Étude par arthroscanner de la cicatrisation tendineuse après réparation arthroscopique de la coiffe des rotateurs

Prospective study of 90 arthroscopic rotator cuff repairs for isolated distal supraspinatus tear, assessing the impact of cardiovascular risk factors on tendon healing

INTRODUCTION

Cardiovascular risk factors have been shown to be relevant to onset of rotator cuff tear, but their influence on healing remains to be determined.

OBJECTIVE

To assess the individual and cumulative impact of cardiovascular risk factors on tendon healing after arthroscopic rotator cuff repair.

MATERIAL AND METHOD

A single-center prospective study included 90 patients undergoing arthroscopic repair of isolated distal supraspinatus tendon tear. Only isolated full-thickness tears without anteroposterior extension, retraction (Patte stage ≤ 2) or fatty involution were included. Tendon healing was assessed on ultrasound according to the 5 types of the Sugaya classification. Clinical and functional assessment at 12 months used Constant score. Cardiovascular comorbidities were screened for in the preoperative anesthesiology consultation and control consultation: smoking, high blood pressure, dyslipidemia, diabetes, obesity, cardiovascular history, and obstructive sleep apnea syndrome.

RESULTS

Ninety patients with a mean age of 59.6±6.95 years were included for analysis. 77.7% of cuffs showed healing on ultrasound, without signs of retear (stage 1-3), 16.6% showed partial retear (stage 4) and 6.6% showed no healing, with tendon retraction (stage 5). Mean Constant score improved by 37.5 points (p=0.001), for a global score of 78 at 12 months. Multivariate analysis identified several significant cardiovascular factors for poor healing: active smoking (p=0.002), dyslipidemia (p=0.006), high blood pressure (p≤0.001) and obesity (p=0.02). Cumulative comorbidity was associated with poor tendon healing, with significant impact as of 2 cardiovascular risk factors. Constant score decreased significantly according to healing stage (p≤0.001).

CONCLUSION

The present study confirmed the involvement of cardiovascular risk factors in bone-tendon healing disorder, with significant impact as of 2 factors.

LEVEL OF EVIDENCE

IV; low-power prospective clinical series.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.

METHODS

Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).

RESULTS

The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.

CONCLUSION

Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Difference in the results of repair made with single or double rows according to the shape and size of the tear in arthroscopic rotator cuff surgery

The aim of this study was to evaluate the effect on the results of patients applied with arthroscopic full layer total layer rotator cuff repair made according to the shape and size of the tear.The study included a total of 120 patients applied with arthroscopic full layer rotator cuff repair as single or double row repair. The patients were separated into 3 groups of 40 according to the shape of the tear, as Group A (crescent type), Group B (U type), and Group C (L type).The mean age of the whole sample was 66.68 ± 6.86 years (range, 50-81 years). A statistically significant difference was determined between the groups in respect of constant murley (CM), American shoulder and elbow surgeons score (ASES), and University of California Los Angeles score (UCLA) scores (P < .05). The scores of Group A of all the scales were found to be higher than those of Group C (P < .05). In single row and double row repair of small and medium-sized tears of all shapes, no significant difference was determined in respect of the CM and UCLA scores (P > .05).No significant difference was determined between single and double row repair of crescent type tears of all sizes. In large U-shaped tears, the CM, ASES, and UCLA scores were determined to be high in double row repair.

Failed rotator cuff repair

After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90̊ of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.

Clinico-radiological evaluation of retear rate in arthroscopic double row versus single row repair technique in full thickness rotator cuff tear

BACKGROUND

Rotator cuff tear is most troublesome issue in shoulder surgery. Retear is seen in arthroscopically repaired rotator cuff tear.

PURPOSE

The functional outcome and retear rate in primary full thickness rotator cuff tear operated by single and double row repair technique.

METHODS

56 cases with full thickness tear of rotator cuff operated by single or double (28 each) were studied. Retear rate is evaluated after at least 6 months after surgery.

RESULTS

There was a statistical difference in retear rate between double row and single row repair (p value <0.01).

CONCLUSION

Retear rate is low in double row repair technique.

Surgical repair of massive rotator cuff tendon tears: Autologous quadriceps tendon graft versus arthroscopic repair

INTRODUCTION

Massive rotator cuff tear repair results are variable. The main purpose of this study was to compare functional outcome between two procedures: open repair by autologous quadriceps-patella tendon patch, and arthroscopic suture. The study hypothesis was that there is no significant difference in results between the two techniques.

MATERIAL AND METHODS

A retrospective study included all patients younger than 70 years operated on from 1995 to 2013 for massive rotator cuff tear. Exclusion criteria comprised history of dislocation, fracture or surgery or osteoarthritis in the affected shoulder, and infra- and supra-spinatus fatty degeneration equal to or greater than stage 3. Two consecutive groups were distinguished: group 1, from 1995 to 2003, comprised 23 patients (24 shoulders; mean age, 55.8 years) treated by open repair using quadriceps tendon autograft; group 2, from 2003 to 2013, comprised 27 patients (29 shoulders: mean age, 60.3 years) treated by arthroscopic repair.

RESULTS

Preoperatively, mean Constant score was 42.9 in group 1 and 45.7 in group 2 (P=0.36), pain score 5.5/15 and 7.6/15 (P=0.08), strength 3.0kg and 2.4kg (P=0.30), and subacromial space 6.3 and 6.7mm (P=0.05), respectively. At respectively 58 and 55 months' mean follow-up, Constant score was 71.1 in group 1 and 71.8 in group 2 (P=0.086), pain 11.9/15 and 12.7/15 (P=0.76), gain in strength 1.4kg and 2.3kg (P=0.0006), and subacromial space 7.1mm and 6.3mm (P=0.29), respectively. The complications rate was 70% in group 1 and there were no specific complications in group 2.

CONCLUSION

Functional improvement was significant and comparable between the 2 groups. Quadriceps tendon harvesting was associated with high morbidity, but the technique increased subacromial space.

LEVEL OF EVIDENCE

IV, retrospective, single-center.

Arthroscopic single-row versus double-row technique for repairing rotator cuff tears: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to systematically review published reports that compare the outcomes of single-row and double-row suture anchor fixation in arthroscopic rotator cuff repair.

METHODS

Combined data regarding relevant patient characteristics, rotator cuff pathology, surgical techniques, postoperative rehabilitation regimens, University of California at Los Angeles (UCLA) Scores, Constant scores, American Shoulder and Elbow Society (ASES) scores, tendon healing, incidence of recurrent rotator cuff defects, shoulder muscle strength, range of motion, surgical time and patient satisfaction were assessed.

RESULTS

Seven eligible randomized controlled studies and four prospective cohort studies were identified. There were no significant differences between the single-row and double-row groups in terms of Constant or ASES scores. However, UCLA scores, tendon healing, abduction shoulder strength index (SSI), external rotation SSI and internal rotation SSI were significantly better for double-row technique than for single-row technique. A statistically significant advantage for double-row repair according to UCLA score and external rotation SSI was found in the subgroup with tears greater than 3 cm.

CONCLUSION

No definite conclusion could be drawn about differences in overall outcomes of double- and single-row techniques for repairing for small to medium (<3 cm) or large to massive (>3 cm) rotator cuff tears, even though some measures of clinical outcome showed significant differences between these two techniques.

Repaired supraspinatus tendons in clinically improving patients: early postoperative findings and interval changes on MRI

Objective

To demonstrate and further determine the incidences of repaired supraspinatus tendons on early postoperative magnetic resonance imaging (MRI) findings in clinically improving patients and to evaluate interval changes on follow-up MRIs.

Materials and Methods

Fifty patients, who showed symptomatic and functional improvements after supraspinatus tendon repair surgery and who underwent postoperative MRI twice with a time interval, were included. The first and the second postoperative MRIs were obtained a mean of 4.4 and 11.5 months after surgery, respectively. The signal intensity (SI) patterns of the repaired tendon on T2-weighted images from the first MRI were classified into three types of heterogeneous high SI with fluid-like bright high foci (type I), heterogeneous high SI without fluid-like bright high foci (type II), and heterogeneous or homogeneous low SI (type III). Interval changes in the SI pattern, tendon thickness, and rotator cuff interval thickness between the two postoperative MRIs were evaluated.

Results

The SI patterns on the first MRI were type I or II in 45 tendons (90%) and type III in five (10%). SI decreased significantly on the second MRI (p < 0.050). The mean thickness of repaired tendons and rotator cuff intervals also decreased significantly (p < 0.050).

Conclusion

Repaired supraspinatus tendons exhibited high SI in 90% of clinically improving patients on MRI performed during the early postsurgical period. The increased SI and thickness of the repaired tendon decreased on the later MRI, suggesting a gradual healing process rather than a retear.

Comparative analysis on arthroscopic sutures of large and extensive rotator cuff injuries in relation to the degree of osteopenia

OBJECTIVE

To analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia.

METHOD

138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55).

RESULTS

In analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027).

CONCLUSION

The results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry.

Single-row or double-row fixation technique for full-thickness rotator cuff tears: a meta-analysis

Background

The single-row and double-row fixation techniques have been widely used for rotator cuff tears. However, whether the double-row technique produces superior clinical or anatomic outcomes is still considered controversial. This study aims to use meta-analysis to compare the clinical and anatomical outcomes between the two techniques.

Methods

The Pubmed, Embase, and Cochrane library databases were searched for relevant studies published before November 1, 2012. Studies clearly reporting a comparison of the single-row and double-row techniques were selected. The Constant, ASES, and UCLA scale systems and the rotator cuff integrity rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed-effects or random-effects model.

Results

Eight studies were included in this meta-analysis. The weighted mean differences of the ASES (−0.84; P = 0.04; I² = 0%) and UCLA (−0.75; P = 0.007; I² = 0%) scales were significantly low in the single-row group for full-thickness rotator cuff tears. For tear sizes smaller than 3 cm, no significant difference was found between the groups no matter in Constant (P = 0.95; I² = 0%), ASES (P = 0.77; I² = 0%), or UCLA (P = 0.24; I² = 13%) scales. For tear sizes larger than 3 cm, the ASES (−1.95; P = 0.001; I² = 49%) and UCLA (−1.17; P = 0.006; I² = 0%) scales were markedly lower in the single-row group. The integrity of the rotator cuff (0.81; P = 0.0004; I² = 10%) was greater and the partial thickness retear rate (1.93; P = 0.007; I² = 10%) was less in the double-row group. Full-thickness retears showed no difference between the groups (P = 0.15; I² = 0%).

Conclusion

The meta-analysis suggests that the double-row fixation technique increases post-operative rotator cuff integrity and improves the clinical outcomes, especially for full-thickness rotator cuff tears larger than 3 cm. For tear sizes smaller than 3 cm, there was no difference in the clinical outcomes between the two techniques.

Level of Evidence

Level I.

Factors that impact rehabilitation strategies after rotator cuff repair

Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.

Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation

PREAMBLE: Arthroscopic repair is our treatment of choice for massive rotator cuff tears. In order to reduce tension, we perform a side-to-side suture technique. The purpose of our work was to study the outcome of such technique by evaluating functional score and rotator cuff integrity using ultrasound at 2-year follow-up.

HYPOTHESIS

The "side-to-side" arthroscopic repair of large and massive rotator cuff tears provides a long-term continuity of rotator cuff mechanism, enhances function and relieves pain with low morbidity.

TYPE OF STUDY

Retrospective monocenter study.

MATERIAL AND METHODS

We included a continuous series of 50 patients of mean age 66.6 years (46-80), operated on between January 2007 and March 2008 for full-thickness retracted tears of the supraspinatus extending or not to the infraspinatus tendon. Management consisted of arthroscopic subacromial bursectomy, acromioplasty and side-to-side repair of the rotator cuff tendons with secure anchor fixation to the tuberosity. The relative Constant score was used for clinical evaluation preoperatively and at a minimum of 24 months after surgery. The continuity of rotator cuff mechanism was evaluated using ultrasound.

RESULTS

The mean relative Constant score improved significantly (p<0.05) from 40% (18-67) preoperatively to 91.7% (40-107) postoperatively. Fifty-six percent of the rotator cuffs from this series demonstrated continuity with a postoperative relative Constant score of 98.4% (74-121) and an increase in the shoulder strength score of 3.6 kg (1-6). Forty-four percent of the rotator cuffs had recurrent tear with an overall relative Constant score of 83.6% (4-126) and we did not observe any improvement in the strength score in this sub-group. Eighty-eight percent of the patients were satisfied or very satisfied with their outcome.

DISCUSSION

At a minimum 24-month follow-up, the side-to-side suturing technique reported excellent functional results with a very high satisfaction rate. For these large and massive rotator cuff tears sometimes considered as irreparable, ultrasound confirmed the continuity of the repair in 56% of the cases. Unhealed patients were not disadvantaged since they experienced pain relief and functional improvement. However, in this sub-group of patients, recovery of shoulder strength was poor.

LEVEL OF EVIDENCE

Level IV.

Structure of retracted tendons after staged repair following continuous traction

PURPOSE

The effect of staged repair involving continuous re-lengthening of the retracted musculotendinous unit after rotator cuff tear is not known. We quantified changes in chronically retracted tendons undergoing no repair or a staged repair involving an initial re-lengthening of the musculotendinous unit by traction in a sheep model of massive rotator cuff tear.

MATERIALS AND METHODS

Infraspinatus tendons of 12 sheep were released and allowed to retract for 4 months. Repair was performed after the retracted musculotendinous unit had been progressively returned to its original length through continuous traction in 8 sheep (group I). In the other 4 sheep (group II) traction was not successful and the tendons remained retracted. Tendon structure was assessed macroscopically, by MRI, histology, and TEM.

RESULTS

Normalized to their contralateral controls, at sacrifice, tendon thickness was unchanged in group I (116%, n.s) and increased in group II (129%, P < 0.05), however with substantial shortening. Increased collagen fiber crimping and disorganization was found in group II, whereas in group I the differences from normal tendon were less pronounced.

CONCLUSION

Retracted musculotendinous units have deteriorated tendons, characterized by increased collagen fiber crimp, and ultrastructural collagen fibril atrophy and disorganization. Continuous traction may arrest and partially restore degenerative changes in retracted tendon. The findings of this study might contribute to new approaches for the treatment of chronic "irreparable" rotator cuff tears.

Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplasty-tenotomy in the short term

INTRODUCTION

The principal study objective was to compare clinical results for arthroscopic repair of rotator cuff tear and acromioplasty-tenotomy in patients aged over 60 years.

HYPOTHESES

Repair provides better clinical results than isolated acromioplasty-tenotomy. Shoulder function is improved when healing is obtained.

PATIENTS AND METHODS

One hundred and forty-two patients aged over 60 years (mean age, 67 years) presenting with reparable supraspinatus tear, extending to a greater or lesser degree to the infraspinatus, agreed to take part in a randomized prospective study. Fifteen were excluded from statistical analysis. All underwent acromioplasty and biceps tenotomy. They were randomly assigned to arthroscopic rotator-cuff repair (CR group) or not (AT group). The principal evaluation criterion was mean weighted Constant score at one year's follow-up. Healing in the CR group was assessed on ultrasound at one year.

RESULTS

The complications rate was 7.9%. Mean weighted Constant score was significantly better in group CR: 75.8%, versus 68.8% in AT. In the CR group, the 1-year healing rate was 67.6%. Healing significantly impacted mean weighted Constant score: 80% with healing, versus 66.9% in iterative tearing. Whatever the size of the tear, mean weighted Constant score was significantly better in patients with than without (no repair or iterative tear) tendon healing.

DISCUSSION

The study demonstrated the interest of arthroscopic rotator cuff repair in patients aged over 60 years. The benefit of repair compared to isolated acromioplasty-tenotomy depended on tendon healing.

LEVEL OF EVIDENCE

Randomized prospective study, level II.

Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors

BACKGROUND

The prognostic factors associated with structural outcome after arthroscopic rotator cuff repair have not yet been fully determined.

HYPOTHESIS

The hypothesis of this study was that bone mineral density (BMD) is an important prognostic factor affecting rotator cuff healing after arthroscopic cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 408 patients who underwent arthroscopic repair for full-thickness rotator cuff tear between January 2004 and July 2008, 272 patients were included whose postoperative cuff integrity was verified by computed tomography arthrography (CTA) or ultrasonography (USG) and simultaneously who were evaluated by various functional outcome instruments. The mean age at the time of operation was 59.5 ± 7.9 years. Postoperative CTA or USG was performed at a mean 13.0 ± 5.1 months after surgery, and the mean follow-up period was 37.2 ± 10.0 months (range, 24-65 months). The clinical, structural, and surgery-related factors affecting cuff integrity including BMD were analyzed using both univariate and multivariate analysis. Evaluation of postoperative cuff integrity was performed by musculoskeletal radiologists who were unaware of the present study.

RESULTS

The failure rate of rotator cuff healing was 22.8% (62 of 272). The failure rate was significantly higher in patients with lower BMD (P < .001); older age (P < .001); female gender (P = .03); larger tear size (P < .001); higher grade of fatty infiltration (FI) of the supraspinatus, infraspinatus, and subscapularis (all P < .001); diabetes mellitus (P = .02); shorter acromiohumeral distance (P < .001); and associated biceps procedure (P < .001). However, in the multivariate analysis, only BMD (P = .001), FI of the infraspinatus (P = .01), and the amount of retraction (P = .03) showed a significant relationship with cuff healing failure following arthroscopic rotator cuff repair.

CONCLUSION

Bone mineral density, as well as FI of the infraspinatus and amount of retraction, was an independent determining factor affecting postoperative rotator cuff healing. Further studies with prospective, randomized, and controlled design are needed to confirm the relationship between BMD and postoperative rotator cuff healing.

Single-row repair versus double-row repair of full-thickness rotator cuff tears

PURPOSE

The purpose of this meta-analysis was to assess whether there are differences in the outcomes between single-row and double-row rotator cuff repair.

METHODS

Using MEDLINE, SCOPUS, SCIRUS, CINAHL, and the Cochrane Library, as well as a hand search, we searched for articles comparing single-row and double-row rotator cuff repair that were published before September 2009. The controlled clinical studies that met the inclusion and exclusion criteria were assessed for quality of methodology. Two of the authors performed this review and assessment. Any disagreements were resolved by the third author.

RESULTS

Three randomized controlled studies and two controlled clinical cohort studies were included in this meta-analysis. These studies were assessed as having a moderate to high level of evidence. The results showed that double-row repair improved tendon healing and provided greater external rotation but with significantly increased operative time. Furthermore, this study found that double-row repair decreased the recurrence rate. However, there were no statistically significant differences found in shoulder function as assessed by Constant score; American Shoulder and Elbow Surgeons (ASES) score; University of California, Los Angeles (UCLA) score; Western Ontario Rotator Cuff (WORC) index; Disabilities of the Arm, Shoulder and Hand (DASH) score; muscle strength; forward flexion; internal rotation; patient satisfaction; return to work; and adverse events.

CONCLUSIONS

Despite the fact that double-row repair shows a significantly higher rate of tendon healing and greater external rotation than does single-row repair, there is no significant improvement in shoulder function, muscle strength, forward flexion, internal rotation, patient satisfaction, or return to work.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and Level II studies.

In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions

HYPOTHESIS

We assessed bone-tendon contact surface and pressure with a continuous and reversible measurement system comparing 3 different double- and single-row techniques of cuff repair with simulation of different joint positions.

MATERIALS AND METHODS

We reproduced a medium supraspinatus tear in 24 human cadaveric shoulders. For the 12 right shoulders, single-row suture (SRS) and then double-row bridge suture (DRBS) were used. For the 12 left shoulders, DRBS and then double-row cross suture (DRCS) were used. Measurements were performed before, during, and after knot tying and then with different joint positions.

RESULTS

There was a significant increase in contact surface with the DRBS technique compared with the SRS technique and with the DRCS technique compared with the SRS or DRBS technique. There was a significant increase in contact pressure with the DRBS technique and DRCS technique compared with the SRS technique but no difference between the DRBS technique and DRCS technique.

CONCLUSIONS

The DRCS technique seems to be superior to the DRBS and SRS techniques in terms of bone-tendon contact surface and pressure.

Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older?

PURPOSE

The aim of this study was to assess tendon healing and clinical results of rotator cuff tears (RCTs) repaired arthroscopically in patients aged 65 years or older.

METHODS

Between January 2001 and December 2004, 88 patients with a mean age of 70 years (range, 65 to 85 years) had arthroscopic RCT repair. The repair was performed on 54 women (61%). The dominant arm was involved in 72 patients (82%). RCT included more than 2 tendons in 45 cases. Functional outcomes were assessed by use of the Constant score and Simple Shoulder Test. Tendon healing was estimated by use of a computed tomography (CT) arthrogram, which was obtained 6 months postoperatively, and was classified into 3 categories: stage 1, watertight and anatomic healing; stage 2, watertight and partial healing; and stage 3, not watertight and retear.

RESULTS

The mean duration of follow-up was 41 months (range, 24 to 77 months). The mean clinical outcome scores all improved significantly at the time of the final follow-up (P < .01). Computed tomography arthrogram imaging showed 27 shoulders with a stage 1 repair, 20 with a stage 2 repair, and 34 with a stage 3 repair. The retear rate was 42% (34 of 81). The patients with tendon healing stage 1 or 2 had a significantly superior functional outcome in terms of overall scores and strength compared with the stage 3 repairs (P < .01). In our study we had 39 isolated supraspinatus tears (small or medium tears); 11 (28.9%) had a retear (stage 3).

CONCLUSIONS

Arthroscopic repair in patients aged 65 years or older can yield tendon healing resulting in significant functional improvement. Our data suggest that arthroscopic repair can be considered successful for the older patient specifically when the tear is limited to the supraspinatus tendon.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The time for functional recovery after arthroscopic rotator cuff repair: correlation with tendon healing controlled by computed tomography arthrography

PURPOSE

We investigated how soon postoperative functional recovery became significant after arthroscopic rotator cuff repair and the influence of tendon healing.

METHODS

We conducted a prospective study on 114 cases of full-thickness rotator cuff tears arthroscopically repaired from January 2001 to December 2003. All patients were evaluated by the Constant scoring system at 3, 6, 12, and 24 months after surgery and at last follow-up. Computed tomography arthrography was done at 6 months postoperatively to study the progression of tendon healing.

RESULTS

The Constant score significantly improved from the third month after surgery (P < .0001) until the twelfth month, after which it stabilized (P < .0001). At last follow-up (31 months), the mean score was 80.1 points (range, 50 to 95 points). Female sex (P < .0001), upper-limb heavy work (P < .0001), poor bone quality (P = .039), and absence of healing (P = .002) were negative predictive factors. In particular, the absence of tendon healing leads to a worsening of the results from the twelfth month onward.

CONCLUSIONS

Arthroscopic repair of rotator cuff lesions as performed in this study gives very good results in terms of functional recovery. Our study showed functional recovery as early as 3 months after surgery and further improvement over the first year, followed by stabilization. We found that female sex, upper-limb heavy work, poor bone quality, and lack of tendon healing were all negatively associated with outcome. Patients presenting with a retear differed from the other patients, in that their clinical progression showed a significant rise in the Constant score over the first year, with a lowering of the score thereafter.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair?: A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment

BACKGROUND

Increasing the rate of watertight tendon healing has been suggested as an important criterion for optimizing clinical results in rotator cuff arthroscopic repair.

HYPOTHESIS

A double-row anchorage technique for rotator cuff repair will produce better clinical results and a better rate of tendon healing than a single-row technique.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

We compared 31 patients undergoing surgery with a double-row anchorage technique using Panalok anchors and Cuff Tack anchors and 35 patients with rotator cuff tear undergoing surgery with a single-row anchorage arthroscopic technique using Panalok anchors. We compared pre- and postoperative Constant score and tendon healing, as evaluated by computed tomographic arthrography 6 months after surgery, in these 2 groups.

RESULTS

The Constant score increased significantly in both groups, with no difference between the 2 groups (P = .4). Rotator cuff healing was judged anatomic in 19 patients with double-row anchorage and in 14 patients with single-row anchorage; this difference between the groups was significant (P = .03).

CONCLUSION

In this first study comparing double- and single-row anchorage techniques, we found no significant difference in clinical results, but tendon healing rates were better with the double-row anchorage. Improvements in the double-row technique might lead to better clinical and tendon healing results.

Multimodality imaging of the postoperative shoulder

Multimodality imaging of the postoperative shoulder includes radiography, magnetic resonance (MR) imaging, MR arthrography, computed tomography (CT), CT arthrography, and ultrasound. Target-oriented evaluation of the postoperative shoulder necessitates familiarity with surgical techniques, their typical complications and sources of failure, knowledge of normal and abnormal postoperative findings, awareness of the advantages and weaknesses with the different radiologic techniques, and clinical information on current symptoms and function. This article reviews the most commonly used surgical procedures for treatment of anterior glenohumeral instability, lesions of the labral-bicipital complex, subacromial impingement, and rotator cuff lesions and highlights the significance of imaging findings with a view to detection of recurrent lesions and postoperative complications in a multimodality approach.