Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents

Risk Factors for High Repair Tension During Rotator Cuff Repair

Background

Excessively high repair tension, especially tension ≥10 N, can lead to unsuccessful rotator cuff repair.

Purpose/Hypothesis

The purpose of this study was to identify the preoperative risk factors for high repair tension in rotator cuff repair. It was hypothesized was that older age, longer symptom duration, nontraumatic (ie, degenerative) tear onset, progressive fatty degeneration, and larger tear size would be among the risk factors.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

This retrospective study involved 80 patients (80 shoulders) diagnosed with rotator cuff tears by magnetic resonance imaging between July 2018 and August 2020. Repair tension was measured intraoperatively using a digital tension meter. Risk factors for high repair tension (≥10 N) were evaluated. The t test was used to assess the relationship of repair tension with patient characteristics and surgical parameters. Parameters with a P value of <.05 in the univariate analysis were entered into a multivariate logistic regression model to determine their relationship with repair tension ≥10 N.

Results

Symptom duration of ≥4 months, nontraumatic tear onset, large/massive tears, mediolateral (ML) tear length of ≥20 mm, and anteroposterior (AP) tear length of ≥18 mm were associated with high odds of repair tension ≥10 N (P≤ .013 for all). Multivariate analysis showed that nontraumatic onset, ML tear length of ≥20 mm, and AP tear length of ≥18 mm were independent risk factors for repair tension ≥10 N (P≤ .035 for all).

Conclusion

The independent risk factors for high repair tension (≥10 N) during rotator cuff repair were nontraumatic tear onset, ML tear length of ≥20 mm, and AP tear length of ≥18 mm. Symptom duration of ≥4 months and large/massive tears were associated with high odds of repair tension ≥10 N, although they were not considered independent risk factors. Prospective cohort studies with larger sample sizes are needed to confirm the clinical value of the risk factors identified in this study.

MRI Reveals Rotator Cuff Tear Size, Retraction, Length, and Geometry; Muscle Volume and Degeneration, and Tendon Quality

Magnetic resonance imaging (MRI) of the shoulder is commonly used for evaluating muscle bulk and fatty degeneration as well as tendon tear size, geometry, retraction, and length. However, MRI can also be used to evaluate tendon quality. Increased rotator cuff tendon signal on T2-weighted fat-suppressed MRI appears to be a marker of tendon degeneration, and potentially of impaired healing potential. Tendon signal intensity merits closer attention and may be especially relevant when selecting chronic degenerative tears for repair in patients with other risk factors for nonhealing.

Editorial Commentary: Muscle Advancement, Footprint Medialization, and Repair Medialization Could Improve Healing and Clinical Outcomes of Massive Rotator Cuff Tears as a Result of Low-Tension Repair

The goal of massive, retracted rotator cuff repair surgery is structural healing that produces pain relief and strength restoration. Healing is difficult to achieve in patients with large, retracted, chronic, and fatty degenerated tears. High repair tension previously has been shown to be a risk factor for clinically and structurally failed repairs. Repair tension can be decreased by arthroscopic mobilization and muscle advancement (AMA) of the supraspinatus and infraspinatus muscle bellies from their scapular origins with subsequent lateralization of the muscle-tendon units toward the repair site. Linked double-row repair of the tendons after AMA has been shown to improve the outcomes of repairs in high-risk rotator cuff repairs. Surgeons should consider adding AMA to their intraoperative armamentarium for use in retracted cuff tears when traditional techniques fail to achieve a low-tension repair state.

Arthroscopic Repair of Rotator Cuff Tears Using a Suture Hook With Lasso Loop for Forward Suture Passing

Rotator cuff injury is a common shoulder injury. Arthroscopic repair of rotator cuff tears has become a common way. Suture anchor is a commonly used fixation device. Threading the suture through the rotator cuff tendon is a key step in arthroscopic repair of rotator cuff tears. Common methods of passing suture through the rotator cuff tendon include using a suture hook or rotator cuff suture passer device. However, the suture using suture hook is a kind of reverse suture, and the operation is more troublesome. The rotator cuff suture passer device shows poor economy, which cannot be ignored at the risk of needle core breakage. We combined the advantages of the two suture passing methods to design an improved method by using a suture hook with the Lasso loop for forward suture passing. The key step of our improved technique is to deliver the end of the anchor suture 2-3 cm into the tip opening of suture hook, and ejecting the suture through pushing the Lasso loop after suture forward passing through the tendon. Our technique has achieved economy, safety, and simplicity, and has good clinical application value.

Cancellous bone should not be exposed during medialized rotator cuff repair based on bone-to-tendon healing in a rat mode

PURPOSE

To compare the biological bone-to-tendon healing using three different medialized bone bed preparation techniques (i.e. cortical bone exposure, cancellous bone exposure, and no cartilage removal) in a rat model of medialized rotator cuff repair.

METHODS

Twenty-one male Sprague-Dawley rats with 42 shoulders were subjected to bilateral supraspinatus tenotomy from the greater tuberosity. The rotator cuff was repaired using medialized anchoring with the cortical bone exposed, the cancellous bone exposed, or no cartilage removed. Four and three rats in each group were killed for biomechanical testing and histological evaluation, respectively, at postoperative 6 weeks.

RESULTS

All rats survived until the end of the study, but one infected shoulder in the cancellous bone exposure group was excluded from further analysis. Compared with the cortical bone exposure and no cartilage removal groups, the rotator cuff healing of the cancellous bone exposure group showed significantly lower maximum load (cancellous bone exposure group: 26.2 ± 2.3 N, cortical bone exposure group: 37.6 ± 7.9 N, no cartilage removal group: 34.6 ± 7.2 N, P = 0.005 and 0.029) and less stiffness (cancellous bone exposure group: 10.5 ± 2.4 N/mm, cortical bone exposure group: 17.4 ± 6.7 N, no cartilage removal group: 16.0 ± 3.9 N, P = 0.015 and 0.050) at postoperative 6 weeks. In all three groups, the repaired supraspinatus tendon healed towards the original insertion rather than the medialized insertion. The cancellous bone exposure group showed inferior fibrocartilage formation and insertion healing.

CONCLUSIONS

The medialized bone-to-tendon repair strategy does not guarantee complete histological healing, and the removal of excessive bony structure impairs bone-to-tendon healing. This study concludes that surgeons should not expose the cancellous bone during the medialized rotator cuff repair.

The role of bone marrow stimulation in rotator cuff repair: a systematic review and meta-analysis

PURPOSE

The objective of this study was to investigate whether RCR (rotator cuff repair) with BMS (bone marrow stimulation) can provide a lower retear rate and better shoulder function than arthroscopic RCR alone in rotator cuff tear (RCT) patients.

METHOD

The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched until Feb 2022. Risk of bias for randomized controlled trials was evaluated by two independent reviewers with Cochrane collaboration risk bias of tool, and that for cohort studies was evaluated with the Newcastle-Ottawa Scale (NOS). The primary outcome was the retear rate. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles Shoulder Scale (UCLA) score, Constant-Murley score (CMS) and visual analogue scale (VAS) score. Subgroup analysis was performed to explore the effect of suture method and tear size on BMS procedure.

RESULT

Five randomized controlled trials and four cohort studies with a total of 827 patients were included. The pooled retear rate between the RCR with BMS group and the RCR alone group was significantly different (17.5% vs. 28.9%; P < 0.0001). There were no differences in the ASES score, UCLA score and VAS score. The CMS was significantly higher in RCR with BMS group than the RCR alone groups (P = 0.02), while the difference was well below the MCID. RCR with BMS resulted in a significantly lower retear rate than RCR alone for large and massive RCTs (19.7% vs. 32.5%; P = 0.01).

CONCLUSION

Compared with RCR alone, RCR with BMS can significantly reduce the retear rate in arthroscopic RCT patients while not clinically relevant differences were found. BMS may further reduce the retear rate of large and massive RCTs.

LEVEL OF EVIDENCE

Level III; Systematic Review and Meta-analysis.

Local Intraoperative Marrow-Derived Augmentation for Primary Rotator Cuff Repair: An Updated Systematic Review and Meta-analysis of Studies From 2010 to 2022

Background

Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair.

Purpose

To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I ².

Results

A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I ² = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I ² = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls.

Conclusion

Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.

Cyst formation and bony ingrowth inside coil-type open-architecture anchors used for arthroscopic remplissage: a volumetric computed tomographic study of 50 anchors

BACKGROUND

The use of anchors in the proximal humerus during arthroscopic surgery can cause localized bone loss due to osteolysis and cyst formation. The purpose of this study was to use computed tomography (CT) to evaluate the incidence of implant-related bone loss and cyst formation after implantation of polyetheretherketone (PEEK) coil-type open-architecture anchors during remplissage for the management of Hill-Sachs defects (HSDs) in patients with shoulder instability.

METHODS

This was a single-cohort, observational study with a minimum of 12 months of follow-up. Subjects undergoing arthroscopic instability surgery with HSD requiring remplissage were included. The volume of the bone defects and the degree of bony ingrowth into the anchor were measured on CT images.

RESULTS

Thirty-one participants (28 males, 3 females; mean age 29.4 years, standard deviation [SD] 10.6) in whom 50 anchors (4.5-mm Healicoil PEEK double-loaded anchors) were used were evaluated with a CT performed at a mean of 14.1 (SD 3.74) months after surgery. Full bony ingrowth inside the anchor was found in 15 anchors (30%, range 17.8%-44.5%); clear ossification with a thin lucent rim was found in 10 anchors (20%, range 10.0%-33.7%); discontinuous ossification was found in 8 anchors (16%, range 7.2%-29.1%); and no ossification was observed inside 17 anchors (34%, range 21.2%-48.7%). Regarding bone defect size, no bone defect was identified in 15 anchors (30%, 95% CI 17.9%-44.6%), a partial bone defect was found in 17 anchors (34%, 95% CI 21.2%-48.7%), hole enlargement was found in 17 anchors (34%, 95% CI 21.2%-48.7%), and 1 anchor caused a cyst larger than twice the size of the hole made for anchor insertion (2%, 95% CI 0.1%-8.6%). At the 1-year evaluation, none of the participants presented recurrence or residual apprehension.

CONCLUSION

The use of PEEK coil-type open-architecture anchors for remplissage during instability surgery caused large cystic lesions in less than 10% of anchors. There was full bony ingrowth in one-third of anchors, and partial cancellous bone ingrowth occurred in another third of anchors.

Does Complete Footprint Coverage Affect Outcomes After Conventional Arthroscopic Repair of Large-Sized Rotator Cuff Tears?

Background:

In large-sized rotator cuff tears, tendon repair with incomplete footprint coverage is performed frequently as a way of tension-free or low-tension repair.

Purpose:

To compare clinical outcomes after arthroscopic repair of large-sized rotator cuff tears between patients with complete versus incomplete footprint coverage.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among 297 patients who underwent arthroscopic surgery for a large-sized rotator cuff tear, we selected 58 patients (<50% coverage; mean age, 63.34 ± 6.8 years; 34 men and 24 women) with incomplete footprint coverage. Using propensity score matching, another 58 patients with complete footprint coverage (mean age, 63.4 ± 8.03 years; 34 men and 24 women) were selected after 1:1 matching for age, sex, and tear size—the main demographic and prognostic factors of outcomes after rotator cuff repair. Clinical outcomes were compared on magnetic resonance imaging or ultrasonography at minimum of 6 months postoperatively, and functional outcomes were compared using range of motion and pain visual analog scale; American Shoulder and Elbow Surgeons; Constant; University of California, Los Angeles; and Simple Shoulder Test scores at a minimum of 2 years postoperatively.

Results:

A total of 18 patients in the incomplete footprint coverage group (31.0%) and 20 patients in the complete footprint coverage group (34.5%) showed healing failure, with no significant difference between groups (P = .843). In addition, there were no differences in functional outcomes between groups (P > .05 for all).

Conclusion:

Whether the rotator cuff footprint was completely covered did not affect clinical outcomes in conventional arthroscopic repair of large-sized rotator cuff tears.

Single Row Rotator Cuff Repair with Triple Loaded Suture Anchors: The SCOI Row Technique

Since the introduction of rotator cuff repair in the beginning of the 20th century, there have been significant advances in the surgical techniques and improvement in patient outcomes. However, controversy remains regarding the best method for tendon repair, including implant choice, ideal suture construct, and the potential benefits of supplemental biologic additives in order to achieve repair with the best opportunity for healing. The "SCOI Row" technique has been refined over three decades with extensive application and consistently good outcomes. Our technique uses a single row of anchors, triple loaded with a high-strength suture maximizing the number of sutures passed through the tendon to repair the rotator cuff arthroscopically. These anchors are placed 3-4 millimeters from the articular cartilage, providing strong anchorage and a low-tension repair. Debridement of devitalized tendon and only incorporating healthy tendon into the repair is imperative. The biology of the repair is enhanced with bone marrow vents created via microfracture of the greater tuberosity, forming the "Crimson Duvet" or bone marrow super-clot that will envelope the repair site. The bone marrow vents deliver marrow elements, including growth factors and mesenchymal cells that will help to regenerate the footprint of the rotator cuff. This repair construct has been evaluated biomechanically by other investigators and is favorable, as compared to dual row repairs. Our outcomes show greater than 90 % healing rate on postoperative magnetic resonance imaging and excellent patient-reported outcomes.

Editorial Commentary: Biology and Biomechanics Must Be Carefully Balanced for a Durable Rotator Cuff Repair

Arthroscopic rotator cuff repair strategies have evolved over 3 decades, but suture anchor design, anchor configuration, and stitches have been largely driven by repair biomechanics. In recent years there has been a shift toward repair strategies that enhance the biology of tendon repair. Double-row and transosseous equivalent suture anchor repair constructs demonstrate excellent time zero mechanical properties, but the resulting increased repair tension and tendon compression may compromise tendon healing. Modern single-row repairs employing medialized triple-loaded suture anchors, simple stitches, and lateral marrow venting avoid some of the problems associated with double-row repairs and demonstrate excellent short-term healing and clinical results. The most robust repair fails if the tendon does not heal. Biology and biomechanics must be carefully balanced.