Clinical and radiological outcomes of osteoarthritis twenty years after rotator cuff repair

Association of Preoperative Shoulder Osteoarthritis Severity Score With Change in American Shoulder and Elbow Surgeons Score at 2 Years After Rotator Cuff Repair

Background

The impact of early glenohumeral osteoarthritis (GHOA) on clinical outcomes after rotator cuff repair (RCR) remains unclear. The magnetic resonance imaging (MRI)-based Shoulder Osteoarthritis Severity (SOAS) score is a comprehensive approach to quantifying glenohumeral degeneration.

Purpose

To investigate the association between SOAS scores and changes in American Shoulder and Elbow Surgeons (ASES) scores in patients who underwent RCR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two reviewers independently analyzed the preoperative MRI scans of 116 shoulders and assigned SOAS scores. Spearman correlation was used to calculate the association of mean SOAS scores with patient demographic characteristics and change in ASES scores over the 2-year follow-up period (ΔASES). Multivariate regression analysis was performed between the independent variables of patient age, sex, body mass index, and significant SOAS score components as determined by univariate analysis, with the dependent variable being ΔASES. Significance was defined as P < .05 for univariate analysis and P < .0125 after application of the Bonferroni correction for multivariate analysis.

Results

The mean ASES scores were 55.8 ± 18.6 preoperatively and 92.1 ± 12.1 at 2 years postoperatively. The mean preoperative SOAS score was 15.2 ± 7.1. On univariate analysis, the total SOAS score was positively correlated with patient age (r S = 0.41; P < .001), whereas ΔASES was negatively correlated with patient age (r S = -0.27; P = .0032). Increasing SOAS subscores for supraspinatus/infraspinatus tear size (r S = -0.28; P = .024), tendon retraction (r S = -0.23; P = .015), muscle atrophy (r S = -0.20; P = .034), paralabral ganglia (r S = -0.23; P = .015), and cartilage degeneration (r S = -0.21; P = .024) were negatively correlated with ΔASES. A negative correlation was found between increasing total SOAS score and ΔASES (r S = -0.22; P = .016). On multivariate analysis, increasing supraspinatus/infraspinatus tear size was significantly and negatively correlated with ΔASES (β = -3.3; P = .010).

Conclusion

Increasing the total SOAS score was predictive of less improvement in ASES scores at 2 years postoperatively. On univariate analysis, SOAS subscores with the strongest negative correlations with ΔASES scores included tear size, muscle atrophy, tendon retraction, paralabral ganglia, and cartilage wear. On multivariate analysis, only tear size was significantly associated with a lower change in the ASES score.

Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis

Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.

Arthroscopic advancement of the supraspinatus muscle and tendon for posterosuperior massive rotator cuff tears

The tension-free repair of retracted supraspinatus tears with the open muscle and tendon advancement technique first described by Debeyre in 1965 gave satisfactory clinical results. The purpose of this anatomical study was to test the feasibility of an arthroscopic supraspinatus advancement technique. A total of 10 cadaveric shoulders were operated. We assessed the feasibility, measured the slide distance, and recorded the position of the suprascapular nerve (SSN) for each shoulder. Reattachment of the tendon to its native footprint was achieved in all cases. The mean slide distance was 38.8 mm ± 3.6 (33-44). The SSN was released and tension-free in all shoulders. Arthroscopic advancement of the supraspinatus muscle and tendon enables complete rotator cuff repair in irreparable retracted posterosuperior tears and is a noteworthy alternative to the other techniques. Level of Evidence: IV.

Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022

BACKGROUND

Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies.

RESULTS

A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11).

CONCLUSIONS

Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.

Which preoperative factors influence the patient's short-term subjective assessment after rotator cuff repair?

INTRODUCTION

To highlight the preoperative risk factors that influence postoperative patient satisfaction following Rotator Cuff Repair (RCR) and to determine whether this satisfaction was correlated with tendon healing.

HYPOTHESIS

Preoperative factors influence patient satisfaction, assessed by SSV (Subjective Shoulder Value) postoperatively, with a correlation with tendon healing.

METHODS

With a mean age of 60.6 years (40-72), 102 patients with arthroscopic RCR were included retrospectively. The preoperative SSV score was less than or equal to 50%. There was clinical and radiological follow-up with an ultrasound evaluation of tendon healing 6 months postoperatively. We divided the patients into 2 groups using a postoperative SSV of 85% as the cut-off; 55 patients in the first group (SSV>85%); and 47 patients in the second group (SSV<85%).

RESULTS

In multivariate analysis, Preoperative risk factors for poor postoperative SSV after RCR were: tobacco use [-8.41 (-13.64; -3.17) p=0.002], fatty infiltration [-3.65 (-6.24 -1.06) p=0.006] and workers compensation [-19.15 (-24.04; -14.27) p<0.001]. When patients were not in workers compensation, the lower their SSV score before surgery, the higher their postoperative SSV score. For patients in workers compensation, the higher the SSV preoperatively, the less elevated was SSV postoperatively. The Sugaya ultrasound classification did not influence the SSV score (p=0.15) CONCLUSIONS: Smoking, fatty infiltration and patients in workers compensation are factors of poorer subjective results evaluated by the SSV score. Tendon healing did not influence the SSV score and patient satisfaction.

LEVEL OF EVIDENCE

IV, cohort study.

Arthroscopic Rotator Cuff Repair Results in Improved Clinical Outcomes and Low Revision Rates at 10-Year Follow-Up: A Systematic Review

PURPOSE

To study the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following arthroscopic rotator cuff repair (ARCR) at a minimum of 10-years follow-up.

METHODS

Two independent reviewers performed a literature search of PubMed, Embase, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only studies reporting on outcomes of ARCR with a minimum 10-year follow-up were considered for inclusion. Patient demographics, satisfaction, and clinical, radiologic, and surgical outcomes were evaluated.

RESULTS

Our search found 9 studies including 455 shoulders in 448 patients (51.6% male patients), with age at time of surgery ranging from 45 to 90 years met our inclusion criteria. Overall follow-up ranged from 10 to 18 years. At final follow-up, the ranges of American Shoulder & Elbow Surgeons, age- and sex-adjusted Constant-Morley, and University of California Los Angeles scores were reported in 5, 6, and 3 studies, respectively, as 79.4 to 93.2, 73.2 to 94, and 26.5 to 33, respectively. Of the included studies, satisfaction rates varied in 6 studies from 85.7% to 100% in the long-term. Additionally, the overall radiologic retear rate ranged from 9.5% to 63.2%. The overall surgical revision rates ranged in 6 studies from 3.8% to 15.4%, with from 0% to 6.7% requiring revision ARCR and from 1.0% to 3.6% requiring revision subacromial decompression in 6 and 2 studies, respectively, at minimum 10-years' follow-up.

CONCLUSIONS

In this study, we found that ARCR results in high rates of patient satisfaction, satisfactory clinical outcomes with respect to patient-reported functional outcomes and range of motion, and low revision rates at minimum 10-years' follow-up. However, an overall 30% retear rate was observed in asymptomatic patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Long-term functional and structural outcome of rotator cuff repair in patients 60 years old or less

Background

The long-term outcomes of rotator cuff repair (RCR) have not been well studied. The purpose of this study was to evaluate long-term functional and structural outcomes after RCR in younger patients.

Methods

A total of 49 patients (34 [69%] male) with a mean age of 51 ± 6 years were evaluated preoperatively, and at short- and long-term follow-ups (minimum 15 years). There were 13 (27%) small, 17 (35%) medium, 14 (29%) large, and 5 (10%) massive tears. 15 (31%) had an acute repair of a traumatic tear. Long-term evaluation included physical examination, plain radiographs, ultrasound, and patient reported outcome measures (PROMs) (visual analog scale pain, Disability of Arm, Shoulder and Hand, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and Short Form-36). Statistical analysis was performed to determine associations between preoperative and intraoperative factors and long-term functional and structural outcome.

Results

There were significant improvements in the mean short- and long-term PROMs compared to preoperatively that exceeded reported minimal clinically important differences and substantial clinical benefits. There was a slight decrease in the PROMs from the short-term to long-term follow-up. Male sex and traumatic rotator cuff tears were associated with better long-term outcomes. The number of medical co-morbidities was associated with worse long-term outcomes. Smaller initial tear size was associated with better long-term outcomes. There were 15 (31%) full thickness and 9 (18%) partial thickness recurrent rotator cuff tears, 17 (35%) had rotator cuff tear arthropathy (2 Hamada grade 1, 15 Hamada grade 2), 5 (10%) had revision surgery (2 revision RCR, 2 anatomic total shoulder, and 1 reverse total shoulder), and 13 (26%) had subsequent contralateral RCR. There were weak correlations between the presence of arthropathy and DASH (r = 0.34; P = .02) and visual analog scale pain (r = 0.29; P = .049). There were no significant correlations between the structural outcomes (recurrent rotator cuff tear, recurrent full thickness tear, acromiohumeral space, and critical shoulder angle,) and the PROMs.

Discussion and Conclusion

Long-term follow-up of RCR in this relatively young patient cohort demonstrated substantial and durable patient reported functional outcome and improvement despite considerable structural deterioration. This suggests that while RCR does not arrest the progression of rotator cuff disease it may delay this progression and that patients adapt to the structural changes as they age.

Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair

Background:

Radiographic changes in the glenohumeral joint often occur after rotator cuff repair; however, the details of the progression and underlying causes remain unknown.

Purpose:

To retrospectively evaluate the timing and frequency of radiographic changes after arthroscopic rotator cuff repair and to clarify the predictive factors that affect the onset of such changes using multivariate analysis.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed 100 patients with 5 years of follow-up after arthroscopic rotator cuff repair and evaluated the postoperative shift in radiographic findings on plain radiographs every year during follow-up. Factors related to osteoarthritis, acromial spur re-formation, and greater tuberosity resorption at 5 years after surgery were evaluated using logistic regression analyses. Explanatory variables included preoperative factors, intraoperative factors, and postoperative retear. Baseline variables significant in the univariate analyses were included in the multivariate models.

Results:

Of the 100 patients, 12 developed osteoarthritis, 26 developed acromial spur formation, and 16 developed greater tuberosity resorption at 5 years after surgery. The incidence and grade of osteoarthritis and acromial spur gradually increased over time postoperatively. On the other hand, greater tuberosity resorption developed within 2 years after surgery but did not progress later. Multivariate analysis showed that a larger anteroposterior tear size (odds ratio [OR], 1.09; 95% CI, 1.01-1.17; P = .037) was a risk factor for postoperative osteoarthritis. Early retear (OR, 10.26; 95% CI, 1.03-102.40; P = .047) was a risk factor for acromial spur re-formation. Roughness of the greater tuberosity (OR, 9.07; 95% CI, 1.13-72.82; P = .038) and larger number of suture anchors (OR, 3.34; 95% CI, 1.66-6.74; P = .001) were risk factors for greater tuberosity resorption.

Conclusion:

Our study showed that radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. While the osteoarthritic changes and acromial spur re-formation gradually progressed postoperatively, the greater tuberosity resorption stopped within 2 years after surgery. Tear size, morphology of the greater tuberosity, and the number of suture anchors can affect radiographic changes. Furthermore, this study suggested that acromial spur re-formation may be an indicator of early retears.

Risk factors for the development of degenerative changes among patients undergoing rotator cuff repair: A systematic review

BACKGROUND

Osteoarthritis (OA) of the glenohumeral joint results in significant pain and functional limitations. It is unclear which risk factors increase the risk of developing glenohumeral OA amongst Rotator Cuff Repair (RCR) patients. The purpose of this systematic review was to examine the risk factors which may contribute to the development of osteoarthritic changes post-operatively.

METHODS

MEDLINE, Embase, and PubMed databases were searched to identify studies reporting on demographics of patients who develop OA following RCR.

RESULTS

Seventeen articles were identified investigating a total of 1292 patients. The overall quality of evidence was low. Pooled assessment of OA incidence following RCR at minimum 5 years follow-up found 26% of patients developed OA. Patients requiring revision surgery following retears developed OA at a rate of 29%. Surgical technique and patient demographics may also contribute to degenerative changes.

DISCUSSION

This review found correlations between the aforementioned risk factors and glenohumeral joint degeneration at long-term follow-up after RCR. These findings suggest that future long-term studies should aim to identify prognostic factors that may place a patient at increased risk of developing OA. Such data can be used to counsel patients with respect to long-term outcomes following surgical intervention.

Relationship between the Hamada Grade and underlying pathological conditions in the rotator cuff and long head of biceps in symptomatic patients with rotator cuff tears

Background

This study aimed to investigate the relationship between Hamada Grade and rotator cuff and long head of the biceps (LHB) pathologies in symptomatic patients with rotator cuff tears (RCTs).

Methods

We retrospectively reviewed 376 patients (156 men and 220 women; mean age, 68.4 years) who had undergone surgery for complete RCTs. Preoperative plain radiography, magnetic resonance imaging, and intraoperative findings were assessed. All cases were allocated to the Hamada Grade 1, 2, 3, and 4-5 groups to investigate the correlation between Hamada Grade severity and underlying rotator cuff and LHB pathologies.

Results

The rate of RCTs involving the infraspinatus was significantly higher in Grade 2 than in Grade 1 (P < .0001). The tear size and fatty muscle degeneration of the subscapularis in Hamada Grade 3 were significantly more severe than those in Grade 2 (P = .01 and P < .0001, respectively). The tear size and fatty muscle degeneration of the rotator cuff in Grade 4-5 were significantly more severe than those in Grade 3 (all P < .05). The complete LHB rupture rate was significantly higher in Hamada Grade 4-5 than in Grades 1, 2, and 3 (all P < .001).

Conclusion

Rotator cuff tears involving the infraspinatus were associated with Hamada Grade 2. The rate of concomitant subscapularis tears with posterosuperior RCTs was significantly higher in Hamada Grade 3 than in Hamada Grade 2. RCT enlargement, progression of fatty muscle degeneration of the subscapularis and posterosuperior rotator cuff muscles, and the increase in complete LHB rupture were associated with Hamada Grade 4-5.

Arthroscopic Rotator Cuff Repair Results in Lower Two-Year Reoperation Rates Compared With Open Rotator Cuff Repair in a Large Cross-sectional Cohort

PURPOSE

To use a large, contemporary database to perform a cross-sectional analysis of current practice trends in rotator cuff repair (RCR) for the treatment of full-thickness rotator cuff tear (RCT) and determine outcomes of arthroscopic and open RCR, including hospital readmissions and 2-year reoperation rates with accurate laterality tracking using International Classification of Diseases, Tenth Revision (ICD-10) codes.

METHODS

The PearlDiver Mariner dataset was used to query patients with full-thickness RCTs from 2010 to 2017. Propensity-score matching was performed to account for differences in age and comorbidities and allow for comparison between those undergoing open RCR and arthroscopic RCR. Subsequent procedures were tracked using ICD-10 codes to identify ipsilateral surgery within 2 years of index surgery. Hospital and emergency department admission within 30 days of surgery were investigated.

RESULTS

Of 534,076 patients diagnosed with full-thickness RCT, 37% underwent RCR; 73% of which were arthroscopic. From 2010 to 2017, arthroscopic RCRs increased from 65% to 80%, whereas open RCRs decreased from 35% to 20% (P < .0001). Younger patients underwent arthroscopic RCR more frequently, and patients who underwent open RCR had greater rates of 30-day emergency department (7.0%) and hospital readmission (2.0%) compared with arthroscopic RCR (6.3%, 1.0%, respectively) (P < .0001). For 24,392 patients with ICD-10 coding and 2-year follow-up, 10.4% of patients required reoperation, with the most common procedure being revision RCR, and 1.3% required conversion to arthroplasty. Open RCRs were more likely to require subsequent surgery (11.3%) compared with arthroscopic RCR (9.5%) (P < .0001). Patients aged 50 to 59 had the greatest rate of reoperation (14.0%), but no patients younger than age 40 years required reoperation, and no patients younger than age 50 years required conversion to arthroplasty.

CONCLUSIONS

The frequency of arthroscopic RCR has continued to increase compared to open RCR. In this large cross-sectional analysis, arthroscopic RCR demonstrated lower 2-year reoperation rates and 30-day readmission rates compared to open RCR.

LEVEL OF EVIDENCE

III, cross-sectional study.

Factors associated with the development of early- to mid-term cuff-tear arthropathy following arthroscopic rotator cuff repair

BACKGROUND

Few studies have specifically evaluated the development of cuff-tear arthropathy (CTA) after a rotator cuff repair in the postoperative early to mid-term. This study aimed to identify the factors associated with the development of CTA, to evaluate the effect of arthropathy on functional outcomes, and to evaluate the incidence of CTA 3-10 years after an arthroscopic rotator cuff repair.

METHODS

A total of 312 patients who underwent an arthroscopic repair of a large or massive full-thickness rotator cuff tear with a minimum follow-up of 3 years were retrospectively divided into 2 groups for analysis: those with postrepair CTA (arthritic glenohumeral changes due to rotator cuff insufficiency) and those without. CTA was assessed using the Seebauer and modified Hamada-Fukuda classification systems. Pre-, intra-, and postoperative patient characteristics; characteristics of the rotator cuff tear; clinical and radiological parameters; and pre- and postoperative functional scores were compared.

RESULTS

The rate of development of CTA was 11.5% (36 of 312 patients, 13 centric and 23 eccentric arthropathy). CTA was more frequently associated with the poor integrity of the supraspinatus tendon after repair (P < .001) and massive tears (P = .006). Postoperative pseudoparalysis (P < .001), symptomatic retear (P < .001), tear size (P = .026), critical shoulder angle (P = .001), preoperative acromiohumeral interval (P = .046), and the humeral head superior migration (P = .001) were found to be associated with the development of CTA. However, only postoperative pseudoparalysis was found to be an independent risk factor (P < .001, odds ratio: 2.965). Patients with postrepair CTA had significantly worse functional outcome scores.

CONCLUSION

The postoperative development of pseudoparalysis may be a marker of CTA in the future and that closer follow-up may be necessary.

Outcomes of rotator cuff repair with concurrent microfracture of focal glenohumeral osteoarthritis

BACKGROUND

The benefit of rotator cuff repair (RCR) in patients with concurrent osteoarthritic changes remains unclear. RCR has the theoretical potential to increase the compressive force across the glenohumeral joint, further exacerbating osteoarthritis pain. The purpose of this study is to investigate pain relief and patient-reported outcomes of patients undergoing simultaneous RCR and microfracture of focal glenohumeral osteoarthritis.

METHODS

Thirty-four patients undergoing simultaneous RCR and microfracture were retrospectively reviewed at a minimum 1-year follow-up. Patient demographics, preoperative range of motion, functional outcomes (visual analog scale [VAS], Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Simple Shoulder Test [SST]), and operative metrics were recorded. The patients were then contacted to obtain postoperative functional outcome scores (VAS, SANE, ASES, and SST).

RESULTS

Twenty-seven patients (11 male/16 female [79%]) were evaluated at a mean follow-up of 25.8 months (range, 12-46). The average age at surgery was 64.9 years (range, 56-78). Chronic tears were more common than acute tears (57.7% vs. 42.3%). The majority of patients had a full rotator cuff tear (89%) involving a mean 1.7 ± 0.8 tendons (range, 1-3). Eighty-eight percent of the humeral lesions were Outerbridge 4 compared with 84% on the glenoid. The mean estimated involvement between the 2 groups with 38.4% ± 18.4% of the humeral head involved and 34.6% ± 18.4% of the glenoid involved. PRO scores improved postoperatively with a reduction in mean VAS (6.6-2.0, P < .01), SANE (33.8-79.8, P < .01), ASES (38.0-80.9, P < .01), and SST (3.07-9.70, P < .01) scores. Cumulatively, only 52% (14/27) of the patients improved, however, by the MCID for all collected PROs.

CONCLUSIONS

Our results demonstrate modest improvements in postoperative pain and functional scores at a minimum of 1-year follow-up in a cohort of patients who have undergone RCR and glenohumeral microfracture. In cases of small focal lesions of full-thickness cartilage loss, RCR with microfracture is a reasonable treatment option; however, patients should be counseled on expectations accordingly.

Comparison between partial and full coverage repair in massive rotator cuff tears. A minimum five year follow-up

BACKGROUND

Massive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs.

PATIENTS AND METHODS

A retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome.

RESULTS

The average ASES score was 76.3±25.2, and average Penn Shoulder Score was 75.8±23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p=0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p=0.20 and p=0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R² of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI <1.5 was associated with improved functional outcome.

DISCUSSION

No difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Treatment of non-arthritic pseudoparetic shoulders with irreparable massive rotator cuff tears: arthroscopic procedures yield comparable midterm results to reverse arthroplasty

Background

Irreparable massive rotator cuff tears (IMRCTs) are a well-known cause for functional limitation and difficult to treat. Although several joint-preserving as well as joint-replacing procedures were found to provide pain relief and gain of function, midterm results are scarce, particularly in pseudoparetic shoulder joints unaccompanied by severe osteoarthritis. The purpose of this study was to compare the midterm functional outcomes of arthroscopic procedures to those of reverse total shoulder arthroplasty (RTSA) in pseudoparetic shoulders with IMRCTs unaccompanied by severe osteoarthritis.

Methods

All patients who underwent either joint-preserving (group A) or joint-replacing (group B) procedures for IMRCT unaccompanied by severe osteoarthritis with a pseudoparetic shoulder function were retrospectively included. Clinical assessment included the Constant Score (CS), the Subjective Shoulder Value (SSV) and the Visual Analog Score (VAS) at baseline and at latest follow-up. Furthermore, the complication and revision rates were assessed.

Results

Overall, a total 56 patients were included of whom each 28 patients formed group A (male, 36%) and B (male, 53%) with a mean patient age at time of surgery of 70 ± 7 years and 72 ± 7 years, respectively. The mean follow-up period was 56 ± 17 months. At final follow-up, the total CS (group A: 66 ± 14 points; group B 54 ± 15 points) was significantly increased after arthroscopic treatment when compared to RTSA (p=0.011). However, no significant differences were detected with SSV (p=0.583) and VAS (p=0.536). Although complication rate (11% versus 18%) was not significantly different (p=0.705), number of revision surgeries was significantly higher in group B when compared to group A (p=0.041).

Conclusions

In non-arthritic pseudoparetic shoulders, both joint-preserving and joint-replacing procedures yielded good clinical midterm outcomes for the treatment of degenerative IMRCTs. Despite of comparable functional and satisfactory functional improvement, increased complication rates and surgical invasiveness outweigh the benefits of primary RTSA and therefore reserve this procedure to a second-line treatment in pseudoparetic patients without any signs of severe cuff arthropathy.

3-T T2 mapping magnetic resonance imaging for biochemical assessment of normal and damaged glenoid cartilage: a prospective arthroscopy-controlled study

This study evaluated the ability of T2 mapping to assess the glenoid cartilage using arthroscopy as the gold standard. Eighteen consecutive patients (mean age: 52.4 ± 14.72 years, including 12 men) with shoulder pain underwent T2 mapping at 3-T with subsequent shoulder arthroscopy. With correlation to cartilage-sensitive morphologic sequences regions-of-interest were placed in the corresponding T2 maps both in normal-appearing cartilage and focal cartilage lesions using a quadrant-wise approach. Inter-reader and intra-reader correlation coefficients (ICCs) between two independent radiologists as well as cut-off values with their sensitivities/specificities for the detection of cartilage damage were calculated. The mean T2 value for healthy cartilage was 23.0 ± 3 ms with significantly higher values in the superior quadrants compared to the inferior quadrants (p < 0.0001). In 5 patients with focal cartilage damage significantly higher T2 values of 44.7 ± 3.7 ms (P < 0.01) were observed. The maximum T2 value in normal cartilage (27.3 ms) was lower than the minimum value in damaged cartilage (40.8 ms) resulting in perfect sensitivities/specificities of 100% (95% confidence-interval 47.8-100.0) for all cut-off values between 27.3-40.8 ms. ICCs ranged between 0.63 and 0.99. In conclusion, T2 mapping can evaluate biochemical cartilage integrity and discriminates arthroscopy-proven healthy and damaged glenoid cartilage with high diagnostic performance.

Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques

BACKGROUND

Arthroscopic rotator cuff repair (RCR) with suture anchor-based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results.

PURPOSE

To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture-grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis.

RESULTS

A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant.

CONCLUSION

Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.