Does partial tear repair of adjacent tendons improve the outcome of supraspinatus tendonfull-thickness tear reinsertion?

Outcomes After Double-Layer Repair Versus En Masse Repair for Delaminated Rotator Cuff Injury: A Systematic Review and Meta-analysis

Background

Delamination of rotator cuff tears during arthroscopic shoulder surgery has an incidence of 38% to 92%. Double-layer (DL) repair and en masse (EM) repair are most commonly used in this situation.

Purpose

To compare the clinical results of the DL versus EM repair techniques for delaminated rotator cuff tears using a meta-analysis.

Study Design

Systematic review; level of evidence, 3.

Methods

We identified relevant studies comparing the clinical results of DL and EM repair for delaminated rotator cuff injuries in the PubMed, Embase, and Cochrane databases after the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcomes were the Constant score and retear rate. Additionally, we compared other postoperative shoulder functional scores, shoulder range of motion, and visual analog scale (VAS) pain scores between the 2 suture methods using a meta-analysis. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes.

Results

Of the 197 studies initially identified, 6 studies were included in this analysis. There were significant differences in the Constant score (MD, 8.64 [95% CI, 4.47 to 12.8]; P < .05) and external rotation (MD, 5.10 [95% CI, 2.63 to 7.56]; P < .05) between the 2 techniques, with DL repair having superior outcomes. No significant differences were observed between the 2 techniques in forward flexion (MD, 0.62 [95% CI, -1.18 to 2.43]; P = .50), VAS pain (MD, -0.03 [95% CI, -0.34 to 0.27]; P = .84), or retear rate (OR, 0.73 [95% CI, 0.37 to 1.41]; P = .35).

Conclusion

Results of this review and meta-analysis suggest that DL repair was more beneficial than EM repair in terms of the Constant score and shoulder external rotation in patients with delaminated rotator cuff injuries.

Magnetic resonance imaging could precisely define the mean value of tendon thickness in partial rotator cuff tears

PURPOSE

Rotator Cuff (RC) lesions are classified in full-thickness and partial-thickness tears (PTRCTs). To our knowledge, no studies investigated the mean size of shoulder tendons in healthy and PTRCT patients using MRI scans. The aim of the study was to provide data to obtain and compare the mean value of tendon sizes in healthy and PTRCTs groups.

METHODS

From 2014 to 2020, 500 were included in the study. They were divided into two groups: Group 1 (100 subjects) was composed of people positive for partial-thickness rotator cuff tears (PTRCTs), while the 400 subjects in Group 2 were negative for PTRCTs.

RESULTS

Overall, of the patients included in the study, 231 were females and 269 were males. The mean age of the patients was 49 ± 12.7 years. The mean thickness of the supraspinatus tendon (SSP) was 5.7 ± 0.6 mm in Group 1, 5.9 ± 0.6 mm in Group 2 (p < 0.001). The mean length of the ISP tendon was 27.4 ± 3.2 mm in Group 1, 28.3 ± 3.8 mm in Group 2 (p = 0.004). The mean width of the SSP tendon was 17 ± 1.6 mm in Group 1, 17.6 ± 2 mm in Group 2 (p = 0.004). The mean width of the infraspinatus tendon (ISP) tendon was 17.7 ± 1.4 mm in Group 1, 18.3 ± 2.1 mm in Group 2 (p = 0.02).

CONCLUSION

The anatomical data present in this paper may serve as a tool for surgeons to properly manage PTRCTs. The findings of the present study aimed to set the first step towards reaching unanimity to establish international cut-off values to perform surgery. Additionally, they could widely increase diagnostic accuracy, improving both conservative and surgical approaches. Lastly, further clinical trials using more accurate diagnostic MRI tools are required to better define the anatomical differences between PTRCT and healthy patients.

LEVEL OF EVIDENCE

Level II, Retrospective Comparative Trial.

Long-term Results of Arthroscopic Rotator Cuff Repair: Initial Tear Size Matters: A Prospective Study on Clinical and Radiological Results at a Minimum Follow-up of 10 Years

BACKGROUND

Arthroscopic techniques are now considered the gold standard for treatment of most rotator cuff (RC) tears; however, no consensus exists on the maintenance of results over time, and long-term follow-up data have been reported for few cohorts of patients.

PURPOSE

To present the long-term results associated with the arthroscopic treatment of RC tears and to evaluate associations between preoperative factors and RC integrity at final follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 169 patients were contacted at least 10 years after arthroscopic RC surgery and were invited to a clinical evaluation. Information on preoperative conditions, tear size, subjective satisfaction, and functional scores was collected; isometric strength and range of motion were also measured; and each patient underwent an ultrasound examination to evaluate supraspinatus integrity and a shoulder radiograph to evaluate osteoarthritis.

RESULTS

A total of 149 patients (88.2% of the eligible patients) were available for a complete telephonic interview, and 102 patients were available for the final evaluation. Ultrasound revealed an intact supraspinatus in 54 patients (53.47%). By adding the 10 patients who underwent revision surgery to the nonintact group, this percentage would drop to 48.65%. Tear size was associated with supraspinatus integrity in univariate analysis (hazard ratio, 3.04; 95% CI, 1.63-5.69; P = .001) and multivariable analysis (hazard ratio, 2.18; 95% CI, 1.03-4.62; P = .04). However, no significant differences were encountered in the subjective and functional scores collected, with the exception of the Constant-Murley Score, which was significantly higher in patients with smaller tears at the index procedure. Strength testing also revealed significantly superior abduction and flexion strength in this group, and radiographs showed a significantly higher acromion-humeral distance and lower grades of osteoarthritis. Patients with an intact supraspinatus at final follow-up showed superior results in all functional scores, greater satisfaction, superior abduction and flexion strength, higher acromion-humeral distance, and lower grades of osteoarthritis.

CONCLUSION

RC tear size at the time of surgery significantly affects supraspinatus integrity at a minimum follow-up of 10 years. However, a larger tear is not associated with an inferior subjective result, although it negatively influences abduction and flexion strength, range of motion, and osteoarthritis progression. Intraoperative efforts to obtain a durable RC repair are encouraged, since supraspinatus integrity at final follow-up influences clinical and functional outcomes, patient satisfaction, and osteoarthritis progression.

Clinical and structural outcome twenty years after repair of isolated supraspinatus tendon tears

BACKGROUND

This study evaluated the clinical and structural outcome 20 years after repair of isolated supraspinatus tendon tears. We hypothesized that the results would deteriorate over time.

MATERIALS AND METHODS

For this retrospective multicenter study, 137 patients were recalled for a clinical and imaging assessment. Six patients (4.3%) had died from unrelated causes, 52 (38.0%) were lost to follow-up, and 13 (9.5%) had undergone reoperations. This left 66 patients for clinical evaluation. Radiographs and magnetic resonance imaging were additionally performed for 45 patients, allowing assessment of osteoarthritis, tendon healing, fatty infiltration (FI), and muscle atrophy.

RESULTS

The Constant Score (CS) improved from 51.5 ± 14.1 points preoperatively to 71 points (P < .05) with a mean Subjective Shoulder Value (SSV) of 77.2% ± 22%. Tendon discontinuity (Sugaya IV-V) was present in 19 of 45 patients (42 %), and there was advanced FI (Goutallier III-IV) of the supraspinatus in 12 (27%) and of the infraspinatus muscle in 16 (35%). Supraspinatus atrophy was present in 12 patients (28%), advanced arthritis in 6, and cuff tear arthropathy in 12 (30%). The CS and SSV were significantly inferior for shoulders with FI of stages III to IV (P < .05). The CS was lower in cuff tear arthropathy and correlated with infraspinatus FI.

CONCLUSIONS

At 20 years after surgical repair of isolated supraspinatus tears, the clinical outcome remains significantly above the preoperative state. FI of the infraspinatus is the most influential factor on long-term clinical outcome.

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

PURPOSE

To evaluate the arthroscopic double-layer lasso loop repair technique for delaminated posterosuperior rotator cuff tears.

METHODS

Forty-one patients underwent arthroscopic rotator cuff repair of a delaminated posterosuperior rotator cuff tear by the double-layer lasso loop technique. Their preoperative and postoperative clinical and functional scores were compared to evaluate surgical outcomes. The prerequisite for inclusion was a minimum follow-up period of 2 years. We excluded patients with a history of shoulder surgery before the double-layer lasso loop repair.

RESULTS

Statistically significant improvements (P < .001) were found in the Constant score (54 vs 83) and University of California, Los Angeles functional score (6.4 vs 9.5). Pain and strength improved according to the Jobe test, bear-hug test, belly-press test, Gerber lift-off test, and external rotation test (P < .001). No significant difference in strength was noted between the operated and nonoperated sides. There was only 1 complete rerupture (3.1%), whereas 5 patients (15.6%) had partial ruptures.

CONCLUSIONS

The arthroscopic double-layer lasso loop repair technique for delaminated posterosuperior rotator cuff tears is an effective procedure. Our series showed a low rerupture rate. At a mean follow-up of 44 months, postoperative recovery with resultant functional, pain, and patient satisfaction scores was good to excellent and was comparable with the nonoperated side.

LEVEL OF EVIDENCE

Level IV, case series.

Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type

PURPOSE

Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear.

METHODS

The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension.

RESULTS

The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P < 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs > 2) in the P (P < 0.001) and AP (P < 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs > 2) in the A (P < 0.001) and AP (P < 0.001) groups. The rate of osteoarthritis (Samilson > 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups.

CONCLUSIONS

The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery.

LEVEL OF EVIDENCE

IV.

Ten-Year Multicenter Clinical and MRI Evaluation of Isolated Supraspinatus Repairs

BACKGROUND

Early repair of isolated supraspinatus tears could prevent further deterioration of the rotator cuff; however, there is no consensus on the management of such tears because of a lack of long-term outcome studies. The purposes of this study were to report the 10-year outcomes of isolated supraspinatus repairs and to investigate the factors that favor healing and recovery.

METHODS

We retrieved the records of all 511 patients who, in 2003, underwent repair of full-thickness isolated supraspinatus tears, performed by 15 surgeons at 15 centers. In 2014, the patients were asked to return for evaluation at a minimum follow-up of 10 years. One hundred and eighty-eight patients could not be reached, and 35 were excluded because they had a reoperation (17 had a retear, 7 had conversion to an arthroplasty, and 11 had other causes). A total of 288 patients (50% were men) who had a mean age (and standard deviation) at index surgery of 56.5 ± 8.3 years (range, 32 to 77 years) were evaluated clinically, and 210 of them were also evaluated using magnetic resonance imaging (MRI).

RESULTS

Thirty shoulders (10.4%) had complications, including stiffness (20 shoulders), infection (1 shoulder), and other complications (9 shoulders). The total Constant score improved from a mean of 51.8 ± 13.6 points (range, 19 to 87 points) preoperatively to 77.7 ± 12.1 points (range, 37 to 100 points) at 10 years. At the 10-year follow-up evaluation, the mean Subjective Shoulder Value (SSV) was 84.9 ± 14.8 (range, 20 to 100), and the mean Simple Shoulder Test (SST) was 10.1 ± 2.2 (range, 3 to 12). Of the 210 shoulders evaluated using MRI, the repair integrity was Sugaya type I in 26 shoulders (12%), type II in 85 (41%), type III in 59 (28%), type IV in 27 (13%), and type V in 13 (6%). The total Constant score at the final follow-up was significantly associated with tendon healing (p < 0.005) and was inversely associated with preoperative fatty infiltration (p < 0.001). Neither the surgical approach nor the preoperative retraction influenced the outcomes.

CONCLUSIONS

Repairs of isolated supraspinatus tears maintained considerable improvement in clinical and radiographic outcomes at 10 years. Preoperative fatty infiltration and postoperative retear have a significantly detrimental effect on the long-term functional outcome of rotator cuff repair.

LEVEL OF EVIDENCE

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

Reconstruction of 25 and 50 % subscapularis tears: a single anchor with a double-mattress suture is sufficient for the reconstruction

PURPOSE

Evaluation of the biomechanical performance of repairs of 25 % (Fox/Romeo II) and 50 % (Fox/Romeo III) full-thickness subscapularis tears using a single-suture anchor.

METHODS

Six pairs of human cadaver specimens were used for the testing. Artificial subscapularis tears were created in order to simulate a 25 % (6) and a 50 % (6) full-thickness tear. The reconstructions were made with a double-loaded suture anchor (5.5-mm Bio-Corkscrew with two No. 2 Fiberwire) creating a double-mattress suture repair. Reconstructions were cyclically loaded from 10 to 60 N. The load was increased stepwise up to 100 and 180 N. Cyclic displacement (means + standard dev.) as well as load-to-failure was determined, and mode of failure was recorded.

RESULTS

In the reconstructed shoulders at 60 N, a mean cyclic displacement of 3.2 ± 0.7 mm was found in the 25 % tear, 2.6 ± 0.6 mm in the 50 % tear. At 100 N, 5.1 ± 1.2 mm was seen in the 25 % tear and 4.3 ± 0.3 mm in the 50 % tear. At highest load of 180 N, 7.6 ± 2.2 mm was recorded in the 25 % tear, 6.5 ± 0.8 mm was found in the 50 % tear. Ultimate failure load was 486 ± 167 N in the 25 % tear and 455 ± 213 N in the 50 % tear. Statistically significant differences between the tested repairs were seen neither in cyclic displacement nor in ultimate failure loads (p > 0.05). Mode of failure revealed bone fractures and anchor pull-out as major cause in the 25 % group, whereas failure of the suture-tendon interface was the major cause of failure in the 50 % group.

CONCLUSIONS

Subscapularis repair using a single double-loaded suture anchor revealed similar biomechanical performance in 25 % compared to 50 % full-thickness subscapularis tears. With increased tear size, however, an optimized suture-tendon interface seems to become more relevant in order to decrease failure rate of the repair.

CLINICAL RELEVANCE

A single double-loaded suture anchor provides sufficient biomechanical strength even in Fox/Romeo grade III tears of the subscapularis tendon. However, a modified suture configuration is recommended, especially in grade III tears as the suture-tendon interface is the weakest point of the construct.

[Diagnostics and treatment of anterosuperior rotator cuff tears]

INTRODUCTION

Anterosuperior rotator cuff lesions are defined as combined tears of the subscapularis and the supraspinatus tendon and are usually accompanied by an associated lesion of the rotator interval. There are three different types of lesion: extended lesions of the biceps pulley, transmural tears of the supraspinatus with an associated partial lesion of the subscapularis tendon, and massive anterosuperior rotator cuff tears. None of these lesions responds well to physiotherapy because of biceps tendon instability. Therefore, surgical treatment is required, including tenodesis or tenotomy of the biceps tendon and additional repair of the rotator cuff. Deep partial tears of the subscapularis or the supraspinatus tendon (≥ 6 mm) should be refixed as well. Massive anterosuperior rotator cuff tears should be treated immediately because of the high retraction tendency of the subscapularis tendon.