Healing disturbance with suture bridge configuration repair in rabbit rotator cuff tear

Arthroscopic Modified Double-Pulley Suture-Bridge Repair of Medium-Sized Supraspinatus Tendon Tears

At present, the repair patterns for medium-sized supraspinatus tendon tears are double- and single-row repairs. However, the limitations of double-row repair include excessive anchor implantation and incremental surgical cost and time, whereas a deficient tendon-bone contact area exists with single-row repair. The modified double-pulley suture-bridge repair presented in this study is an arthroscopic technique using 3 double-loaded suture anchors combined with a double-pulley technique to form a hybrid repair pattern with a double row as the mainstay and a single row as the supplement. In the treatment of medium-sized tendon tears, the modified double-pulley suture-bridge repair can not only maximize the tendon-bone contact area but also lower the surgical cost and shorten the operative time. The surgical technique is described, including pearls and pitfalls, as well as advantages and disadvantages.

The Combined Suture Bridge With Mason-Allen Technique Is Superior to the Conventional Suture Bridge Technique for Arthroscopic Rotator Cuff Repair

PURPOSE

To compare clinical results and retear rates between the combined suture bridge with Mason-Allen (SBMA) technique and the conventional suture bridge (SB) technique in patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair.

METHODS

One hundred two patients who underwent arthroscopic rotator cuff repair using the SB technique (n = 50) or SBMA technique (n = 52) for a full-thickness rotator cuff tear and had at least 2 years of follow-up were retrospectively analyzed. Magnetic resonance imaging was performed before surgery and 2 years after to determine preoperative tear size, Goutallier stage, and presence of retear after surgery. Patients were clinically evaluated using the Japanese Orthopaedic Association (JOA) score.

RESULTS

The groups did not significantly differ in terms of follow-up period, age, sex, tear size, Goutallier stage, or number of suture anchors. The retear rate was significantly lower in the SBMA group (7.7% vs 28.0%; P < .01). The JOA score was significantly higher at last follow-up than before surgery in both groups (P <.01). The JOA score at last follow-up was significantly higher in the SBMA group (P = .02).

CONCLUSIONS

Arthroscopic rotator cuff repair using the SBMA technique may provide better clinical and anatomical outcomes than the conventional SB technique.

LEVEL OF EVIDENCE

Level III, retrospective cohort design; treatment study).

Arthroscopic Double-Pulley Suture-Bridge Repair of Supraspinatus Tendon Tear

At present, the suture bridge is a widely used surgical pattern in the treatment of supraspinatus tendon tear, but the shortcomings of a suture bridge, including expensive lateral-row anchor and increased type 2 retear rate, is obvious. The double-pulley suture-bridge described in this Technical Note uses a double-loaded suture anchor (medial-row anchor) as lateral-row anchor instead of traditional lateral-row anchor, combined with double-pulley technology forming suture-bridge in treatment of supraspinatus tendon tears. The surgical technique is described in pearls, pitfalls, advantages, and disadvantages.

H-loop Knotless Double-Row Repair Versus Knotted Suture Bridge for Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model [Formula: see text]

BACKGROUND

Knotted suture bridge repair (KSBR) has been widely proven to be an effective method for rotator cuff repairs. However, the occurrence of type 2 failure after suture bridge repair remains a frequent problem because of the stress concentration and disturbance of tendon perfusion in the medial row. The authors have developed the H-loop knotless double-row repair (HLDR) to counteract these problems.

PURPOSE

To compare the biomechanical and histological outcomes of HLDR and KSBR for rotator cuff tear in the rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Acute bilateral supraspinatus tears were created on the shoulders of 46 New Zealand White rabbits. HLDR and KSBR were randomly performed on the left side or right side. Thirteen animals each were sacrificed at 2, 4, and 8 weeks after surgery (n = 39), with 6 rabbits used for histological evaluation and the other 7 rabbits for biomechanical testing. The remaining 7 animals from the original 46 were only used for initial biomechanical evaluation at week 0.

RESULTS

Macroscopically, all repaired tendons were connected to their footprint on the greater tuberosity without postoperative complications at 8 weeks after surgery. The HLDR group had significantly better histological bone-to-tendon integration compared with the KSBR group in terms of fibrocartilage regeneration, collagen composition, and fiber organization. The biomechanical outcomes in the HLDR group were demonstrated to be better than those of the KSBR group at time 0 and 8 weeks after surgery.

CONCLUSION

Both repair techniques were effective for rotator cuff tears in a rabbit rotator cuff tear model; however, HLDR demonstrated more advantages in improving biomechanical properties and histological tendon-to-bone healing compared with KSBR.

CLINICAL RELEVANCE

This animal study suggested that HLDR might be an alternative choice for rotator cuff tears in humans to increase tendon-to-bone healing and reduce the rate of failure to heal.

Arthroscopic release combined with single-row fixation or double-row suture bridge fixation in patients with traumatic supraspinatus tear and adhesive capsulitis non-responsive to conservative management: A prospective randomized trial

BACKGROUND

There are few previous studies on traumatic supraspinatus tear with adhesive capsulitis. This study used arthroscopic release with single-row fixation or double-row suture bridge fixation to treat adhesive capsulitis of the shoulder with rotator cuff tears. Further, the clinical efficacy of arthroscopic release with single-row fixation and double-row suture bridge fixation was compared.

HYPOTHESES

Arthroscopic release combined with single-row fixation or double-row suture bridge fixation showed good clinical outcomes in patients with traumatic supraspinatus tear with adhesive capsulitis.

METHODS

A single-center prospective randomized trial was performed from June 2013 to June 2017. Of the 68 patients with traumatic supraspinatus tear and adhesive capsulitis who underwent arthroscopic release, 34 (22 with tear measuring≤3cm and 12 with tear measuring>3cm) were included in the single-row fixation group and 34 (20 with tear measuring≤3cm and 14 with tear measuring>3cm) were included in the double-row suture bridge fixation group. The visual analogue scale (VAS) score, University of California Los Angeles (UCLA) and American Shoulder and Elbow Surgeons (ASES) shoulder scores, range of motion, time to achieve satisfactory scores, and rotator cuff re-tear rate were compared between the groups.

RESULTS

The range of motion, VAS score, UCLA and ASES shoulder scores significantly improved after surgery in both groups. There was a significant difference in the UCLA and ASES shoulder scores, time to achieve satisfactory scores, and rotator cuff re-tear rates in patients with tears measuring>3cm between the groups.

CONCLUSIONS

Arthroscopic release combined with single-row fixation or double-row suture bridge fixation showed good clinical outcomes in patients with traumatic supraspinatus tear with adhesive capsulitis. Therefore, the capsule of the shoulder should be thoroughly released to achieve such outcomes. For patients with rotator cuff tears measuring>3cm, double-row suture bridge fixation was superior to single-row fixation and the rotator cuff re-tear rate was low.

LEVEL OF EVIDENCE

I; prospective, randomized trial, treatment study.

Tear Completion Versus In Situ Repair for 50% Partial-Thickness Bursal-Side Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model

BACKGROUND

Tear completion followed by repair (TCR) and in situ repair (ISR) have been widely used for bursal-side partial-thickness rotator cuff tears (PTRCTs). Both techniques have shown favorable results; however, controversy continues in terms of the best management.

PURPOSE

To compare the histological and biomechanical outcomes of these 2 techniques for 50% partial-thickness bursal-side rotator cuff tear repair in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 27 rabbits were used in this experimental study. Seven rabbits were sacrificed at the beginning of the study to form an intact tendon control group. A chronic 50% partial-thickness bursal-side tear model was created in 20 rabbits, and 5 rabbits were sacrificed for biomechanical testing of chronic partial-thickness tears (control group) without repair. In 15 rabbits, partial-thickness tears were repaired after 8 weeks. Partial-thickness tears in the right shoulders were completed to full thickness and repaired; in contrast, left shoulders were repaired in situ. All rabbits were euthanized 8 weeks after the repair. The tendons were tested biomechanically for ultimate failure, linear stiffness, and displacement. Histological evaluations of tendon-to-bone healing were performed via the modified Watkins score.

RESULTS

Macroscopically, all repaired tendons were attached to the greater tuberosity. The TCR group had a higher failure load than the ISR group, with mean values of 140.4 ± 13.8 N and 108.1 ± 16.6 N, respectively (P = .001). The modified Watkins score was significantly higher in the TCR group (23.5; range, 22-27) than in the ISR group (19.5; range, 16-22) (P = .009).

CONCLUSION

Both repair techniques are effective for 50% partial-thickness bursal-side rotator cuff tears; however, TCR yields significantly superior biomechanical and histological characteristics compared with ISR.

CLINICAL RELEVANCE

Tear completion and repair technique may increase tendon-to-bone healing and thereby reduce re-rupture rate in the partial thickness bursal side rotator cuff tears.

Anchorless Arthroscopic Transosseous and Anchored Arthroscopic Transosseous Equivalent Rotator Cuff Repair Show No Differences in Structural Integrity or Patient-reported Outcomes in a Matched Cohort

BACKGROUND

Anchored transosseous equivalent suture-bridge technique (TOE) is widely used for arthroscopic rotator cuff repair. It is unknown how patient outcomes scores, ROM, and integrity of the rotator cuff after repair using this anchored technique compare with those after repair using an anchorless transosseous technique (TO).

QUESTIONS/PURPOSES

(1) What are the differences in patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score) and shoulder ROM between TO and TOE rotator cuff repair techniques at 1 and 2 years after surgery? (2) What is the difference in repair integrity as measured by the re-tear rate, assessed ultrasonographically at 1 year, between these two techniques? (3) What is the difference in procedure duration between the two techniques when performed by a surgeon familiar with each?

METHODS

We reviewed 331 arthroscopic rotator cuff repairs performed by one surgeon from December 2011 to July 2016 in this retrospective, matched-pair study. Of these patients, 63% (208 of 331) underwent repair with standard anchored technique (anchors placed in a double-row, TOE manner) and 37% (123 of 331) underwent anchorless TO repair, with the same indications for surgery between groups. Forty-four percent (91 of 208) of patients in the TOE group and 61% (75 of 123) of patients in the TO group met the inclusion criteria. Eighty percent (73 of 91) of patients in the TOE group and 88% (66 of 75) in the TO group had minimum 2-year follow-up. We matched each group to a cohort of 50 patients by sex, age, smoking status, and tear size (by Cofield classification: small, < 1 cm; medium, 1-3 cm; large, > 3-5 cm; or massive, > 5 cm). The resulting cohorts did not differ in mean age (TO, 62 years [range 53-65 years]; TOE, 58 years [range 53-65 years]; p = 0.79), mean BMI value (TO, 30 [range 27-33]; TOE, 29 [range 27-35]; p = 0.97), or dominant arm involvement (TO, 80%; TOE, 78%; p = 0.81). The cohorts were followed for at least 2 years (median, 3.2 years [interquartile range (IQR) 2.2-4.3] for TO and 2.9 years [IQR 2.0-3.5 years] for TOE). ASES scores and ROM were evaluated before surgery and at follow-up visits and were recorded in a longitudinally maintained institutional database. Repair integrity was assessed using ultrasonography at 1 year, as is standard in our practice. For each tear-size group, we calculated the proportion of intact tendon repairs versus the proportion of re-tears. Duration of surgery was recorded for each patient.

RESULTS

At 1 year, we observed no difference in median ASES scores (90 [IQR 92-98] for TO and 88 [IQR 72-98] for TOE; p = 0.44); external rotation (50° [IQR 45°-60°) for TO and 50° [IQR: 40°-60°] for TOE; p = 0.58); forward flexion (165° [IQR 160°-170°] for both groups; p = 0.91); or abduction (100° [IQR 90°-100°] for TO and 90° [IQR 90°-100°] for TOE; p = 0.06). Fourteen percent of shoulders (seven of 50) in each treatment group had evidence of re-tear at 1 year (p > 0.99): 0 of 2 small tears in each group, 0 of 7 medium tears in each group, five of 32 large tears in each group, and two of 9 massive tears in each group (all, p > 0.99). At 2 years, we found no differences in median ASES scores (92 [IQR 74-98)] for TO and 90 [IQR 80-100] for TOE; p = 0.84); external rotation (60° [IQR 50°-60°] for both groups; p = 0.74); forward flexion (170° [IQR 160°-170°] for both groups; p = 0.69); or abduction (100° [IQR 90°-100°] for both groups; p = 0.95). We found no differences between groups in mean ± SD procedure time, which was 103 ± 20 minutes for TO repair and 99 ± 20 minutes for TOE repair (p = 0.45).

CONCLUSIONS

TO and TOE techniques for arthroscopic rotator cuff repair results in no differences in ROM, ASES scores, re-tear rates, and surgical time. Randomized control trials are needed to confirm these similarities or determine a superior method of repair. Future cost analyses may also help to determine the relative value of each technique.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Suprascapular nerve injury affects rotator cuff healing: A paired controlled study in a rat model

Purpose

We designed a paired controlled study to investigate the role of the suprascapular nerve (SSN) in rotator cuff healing using a rat tear model, and we hypothesised that rotator cuff healing is impaired in the absence of a healthy SSN.

Methods

Bilateral supraspinatus tenotomy from the great tuberosity was performed for 36 Wistar rats, which was then repaired immediately. A defect on the SSN was made on the right side, and a sham surgery was performed on the SSN at the left side. Twelve rats were sacrificed for biomechanical (six rats) and histological (six rats) testing, evaluated at 3, 6, and 9 weeks after surgery.

Results

The bone–tendon junction on the nerve-intact side showed significantly better biomechanical characteristics than the nerve-injured side in terms of maximum load, maximum stress over time, stiffness at 9 weeks, and Young's modulus at 3 and 9 weeks. On the nerve-injured side, significantly smaller fibrocartilage layers and muscle fibres could be obtained over time. In addition, on the nerve-injured side, inferior bone–tendon interface formation was obtained in terms of cell maturity, cell alignment, collagen orientation, and the occurrence of tidemark and Sharpey's fibres through 9 weeks. In addition, neuropeptide Y was secreted in the nerve-intact group at 6 and 9 weeks.

Conclusion

This study showed the inferior healing of the bone–tendon junction on the nerve-injured side compared with the nerve-intact side, which indicates that the SSN plays an important role in rotator cuff healing. Surgeons should pay more attention to SSN injury when treating patients with rotator cuff tear.

Arthroscopic rotator cuff repair: magnetic resonance arthrogram assessment of tendon healing

BACKGROUND

Many poor outcomes after arthroscopic rotator cuff (RC) repair relate to failure of tendon healing. The purposes of this study were to provide a better understanding of the magnetic resonance arthrography (MRA) characteristics of the RC tendon repair site after arthroscopic RC repair and to examine how these findings influence patient-reported outcome measures (PROMs) and the presence of persistent symptoms.

METHODS

We reviewed 48 shoulders (13 female and 35 male patients; average age, 53.8 years) at a minimum of 6 months (average, 11.4 months) after arthroscopic RC repair (average tear size, 2.2 cm). All patients completed PROMs and underwent MRA assessment. Detailed analysis of the RC repair site was undertaken, with findings correlated with clinical outcomes and PROMs.

RESULTS

The average preoperative American Shoulder and Elbow Surgeons (ASES) score of 39.5 improved to 92.8 (P < .001). All but 6 patients (87.5%) had increased signal intensity of the involved tendon, with interstitial splits and/or delamination in 65.6%. These changes had no effect on PROMs or patient satisfaction. Significant partial-thickness tears (>50%) were observed in 7 patients (14.6%), with no effect on outcomes (average ASES score of 95.2 and satisfaction score of 9). There were 2 recurrent full-thickness tears (4.2%), and 4 patients (8.3%) had a failure in continuity. The average ASES score in these 6 cases of failure was 76 (P < .001).

CONCLUSIONS

Structural abnormalities on MRA are common after RC repair but do not always result in clinical failure. However, our results suggest that an ASES score of less than 80 may be useful when considering postoperative imaging, especially in a patient with ongoing pain more than 6 months after surgery.

A Prospective Randomized Trial Comparing Suture Bridge and Medially Based Single-Row Rotator Cuff Repair in Medium-Sized Supraspinatus Tears

PURPOSE

To compare the clinical and imaging outcomes between the suture bridge technique (SB) and the medially based single-row technique (medSR) in patients with 1- to 3-cm tear sizes.

METHODS

All patients were evaluated preoperatively and postoperatively (at 12 and 24 months) using the modified University of California, Los Angeles scoring system; active range of motion (flexion and external rotation); and a visual analog scale for pain. Healing status was examined by postoperative magnetic resonance imaging.

RESULTS

Clinical and imaging evaluations were completed by 92 patients at 1-year follow-up and by 74 patients at 2 years. No significant differences were found between the 2 groups across all measures at final follow-up: The University of California, Los Angeles scores were 33.4 points in SB patients and 33.0 points in medSR patients (P = .58); the visual analog scale scores were 6 mm and 7 mm, respectively (P = .38); the active flexion angles were 161° and 159°, respectively (P = .34); and the external rotation angles were 49° and 52°, respectively (P = .37). Retears were observed in 6.5% of SB patients and 2.1% of medSR patients (P = .31). Medial cuff failure was observed only in SB patients (4.3%, 2 cases), whereas incomplete healing (deep-layer retraction pattern) was observed only in medSR patients (8.7%, 4 cases). Neo-tendon regeneration in the medSR group was observed in 93% of patients.

CONCLUSIONS

This study did not show any significant differences in the clinical outcomes and cuff integrity between the 2 treatment groups at final follow-up; however, medial cuff failure was observed only in the SB group, and incomplete healing was more frequent in the medSR group. One should consider the risk of medial cuff failure and incomplete healing of the repaired cuff before choosing the repair technique for medium-sized supraspinatus tears.

LEVEL OF EVIDENCE

Level I, therapeutic, prospective, randomized trial.

Effect of a poloxamer-based thermosensitive gel on rotator cuff repair in a rabbit model: a controlled laboratory study

BACKGROUND

A common complication after rotator cuff repair is postoperative stiffness, which can be reduced by a simple application of an anti-adhesive agent. However, anti-adhesive agents may affect rotator cuff healing by preventing fibrosis. This experimental animal study evaluated the effect of the application of a poloxamer-based thermosensitive anti-adhesive gel and its influence on the healing of an acute rotator cuff repair in a rabbit model.

METHODS

Acute rotator cuff repair (supraspinatus tendon) was performed using a transosseous suturing method. One shoulder on a randomly selected side was treated with a local application of the anti-adhesive agent (applied side), and saline was applied to the contralateral side (control side). Biomechanical testing and histological analyses were performed at 4 and 8 weeks postoperatively. Eight rabbits were included for each testing and time point, for a total of 32 rabbits.

RESULTS

The failure load at 4 weeks was lower in the experimental group (95.2 ± 19.6 N vs. 110.0 ± 20.5 N; P = 0.017). Conversely, at 8 weeks, the failure load was higher in the experimental group (148.3 ± 16.2 N) than in the control group (122.4 ± 16.9 N; P = 0.002). Histological analyses revealed no statistically significant differences in the tendon maturing scores at 4 and 8 weeks between the two groups (all P > 0.05). The thickness of the fibrosis between the rotator cuff tendon and deltoid was thinner in the experimental group at both time points (0.50 ± 0.25 vs. 1.27 ± 0.47; P = 0.002 at 4 weeks, and 0.37 ± 0.35 vs. 1.39 ± 0.50; P = 0.003 at 8 weeks).

CONCLUSIONS

Application of an anti-adhesive agent in this rotator cuff model confirmed the agent's effectiveness at reducing fibrosis in the subacromial space. The healing of the tendon showed interesting results, as the experimental group had poorer biomechanical strength at 4 weeks but superior strength at 8 weeks.

Enhancement of rotator cuff tendon-bone healing using bone marrow-stimulating technique along with hyaluronic acid

Objective

The purpose of this study was to investigate the effect of hyaluronic acid (HA) in the tendon–bone healing process after rotator cuff repair in a rabbit model.

Methods

In vitro, rat bone marrow stromal cells (rBMSCs) were cultured in media for cartilage-related and inflammation-related gene expression levels examination at 1.0 mg/mL of HA. In vivo, 48 New Zealand white rabbits underwent rotator cuff repair surgery, and they were randomly divided into three groups: (1) control group (n = 16), (2) microfracture (MF) group accepting MF treatment (n = 16) and (3) MF/HA group accepting MF with HA treatment (n = 16). Four rabbits from each group were sacrificed at 6 and 12 weeks postoperatively for histological evaluation and biomechanical testing.

Results

In vitro experiments reveal that HA significantly decreased inflammation-related mRNA expression (IL-1, TNFα) compared with the control group. At 6 weeks after surgery, there was no significant difference of load-to-failure between groups. At 12 weeks after surgery, the mean failure load of the MF/HA group was significantly higher than that of the control group (100.5 ± 10.1 N vs. 68.0 ± 6.2 N; p = 0.0115). The mean failure load of the MF group appeared higher than that of the control group, whereas there was no significant difference (p > 0.05). Histologically, more chondrocytes were clustered at the tendon–bone interface, and more extracellular matrixes were produced in the MF/HA group. The interface of the MF/HA group appeared similar with the normal tendon–bone interface.

Conclusion

HA may play a crucial role in the acceleration of tendon-to-bone healing which might be through inhibiting inflammation. Rotator cuff repair using MF along with HA led to better tendon–bone healing and a subsequent increase of biomechanical strength at the repair site.

The translational potential of this article

HA injection is very common for patients with rotator cuff disease because of its antiinflammatory action and adhesion prevention preoperatively. The HA injection during surgery provides an antiinflammatory effect during tendon–bone healing process and leads to better tendon–bone healing postoperatively.

Safety evaluation of a laxity-minimizing suture at 5 days and 6 weeks after repair of a sheep infraspinatus tendon

BACKGROUND

The ideal rotator cuff repair achieves high initial fixation strength and secure tendon-to-bone apposition until biological healing occurs. A suture that reacts to the local stress environment by minimizing suture laxity across the repair could theoretically maintain soft-tissue apposition to bone and therefore improve healing.

METHODS

By use of an in vivo ovine shoulder model, the infraspinatus tendon was transected and then repaired with either a laxity-minimizing suture or a traditional high tensile suture. The purpose of this study was to evaluate both sutures' safety at 5 days and 6 weeks after repair.

RESULTS

The macroscopic and microscopic analyses of the repair sites showed similar amounts of surgical trauma. There was no evidence of cheese wiring or tissue necrosis of the repaired tendons for either suture. There was no evidence of systematic toxicity in any animal. The maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture.

CONCLUSION

The laxity-minimizing suture was as safe at 5 days and 6 weeks as the predicate suture. Neither suture contributed to local tissue damage or particle generation leading to adverse systematic consequences. An additional observation was that the maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture.

The Surgical Applications of Biologics in Sports Medicine

Over the past 25 years an increased appreciation of the positive impact of biologic interventions has driven significant advances in the surgical treatment of shoulder and knee conditions. These biologic adjuncts to treatment promote improved outcomes and have set the stage and increased research and development in this arena.

Clinical outcomes and repair integrity after arthroscopic full-thickness rotator cuff repair: suture-bridge versus double-row modified Mason-Allen technique

BACKGROUND

This retrospective study compared the clinical and radiologic outcomes of patients who underwent arthroscopic rotator cuff repairs by the suture-bridge and double-row modified Mason-Allen techniques.

METHODS

From January 2012 to May 2013, 76 consecutive cases of full-thickness rotator cuff tear, 1 to 4 cm in the sagittal plane, for which arthroscopic rotator cuff repair was performed, were included. The suture-bridge technique was used in 37 consecutive shoulders; and the double-row modified Mason-Allen technique, in 39 consecutive shoulders. Clinical outcomes at a minimum of 2 years (mean, 35.7 months) were evaluated postoperatively using the visual analog scale; University of California, Los Angeles Shoulder Scale; American Shoulder and Elbow Surgeons Subjective Shoulder Scale; and Constant score. Postoperative cuff integrity was evaluated at a mean of 17.7 months by magnetic resonance imaging.

RESULTS

At the final follow-up, the clinical outcomes improved in both groups (all P < .001) but with no significant differences between the 2 groups (all P > .05). The retear rate was 18.9% in the shoulders subjected to suture-bridge repair and 12.8% in the double-row modified Mason-Allen group; the difference was not significant (P = .361).

CONCLUSIONS

Despite the presence of fewer suture anchors, the patients who underwent double-row modified Mason-Allen repair had comparable shoulder functional outcomes and a comparable retear rate with those who underwent suture-bridge repair. Therefore, the double-row modified Mason-Allen repair technique can be considered an effective treatment for patients with medium- to large-sized full-thickness rotator cuff tears.

Clinical outcomes of arthroscopic rotator cuff repair: a retrospective comparison of double-layer, double-row and suture bridge methods

BACKGROUND

The suture-bridge (SB) method has recently become the mainstream means of repairing full-thickness rotator cuff tears. However, in some patients the deep and superficial layers have moved in different directions because of delamination of their rotator cuffs. In such cases, a simple suture (double-layer, double-row [DD] method) is used to repair the superficial and deep layers separately. The purpose of this study was to analyze the clinical outcomes and re-tear rates of the DD and SB methods, with patients selected according to the condition of their torn cuffs.

METHODS

We retrospectively registered 74 patients with full-thickness rotator cuff tears that had been repaired arthroscopically, 35 shoulders by the DD and 39 by the SB method. Mean ages were 66.1 years in the DD and 62.9 years in the SB group. We evaluated clinical status before and after surgery (Japanese Orthopedic Association [JOA] scores) and re-tear rate. The Wilcoxon signed-ranks test was used to compare JOA scores and active ROM between before and after surgery in each group. Mann-Whitney's U test was used for comparing JOA scores, active ROM, re-tear rates, size of tear, duration of follow-up, sex, and presence of subscapular muscle repair between the DD and SB groups. A hazard ratio of less than 5% was considered to denote significance.

RESULTS

JOA scores improved significantly in the DD and SB groups from preoperative means of 63.4 and 63.3 points, respectively, to postoperative means of 91.8 and 92.1 points, respectively. The active flexural ROM improved significantly from means of 110.1° and 100.0°, respectively, to postoperative means of 142.3° and 142.7°, respectively; the differences between groups were not significant. Re-tear occurred in 5.9% of the DD (two of 34 shoulders) and 7.9% of the SB group (three of 38 shoulders); its incidence did not differ significantly between the two groups.

CONCLUSIONS

Both the DD and SB methods achieve satisfactory clinical outcomes that do not differ significantly. Our results suggest that careful selection of operative method on the basis of the delamination pattern in patients undergoing RCT may reduce the re-tear rate after utilizing the SB method.

Quantitative magnetic resonance imaging (MRI) analysis of anterior talofibular ligament in lateral chronic ankle instability ankles pre- and postoperatively

BACKGROUND

The aim of this study was to quantitatively evaluate and characterize the dimension and signal intensity of anterior talofibular ligament (ATFL) using 3.0 T MRI in the mechanical ankle instability group pre- and postoperatively.

METHODS

A total of 97 participants were recruited retrospectively in this study, including 56 with mechanical chronic ankle instability (CAI group) and 41 without ankle instability (Control group). All the subjects accepted MRI preoperatively. Among the 56 CAI patients, 25 patients, who accepted modified Broström repair of ATFL, underwent a MRI scan at follow-up. The ATFL dimension (length and width) and signal/noise ratio (SNR) were measured based on MRI images. The results of the MRI studies were then compared between groups.

RESULTS

The CAI group had a significantly higher ATFL length (p = 0.03) or ATFL width (p < 0.001) compared with the control group. The mean SNR value of the CAI group was significantly higher than that of the control group (p = 0.006). Furthermore, the mean SNR value of the ATFL after repair surgery (8.4 ± 2.4) was significantly lower than that of the ATFL before surgery (11.2 ± 3.4) (p < 0.001). However, no significant change of ATFL length or ATFL width were observed after repair surgery.

CONCLUSIONS

CAI ankles had a higher ATFL length or width as well as higher signal intensity compared with stable ankles. After repair surgery, the mean SNR value of the ATFL decreased, indicating the relaxed ATFL becomes tight postoperatively.

Rotator Cuff Tears at the Musculotendinous Junction: Classification and Surgical Options for Repair and Reconstruction

Although uncommon, rotator cuff tears that occur medially at the musculotendinous junction can result from acute trauma, anatomic force imbalance, or medial row cuff failure following a previous rotator cuff repair. The quality of the torn muscle and tendon along with the length of the remnant tendon stump should be considered before deciding on the most appropriate repair technique. When muscle and tendon quality are sufficient, the tear can often be repaired directly to the remnant tendon stump and compressed onto the greater tuberosity. If the remnant tendon stump is degenerative, of insufficient length, or lacks tendon in which to place sutures, an allograft patch can be used to augment the repair. When the quality of the remaining muscle and tendon are poor or when the muscle is retracted too far medially and is nonmobile, a bridging technique such as superior capsule reconstruction is preferable. The purpose of this report is to (1) highlight that medial cuff failure can occur both primarily and after previous repair; (2) define and classify the 3 major tear patterns that are encountered, and (3) describe the authors' preferred techniques for medial cuff repair that specifically address each of the major tear patterns.

Arthroscopic trans-osseous rotator cuff repair

BACKGROUND

Mechanical factors are at the basis of any tendon healing process, being pressure an aspect able to positively influence it. For this reason transosseous rotator cuff repair represents the gold standard procedure for patients affected by a cuff tear, maximizing the tendon footprint contact area and reducing motion at the tendon to bone interface.

METHODS

The Authors present an all arthroscopic suture bridge-like transosseous repair with the preparation of a single transosseous tunnel perfor med thanks to a precise dedicated instrument (Compasso®) and one implant (Elite-SPK®) with the use of only 3 suture wires. In addition this technique permits to accurately prepare the bony side of the lesion without any risk or complication, such as anchor pull-out and greater tuberosity bone osteolysis.

CONCLUSIONS

However, even if this technique seems less demanding, the arthroscopic transosseous repair is still an advanced procedure, and should be performed only by well prepared arthroscopic shoulder surgeons.

LEVEL OF EVIDENCE

V.

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.

Editorial Commentary: Reflections From a Mature Arthroscopic Shoulder Surgeon on the History and Current Benefits of Augmentation for the Revision of a Massive Rotator Cuff Tear Using Acellular Human Dermal Matrix Allograft

Acellular human dermal matrix allografts are now being used to augment and sometimes replace severely damaged rotator cuff tissue. I have been interested in this important aspect of orthopaedics for 15 years and am pleased to have the opportunity to share my personal reflections of some of the highlights in science and the literature that helped get to the point now where we can expect greater than 80% healing even in these difficult cases of revision after massive failed cuff repair. The field of tissue engineering will certainly be a critical part of our rotator cuff surgical future.