Arthroscopic Double-Layer Lasso Loop Technique to Repair Delaminated Rotator Cuff Tears

All-Arthroscopic Supraspinatus and Infraspinatus Muscle Advancement Leads to High Healing Rate and Excellent Outcomes in Patients With Massive, Retracted Rotator Cuff Tears, Even in Patients With Pseudoparalysis

PURPOSE

To evaluate the clinical and radiographic outcomes of an all-arthroscopic rotator cuff repair technique involving muscle advancement and double-layer lasso loop (DLLL) repair for massive, retracted posterosuperior cuff tears.

METHODS

This was a retrospective case series of patients with massive, retracted posterosuperior cuff tears who underwent the all-arthroscopic muscle advancement technique from March 2017 to September 2021, with a minimum follow-up of 12 months. Key steps included suprascapular nerve release, advancement of the supraspinatus and infraspinatus muscles, and DLLL repair. Preoperative and postoperative visual analog scale score for pain, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, University of California, Los Angeles (UCLA) shoulder score, active range of motion, and strength were compared. Preoperative and postoperative structural radiologic characteristics were analyzed.

RESULTS

We evaluated 43 shoulders in 38 patients with a mean follow-up period of 18.8 months (range, 12-55 months). Of the 43 shoulders, 4 showed repair failure (9.3% retear rate). Visual analog scale, ASES, Constant, and UCLA scores significantly improved (P < .001) in patients who showed healing on postoperative magnetic resonance imaging (n = 39). ASES, Constant, and UCLA scores were significantly better in the healed group, with 100% exceeding the minimal clinically important difference for the ASES score and UCLA score and 84.2%, for Constant score. A lower proportion of patients in the retear group achieved the minimal clinically important difference. Active range of motion in all planes significantly improved for patients who had healed repairs (P < .001). Relative abduction strength, supraspinatus strength, and infraspinatus strength were at least 90% of those on the contralateral side. The recovery rate of pseudoparalysis (7 patients) was 100%.

CONCLUSIONS

All-arthroscopic muscle advancement, coupled with DLLL repair, leads to a high healing rate with excellent clinical outcomes and recovery of strength to at least 90%, even in patients with pseudoparalysis.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison of En Masse Repair versus Separate Double-Layer Repair for Delaminated Rotator Cuff Tears: A Systematic Review and Meta-Analysis

BACKGROUND

Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears.

METHODS

A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes.

RESULTS

Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35-1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64).

CONCLUSION

The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.

Anatomic restoration of the articular deep layer is a definitive factor for repair status in delaminated rotator cuff tear

BACKGROUND

Recent studies have focused on the deep layer in delaminated rotator cuff tears. However, no studies have discussed the relationship between repair success and the properties of the deep layer. Herein, we aimed to analyze the intraoperative repair tension of the deep layer with respect to clinical outcomes and repair integrity and to evaluate the clinical results of delaminated rotator cuff tears after dual layer-specific repair.

METHODS

A total of 202 patients with delaminated rotator cuff tears had undergone dual layer-specific suture bridge repair; the mean follow-up duration was 28.6 (24-72) months. Intraoperatively, the repair tension of the deep layer was measured using a tensiometer, and mobility was ranked as easy or tight. After repair of the deep layer, the superficial layer tension was measured and ranked in a similar fashion. Clinical outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder values. The relationship between retear and intraoperative qualitative factors of tendons was investigated. Prognostic factors for retear were analyzed using multiple logistic regression analyses.

RESULTS

Postoperative retears occurred in 11 (5.4%) patients. With regard to the deep layer, the tight mobility group had greater tear size, tendon retraction, and fatty infiltration of the supraspinatus and infraspinatus than the easy mobility group. No intergroup difference in postoperative retear rate was observed between the tight and easy deep-layer groups. Logistic regression analysis showed that fatty infiltration of the infraspinatus (odds ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .013) and mobility of the superficial layer after deep layer repair (odds ratio, 8.1; 95% confidence interval, 1.7-38.1; P = .008) were predictors of retear.

CONCLUSION

Intraoperative mobility in the deep layer was not directly related to postoperative retear. Conversely, the quality of the infraspinatus concomitant with mobility of the superficial layer after deep layer repair significantly influenced repair integrity. Good clinical results were obtained even in cases with high repair tension of the deep layer.

Delaminated Tears of the Rotator Cuff: MRI Interpretation with Clinical Correlation

(1) Background: A delaminated tear is described as a horizontal split in the tendon substance. This review summarizes the clinical and radiologic characteristics of delaminated tears of the rotator cuff. (2) Methods: Initial radiological characteristics of a delaminated tear include the horizontal component of a partial-thickness tear determined using magnetic resonance (MR) arthrography. As demonstrated using indirect MR arthrography, the tear gradually progresses to be defined as either horizontal intrasubstantial splitting of the bursal and articular layers or differential retraction of the bursal and articular layers. (3) Results: The existence of delaminated tears is a poor prognostic factor in functional and morphologic outcomes after the repair of rotator cuff tendons and many surgical techniques have been introduced to solve this problem. Although the presence of a delaminated tear does not affect the arthroscopic repair outcome, the presence of medium-to-large, retracted delaminated tears may be an adverse negative prognostic factor after single-row repair. (4) Conclusion: Advances in imaging and surgical techniques have improved the detection of delaminated rotator cuff tears. Preoperative identification of delaminated tears on magnetic resonance imaging is clinically important because tailored surgical repair techniques must be chosen for successful outcomes.

Rotator Cuff Delamination Is Associated With Increased Tendon Retraction and Higher Fatty Muscle Infiltration: A Comparative Study on Arthroscopy and Magnetic Resonance Imaging

PURPOSE

To investigate (1) tendon delamination according to different rotator cuff tear patterns as well as (2) the association of tendon retraction and fatty muscle infiltration with delamination of the rotator cuff. Furthermore, we aimed to establish the accuracy of magnetic resonance imaging for the detection of rotator cuff delamination.

METHODS

Magnetic resonance imaging scans of patients who underwent arthroscopic rotator cuff repair from 2013 to 2015 were retrospectively compared to intraoperative findings. Prevalences of tendon delamination, tendon retraction, and fatty muscle infiltration were categorized according to different rotator cuff tear patterns. For comparability of the amount of tendon retraction of delaminated and non-delaminated rotator cuff tears, we introduced the global retraction index, a description individually assessing tendon retraction in magnetic resonance imaging scans of all visible layers.

RESULTS

Of 349 shoulders, tendon delamination was observed in 231 patients (66.2%). Of these, rotator cuff delamination was most commonly seen in posterosuperior rotator cuff tears (84.6%). Delaminated rotator cuff tears presented with a significantly higher global retraction index (P < .001) as well as higher fatty muscle infiltration of the supraspinatus (P = .001) and infraspinatus (P = .001). Magnetic resonance imaging had only moderate accuracy (57.3%) to detect rotator cuff delamination, with a positive predictive value of 100% (95% confidence interval [CI] 95.6% to 100.0%) and a negative predictive value of 44.2% (95% CI 38.1% to 50.4%).

CONCLUSIONS

Tendon delamination was most commonly observed in posterosuperior rotator cuff tears. Delaminated rotator cuff tears showed a significantly greater tendon retraction as well as a higher amount of fatty muscle infiltration of the supraspinatus and infraspinatus. Magnetic resonance imaging has only moderate accuracy for detection of rotator cuff delamination.

LEVEL OF EVIDENCE

III, retrospective cohort study.

The Application of H-Loop in Arthroscopic Knotless Double-Row Rotator Cuff Repairs

Objective

To determine the functional outcomes after a novel method of H‐loop knotless double‐row technique in patients with rotator cuff tears.

Method

From June 2020 to September 2020, a total of six patients (five women, one man) with arthroscopic rotator cuff repair using the H‐loop knotless double‐row technique were enrolled in our study. The average age is 54 years (range: 50–61 years). The preoperative and final follow‐up clinical outcome were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), University of California Los Angeles (UCLA) score, and Constant–Murley score. The active shoulder range of motion (ROM) was also collected preoperatively and postoperatively at the final follow‐up (forward flexion and abduction). Accordingly, intraoperative and postoperative complications were observed as well.

Result

There were six patients that underwent arthroscopic rotator cuff repair using the H‐loop knotless double‐row technique. The average follow‐up period was 7.52 ± 0.70 months. The VAS, UCLA, ASES, and Constant–Murley scores improved from 5 ± 2.45, 15.67 ± 3.44, 47.67 ± 17.41 and 49.17 ± 8.98 preoperatively, to 0.83 ± 0.75, 36.27 ± 3.83, 91.67 ± 10.76 and 85.83 ± 4.31 at the final follow‐up, with statistical significances of P = 0.009, P < 0.001, P = 0.006, and P = 0.001, respectively. Meanwhile, the active shoulder ROM (forward flexion and abduction) improved from 135.00 ± 46.80 and 125 ± 56.48 preoperatively, to 173.67 ± 4.13 and 172 ± 3.27 at final follow‐up, respectively (P = 0.082, P = 0.088). During the follow‐up, there were no postoperative complications such as wound‐site infection, nerve or vessel damage, subcutaneous hematoma, and suture anchor problems.

Conclusion

With the benefit of reducing the possibility of strangulation and blood supply affection for the rotator cuff, The H‐loop knotless double row technique may be an alternative method to significantly improve subjective functional outcomes and increase the healing rate of medium‐sized rotator cuff tears with degeneration issues and poor tissue quality.

Anterior Capsular Reconstruction With Proximal Biceps Tendon for Large to Massive Rotator Cuff Tears

Massive rotator cuff tears (RCT) have traditionally been a challenging clinical problem for shoulder surgeons. A broad variety of treatment options have been proposed to address this problem, but outcomes have been as variable as the techniques themselves. Superior capsular reconstruction has been presented as a way to restore the restraining effect of the superior joint capsule and balanced force couples in massive tears of the superior rotator cuff. The purpose of this article is to propose a technical modification of the superior capsular reconstruction in large to massive RCT, and, especially in anterior L-shaped RCT, using the long head of the biceps tendon autograft to reinforce the weakest area of the anterior capsule, not as an augmentation of the rotator cuff, but as a static stabilizer of the humeral head, allowing the rotator cuff repair to heal without tension.

All-Arthroscopic Muscle Slide and Advancement Technique to Repair Massive Retracted Posterosuperior Rotator Cuff Tears

Symptomatic massive posterosuperior rotator cuff tears without glenohumeral joint arthritis and chronic medial retraction often are deemed "irreparable." These patients often are treated with alternative joint-sparing procedures including superior capsular reconstruction or tendon transfer procedures. Open and arthroscopic-assisted muscle advancement techniques allow maximal lateral tendon mobilisation during rotator cuff repair. In this report, we present an all-arthroscopic technique of complete supraspinatus and infraspinatus muscle scapular detachment and advancement in retracted massive posterosuperior rotator cuff tears. This allows for an anatomical tendon footprint reduction and tension-free repair.

The Chinese Knot Stitch Technique Using a Footprint Ultrasuture Anchor for Rotator Cuff Repair

Management of the rotator cuff presents specific challenges to orthopaedic surgeons. Several locking suture methods have been reported but often fail for a number of reasons. We describe a different technique that is easy to perform and inspired by the Chinese knot, an arthroscopic double-locking suture using a footprint ultrasuture anchor. This technique is similar to the suture-bridge structure on the bursal side of the tendon in that it increases tissue grip and stabilizes initial tendon-to-bone fixation. This technique is especially suitable for the patients who have bursal-side partial-thickness or degenerative small- and medium-sized rotator cuff tears.

The knotless cinch-bridge technique for delaminated rotator cuff tears leads to a high healing rate and a more favorable short-term clinical outcome than suture-bridge repair

PURPOSE

To compare functional outcomes and magnetic resonance image (MRI) tendon integrity following either the suture bridge or the knotless cinch-bridge technique used for arthroscopic double-layer rotator cuff repair.

METHODS

37 prospectively enrolled patients (46-76 years), who were treated with arthroscopic double-layer rotator cuff repair (group 1: suture bridge n = 20, group 2: cinch bridge n = 17) were clinically and radiographically assessed before and at an average of 24.0 ± 4.7 months after the procedure. Shoulder function was evaluated by the constant score (CS), range of motion, and various patient-related scores. Repaired tendon integrity was evaluated by MRI. Peri- and postoperative complications were recorded.

RESULTS

All functional and patient-related scores significantly improved from pre- to postoperative. Significantly better postoperative CS (P = 0.037), flexion (P < 0.001), and abduction (P = 0.009) were detected after arthroscopic cinch compared to suture-bridge repair. The mean CS improvements from baseline to follow-up were not significantly different between the groups (n.s.). Patient-related scores did not show any statistical significant differences. The MRI healing rate following arthroscopic double-layer repair with the suture- and cinch-bridge technique was 95% and 94%, respectively. Fatty infiltration regarding the supraspinatus and infraspinatus increased in 55% and 35% (group 1) and in 53% and 48% (group 2), respectively. Muscle hypotrophy remained stable in all patients. Overall, 92% of the patients were very satisfied or satisfied with the procedure. No complications were detected.

CONCLUSIONS

Arthroscopic knotless double-layer rotator cuff repair with the cinch-bridge technique showed higher CS, forward flexion, and abduction values, as well as similar patient-related short-term outcome and MRI integrity compared to the suture-bridge technique. These results highlight the potential importance of less tendon strangulation for better clinical short-term outcome.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

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.

Delaminated Rotator Cuff Tear: Concurrent Concept and Treatment

Delaminated rotator cuff tear pertains to the horizontal split of the tendon substance. As reported previously, the presence of a delaminated tear and incidence of delaminated rotator cuff tear ranges from 38% to 92%. The different strain intensities applied across the rotator cuff tendon, and the shear stress between the bursal and articular layers seem to play a role in its pathogenesis. In a delaminated rotator cuff tear, the degree and direction of retraction between two layers differ, with accompanying intrasubstance cleavage. A surgeon therefore needs to consider and carefully evaluate the tear characteristics when repairing delaminated rotator cuff tear. Delaminated rotator cuff tear is considered to be a poor prognostic factor after rotator cuff repair, but numerous surgical repair techniques have been introduced and applied to resolve this problem. Recent literature has reported good clinical outcomes after delaminated rotator cuff repair.

Editorial Commentary: Delaminated Rotator Cuff Tears-Does the Suture Pattern Matter?

The configuration of the suture placed in the rotator cuff tendon in the presence of a delaminated tear may be an important determinant of outcome. Delaminated rotator cuff tears are difficult to repair and probably occur more frequently than appreciated. The goal of anatomic reduction of the tendon to the footprint, attaching the deep tendon layer to the medial aspect of the footprint while approximating the superior tendon layer to the more lateral aspect of the footprint, may best result in complete healing.