Single-row repair versus double-row repair of full-thickness rotator cuff tears

The High Resistance Loop (H-Loop) Technique for Arthroscopic Repair of Subscapularis

The subscapularis tendon is more challenging and riskier to repair than the posterior upper rotator cuff. The knotless anchor suture in subscapularis repair simplified the repair process and had an excellent postoperative effect. We describe a new knotless anchor stitching method, the H-Loop technique. The simplicity and efficiency of the technique make it particularly suitable for small subscapular tendon tears.

Similar Healing Rates of Arthroscopic Rotator Cuff Repair With and Without Bone Marrow Stimulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) techniques such as microfracture, nanofracture, and the crimson duvet procedure expose the bone marrow of the proximal humerus to the rotator cuff tendon footprint. The effect of performing BMS on tendon healing is a subject of interest.

PURPOSE

To compare studies on arthroscopic rotator cuff repair with BMS versus without BMS for rotator cuff tears according to healing rates and clinical and radiological outcomes.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 2.

METHODS

The 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in conducting a search. Studies that compared arthroscopic rotator cuff repair with and without BMS were included if they provided postoperative patient-reported outcomes and healing rates. Dichotomous outcomes were expressed as mean differences (MDs), while continuous outcomes were expressed as odds ratio.

RESULTS

Included were 5 studies (N = 499 shoulders); 4 studies had level 1 evidence, and 1 study had level 2 evidence. The healing rate of rotator cuff repair was similar between the 2 groups (ie, with and without BMS) (odds ratio, 1.58 [95% CI, 0.63 to 4.00]; P = .33). Furthermore, there were no significant differences in the postoperative Constant score (MD, 1.41 [95% CI, -0.58 to 3.39]; P = .16), American Shoulder and Elbow Surgeons score (MD, 0.77 [95% CI, -1.43 to 2.96]; P = .49), or range of motion for forward flexion (MD, 2.45 [95% CI, -0.66 to 5.57]; P = .12) and external rotation (MD, 0.81 [95% CI, -2.35 to 3.97]; P = .62) at the final follow-up between the 2 groups.

CONCLUSION

The healing rate of rotator cuff repair was similar, regardless of whether BMS was performed or not. Additionally, there was no significant difference in postoperative patient-reported outcome scores, range of motion, and complications.

REGISTRATION

CRD42023388427 (PROSPERO).

Comparison of Arthroscopic Single-row and Double-row Repair for Rotator Cuff Injuries With Different Tear Sizes: A Systematic Review and Meta-analysis

Background

There is no clinical gold standard for the indications for single-row (SR) versus double-row (DR) repair according to small, large, or massive rotator cuff tear size.

Purpose

To conduct a meta-analysis to compare the clinical outcomes and retear rates after arthroscopic SR and DR repair for rotator cuff injuries with different tear sizes.

Study Design

Systematic review; Level of evidence, 3.

Methods

On the basis of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, the PubMed, Embase, Cochrane Library databases, Web of Science, China National Knowledge Infrastructure, and China BioMedical Literature database were searched for relevant studies published before November 1, 2021, using the following search terms: "Rotator Cuff Injuries," "Rotator Cuff Tears," "Arthroscopy," "Arthroscopic Surgery," "single-row," and "double-row"; a total of 489 articles were retrieved. Quality evaluation was conducted for all the studies that met the inclusion criteria. This study evaluated the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, and range of motion (ROM) as well as retear rate. A fixed-effects or random-effects model was adopted to calculate the results and assess risk.

Results

A total of 10 clinical studies were included, with 404 cases of DR and 387 cases of SR. Regarding overall results, DR had better forward elevation ROM (mean difference [MD] = -4.03° [95% CI, -6.00° to -2.06°]; P < .0001; I 2 = 46%) and a lower retear rate (MD = 2.39 [95% CI, 1.40 to 4.08]; P = .001; I 2 = 0%) compared with SR repair. With regard to small tears (<3 cm), there was no noticeable difference on any of the 3 outcome scores between SR and DR. For large rotator cuff tears (≥3 cm), DR repair showed significantly better ASES scores (MD = -3.09 [95% CI, -6.19 to 0.02]; P = .05; I 2 = 73%) and UCLA scores (MD = -1.47 [95% CI, -2.21 to -0.72]; P = .0001; I 2 = 31%) compared with SR repair.

Conclusion

Our meta-analysis revealed that DR had better UCLA scores, ASES scores, and ROM in forward elevation and lower retear rates. In rotator cuff tears <3 cm, there were no statistical differences in clinical outcome between SR and DR.

Blended Suture-bridge Technique for Arthroscopic Rotator Cuff Repair

Techniques in rotator cuff repair are constantly evolving, with the main goal of a biologic, stable, and tension-free construct. Significant controversy exists between various methods, and there is no gold standard surgical protocol. We demonstrate an alternative arthroscopic rotator cuff repair technique with 2 key components. First, we performed a transosseous equivalent, suture bridge technique with a combination of triple-loaded medial anchors and knotless lateral anchors. Second, we incorporated 2-strand and 3-strand suture shuttling through the torn rotator cuff and selective medial knot-tying. A total of 6 passes through the tendon are made, comprising 1-2-3-3-2-1 strands each pass. This minimizes the number of passes through the tendon and the overall number of medial knots. Our technique retains the known biomechanical advantages akin to a double-row repair, including less gap formation and wider footprint coverage. In addition, using fewer medial knots with efficient suture passing may result to decreased cuff strangulation and favorable biologic environment for tendon healing. We theorize that this technique may yield lower retear rates while maintaining immediate stability, translating to improved clinical results.

Accuracy of the rotator cuff reparability score

BACKGROUND

The reparability of large or massive rotator cuff tears is difficult to determine pre-operatively. We previously identified age ≥ 65 years, acromiohumeral interval ≤ 6 mm, and anteroposterior tear size ≥ 22 mm as risk factors for rotator cuff repair failure. We therefore developed a rotator cuff reparability score where each of the above risk factors is assigned a score of one point.

AIM

To determine the accuracy of a rotator cuff reparability score.

METHODS

This was a retrospective cohort study of recruited patients with large or massive rotator cuff tears treated at our institution between January 2013 and December 2019. Exclusion criteria were revision surgery and patients with contraindications for surgery. All patients underwent arthroscopic rotator cuff repair and were categorized into either complete or partial rotator cuff repair. Rotator cuff reparability scores were calculated for each patient. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were assessed. A receiver operating characteristic curve was plotted to determine the optimal cut-off rotator cuff reparability score.

RESULTS

Eighty patients (mean age, 61 years; range, 25–84 years; 41 females and 39 males) were recruited. Intra- and inter-observer reliabilities were good to excellent. The number of patients with 0, 1, 2, and 3 risk factors for rotator cuff repair failure were 24, 33, 17, and 6, respectively. Complete repair was performed in all patients without risk factors. Two of the 33 patients with one risk factor and seven of the 17 patients with two risk factors underwent partial repair. One of the six patients with three risk factors underwent complete repair. The area under the curve was 0.894. The optimal cut-off score was two points with a sensitivity of 85.71% and a specificity of 83.33%.

CONCLUSION

A rotator cuff reparability score of two was determined to be the optimal cut-off score for predicting the reparability of large or massive rotator cuff tears.

Transosseous-Equivalent/Suture Bridge Arthroscopic Rotator Cuff Repair in Combination With Late Postoperative Mobilization Yield Optimal Outcomes and Retear Rate: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single-row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR.

METHODS

The literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized SSR-early trials (RCTs) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early vs late postoperative range of motion. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score.

RESULTS

Twenty-eight studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.08-0.46) and DRR-late (OR, 0.25; 95% CI, 0.12-0.52) were found to significantly reduce the rate of retear, with TOE/SB-late resulting in the highest P-score for the American Shoulder and Elbow Surgeons (P-score: 0.7911) score and retear rate (P-score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared with the control.

CONCLUSIONS

The current study suggests that rotator cuff repair using the TOE/SB technique and late postoperative mobilization yields the highest functional outcomes and lowest retear rate in the arthroscopic management of symptomatic rotator cuff tears.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I studies.

A comparison of simple and complex single-row versus transosseous-equivalent double-row repair techniques for full-thickness rotator cuff tears: a systematic review and meta-analysis

Background

Methods

Conclusion

Increased acromiohumeral distance in a double-row arthroscopic rotator cuff surgery compared to a single-row surgery after 12 months

Background

Arthroscopic rotator cuff surgery is an effective treatment for rotator cuff tears with the considered use of double-row repair techniques becoming popular in the last decade. We aim to compare the effects of double- and single-row arthroscopic rotator cuff repairs (ARCR) on repair integrity (RI) and acromiohumeral distance (AHD).

Methods

In this observational study, we retrospectively identified 98 patients with degenerative rotator cuff tear treated with arthroscopic rotator cuff repair between 2016 and 2019. We excluded 22 patients with partial-thickness tears, 15 with associated subscapularis or SLAP tears, 13 with massive tears, and 5 patients lost to follow-up; we included 43 patients who had ARCR for full-thickness cuff tear and clinical, radiologic follow-up. Of these 43 patients, 23 are grouped as double-row repair group (DRG) and 20 as single-row repair group (SRG). A minimum of 12 months after the surgery, bilateral shoulder MRIs were obtained. Contralateral shoulders without asymptomatic rotator cuff tears served as a control group (CG). The operating surgeon and two other surgeons experienced in arthroscopy blindly measured the AHD and determined the RI at the control MRIs in all groups. Functional assessments relied on UCLA and qDASH Scores.

Results

The mean age was 57.89 (45–78) years, and the mean follow-up time was 28,65 (21–43) months. The mean AHD of the CG was 9.7 ± 0.96 mm, the preoperative AHD of DRG was 8.62 ± 1.45 mm, and SRG was 9.71 ± 0.95 mm. The postoperative mean AHD of DRG 9.61 ± 1.83 mm and SRG was 10.21 ± 1.97 mm. AHD differences between the preoperative and postoperative groups were significant (P=0.009). The increase of the AHD in the double-row group was significantly higher than the single-row group (P=0.004). There was a high correlation between the RI and DASH scores (P=0.005). RI did not correlate with the repair method (P=0.580).

Conclusion

Although double-row repairs can maintain greater AHD than single-row repairs in the clinical setting, this difference did not affect functional results. Regardless of the surgical intervention, functional results are favourable if RI is achieved.

Level of evidence

Level III, Retrospective Cohort Study

Fixationssysteme und Techniken zur arthroskopischen Rotatorenmanschettenrekonstruktion

Arthroskopische Rotatorenmanschettenrekonstruktionen wurden initial mit einer einreihigen („single row“) Technik beschrieben. Im Rahmen technischer Weiterentwicklungen der arthroskopischen Chirurgie wurden diverse Techniken zur zweireihigen („double row“), transossären und transossär-äquivalenten Sehnenfixation entwickelt, nicht zuletzt durch eine zunehmende Verbreitung knotenloser Anker. Die klinischen Ergebnisse zeigen keine relevanten Unterschiede zwischen den jeweiligen Techniken. Biomechanisch sind zweireihige Rekonstruktionen jedoch durch Vergrößerung der Kontaktfläche an der Insertionsstelle und der erreichten Stabilität überlegen, insbesondere mit medial geknoteten Fäden, welche in eine laterale Reihe als sog. Suture-Bridge abgespannt werden. Klassischerweise wurden Schraubanker aus Metall für eine arthroskopische Sehnenfixierung verwendet. Im Laufe der letzten Jahre wurde das Anker-Portfolio jedoch durch moderne bioresorbierbare und nichtresorbierbare (PEEK) Schraub- und Einschlaganker sowie auch um reine Fadenanker (All-suture) erweitert. Ein allgemeingültiger Goldstandard für die Ankerverwendung existiert bis dato nicht, wobei die meisten gängigen Anker – zumindest bei guter Knochenqualität – ausreichende Stabilität gewährleisten. Beim Nahtmaterial kam es ebenso zu relevanten Weiterentwicklungen, sodass dem Versagen der Nähte heutzutage weniger Bedeutung zukommt. Das Aufkommen von bandartigem Nahtmaterial (Tapes) konnte in diversen biomechanischen Studien seine Überlegenheit nachweisen, jedoch ist bei geknoteten Techniken mit Tapes aufgrund des womöglich negativen Einflusses durch größere Knoten Vorsicht geboten. Nicht zuletzt ist die mediale Stichposition möglichst nahe des Rotatorenkabels von großer Bedeutung, da der häufigste Versagensmechanismus einer Rotatorenmanschettenrekonstruktion mit modernem Naht- und Ankermaterial weiterhin ein Hindurchschneiden der Fäden durch das vorgeschädigte Sehnengewebe ist.

Update on all-arthroscopic vs. mini-open rotator cuff repair: A systematic review and meta-analysis

Purpose

To provide an updated comparison between modern arthroscopic and mini-open repairs for treating rotator cuff tears.

Methods

Multiple online databases were searched from 2010 to October 1st, 2020. A meta-analysis was conducted for patient-reported outcomes and complications.

Results

Eleven studies were included. Majority of patients underwent mini-open repair (MOR) compared to arthroscopic repair (AR) (57.4% vs 42.6%). A meta-analysis found statistically significant differences (p < 0.05) in patient-reported outcomes favouring AR. While retear rates were higher in AR (p = 0.03) analysis of retear rates for arthroscopic double row and mini-open repairs, yielded no differences between groups (p = 0.48).

Conclusion

Patients undergoing AR for rotator cuff tears had improved post-operative clinical outcomes in some functional outcomes compared to MOR. Modern arthroscopic double row repair result in similar failure rates to open repair techniques.

Level of evidence

Level III, Systematic Review of Level I-III studies.

Arthroscopic Rotator Cuff Repair: A Systematic Review of Overlapping Meta-Analyses

BACKGROUND

Rotator cuff tears are a common pathology, with an increasing number of repairs being performed arthroscopically. The purpose of this study was to systematically review the results in the current meta-analyses on arthroscopic rotator cuff repair, looking specifically at double-row repair compared with single-row repair, at whether platelet-rich plasma should be used adjunctively at the time of the surgical procedure, and at the effects of early-motion compared with late-motion rehabilitation postoperatively.

METHODS

MEDLINE, Embase, and the Cochrane Library were screened for meta-analyses on arthroscopic rotator cuff repair. The levels and quality of the evidence were assessed, and the clinical outcomes were evaluated. A significant result was defined as p < 0.05.

RESULTS

Twenty-four meta-analyses were identified, with 10 meta-analyses on double-row repair compared with single-row repair, 7 meta-analyses on platelet-rich plasma compared with a control, and 7 meta-analyses on early motion compared with late motion. Studies found a significant result in terms of reduced retear rates and/or increased tendon-healing rate for double-row repair (6 of 10 studies; p < 0.05), without a clinically important improvement in functional outcomes (0 of 10 studies). There was a favorable outcome when using platelet-rich plasma in small-to-medium tears in terms of a reduced rate of retear (4 of 4 studies; p < 0.05). However, in the 1 study in which platelet-rich plasma was stratified into pure platelet-rich plasma and platelet-rich fibrin matrix preparation, there was a significantly lower retear rate for tears of all sizes with platelet-rich plasma and not with platelet-rich fibrin (p < 0.05). Range of motion was shown to be significantly better with early motion (5 of 6 studies; p < 0.05) in the majority of the meta-analyses, without an increased risk of retear (6 of 6 studies; p > 0.05).

CONCLUSIONS

The highest Level of Evidence and the highest-quality studies all supported the use of double-row repair, adjunctive platelet-rich plasma, and early-motion rehabilitation postoperatively in arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review

BACKGROUND

The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years.

PURPOSE

To systematically review the literature on the outcomes of RCR among patients ≥70 years old.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included.

RESULTS

Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs (P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively.

CONCLUSION

RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.

Medialization of medial row anchor via the Nevasier portal yield enhanced footprint and outcomes in medium-to-large rotator cuff tears

PURPOSE

To evaluate clinical and radiological outcomes of medial row anchor insertion between 90° or 45° (deadman) angle in the suture-bridge rotator cuff repair of medium-to-large rotator cuff tears.

METHODS

This retrospective analysis included 113 consecutive patients undergoing arthroscopic suture-bridge repair for medium-to-large rotator cuff tears (mean tear size: 2.8 × 2.3 cm) between 2010 and 2013. The patients were divided into two groups: group I (53 patients) and group II (60 patients) involving 90° and 45° medial row anchors, respectively. The conventional lateral row anchors were inserted in the suture-bridge repair. The clinical outcomes at 2 years and radiological outcomes including re-tear or footprint coverage (anteroposterior length and mediolateral width) of the repaired tendon using postoperative MRI were evaluated.

RESULTS

Clinical outcome scores were significantly improved in both groups. However, Group I (90° anchor insertion group) showed better clinical scores without the difference of range of motion. The postoperative MRI revealed enlarged footprint coverage with 90° medial row anchor. The repaired footprint cuff size (mediolateral width) in the coronal plane MRI showed a statistically significant difference (45°: 19 mm vs. 90°: 24 mm) (p < 0.05).

CONCLUSIONS

Enhanced clinical outcomes and additional anatomical footprint coverage (coronal width of repaired tendon) in the suture-bridge repair are obtained with the 90° medial row anchors compared with the 45° medial row anchors. These findings would guide clinical application of 90° medial row anchor insertion for further medialization in the medium-to-large rotator cuff tears.

LEVEL OF EVIDENCE

Level III (retrospective comparative trial).

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.

Pre-operative factors correlated with arthroscopic reparability of large-to-massive rotator cuff tears

Background

The purpose of this study is to determine the pre-operative factors that are associated with reparability of the large-sized and massive rotator cuff tears.

Methods

Sixty-six patients were included in this prognostic study. Demographic data, radiographic and MRI parameters were collected. Arthroscopic rotator cuff repair was performed for all included patient. Complete rotator cuff repair was achieved when the tendon covered up at least 50% of the anatomical footprint. The receiver operating characteristic (ROC) curve was analysed to define the cut-off level of each significant factor.

Results

Eleven large-sized rotator cuff tears and fifty-five massive rotator cuff tears were defined from MRI. Fifty-four patients were in the complete repair group, and twelve patients were in the partial repair group. The mean duration between MRI and surgery of 5.5 weeks. Reparability was correlated with age, mediolateral (ML) and anteroposterior (AP) tear size, rotator cuff arthropathy, superior migration of humeral head, fatty infiltration and atrophy of the supraspinatus muscle, and fatty infiltration of infraspinatus muscle (p < 0.05). The ROC curve defined a cut-off level of each predicting factor which included age of ≥65 years, mediolateral tear size of ≥36 mm, anteroposterior tear size of ≥22 mm, Hamada’s rotator cuff arthropathy of ≥class2, acromiohumeral interval of ≥6 mm, ≥stage3 supraspinatus fatty infiltration, the presence of supraspinatus muscle atrophy, and ≥ stage1 infraspinatus fatty infiltration. In multivariated regression analysis, age, acromiohumeral interval, and anteroposterior tear size were statistically associated with the reparability. The intra- and inter-observer reliabilities were moderate to excellent.

Conclusion

Age, ML tear size, AP tear size, rotator cuff arthropathy, superior migration of humeral head, fatty infiltration of supraspinatus and infraspinatus muscles and supraspinatus muscle atrophy all correlate with reparability of large to massive rotator cuff tear.

The Clinical Effect of Arthroscopic Rotator Cuff Repair techniques: A Network Meta-Analysis and Systematic Review

Rotator cuff tears are common and are associated with shoulder pain, disability, and dysfunction. Previous studies that have reported different arthroscopic techniques are controversial. A network meta-analysis with indirect and direct evidence was performed to compare the effectiveness of arthroscopic techniques for the treatment of rotator cuff tears. PUBMED, the Cochrane Register of Controlled Trials, EMBASE and Scopus were searched based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and related studies that evaluated arthroscopic techniques for the treatment of rotator cuff tears were identified in May 2018. The primary outcome measure was the retear rate. The secondary outcome measures included the constant score and the range of motion (forward flexion and external rotation). Twenty-one trials comprising 1815 shoulders were included in the study. This study indicated that single-row (SR) repair resulted in a higher retear rate than suture bridge (SB) and double-row (DR) repairs. Moreover, the SR and DR repairs resulted in higher incidences of retear than SB repair. The ranking of the treatments based on the constant score and external rotation was SB repair, SR repair and DR repair, whereas the treatment ranking according to forward flexion was SB repair, DR repair and SR repair. In summary, this network meta-analysis provides evidence that SB repairs might be the best choice to improve the postoperative recovery of function and decrease the retear rate.

Tear characteristics and surgeon influence repair technique and suture anchor use in repair of superior-posterior rotator cuff tendon tears

BACKGROUND

The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used.

METHODS

Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used.

RESULTS

A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair.

CONCLUSIONS

Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods.

The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff

Background

Platelet rich plasma (PRP) is widely used in rotator cuff repairs but its effect on the healing process is unclear. Several cell culture studies on the effect of allogenic PRP have reported promising results but are not transferable to clinical practice.

The aim of the present study is to assess the possible effect of autologous PRP on rotator cuff tendon cells. The amount of growth factors involved with tendon-bone healing (PDGF-AB, IGF-1, TGF-β1, BMP-7 and -12) is quantified.

Methods

Rotator cuff tissue samples were obtained from (n = 24) patients grouped by age (>/< 65 years) and sex into four groups and cells were isolated and characterized. Later, autologous PRP preparations were obtained and the effect was analyzed by means of cell proliferation, collagen I synthesis and expression of collagen I and III. Furthermore, the PRPs were quantified for growth factor content by means of platelet-derived growth factor (PDGF-AB), insulin-like growth factor (IGF-1), transforming growth factor (TGF-β1), as well as bone morphogenetic protein (BMP) -7 and − 12.

Results

Cell proliferation and absolute synthesis of collagen I were positively affected by PRP exposure compared to controls (p < 0.05), but expression and relative synthesis of collagen I (normalized to cell proliferation) were significantly reduced.

PRP contained high amounts of IGF-1 and lower levels of TGF-β1 and PDGF-AB. The amounts of BMP-7 and -12 were below the detection limits.

Conclusions

PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect on the human rotator cuff tenocytes of the same individual in vitro by means of cell proliferation and absolute, but not relative collagen I synthesis.

These results encourage further studies on clinical outcomes with more comparable standards in terms of preparation and application methods.

Level of evidence

Controlled laboratory study.

Bone marrow-stimulating techniques in arthroscopic rotator cuff repair: a systematic review protocol

INTRODUCTION

Bone marrow-stimulating (BMS) techniques during arthroscopic rotator cuff repair surgery theoretically enhance the biological component for healing and hence improve tendon healing, but their efficacy remains unproven. The purpose of this review is to determine the effects and associated harms of BMS in arthroscopic rotator cuff repair surgery.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis of randomised-controlled trials (RCTs) and retrospective cohort studies (RCS) that compare outcomes following BMS use against no use of BMS during arthroscopic rotator cuff repair surgery. We will search the databases including the Cochrane Central Register of Controlled Trials, Medline and Embase, and clinical trial registries for relevant studies. We will include studies published from start of indexing until 23 August 2018. Two reviewers will independently assess the eligibility for studies. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will use the Cochrane Collaboration tool to assess the risk of bias of included RCTs, while we will use the Risk Of Bias In Non-randomised Studies - of Interventions tool to evaluate the risk of bias of RCS. We will perform a random-effects meta-analysis in calculating the pooled risk estimates when appropriate. We will assess the overall quality of the data for each individual outcome using the Grading of Recommendations, Assessments, Development and Evaluation approach. The primary outcomes are tendon healing rate, overall pain and shoulder functions. The secondary outcomes are the proportion of participants with adverse events related to interventions, the range of motion and the proportion of participants with return to previous activities.

ETHICS AND DISSEMINATION

We will report this review according to the guidance of the PRISMA statement. The results of this review will be disseminated through conference presentations and publications in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42018087161.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Does structural integrity following rotator cuff repair affect functional outcomes and pain scores? A meta-analysis

BACKGROUND

To assess whether the integrity of rotator cuff repairs has an impact on functional outcomes, as well as pain scores, after surgery.

METHODS

Systematic review and meta-analyses performed for Level Ι, ΙΙ and ΙΙΙ studies that presented functional outcome scores and radiological assessment of integrity following rotator cuff repair. Extracted data included patient demographics, functional outcome scores [Constant Score, University of California at Los Angeles (UCLA) shoulder score, American Shoulder and Elbow Surgeons (ASES) shoulder score, visual analogue scale (VAS) Pain score], as well as assessment of repair integrity on radiological investigations. A meta-analysis was performed using weighted means and a random effects model.

RESULTS

Twelve studies were included in the final analysis. Average re-tear rate for the 800 included patients was 22% at a mean follow-up of 27.5 months after surgery. Patients with intact repairs had a significantly higher Constant Score (8.61 points, p < 0.00001), UCLA shoulder score (2.96 points, p < 0.0001) and ASES shoulder score (9.49 points, p < 0.0006). Patients with intact repairs also reported lower pain VAS Pain scores by 0.62 points (p < 0.0004).

CONCLUSIONS

Our results show better functional outcome and pain scores in patients with intact rotator cuffs at follow-up when compared to those that have re-torn. This difference is equivalent to the published Minimal Clinically Important Difference for the ASES but not Constant Scores. This review has also highlighted that shoulder strength in patients with intact cuff repairs is likely to be greater than in patients with a failed repair.

Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and meta-analysis study

PURPOSE

The purpose of this study is to perform a systematic review and meta-analysis of all available level I prospective randomized controlled trials comparing arthroscopic single-row (SR) with double-row (DR) rotator cuff repairs by both clinical outcomes and radiological re-tear rates.

METHODS

PubMed, EMBASE, Google Scholar, and Cochrane databases search was done for level I RCTs comparing clinical and radiological outcomes after SR versus DR rotator cuff repair. Clinical outcomes included UCLA, ASES, Constant, WORC, and SANE scores; structural outcomes included MRI, MRA, or US.

RESULTS

Seven level I studies were included (5 mid-term and 2 short-term). Postoperative ASES, Constant, WORC, and SANE scores showed nonsignificant slightly better function of DR groups. Only, UCLA score showed significantly better scores with DR repair (p = 0.007). Full-thickness re-tear incidence was reported in 15/174 (8.6%) in DR group and 20/175 (11.4%) in SR group (p = 0.44). Partial-thickness re-tear rate was reported in 18/174 patients (10.3%) in DR group and 41/175 patients (23.4%) in SR group (p = 0.009).

CONCLUSION

Within the domain of level I mid-term and short-term studies, DR repair showed significant better UCLA score only. (ASES, Constant, WORC, and SANE scores showed no significance.) This may correlate weakly with the significant lower partial-thickness re-tear rates of DR repairs. In contrary, long-term level III studies showed a direct correlation of both functional outcomes and cuff structural integrity, with significant superiority of DR over SR repair techniques.

LEVEL OF EVIDENCE

Level 1, systematic review and meta-analysis.

[Arthroscopic rotator cuff surgery : New and established methods]

This present article summarizes established and current developments and aspects of rotator cuff surgery. Achieved milestones as well as current approaches are presented and assessed with respect to their clinical and radiographic impact. Despite biomechanical and technical improvements in modern rotator cuff repair techniques, re-defect and re-tearing rates could not be fully eliminated. Meanwhile, the importance of biological processes around successful tendon-bone reintegration has been increasingly recognized. Hence, this article presents the current scientific standing regarding biological growth factors, platelet-rich plasma and rotator cuff augmentation techniques (with allogenic/autologous grafts). In summary, there are clear biomechanical advantages as well as many promising approaches to biological augmentation; however, the latter have not yet been transferred into regular clinical application.

Repair of rotator cuff injuries using different composites

AIM

Rotator cuff repairs have shown a high level of re-ruptures. It is hypothesised that the use of rhBMP-2 in a carrier could improve the biomechanical and histological properties of the repair.

MATERIAL AND METHODS

Controlled experimental study conducted on 40 rats with section and repair of the supraspinatus tendon and randomisation to one of five groups: Group 1 (control) only suture; Group 2 (double control), suture and alginate-chitin carrier; Group 3 (alginate-control), the rhBMP-2 was added to the alginate; Group 4 (chitin-control) application of the rhBMP-2 to the chitin, and Group 5 (double sample): The two components of the carrier (alginate and chitin) have rhBMP-2. A biomechanical and histological analysis was performed at 4 weeks.

RESULTS

A gap was observed in all cases 4 weeks after supraspinatus detachment. The re-rupture rate was 7.5%, with 20% of them in the control-alginate Group. Histologically the best results were obtained in the double sample group: 4.5 (3.3-5.0). Double sample were also able to support higher loads to failure: 62.9N (59.8 to 69.4) with lower rigidity 12.7 (9.7 to 15.9).

CONCLUSIONS

The use of alginate-chitin carrier with rhBMP-2 improves the biomechanical and histological properties of the repair site in a chronic rotator cuff tear.

[Rotator cuff repair: single- vs double-row. Clinical and biomechanical results]

BACKGROUND

The goal of rotator cuff repair is a high initial mechanical stability as a requirement for adequate biological recovery of the tendon-to-bone complex. Notwithstanding the significant increase in publications concerning the topic of rotator cuff repair, there are still controversies regarding surgical technique.

OBJECTIVES

The aim of this work is to present an overview of the recently published results of biomechanical and clinical studies on rotator cuff repair using single- and double-row techniques.

MATERIALS AND METHODS

The review is based on a selective literature research of PubMed, Embase, and the Cochrane Database on the subject of the clinical and biomechanical results of single- and double-row repair.

RESULTS

In general, neither the biomechanical nor the clinical evidence can recommend the use of a double-row concept for the treatment for every rotator cuff tear. Only tears of more than 3 cm seem to benefit from better results on both imaging and in clinical outcome studies compared with the use of single-row techniques.

CONCLUSIONS

Despite a significant increase in publications on the surgical treatment of rotator cuff tears in recent years, the clinical results were not significantly improved in the literature so far. Unique information and algorithms, from which the optimal treatment of this entity can be derived, are still inadequate. Because of the cost-effectiveness and the currently vague evidence, the double-row techniques cannot be generally recommended for the repair of all rotator cuff tears.

Biomechanical study comparing 3 fixation methods for rotator cuff massive tear: Transosseous No. 2 suture, transosseous braided tape, and double-row

BACKGROUND

Important rotator cuff repair failure rates have prompted this study of the techniques and materials used in order to optimize clinical results.

QUESTIONS/PURPOSES

Is the reconstruction of the rotator cuff biomechanically stronger when using: 1) transosseous with 2 mm braided tape suture (TOT), 2) transosseous with multi-strand No. 2 sutures (TOS), or 3) double row suture bridge with suture anchors loaded with No. 2 braided sutures (DRSB)?

METHODS

Twenty-four cadaveric pig shoulders were randomized in the three repair constructs. The infraspinatus muscle was detached to mimic a complete laceration, repaired with one of the three repair groups and tested with a traction machine. Cameras recorded tendon displacement during trials. The ultimate strength (US), failure mode, and tendon displacement, qualified by the bare footprint area (BFA), during cycling phases were compared.

RESULTS

The US for DRSB was 175 ± 82 Newton (N), 91 ± 51 N for TOS, and 147 ± 63 N for TOT. The BFA after 200 cycles was 81 ± 34% for TOS, 57 ± 41% for TOT, and 26 ± 27% for DRSB repairs. No significant difference was observed between the DRSB and TOT results for US or BFA percentage of loss during all the cycling phases. TOS proved to be weaker than TOT and DRSB.

CONCLUSION

All the ruptures occurred in the tendon, which seems to be the weakness of rotator cuff repairs. The use of braided tape suture with a transosseous technique seems to be a cost effective, equivalent alternative implant compared to anchor fixation.

Functional Outcomes After Double-Row Versus Single-Row Rotator Cuff Repair: A Prospective Randomized Trial

Background:

The functional benefits of double-row (DR) versus single-row (SR) rotator cuff repair are not clearly established.

Purpose:

To examine the effect of DR versus SR rotator cuff repair on functional outcomes and strength recovery in patients with full-thickness tears.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

Forty-nine patients were randomized to DR or SR repairs; 36 patients (13 women, 23 men; mean age, 62 ± 7 years; 20 SR, 16 DR) were assessed at a mean 2.2 ± 1.6 years after surgery (range, 1-7 years; tear size: 17 medium, 13 large, 9 massive). The following data were recorded prior to surgery and at follow-up: Penn shoulder score, American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) results; range of motion (ROM) for shoulder flexion, external rotation (ER) at 0° and 90° of abduction, and internal rotation (IR) at 90° of abduction; and shoulder strength (Lafayette manual muscle tester) in empty- and full-can tests, abduction, and ER at 0° of abduction. Treatment (SR vs DR) × time (pre- vs postoperative) mixed-model analysis of variance was used to assess the effect of rotator cuff repair.

Results:

Rotator cuff repair markedly improved Penn, ASES, and SST scores (P < .001), with similar improvement between SR and DR repairs (treatment × time, P = .38-.10) and excellent scores at follow-up (DR vs SR: Penn, 91 ± 11 vs 92 ± 11 [P = .73]; ASES, 87 ± 12 vs 92 ± 12 [P = .21]; SST, 11.4 ± 1.0 vs 11.3 ± 1.0 [P = .76]). Patients with DR repairs lost ER ROM at 0° of abduction (preoperative to final follow-up, 7° ± 10° loss [P = .013]). ER ROM did not significantly change with SR repair (5° ± 14° gain, P = .16; treatment by time, P = .008). This effect was not apparent for ER ROM at 90° of abduction (treatment × time, P = .26). IR ROM improved from preoperative to final follow-up (P < .01; SR, 17° ± 27°; DR, 7° ± 21°; treatment × time, P = .23). Rotator cuff repair markedly improved strength in empty-can (54%), full-can (66%), abduction (47%), and ER (54%) strength (all P < .001), with no difference between SR and DR repairs (P = .23-.75). All clinical tests with the exception of the lift-off test were normalized at follow-up (P < .05).

Conclusion:

Outcomes were not different between SR or DR repair, with generally excellent outcomes for both groups. Rotator cuff repair and subsequent rehabilitation markedly improved shoulder strength.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

BACKGROUND

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair.

METHODS

In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff.

RESULTS

Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months.

CONCLUSION

Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Summary of Meta-Analyses Dealing with Single-Row versus Double-Row Repair Techniques for Rotator Cuff Tears

Background:

Several meta-analyses of randomized clinical trials have been performed to analyze whether double-row (DR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing compared to single-row (SR) repair. The purpose of this study was to sum up the results of meta-analysis comparing SR and DR repair with respect on clinical outcomes and re-tear rates.

Methods:

A literature search was undertaken to identify all meta-analyses dealing with randomized controlled trials comparing clinical und structural outcomes after SR versus DR RCR.

Results:

Eight meta-analyses met the eligibility criteria: two including Level I studies only, five including both Level I and Level II studies, and one including additional Level III studies. Four meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas four favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas six found DR repair to be superior for tears greater than 3 cm tears.

Conclusion:

No clinical differences are seen between single-row and double-row repair for small and medium rotator cuff tears after a short-term follow-up period with a higher re-tear rate following single-row repairs. There seems to be a trend to superior results with double-row repair in large to massive tear sizes.

Proximal Rectus Femoris Avulsion Repair

Proximal rectus femoris tendon avulsions are rare and occur mostly in male athletes. Currently, the standard of care for complete tendinous avulsions of the direct arm of the rectus femoris is nonoperative treatment. However, surgical repair may be considered in high-level athletes who have a high demand for repetitive hip flexion performed in an explosive manner or in patients in whom nonoperative treatment has failed. The purpose of this technical note is to describe the method for surgical repair of the proximal direct arm of the rectus femoris to its origin at the anterior inferior iliac spine using suture anchors.

Rotator cuff tears: Review of epidemiology, clinical assessment and operative treatment

Rotator cuff tears (RTCs) are the most common cause of shoulder disability. There has been a proportional increase in the prevalence of RCT in accordance with the rising trend of an ageing population. In this article we review the current literature encompassing RCT epidemiology, risk factors and aetiopathogenesis. We also summarize the current diagnostic modalities, treatment options, rehabilitation and outcomes.

Rotator cuff tears: An evidence based approach

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Do patient age and sex influence tendon cell biology and clinical/radiographic outcomes after rotator cuff repair?

BACKGROUND

Many clinical and radiographic studies suggest that patient age and sex have an influence on rotator cuff (RC) repair outcomes. However, these findings result from retrospective statistical analyses and cannot provide a causal answer.

PURPOSE

To analyze whether age and sex influence the biological potential at the time of RC repair or midterm clinical and radiographic outcomes. Also assessed was the effect of the biological potential on intraindividual clinical/radiographic results.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 40 patients underwent arthroscopic RC repair. At the time of surgery (t = 0), supraspinatus tendon biopsy specimens were obtained, cultivated, and assessed for their biological potential, particularly (1) cell growth and (2) collagen type I production. After a follow-up at 24 months (t = 1), all patients were assessed by clinical scores (Constant score, subjective shoulder value, American Shoulder and Elbow Surgeons [ASES] score, and Western Ontario Rotator Cuff Index [WORC] score) and underwent magnetic resonance imaging to determine RC integrity. The data were examined for age- and sex-related differences and to identify the correlation between biological potential (t = 0) and clinical/radiographic outcome (t = 1).

RESULTS

The follow-up rate for the imaging and clinical evaluation was 100%. Age, but not sex, influenced the biological tendon cell parameters at t = 0. However, there was no effect of age or sex on the clinical and radiographic results at t = 1. Furthermore, no correlation was observed between the initial biological parameters and later clinical outcomes or radiographic RC integrity. Finally, there was no significant difference between intact and nonhealed repairs in terms of the respective clinical scores.

CONCLUSION

Age, but not sex, was found to have a negative effect on RC tendon cell biology. However, neither sex nor, in particular, a higher age influenced repair outcomes after 24 months.

Incidence of retear with double-row versus single-row rotator cuff repair

Rotator cuff tears have a high recurrence rate, even after arthroscopic rotator cuff repair. Although some biomechanical evidence suggests the superiority of the double-row vs the single-row technique, clinical findings regarding these methods have been controversial. The purpose of this study was to determine whether the double-row repair method results in a lower incidence of recurrent tearing compared with the single-row method. Electronic databases were systematically searched to identify reports of randomized, controlled trials (RCTs) comparing single-row with double-row rotator cuff repair. The primary outcome assessed was retear of the repaired cuff. Secondary outcome measures were the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Constant shoulder score, and the University of California, Los Angeles (UCLA) score. Heterogeneity between the included studies was assessed. Six studies involving 428 patients were included in the review. Compared with single-row repair, double-row repair demonstrated a lower retear incidence (risk ratio [RR]=1.71 [95% confidence interval (CI), 1.18-2.49]; P=.005; I(2)=0%) and a reduced incidence of partial-thickness retears (RR=2.16 [95% CI, 1.26-3.71]; P=.005; I(2)=26%). Functional ASES, Constant, and UCLA scores showed no difference between single- and double-row cuff repairs. Use of the double-row technique decreased the incidence of retears, especially partial-thickness retears, compared with the single-row technique. The functional outcome was not significantly different between the 2 techniques. To improve the structural outcome of the repaired rotator cuff, surgeons should use the double-row technique. However, further long-term RCTs on this topic are needed.

Is double-row rotator cuff repair clinically superior to single-row rotator cuff repair: a systematic review of overlapping meta-analyses

PURPOSE

Multiple meta-analyses of randomized clinical trials, the highest available level of evidence, have been conducted to determine whether double-row (DR) or single-row (SR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and to determine which meta-analysis provides the current best available evidence.

METHODS

In this study we evaluated available scientific support for SR versus DR RCR by systematically reviewing the literature for published meta-analyses. Data were extracted from these meta-analyses for patient outcomes and structural healing. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Eight meta-analyses met the eligibility criteria: 4 including Level I evidence and 4 including both Level I and Level II evidence. Six meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas 2 favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears. Four meta-analyses had low Oxman-Guyatt scores (<3) indicative of major flaws. After application of the Jadad algorithm, 3 concordant high-quality meta-analyses were selected, all of which found significantly better structural healing with DR compared with SR RCR.

CONCLUSIONS

According to this systematic review of overlapping meta-analyses comparing SR and DR RCR, the current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Capstan screw rotator cuff repair: a novel two-row mini-open technique

BACKGROUND

Prospective data collection occurred between 2000 and 2010 on 143 consecutive patients with symptomatic rotator cuff tears, aiming to examine the end-result of a new technique of mini-open double row repair: the Capstan screw technique.

METHODS

All patients had a pre- and postoperative Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) score and range of movement measurements. All were followed up for a minimum of 1 year with an exit questionnaire. Subscapularis repairs, small (<1 cm) and massive (>5 cm) supraspinatus repairs were excluded. Ninety-nine patients fitted the inclusion and exclusion criteria of whom 87 had a complete data set.

RESULTS

The mean (SD) pre-operative OSS was 21.85 (8.6) and the mean (SD) postoperative OSS was 44.58 (5.2) (p < 0.0001). The mean (SD) pre-operative ASES score was 51.5 (19.4) and the mean (SD) postoperative ASES score was 86.42 (17.06) (p < 0.0001). Flexion improved from a mean of 119° to 170° (p < 0.0001). The clinical re-tear rate was 3.4% and the imaged re-tear rate was 6.8%. In total, 91% of patients were satisfied with the procedure. There were no deep infections and two (2%) minor wound infections. There was no single instance of deltoid dysfunction.

CONCLUSIONS

The Capstan screw technique represents a simple, rapid, strong and reliable mini-open technique.

Intensity and distribution of shoulder pain in patients with different sized postero-superior rotator cuff tears

BACKGROUND

The vast majority of studies regarding rotator cuff tears (RCTs) are focused on etiopathogenesis and treatments, but information on shoulder pain characteristics needs further investigation. We analyzed the intensity and distribution of shoulder pain in patients with different sizes of RCTs.

METHODS

Two hundred eighty-five consecutive patients with postero-superior RCTs were enrolled for this study. Tear size was intraoperatively classified. Before surgery, all patients completed an upper limb pain map (dermatome map made by Keegan). Shoulder pain intensity was assessed with a visual analogue scale (VAS). Data were submitted to statistical analysis.

RESULTS

Shoulder pain intensity caused by a RCT was greater in females (P = .024); it did not vary with the side nor with age. Pain intensity was less in massive tears (P < .05) and in patients whose pain was distributed only to the shoulder (P = .035). Furthermore, patients whose pain persisted for more than 6 months maintained the same pain intensity. Pain was localized predominantly on dermatomes C5-C6, was more diffuse in massive tears (P < .05), and rarely extended beyond the elbow. In the presence of intense shoulder pain, its precise distribution was not well-delimited.

CONCLUSION

Shoulder pain characteristics in patients with RCTs may be influenced by gender and size of tear. Cuff tear pain distribution principally involves the antero-lateral aspect of the shoulder with extension down the lateral surface of the arm to the elbow. Information about pain intensity and distribution in patients with RCTs may contribute to a more accurate diagnosis.

LEVELS OF EVIDENCE

Level III, cross sectional study.

Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row with double-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates.

METHODS

A literature search was undertaken to identify all level I randomized controlled trials comparing structural or clinical outcomes after single-row versus double-row rotator cuff repair. Clinical outcomes measures included in the meta-analysis were the American Shoulder and Elbow Surgeons, University of California-Los Angeles, and Constant scores; structural outcomes included imaging-confirmed re-tears. Meta-analyses compared raw mean differences in outcomes measures and relative risk ratios for imaging-diagnosed re-tears after single-row or double-row repairs by a random-effects model.

RESULTS

The literature search identified a total of 7 studies that were included in the meta-analysis. There were no significant differences in preoperative to postoperative change in American Shoulder and Elbow Surgeons, University of California-Los Angeles, or Constant scores between the single-row and double-row groups (P = .440, .116, and .156, respectively). The overall re-tear rate was 25.9% (68/263) in the single-row group and 14.2% (37/261) in the double-row group. There was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group (relative risk, 1.76 [95% confidence interval, 1.25-2.48]; P = .001), with partial-thickness re-tears accounting for the majority of this difference (relative risk, 1.99 [95% confidence interval, 1.40-3.82]; P = .039).

CONCLUSION

Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears. However, there were no detectable differences in improvement in outcomes scores between single-row and double-row repairs.

Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis

BACKGROUND

The correlation between the structural integrity of rotator cuff repair and the clinical outcome for the patient remains controversial. The purpose of this study was to assess the relationship between patient function and structural integrity of the rotator cuff after repair.

METHODS

A systematic review and a meta-analysis were conducted for Level-I and Level-II studies showing outcome measures after rotator cuff repair and an imaging assessment of the structural integrity of the repair. Data extracted included patient demographics, tear size, repair type, clinical outcome measures, and repair integrity. Statistical analysis was performed to compare outcomes in patients on the basis of the structural integrity of repair at the time of the latest follow-up.

RESULTS

Fourteen studies met inclusion criteria and were included in the latest analysis. Of the 861 patients who underwent rotator cuff repair with a minimum of a one-year follow-up, 674 patients (78.3%) had intact repairs at the time of latest follow-up. There was no difference in tear size between patients with intact repairs and those with retears (p = 0.866). The University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score increased and the visual analog scale score decreased in patients regardless of the structural integrity of the repair. Patients with intact repairs had higher Constant scores by 8.93 points (p < 0.0001) and higher University of California Los Angeles shoulder scores by 2.95 points (p = 0.0004). Postoperative American Shoulder and Elbow Surgeons scores were no different in patients with intact repairs or retears (p = 0.15). Postoperative visual analog scale scores were 0.93 points lower in patients with intact repairs (p = 0.01). Patients with intact repairs had increased strength in forward elevation by 2.40 kilograms (5.29 pounds) (p < 0.00001) and had a trend toward increased strength in shoulder external rotation (p = 0.06). Although these results are significant, the differences are not clinically important on the basis of the validation of these outcome measures.

CONCLUSIONS

The results of this study suggest that there is not a clinically important difference in validated functional outcome scores or pain for patients who have undergone rotator cuff repair regardless of the structural integrity of the repair. Patients with intact repairs do have significantly greater strength than those with retears.

Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears

BACKGROUND

Rotator cuff tears are among the most common shoulder injuries and can be a source of persistent pain, disability, and decreased range of motion and strength. Our hypothesis was to conduct a meta-analysis of recently published studies to compare the clinical results of a double-row technique with the results of a single-row technique for different tear sizes.

METHODS

A search was performed in the MEDLINE, EMBASE, and Ovid databases. All randomized and quasi-randomized clinical trials that reported the outcome of single-row repair and double-row repair techniques were included in our meta-analysis. Two subgroups were set according to the tear size. The outcomes were the Constant score, American Shoulder and Elbow Surgeons (ASES) score, UCLA score, re-tear rate, range of motion, and muscle strength.

RESULTS

We included 9 studies in this meta-analysis, 5 of which were randomized prospective studies. There was a statistically significant difference in favor of double-row repair for the overall ASES score, re-tear rate, and internal rotation range of motion. In subgroup 2 (tear size > 30 mm in the anteroposterior dimension), double-row techniques produced better outcomes than single-row techniques. There were no statistically significant differences in the overall Constant score, UCLA score, external rotation and forward elevation range of motion, or muscle strength.

CONCLUSION

Double-row rotator cuff repair techniques have a significantly lower re-tear rate, higher ASES score, and greater range of motion of internal rotation compared with single-row repair techniques. Especially in those rotator cuff tears with a size >30 mm, the double-row technique is recommended for repair.

The Mature Athlete's Shoulder

CONTEXT

The mature athlete's shoulder remains a challenging clinical condition to manage. A normal natural history of the shoulder includes stiffness, rotator cuff tears, and osteoarthritis, all of which can become increasingly more symptomatic as an athlete ages.

EVIDENCE ACQUISITION

PubMed (1978-2013).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3-4.

RESULTS

Rotator cuff pathology increases with age and activity level. Partial tears rarely heal, and debridement of significant partial tears results in poorer outcomes than those of repair. Repair of partial-thickness tears can be accomplished with completion and subsequent repair or in situ repair. The most successful result for treatment of osteoarthritis in the shoulder remains total shoulder arthroplasty, with more than 80% survival at 20 years and high rates of return to sport. Caution should be taken in patients younger than 60 years, as they show much worse results with this treatment. Adhesive capsulitis of the shoulder can be successfully treated with nonoperative management in 90% of cases.

CONCLUSION

Mature athletes tend to have rotator cuff pathology, osteoarthritis, and stiffness, which may limit their participation in athletic events. Age is a significant consideration, even within the "mature athlete" population, as patients younger than 50 years should be approached differently than those older than 65 years with regard to treatment regimens and postoperative restriction.

Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Outcomes of single-row versus double-row arthroscopic rotator cuff repair: a systematic review and meta-analysis of current evidence

PURPOSE

Our purpose was to perform a systematic review and meta-analysis of the clinical outcomes of single-row versus double-row repair.

METHODS

An electronic search was performed using PubMed, EMBASE, and the Cochrane Library up to September 30, 2012. Studies that met the inclusion and exclusion criteria were assessed for quality of methodology. The primary analysis included Level I evidence from studies examining single-row versus double-row repair. The second meta-analysis and subgroup analysis were performed for evidence Levels I, II, and III.

RESULTS

The primary analysis of studies providing 6 Level I randomized controlled trials showed no clinically significant differences in Constant scores, University of California, Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores between double-row and single-row rotator cuff repair. The overall odds ratio (OR) of intact rotator cuff tendon healing was 1.93 in patients treated with double-row versus single-row repair, and the difference was significant. The results of the second meta-analysis including evidence Levels I, II, and III were similar to those of the primary analysis. In the subgroup with tears less than 3 cm, there was no statistically significant difference between the groups with regard to shoulder functional score and structure integrity. A statistically significant benefit of double-row repair in the ASES and UCLA scores was observed in the subgroup with tears greater than 3 cm; however, these differences were not clinically significant. The OR for tendon healing was found to be more favorable for double-row repair than for single-row repair in the subgroup with tears greater than 3 cm.

CONCLUSIONS

Double-row repair provides a significantly higher rate of intact tendon healing than does single-row repair, and this advantage was mainly reflected in patients with large or massive tears. However, this benefit did not translate into clinically confirmed functional improvement. Thus, the double-row technique should be used only in carefully selected patients.

LEVEL OF EVIDENCE

Level III, systematic review of Levels I, II, and III studies.

Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study

PURPOSE

To evaluate the efficacy of a marrow-stimulating technique with microfractures of the greater tuberosity during arthroscopic rotator cuff repair.

METHODS

Eighty patients with a full-thickness rotator cuff tear underwent an arthroscopic single-row repair. Patients were divided into 2 groups of 40 cases each. In group 1, standard repair was performed; in group 2, microfractures of the greater tuberosity were performed to enhance tendon repair. Clinical outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score and normalized Constant score. Tendon integrity was assessed with magnetic resonance imaging. Multivariate analysis was performed to determine which predictors were independently associated with the outcome. Significance was set at P < .05.

RESULTS

The mean follow-up was 28.1 ± 3 months. Seven patients were lost to follow-up (2 in group 1 and 5 in group 2). Comparison between groups did not show significant differences for baseline characteristics. The mean DASH score was 28.6 ± 21.3 points in group 1 and 23.3 ± 20.1 points in group 2. Although the difference was not statistically significant, the confidence interval included a 10-point value (minimal clinically important difference) in favor of the microfracture group. The difference in the Constant score between groups was not significant. The tendon healing rate was 52.6% in group 1 and 65.7% in group 2, without a significant difference between groups. Subgroup analysis for tear size showed that group 2 had a significantly greater healing rate than group 1 for large tears (P = .040). Multivariate analysis showed that age, timing of symptoms, tear location, tendon retraction, and fatty infiltration significantly affected the outcomes.

CONCLUSIONS

Postoperative magnetic resonance imaging did not show any significant difference between groups in structural integrity. However, subgroup analysis showed a significantly greater healing rate in the microfracture group for large tears involving the supraspinatus and infraspinatus.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with no statistically significant difference but narrow confidence intervals.

Biomechanical and magnetic resonance imaging evaluation of a single- and double-row rotator cuff repair in an in vivo sheep model

PURPOSE

To investigate the biomechanical and magnetic resonance imaging (MRI)-derived morphologic changes between single- and double-row rotator cuff repair at different time points after fixation.

METHODS

Eighteen mature female sheep were randomly assigned to either a single-row treatment group using arthroscopic Mason-Allen stitches or a double-row treatment group using a combination of arthroscopic Mason-Allen and mattress stitches. Each group was analyzed at 1 of 3 survival points (6 weeks, 12 weeks, and 26 weeks). We evaluated the integrity of the cuff repair using MRI and biomechanical properties using a mechanical testing machine.

RESULTS

The mean load to failure was significantly higher in the double-row group compared with the single-row group at 6 and 12 weeks (P = .018 and P = .002, respectively). At 26 weeks, the differences were not statistically significant (P = .080). However, the double-row group achieved a mean load to failure similar to that of a healthy infraspinatus tendon, whereas the single-row group reached only 70% of the load of a healthy infraspinatus tendon. No significant morphologic differences were observed based on the MRI results.

CONCLUSIONS

This study confirms that in an acute repair model, double-row repair may enhance the speed of mechanical recovery of the tendon-bone complex when compared with single-row repair in the early postoperative period.

CLINICAL RELEVANCE

Double-row rotator cuff repair enables higher mechanical strength that is especially sustained during the early recovery period and may therefore improve clinical outcome.