedures. Overall, both techniques showed excellent clinical outcomes and could be safely utilized to treat rotator cuff injuries.

"Triple Package" Modified SpeedBridge Rotator Cuff Repair Technique

Treatment of full-thickness rotator cuff repairs vary in surgical technique depending on many factors including tear geometry, delamination of soft tissue, tissue quality, and rotator cuff retraction. The described technique presents a reproducible method of addressing tear patterns where the tear may be larger laterally, but the medial footprint exposure is small. This can be addressed with a single medial anchor combined with a knotless lateral-row technique to provide compression for small tears or two medial row anchors for moderate to large tears. In this modification of the standard knotless double row (SpeedBridge) technique, 2 medial row anchors are used, with 1 augmented with additional fiber tape and an additional lateral row anchor to create a triangular repair construct, increasing the size and stability of the footprint of the lateral row.

CEUS-assessed supraspinatus muscle perfusion improves after tendon repair and predicts anatomical and functional outcome: A 1-year prospective pilot study

Rotator cuff tear including SSP (Supraspinatus) tendon tears are a very common and often painful condition with several therapeutic options such as tendon repair. Reflected by the high retear rates, the preoperative selection of patients suitable for surgery or conservative treatment, which often yields comparable results, remains difficult. Using contrast-enhanced ultrasound (CEUS), it is possible to quantify the SSP muscle perfusion as a surrogate parameter for its vitality and healing capabilities. In this study, we enrolled 20 patients who underwent an SSP repair for a preoperative and two postoperative (6 months and 1 year) clinical and sonographic exams including CEUS. Along with functional improvement (p < 0.001, Constant score), we found a significant increase in CEUS-assessed muscle perfusion after tendon repair (p < 0.001). Furthermore, weak preoperative muscle perfusion was associated with a higher risk of a retear (χ²  = 0.045) and a moderate trend toward lower postoperative shoulder function that did not reach significance (r = 0.435; p = 0.055, DASH score). If confirmed in larger studies, CEUS might be a valuable additional diagnostic method for a precise selection of patients who most likely profit from a tendon repair and those who can be treated conservatively with an equally good outcome.

Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes

PURPOSE

To compare failure rates and outcomes after transosseous equivalent (TOE) double row (DR) knotted suture bridge versus knotless suture tape bridge repair techniques for rotator cuff tears.

METHODS

A consecutive series of 272 shoulders in 256 patients who underwent arthroscopic, double row, TOE repair for full-thickness tears of the supraspinatus tendon were reviewed. Eighty-four shoulders were repaired using knotted suture bridge (KSB) technique, and 188 shoulders were repaired using all knotless suture tape bridge (KTB) technique. Revision procedures and concomitant subscapularis tendon repairs were excluded from analysis. The minimum follow-up was 12 months. Primary outcome was failure of surgical repair, defined as either confirmed retear on MRI and/or need for revision surgery. Secondary clinical outcome measures were assessed including range of motion, strength, visual analog scale (VAS), operative time, subjective shoulder value (SSV), Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Brophy shoulder activity scores, and need for manipulation under anesthesia (MUA).

RESULTS

A total of 127 shoulders (38 KSB and 89 KTB) met inclusion criteria for the study. No significant difference in demographic variables were present between the groups at baseline. Supraspinatus tear size and average follow-up time did not differ significantly between groups. Failure rates were similar between the KSB and KTB repairs (13.1 vs 7.9%, n.s.). There was no significant difference in functional outcomes including strength, range of motion in forward flexion and external rotation, as well as patient reported outcomes including VAS, SSV, PROMIS, ASES, and Brophy scores between the groups. There was also no difference in post-operative stiffness requiring MUA.

CONCLUSION

Both KSB and KTB repair techniques demonstrate low retear rates with excellent functional outcomes when compared to pre-operative examination. Both KSB and KTB techniques are viable options for achieving a successful rotator cuff repair.

LEVEL OF EVIDENCE

Level III.

Learning Causal Effects From Observational Data in Healthcare: A Review and Summary

Causal inference is a broad field that seeks to build and apply models that learn the effect of interventions on outcomes using many data types. While the field has existed for decades, its potential to impact healthcare outcomes has increased dramatically recently due to both advancements in machine learning and the unprecedented amounts of observational data resulting from electronic capture of patient claims data by medical insurance companies and widespread adoption of electronic health records (EHR) worldwide. However, there are many different schools of learning causality coming from different fields of statistics, some of them strongly conflicting. While the recent advances in machine learning greatly enhanced causal inference from a modeling perspective, it further exacerbated the fractured state in this field. This fractured state has limited research at the intersection of causal inference, modern machine learning, and EHRs that could potentially transform healthcare. In this paper we unify the classical causal inference approaches with new machine learning developments into a straightforward framework based on whether the researcher is most interested in finding the best intervention for an individual, a group of similar people, or an entire population. Through this lens, we then provide a timely review of the applications of causal inference in healthcare from the literature. As expected, we found that applications of causal inference in medicine were mostly limited to just a few technique types and lag behind other domains. In light of this gap, we offer a helpful schematic to guide data scientists and healthcare stakeholders in selecting appropriate causal methods and reviewing the findings generated by them.

SpeedBridge Knotless Double-Pulley Rotator Cuff Repair

Rotator cuff tears remain a common injury, and may require rotator cuff repair, one of the most frequently performed orthopaedic procedures. Achieving an ideal construct during rotator cuff repair is crucial, and while many techniques exist to accomplish this, they are continuously evolving to improve stability and biomechanics of the repaired shoulder. Improving efficiency of the procedure alongside the increasing complexity of innovative techniques remains of the utmost importance. The double-pulley SpeedBridge technique achieves medial fixation in a double-row, transosseus-equivalent repair, and the knotless nature of the technique creates for a low-profile construct and improves overall efficiency. The purpose of this Technical Note is to describe a reproducible and efficient approach to arthroscopic rotator cuff repair using the SpeedBridge knotless double-pulley technique.

Knotted Versus Knotless Medial-Row Transosseous-Equivalent Double-Row Rotator Cuff Repairs Have Similar Clinical and Functional Outcomes

Purpose

To retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR).

Methods

A retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled.

Results

A total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P = .743).

Conclusions

The knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up.

Level of Evidence

Level III, retrospective therapeutic comparative trial.

Results of arthroscopic rotator cuff repair for calcific tendonitis: a comparative analysis

BACKGROUND

Outcomes following arthroscopic excision of calcific tendonitis and arthroscopic rotator cuff repair (CT-ARCR) are relatively limited without comparison analysis to standard arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate patient-reported outcomes (PROs) after CT-ARCR compared against a matched cohort who received standard ARCR.

METHODS

An institutional review board-approved retrospective review was performed for patients aged 18-80 years receiving CT-ARCR by a single surgeon from 2006-2018. These were matched 1:3 with patients receiving ARCR. Patients with concurrent labral repair, subscapularis repair, or glenohumeral joint arthritis procedures; refusal to participate; deceased; inadequate contact information; or those with inadequate records were excluded. PROs included Short Form-12 Physical Component Summary (SF-12 PCS) score; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES); Single Assessment Numeric Evaluation (SANE); Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH); patient satisfaction; activity level/symptoms; and sport participation scores.

RESULTS

21 CT-ARCR patients (mean age 50 years, range 36-62) and 54 ARCR patients (mean age 52 years, range 19-77) were included. Minimum 2-year follow-up was obtained in 18 of 21 (86%) CT-ARCR (mean 5.9 years) and 45 of 54 (83%) ARCR patients (mean 5.6 years). CT-ARCR patients improved pre- to postoperation in mean SF-12 PCS (41.1 to 50.0), ASES (54.2 to 94.0), and QuickDASH (54.2 to 94.0). SANE score improvements (57.6 to 82.8) were not significant. ARCR controls improved pre- to postoperation in mean SF-12 PCS (41.4 to 49.0), ASES (59.4 to 88.0), QuickDASH (35.1 to 13.8), and SANE scores (52.6 to 80.8). Pre- to postoperative pain during recreation and sport participation similarly improved in both groups. The only postoperative difference observed between CT-ARCR and ARCR was better patient satisfaction with CT-ARCR (9.7 vs. 8.3).

CONCLUSION

CT-ARCR results in excellent PROs, activity symptoms, and sports participation at final follow-up. CT-ARCR results were comparable to patients who received conventional ARCR for similar-sized rotator cuff tears that did not have calcific tendonitis.

Use of Suture Tapes Versus Conventional Sutures for Arthroscopic Rotator Cuff Repairs: A Systematic Review and Meta-analysis

BACKGROUND

Various suture materials are available for arthroscopic rotator cuff repair. More recently, suture tapes have become popular as they are perceived to be easier to use with less soft tissue irritation. However, little is known about their biomechanical and clinical properties compared with conventional sutures in rotator cuff repairs.

PURPOSE

To perform a systematic review and meta-analysis on whether suture tapes are biomechanically superior to conventional sutures in arthroscopic rotator cuff repairs and whether this translates to superior functional outcomes and a lower incidence of retears.

STUDY DESIGN

Meta-analysis.

METHODS

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (rotator cuff repair OR arthroscopic rotator cuff repair) AND ("tape" OR "wire" OR "cord" OR "suture"). Data pertaining to certain biomechanical properties (contact area, contact pressure, gap formation, load to failure, and stiffness), retears, and patient-reported outcome measures (PROMs) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models.

RESULTS

After abstract and full-text screening, 7 biomechanical and 6 clinical studies were included. All biomechanical studies were on animals, with 91 suture tapes and 91 conventional sutures compared. Suture tapes had higher contact pressure (mean difference [MD], 0.04 MPa; 95% CI, 0.01-0.08; P = .02), higher load to failure (MD, 52.62 N; 95% CI, 27.34-77.90; P < .0001), greater stiffness (MD, 4.47 N/mm; 95% CI, 0.57-8.38; P = .02), and smaller gap formation (MD, -0.30 mm; 95% CI, -0.45 to -0.15; P < .0001) compared with conventional sutures. From the clinical analysis of the 681 rotator cuff repairs treated with a suture tape (n = 380) or conventional suture (n = 301), there were no differences in retear rates between the groups (16% vs 20% suture tape and wire, respectively; P = .26) at a mean of 11.2 months. Qualitatively, there were no differences in PROMs between the groups at a mean of 36.8 months.

CONCLUSION

Although biomechanically superior, suture tapes showed similar retear rates and postoperative function to conventional sutures. However, higher-quality clinical studies are required to investigate whether there are no true differences.

The Evolution of Arthroscopic Rotator Cuff Repair

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.

Intratendinous Strain Variations of the Supraspinatus Tendon Depending on Repair Technique: A Biomechanical Analysis Regarding the Cause of Medial Cuff Failure

BACKGROUND

Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far.

PURPOSE

To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions-(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction-using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair.

RESULTS

The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N (P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N (P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group (P≤ .029).

CONCLUSION

While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon.

CLINICAL RELEVANCE

DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

Excellent Clinical Outcomes and Rates of Return to Play After Arthroscopic Rotator Cuff Repair for Traumatic Tears in Athletes Aged 30 Years or Less

Purpose

To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma.

Methods

We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned.

Results

Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level.

Conclusions

After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure.

Level of Evidence

Level IV, therapeutic case series.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Why are tapes better than wires in knotless rotator cuff repairs? An evaluation of force, pressure and contact area in a tendon bone unit mechanical model

PURPOSE

Knotless repairs have demonstrated encouraging performance regarding retear rate reduction, but literature aiming at identifying the specific variables responsible for these results is scarce and conflictive. The purpose of this paper was to evaluate the effect of the material (tape or wire suture) and medial tendon passage (single or double passage) on the contact force, pressure and area at the tendon bone interface in order to identify the key factors responsible for this repairs´ success.

METHODS

A specific knotless transosseous equivalent cuff repair was simulated using 2 tape or suture wire loaded medial anchors and 2 lateral anchors, with controlled lateral suture limb tension. The repair was performed in a previously validated sawbones® mechanical model. Testing analyzed force, pressure and area in a predetermined and constant size "repair box" using a Tekscan® sensor, as well as peak force and pressure, force applied by specific sutures and force variation along the repair box.

RESULTS

Tapes generate lower contact force and pressure and double medial passage at the medial tendon is associated with higher contact area. Suture wires generate higher peak force and pressure on the repair and higher mean force in their tendon path and at the medial bearing row. Force values decrease from medial to lateral and from posterior to anterior independently of the material or medial passage.

CONCLUSION

Contrary to most biomechanical literature, suture tape use lowers the pressure and force applied at the tendon bone junction, while higher number of suture passage points medially increases the area of contact. These findings may explain the superior clinical results obtained with the use uf suture tapes because its smaller compressive effect over the tendon may create a better perfusion environment healing while maintaining adequate biomechanical stability.

Comparison of clinical outcomes between knotted and knotless double-row arthroscopic rotator cuff repairs: a meta-analysis

Background

The ideal rotator cuff repair technique should allow for a quick and simple arthroscopic application which provides both adequate biomechanical stability and an appropriate biological state with the intention of promoting eventual healing of tendon to bone. While the biomechanical superiority of double-row repairs including higher repair strength, reduced gap formation, and wider footprint restoration have been proven, controversy remains regarding the clinical benefits of knotless compared with knot tying techniques. Our study aims to review the available evidence in the literature comparing the clinical outcomes between knotted and knotless transosseous double-row rotator cuff repair techniques.

Methods

A systematic literature search via PubMed, Embase, and Scopus was conducted by 2 independent reviewers. Studies reporting clinical outcomes of arthroscopic rotator cuff repair using the double-row knotted and knotless surgical techniques were identified. Data were analyzed with Review Manager 5.3, using Mantel-Haenszel statistics with both fixed and random effect models.

Results

A total of 1144 studies were identified from our initial search. Based on our inclusion and exclusion criteria, 8 studies were eventually selected for our review. The selected studies were published between 2012 and 2018. Of the 8 studies, 3 reported level 2 evidence and 5 reported level 3 evidence. There were a total of 589 subjects. Our meta-analysis revealed that there were no significant differences in functional outcomes postoperatively when comparing Constant score (mean difference = −1.85, 95% confidence interval: −4.42 to 0.73), University of California at Los Angeles score (mean differences = −0.14, 95% confidence interval: −0.90 to 0.62), and American Shoulder and Elbow Surgeons score (mean differences = −2.19, 95% confidence interval: −5.55 to 1.17) between patients who underwent knotted and knotless rotator cuff repairs.

Discussions and Conclusion

Our review revealed no statistically significant difference in functional outcomes between knotted and knotless transosseous double-row techniques for arthroscopic rotator cuff repairs. To our knowledge, this is the first meta-analysis related to this topic. However, no level 1 studies were available for this review. Further studies related to this topic should focus on reporting level 1 evidence comparing the clinical outcomes of knotless and knotted techniques for double-row repairs.

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

PURPOSE

To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

RESULTS

A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; P = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; P = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; P = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; P = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; P = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, P = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; P = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; P < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; P = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; P < .001).

CONCLUSION

A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.

Does the supraspinatus tear pattern affect the results of the arthroscopic repair?

Objective  To evaluate the influence of the supraspinal tear pattern on the pre- and postoperative functional evaluations. Methods  A retrospective cohort study comparing patients with supraspinatus crescent-shaped tears versus L- or U-shaped tears. We included patients undergoing complete supraspinatus arthroscopic repair. We did not include patients with subscapularis or infraspinatus repair, those submitted to open surgery, or those in whom only partial repair was achieved. The clinical scales used were the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) and the Modified-University of California at Los Angeles Shoulder Rating Scale (UCLA), which were applied 1 week before and 24 months after the procedure. Results  We analyzed 167 shoulders (from 163 patients). In the preoperative period, the ASES scale was significantly higher in the crescent-shaped pattern (43.5 ± 17.6 versus 37.7 ± 13.8; p  = 0.034). The UCLA scale followed the same pattern (15.2 ± 4.6 versus 13.5 ± 3.6; p  = 0.028). In the postoperative period, however, there was no significant difference. According to the ASES scale, crescent-shaped tears scored 83.7 ± 18.7 points, and L- or U-shaped tears scored 82.9 ± 20.1 ( p  = 0.887). The values were 30.9 ± 4.9 and 30.5 ± 5.6 ( p  = 0.773) respectively, by the UCLA scale. Conclusion  Crescent-shaped and L- or U-shaped supraspinatus tears have similar postoperative functional results. In the preoperative period, the functional results are superior in crescent-shaped tears.

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes

Background:

Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs.

Purpose:

To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05.

Results:

A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up.

Conclusion:

Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

Factors influencing operative time in arthroscopic rotator cuff repair: a comparison of knotless single-row vs. transosseous equivalent dual-row techniques

BACKGROUND

Despite the widespread use of arthroscopic rotator cuff repair (aRCR), there remains considerable debate on the benefits of a dual-row vs. a single-row (SR) repair technique. This study compares operative time of a knotless SR technique with transosseous equivalent (TOE) dual-row technique for aRCR and defines patient-specific factors that affect operative time.

METHODS

Data from 118 patients who underwent aRCR with a knotless SR technique was compared with data from 95 patients who underwent aRCR with a TOE technique by a single surgeon between 2014 and 2018. Baseline patient demographic information and operative time were recorded and compared between the 2 groups. Subgroup analysis was performed to determine if demographic information or tear size influenced operative time.

RESULTS

The average operative time in the SR group was 75.68 minutes and the average operative time in the TOE group was 89.24 minutes (P < .001). When controlling for all concomitant procedures, the operative time in the TOE group was 8.1 minutes longer than the SR group (P = .029). Average tear size in an anterior-posterior direction was larger in the TOE group vs. the SR group, 26.09 mm vs. 15.18 mm (P < .001).

CONCLUSION

When controlling for concomitant procedures, a knotless, TOE dual-row technique for aRCR adds an average of 8 minutes' operative time compared with a knotless SR technique. This was despite a significantly larger tear size in the TOE group.

Predictive Modeling to Determine Functional Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) is one of the most commonly performed orthopaedic surgical procedures; however, patient-reported outcomes have varied greatly in the literature.

PURPOSE

To identify preoperative factors that affect outcomes and to develop prognostic tools for predicting functional outcomes in future ARCR cases.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were included who underwent ARCR for repairable full-thickness rotator cuff tears with at least 2 years of follow-up. Twelve predictors were entered as candidate predictors in each model: age, sex, workers' compensation (WC) status, previous cuff repair, tear size, tear shape, multiple-tendon involvement, tendon stump length, Goutallier classification, critical shoulder angle, length of follow-up, and baseline subjective outcomes score. Postoperative American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand), and patient satisfaction were each modeled through proportional odds ordinal logistic regression. Model results were presented with marginal covariate effect plots and predictive nomograms.

RESULTS

Overall, 552 shoulders fit inclusion criteria. The mean age at surgery was 60.2 years (range, 23-81 years). Twenty-five (4.5%) shoulders underwent revision cuff repair or reverse arthroplasty at a mean 1.9 years (range, 0.1-7.9 years) postoperatively. Overall, 509 shoulders were eligible for follow-up, and minimum 2-year postoperative patient-reported outcomes were obtained for 449 (88.2%) at a mean 4.8 years (range, 2-11 years). The ASES score demonstrated significant improvement from pre- to postoperative median (interquartile range): 58 (44.9-71.6) to 98.3 (89.9-100; P < .001). Women demonstrated significantly higher 2-year reoperation rates than men (5.8% vs 1.6%; odds ratio, 2.8 [95% CI, 0.73-9.6]; P = .023). Independently significant predictors for lower postoperative ASES scores included previous ARCR (P < .001), female sex (P < .001), and a WC claim (P < .001). Significant predictors for worse QuickDASH scores included WC claim (P < .001), female sex (P < .001), previous ARCR (P = .007), and ≥7 years of follow-up time. Significant predictors for lower SF-12 PCS scores included WC claim (P < .001), female sex (P = .001), and lower baseline SF-12 PCS. Last, significant independent predictors of patient satisfaction included previous ARCR (P = .004), WC claim (P = .011), female sex (P = .041), and age (P = .041).

CONCLUSION

Excellent clinical outcomes and low failure rates were obtained after ARCR by using careful patient selection and modern surgical techniques for ARCR. Female sex, WC claim, and previous ARCR were significant predictors of poorer outcomes in at least 3 patient-reported outcome models. Prognostic nomograms were developed to aid in future patient selection, clinical decision making, and patient education.

Does the Use of Knotted Versus Knotless Transosseous Equivalent Rotator Cuff Repair Technique Influence the Incidence of Retears? A Systematic Review

PURPOSE

To compare knotted and knotless transosseous equivalent (TOE) rotator cuff repair (RCR) techniques and evaluate their imaging-diagnosed retear rates.

METHODS

The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008 to 2019), EMBASE (2008 to 2019), and Medline (2008 to 2019) were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, with the following search terms: rotator cuff repair AND (knotless OR knotted) AND transosseous; rotator cuff repair AND (knotless OR knotted or transosseous); rotator cuff repair AND ("suture bridge" OR "suture bridging"). Data pertaining to demographic characteristics, surgical techniques, retears, and patient-reported outcomes were extracted from each study. Rates and locations of retear were reported using ranges, and risks of bias and heterogeneity for each study were assessed.

RESULTS

A total of 7 studies (552 shoulders) were included. Patients had a weighted mean (± standard deviation) age of 60.5 ± 2.4 years with 27.8 ± 7.9-month follow-up. The incidence of retears ranged from 5.1% to 33.3% in patients treated with knotless TOE RCR, and the incidence for patients treated with knotted TOE RCR ranged from 7.5% to 25%. The incidence of type I retears ranged from 42.9% to 100% for patients treated with knotless TOE RCR and 20% to 100% for patients treated with knotted TOE RCR. The incidence of type II retears ranged from 0% to 57.1% in patients treated with knotless TOE RCR and 0% to 100% in patients treated with knotted TOE RCR.

CONCLUSIONS

The incidence and location of retears after knotless and knotted TOE RCR appear to be similar.

Is it necessary to tie the medial row in rotator cuff repair double-row constructs when using suture tape?

PURPOSE

To evaluate the selected biomechanical differences of a double-row trans-osseous equivalent rotator cuff repair with a knotless versus knot-tying medial row using suture tape in regard to repair displacement, stiffness, and ultimate load to failure.

METHODS

In 16 fresh-frozen human shoulders (8 matched pairs), double-row rotator cuff repairs were performed with medial-row mattress knots (MK) on one side, the other without (NK). Two DVRT (Differential Variable Reluctance Transducer) sensors were attached between the humerus and 3 mm above the repair site and were used to measure the displacement across the repair during cycling. The biomechanical parameters measured were repair displacement, stiffness, and ultimate load to failure. The supraspinatus was loaded in a similar fashion to previously described protocol using cyclic loading and load to failure testing.¹.

RESULTS

All data from paired specimens were compared using paired Student t tests. No statistically significant difference (SSD) in displacement across the repair over the 200 cycles of the test was noted between the two groups (MK = 0.591 ± 0.501 mm; NK = 0.439 ± 0.417 mm, p = 0.618). No SSD in stiffness was noted between the two groups (MK = 32.87 ± 6.31 N/mm; NK = 27.98 ± 9.69 N/mm, p = 0.120). No SSD in ultimate load to failure was noted between the two groups (MK = 501.2 ± 126.1 N; NK = 416.8 ± 120.0 N, p = 0.116).

CONCLUSION

There was no statistically significant different between knotless versus knotted medial row double row rotator cuff repair constructs using suture tape in regard to displacement across the repair site, stiffness and ultimate load to failure. Despite previous evidence suggesting inferiority of knotless medial row technique using suture constructs, this evidence may support the biomechanical equivalency of knotless medial row technique using suture tape.

Bony Ingrowth of Coil-Type Open-Architecture Anchors Compared With Screw-Type PEEK Anchors for the Medial Row in Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To evaluate outcomes of screw-type and coil-type open-architecture suture anchors with respect to bony ingrowth, release of biological markers, and patient-reported outcome measures when used in rotator cuff repair (RCR).

METHODS

Forty patients undergoing arthroscopic RCR for full-thickness rotator cuff tears were enrolled and prospectively randomized to receive a screw-type (19 patients) or coil-type (21 patients) suture anchor for the medial row during repair. All repairs used a transosseous-equivalent configuration with footprint anchors laterally. Marrow elements released during surgery were evaluated for 9 cytokine markers (insulin-like growth factor 1, fibroblast growth factor 2, bone morphogenetic proteins 7 and 2, platelet-derived growth factors AA and BB, epidermal growth factor, transforming growth factor beta1, and vascular endothelial growth factor). Postoperative computed tomography scans were performed at 6 months. Range of motion, strength, and validated patient-reported outcome measures (Simple Shoulder Test, Single Assessment Numeric Evaluation, visual analog scale, and American Shoulder and Elbow Surgeons scores) were gathered before the operation and at 6 months and 1 year postoperatively.

RESULTS

Bone mineral density surrounding the coil-type anchor was significantly greater than that surrounding the screw-type anchor (P = .005). Bone mineral density values within the coil-type and screw-type anchors were comparable (P = .527); however, a larger amount of total bone mineral mass (in milligrams) was shown within the coil-type anchor owing to its larger volume (P < .01). Marrow elements released at the repair site were similar between groups (P > .05). Postoperatively, no statistically significant difference was found between groups for clinical outcome measures at 6 months or 1 year. Retear and complication rates were similar between groups (P > .05).

CONCLUSIONS

Both the coil-type and screw-type anchors can be reliably used for RCR and produce similar clinical outcomes. The coil-type anchor resulted in superior bony growth surrounding the anchor and a larger total bone mineral mass within the anchor owing to its larger volume.

LEVEL OF EVIDENCE

Level II, randomized prospective comparative study.

Minimum Five-year Outcomes and Clinical Survivorship for Arthroscopic Transosseous-equivalent Double-row Rotator Cuff Repair

INTRODUCTION

Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques.

METHODS

Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery.

RESULTS

One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively.

CONCLUSION

TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

A Modified SpeedBridge Technique for Retracted or Delaminated Rotator Cuff Repairs

Treatment of full-thickness rotator cuff tears vary in surgical technique dependent on the amount of retraction of the rotator cuff and/or delamination of the soft tissue. The described technique addresses both of those concerns. We present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique.

Biomechanical analysis of four different medial row configurations of suture bridge rotator cuff repair

BACKGROUND

Rotator cuff tendon rupture after suture bridge repair occasionally occurs at the medial row, with remnant tendon tissue remaining at the footprint. While concentrated medial row stress is suspected to be involved in such tears, the optimal suture bridge technique remains controversial.

METHODS

This study aimed to investigate the construct strength provided by suture bridge techniques having four different medial row configurations using artificial materials (n = 10 per group): Group 1, four-hole (two stitches per hole) knotless suture bridge; Group 2, eight-hole (one stitch per hole) parallel knotless suture bridge; Group 3, eight-hole non-parallel knotless suture bridge; and Group 4, eight-hole knot-tying suture bridge. Each construct underwent cyclic loading from 5 to 30 N for 20 cycles, followed by tensile testing to failure. The ultimate failure load and linear stiffness were measured.

FINDINGS

Group 2 had the highest ultimate failure load (mean 160.54 N, SD 6.40) [Group 4 (mean 150.21 N, SD 9.76, p = 0.0138), Group 3 (mean 138.80 N, SD 7.18, p < 0.0001), and Group 1 (mean 129.35 N, SD 4.25, p < 0.0001)]. The linear stiffness of Group 2 (mean 9.32 N/mm, SD 0.25) and Group 4 (mean 9.72 N/mm, SD 0.40) was significantly higher (p = 0.0032) than that of Group 1 (mean 8.44 N/mm, SD 0.29) and Group 3 (mean 8.61 N/mm, SD 0.31).

INTERPRETATION

In conclusion, increasing the number of suture-passed holes, arranging the holes in parallel, and a knotless technique improved the failure load following suture bridge repair.

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.

Current Concepts in Rotator Cuff Repair Techniques: Biomechanical, Functional, and Structural Outcomes

There is substantial evidence indicating that double-row (DR) repair restores more of the anatomic rotator cuff footprint and is biomechanically superior to single-row (SR) repair. Transosseous-equivalent (TOE) techniques have shown biomechanical advantages when compared with traditional DR, including increased contact at the rotator cuff footprint, higher pressure at the tendon-bone interface, and increased failure strength. Several meta-analyses of evidence level 1 and 2 studies have shown a lower rate of failed/incomplete healing when DR repair was compared with SR repair types. There is some limited evidence that TOE techniques improve healing rates in large and massive tears as compared with SR and DR. Overall, most level 1 and 2 studies have failed to prove a significant difference between SR and DR repairs in terms of clinical outcomes. However, most studies include only short-term follow-up, minimizing the impact that the higher rate of retears/failed healing seen with SR repairs can have in the long term. There are no high-quality clinical studies comparing different DR configurations, and there are currently not enough clinical data to determine the functional advantages of various DR technique modifications over one another. Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance. It is essential for the orthopaedic surgeon to know in detail the available literature to be able to apply the most appropriate and cost-effective technique in terms of healing and functional outcomes. This review provides a critical analysis of the comparative biomechanical and clinical studies among SR, DR, and TOE techniques reported in the literature in the past decade.

Arthroscopic Rotator Cuff Repair With a Knotless Suture Bridge Technique: Functional and Radiological Outcomes After a Minimum Follow-Up of 5 Years

PURPOSE

To evaluate clinical and radiological outcomes of knotless suture bridge repair after a minimum of 5 years of follow-up.

METHODS

A prospective consecutive series of full-thickness supraspinatus atraumatic chronic tears was evaluated in the study. Tears were medium or large. Further inclusion criteria were minimum clinical follow-up of 5 years with magnetic resonance imaging (MRI) at 24 months and fatty infiltration <2. Patients with shoulder stiffness, arthritis, or rotator cuff tear involving the subscapularis tendon were excluded. An arthroscopic cuff repair was performed using a knotless double-row suture bridge technique with braided suture tapes. Clinical outcomes were evaluated using the Constant score, the American Shoulder and Elbow Surgeons score, strength score, and a visual analog scale. Tendon healing was analyzed according to Sugaya MRI classification at 24 months. A Sugaya score of 1 or 2 was considered as tendon healing. Statistical analysis was performed with the Student's t-test. P = .05 were considered statistically significant.

RESULTS

Sixty-eight patients were included in this series. Mean follow-up was equal to 68.8 ± 7 months. At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons score, and Constant scores improved significantly from 5.5 ± 1.6, 48.2 ± 13.1, 37.8 ± 8.3, to 2.1 ± 2.1 (P = 5.43 E-14), 87.4 ± 15.8 (P = 7.15 E-27), and 82.8 ± 14.7 (P = 1.01 E-33), respectively. Anteflexion improved from 99.3° ± 13.4° preoperatively to 136.6° ± 15.9° at last follow-up (P = 3.08 E-21). Strength score was significantly higher postoperatively (18.4 ± 6.7 vs 8.3 ± 3.5). MRI showed 88% (n = 57) of Sugaya 1-2 repairs. Patients with unhealed rotator cuffs showed significantly lower functional results than the Sugaya 1-2 group. No correlation between degree of retraction and rate of healing was observed. Four symptomatic patients (6%) required revision for failed rotator cuff repair.

CONCLUSIONS

Despite potential confounding factors, arthroscopic knotless suture bridge repair of rotator cuff tears with acromioplasty demonstrated excellent long-term results of tendon healing, pain relief, and improvement of shoulder function.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Functional outcomes and repair integrity after arthroscopic repair of partial articular supraspinatus tendon avulsion

INTRODUCTION

Partial-thickness rotator cuff tears are a common cause of shoulder pain and disability. Arthroscopic repair is an effective treatment for partial articular supraspinatus tendon avulsion (PASTA) lesions, and transtendon repair and completion of the tear and repair are the surgical techniques commonly used to treat such lesions. Our aim was to retrospectively evaluate the minimum 24-month clinical and radiological results of PASTA.

MATERIALS AND METHODS

Patients suffering from PASTA lesion who underwent arthroscopic repair with a minimum 24-month follow-up were included in this study. The Constant and Murley score (CMS) was used to assess the patients' functionality pre- and postoperatively. The postoperative patient assessment included the simple shoulder test (SST). Postoperative tendon integrity was evaluated by ultrasound examination.

RESULTS

151 patients (153 shoulders) were retrospectively evaluated 73.9 (24-142) months after a completion-repair (94 cases) or transtendon repair (59 cases) of a PASTA lesion. The CMS significantly improved from 47.7 (22-63) preoperatively to 84.2 (62-100) postoperatively (p < 0.001). The mean postoperative SST score was 10.1 (5-12), and 95% of patients were satisfied with the surgery. No significant differences were noted between the two techniques in terms of postoperative CMS, SST score and satisfaction. Seventy-four and 43 cases treated with completion and repair and transtendon repair, respectively, performed ultrasound examination 66.1 (24-142) months after surgery. The overall retear rate was 13.7%, supraspinatus retears were observed in ten shoulder subjected to completion and repair (13.5%) and six shoulders subjected to transtendon repair (13.9%), and no significant differences were noted between the two techniques as for CMS (p = 0.896), SST (p = 0.973), satisfaction (p = 0.621) and retear (p = 0.999). Males and younger patients had a higher postoperative CMS (p values < 0.001), and SST score (p < 0.001 and p = 0.038, respectively).

CONCLUSIONS

Arthroscopic repair of PASTA lesion achieves high rates of repair integrity regardless of repair type and high levels of functional recovery and patient satisfaction 6 years after surgery.

Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome

INTRODUCTION

Arthroscopic superior capsule reconstruction (ASCR) using fascia lata autograft is a new surgical technique developed to overcome irreparable rotator cuff tears. There is little information about graft tear after ASCR and its impact on clinical outcome. This study is to investigate the graft tear rate, pattern of failure, and its correlation with clinical outcomes after arthroscopic superior capsule reconstruction (ASCR).

MATERIALS AND METHODS

From June 2013 to June 2016, 31 shoulders in 31 consecutive patients (mean 65.3 years) underwent ASCR using fascia lata autograft for irreparable large-to-massive tears. Magnetic resonance imaging (MRI) was performed before surgery and at mean 12.8 months (12-24 months) after surgery to assess fatty infiltration progression and graft integrity. Graft tear was defined as the loss of graft continuity and was categorized as medial and lateral rows according to the failure location. Acromiohumeral distance (AHD) was pre- and postoperatively measured with the standard radiograph. Pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, and physical examination were used to assess clinical outcomes. Average follow-up was 15 months (range 12-24 months) after surgery.

RESULTS

Mean active forward elevation increased from 133° to 146° (P = 0.011). Mean VAS score, ASES score, and constant score significantly improved: from 6 to 2.5, 54.4 to 73.7, and 51.7 to 63.7, respectively (P < 0.001). There was no remarkable progression of fatty infiltration after surgery. AHD increased from 5.3 mm preoperatively to 6.4 mm postoperatively (P < 0.016). Nine patients (29%) showed graft tear on follow-up MRI: 7 and 2 at the medial and lateral rows, respectively. Although the intact graft group showed better outcomes than the graft tear group (pain VAS score 2.3 vs. 3.0; ASES score 74.1 vs. 69.8; constant score 63.4 vs. 57.9), the results were not statistically significant.

CONCLUSIONS

Graft tear rate after ASCR assessed by MRI was 29%, and failures mostly occurred at the medial row. The graft tear group showed clinical improvement despite the recurred superior capsule defect.

LEVEL OF EVIDENCE

IV, case series, treatment study.

Performance of PROMIS Global-10 Compared With Legacy Instruments for Rotator Cuff Disease

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was recently developed to assess physical and mental health and provide an estimated EuroQol-5 Dimension (EQ-5D) score. This instrument needs to be validated for specific patient cohorts such as those with rotator cuff pathology.

HYPOTHESIS

There is moderate to high correlation between the PROMIS Global-10 and legacy patient-reported outcome measures; PROMIS Global-10 will not show ceiling effects; and estimated EQ-5D scores will show good correlation and low variance with actual EQ-5D scores.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

A total of 323 patients with rotator cuff disease were prospectively enrolled before treatment. Each patient completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES) shoulder assessment form, and Single Assessment Numeric Evaluation (SANE), and those with known rotator cuff tears completed the Western Ontario Rotator Cuff Index (WORC). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were assessed, defined as ≥15% respondents with highest or lowest possible score.

RESULTS

Correlation between the PROMIS Global-10 and EQ-5D was excellent (0.70, P < .0001). Correlation of the PROMIS physical scores was excellent-good with the ASES (0.62, P < .0001), good with the WORC (0.47, P < .0001), and good with the SANE (0.41, P < .0005). Correlation between the PROMIS mental scores was poor with the ASES (0.34, P < .0001), the WORC (0.32, P = .0016), and the SANE (0.24, P < .0001). No floor or ceiling effects were found. Agreement analysis showed substantial variance in individual scores, despite the overall similarity in mean scores between the estimated and actual EQ-5D scores, indicating poor agreement. Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 34% below to 31% above actual EQ-5D scores.

CONCLUSION

Physical function scores of the PROMIS Global-10 show high correlation with legacy patient-reported outcome instruments, suggesting that it is a reliable tool for outcome assessment in a population with rotator cuff pathology. The large variability in 95% limit of agreement suggested that the estimated EQ-5D scores from the PROMIS Global-10 cannot replace traditional EQ-5D scores.

Clinical outcomes and repair integrity of arthroscopic rotator cuff repair using suture-bridge technique with or without medial tying: prospective comparative study

Background

There have been few studies comparing clinical and radiological outcomes between the conventional and knotless suture-bridge techniques. The purpose of this study was to evaluate and compare the functional outcomes and repair integrity of arthroscopic conventional and knotless suture-bridge technique for full-thickness rotator cuff tears.

Methods

We prospectively followed 100 consecutive patients (100 shoulders) with full-thickness rotator cuff tears treated with the arthroscopic conventional or knotless suture-bridge technique from October 2012 to July 2014. Enrolled patients returned for follow-up functional evaluations at 1 and 2 years after the operation. There were four outcome measures in this study: American Shoulder and Elbow Surgeons (ASES) scores, Shoulder Rating Scale of the University of California at Los Angeles (UCLA) scores, Constant scores, and visual analog scale (VAS) pain scores. Enrolled patients returned for follow-up magnetic resonance imaging or ultrasonography evaluation to confirm the integrity of the repaired cuff at 6 months post-operation (97% follow-up rate). Also, we investigated the preoperative cuff retraction of enrolled patients using preoperative MRI to find out correlation between the stage of cuff retraction and re-tear rate.

Results

At final follow-up, the average UCLA, ASES, Constant, and VAS scores had improved significantly to 32.5, 88.0, 80.4, and 1.3, respectively, in the conventional suture-bridge technique group and to 33.0, 89.7, 81.2, and 1.2, respectively, in the knotless suture-bridge technique group. The UCLA, ASES, Constant, and VAS scores improved in both groups after surgery (all p < 0.001), and there were no significant differences between the two groups at 2-year follow-up (p = 0.292, 0.359, 0.709, and 0.636, respectively). The re-tear rate of repaired rotator cuffs was 16.3% (8/49 shoulders) in the conventional suture-bridge technique group and 29.2% (14/48 shoulders) in the knotless suture-bridge technique group; this difference was not significant (p = 0.131). There were no significant differences between the re-tear rate of the two groups in the Patte stage I and II (p = 0.358 and 0.616).

Conclusions

The knotless suture-bridge technique showed comparable functional outcomes to those of conventional suture-bridge techniques in medium-to-large, full-thickness rotator cuff tears at short-term follow-up. The knotless suture-bridge technique had a higher re-tear rate compared with conventional suture-bridge technique, although the difference was not significant.

Obesity causes poorer clinical results and higher re-tear rates in rotator cuff repair

BACKGROUND

The purpose of this retrospective study was to report on the functional outcome after both open and arthroscopic rotator cuff (RC) repair in normal weight, pre-obese and obese patients. It was hypothesized that obesity is a negative prognostic factor for clinical outcome and failure for the RC repair.

METHODS

One hundred and forty-six patients who underwent either open or arthroscopic rotator cuff repair between 2006 and 2010 were included in this study. Seventy-five patients (56.7 ± 10.1 years of age) after open RC repair and 71 patients (59.0 ± 9.1 years of age) treated arthroscopically were available for evaluation. In both groups a double-row reconstruction was performed. Patients were divided in three groups according to their body-mass index. The mean follow-up was at 43 ± 16 (minimum 24) months. At follow-up, the clinical outcome was assessed by the DASH and Constant score. An ultrasound of both shoulders was performed in all patients.

RESULTS

The mean BMI was 28.3 ± 5.3 in the arthroscopic group and 27.7 ± 4.3 in the open group. Overall, in both groups similar clinical results were noted [Constant-Murley score 78.3 ± 18.2 arthroscopic vs. 77.0 ± 21.8 for open surgery; DASH 12.7 ± 18.2 arthroscopic vs. 15.6 ± 21.6 for open surgery (p = 0.81)]. Both the failure rate and the clinical outcome were significantly worse for obese patients (BMI > 30, p = 0.007). The failure rate was 15.8% for the normal-weight patients, 8.2% in the pre-obese group and in the obese group 28.6%. The RC repair failure occurred in 11 cases in both groups after arthroscopic or open treatment (15.0%).

CONCLUSIONS

Both the arthroscopic and the open approach showed equivalent clinical results and failure rates. Obesity (BMI > 30) causes less favorable results in the Constant and DASH scores and showed higher re-tear rates.