Outcome and structural integrity of rotator cuff after arthroscopic treatment of large and massive tears with double row technique: a 2-year followup

Patient-reported outcome tools and baseline scores vary by country and region for arthroscopic repair of massive rotator cuff tears: a systematic review

Background

Different patient-reported outcome (PRO) tools are used in patients with arthroscopic rotator cuff repair (ARCR) which complicates outcome comparisons. The purpose of this systematic review was to compare PRO usage and baseline scores across world regions and countries in patients with ARCR of massive rotator cuff tears (MRCT).

Methods

A systematic review was performed on ARCR for MRCT. The search was conducted from September to November of 2022 using the MEDLINE database for articles published in the last 15 years. Thirty-seven articles were included after initial screening and full-text review. In each article, PRO usage, baseline scores, and country of origin were collected. PRO usage was reported in percentages and baseline scores were normalized for each region to facilitate comparisons. Normalization was performed using the PRO means from each article. These averages were converted to fractions using the worst and best possible scores. These were combined into a single numerical value, expressed as a decimal from 0 to 1, using the total sample size for each tool per region. Values closer to 0 represent worse functional outcomes.

Results

Thirty-two percent (n = 12) of articles were from Asia, 43.2% (n = 16) from Europe, 5.4% (n = 2) from the Middle East, and 18.9% (n = 7) from North America. The most commonly reported PRO tools were American Shoulder and Elbow Surgeons (ASES) in 19 papers, Constant-Murley Score (CMS) in 26 papers, Visual Analog Scale for pain (VAS) in 19 papers, and University of California in Los Angeles (UCLA) in 11 papers. ASES was reported in 51% of articles with 63% being from Asia (n = 12) compared to 21% from North America (n = 4). CMS was reported in 70% of studies with 58% being from Europe. Upon normalization, the preoperative score ranged from 0.30 to 0.44. Europe (0.39), and North America (0.40) showed similar scores. The lowest and highest scores were seen in the Middle East (0.3) and Asia (0.44) respectively.

Conclusion

There is no standardized method to report outcomes in patients undergoing ARCR for MRCT. Great variation in usage exists in PROs which complicates data comparison between world regions. With normalization, baseline scores where similar among Asia, North America, and Europe, and lowest in the Middle East.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Clinical outcomes in patients with retear after arthroscopic rotator cuff repair: A meta-analysis

BACKGROUND

Rotator cuff retear is a major concern after arthroscopic rotator cuff repair (ARCR); however, the effects of retear remain unclear. Therefore, the purpose of this study was to assess the clinical outcomes of postoperative retear and intact tendons after ARCR.

METHODS

We searched PubMed, Cochrane Library, Scopus, and PEDro databases for studies performed from January 2000 to June 2020. Clinical outcomes included the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles shoulder (UCLA) score, pain score, range of motion, and muscle strength. Meta-analysis using random-effects models was performed on the pooled results to determine significance.

RESULTS

The initial database search yielded 3141 records. After removal of duplicates, 26 of which met the inclusion criteria. Patients in the retear group had significantly lower Constant score [- 8.51 points (95% CI, - 10.29 to - 6.73); P < 0.001], ASES score [- 12.53 points (95% CI, - 16.27 to - 8.79); P < 0.001], UCLA score [- 3.77 points (95% CI, - 4.72 to - 2.82); P < 0.001], and significantly higher pain score [0.56 cm (95% CI, 0.10 to 1.01); P = 0.02] than the intact group. In addition, the retear group had significantly lower flexion [- 10.46° (95% CI, - 19.86 to - 1.07); P = 0.03], abduction [- 14.84° (95% CI, - 28.55 to - 1.14); P = 0.03], and external rotation [- 7.22° (95% CI, - 13.71 to - 0.74); P = 0.03] range of motion, and flexion [- 1.65 kg·f (95% CI, - 2.29 to - 1.01); P < 0.001], abduction [- 1.87 kg·f (95% CI, - 3.02 to - 0.72); P = 0.001], and external rotation [- 1.66 kg·f (95% CI, - 3.25 to - 0.07); P = 0.04] muscle strength.

CONCLUSION

Our results suggest that retear after ARCR leads to poor clinical outcomes after surgery.

Three-dimensionally printed recombinant human parathyroid hormone-soaked nanofiber sheet accelerates tendon-to-bone healing in a rabbit model of chronic rotator cuff tear

BACKGROUND

Recombinant human parathyroid hormone (rhPTH) promotes tendon-to-bone healing in humans and animals with rotator cuff tear (RCT). However, problems regarding repeated systemic rhPTH injections in humans exist. This study was conducted to evaluate the effect of topical rhPTH administration using 3-dimensionally (3D) printed nanofiber sheets on tendon-to-bone healing in a rabbit RCT model compared to that of direct topical rhPTH administration.

METHODS

Eighty rabbits were randomly assigned to 5 groups (n = 16 each). To create the chronic RCT model, we induced complete supraspinatus tendon tears in both shoulders and left them untreated for 6 weeks. All transected tendons were repaired in a transosseous manner with saline injection in group A, hyaluronic acid (HA) injection in group B, 3D-printed nanofiber sheet fixation in group C, rhPTH and HA injection in group D, and 3D-printed rhPTH- and HA-soaked nanofiber sheet fixation in group E. Genetic (messenger RNA expression evaluation) and histologic evaluations (hematoxylin and eosin and Masson trichrome staining) were performed in half of the rabbits at 4 weeks postrepair. Genetic, histologic, and biomechanical evaluations (mode of tear and load to failure) were performed in the remaining rabbits at 12 weeks.

RESULTS

For genetic evaluation, group E showed a higher collagen type I alpha 1 expression level than did the other groups (P = .008) at 4 weeks. However, its expression level was downregulated, and there was no difference at 12 weeks. For histologic evaluation, group E showed greater collagen fiber continuity, denser collagen fibers, and more mature tendon-to-bone junction than did the other groups (P = .001, P = .001, and P = .003, respectively) at 12 weeks. For biomechanical evaluation, group E showed a higher load-to-failure rate than did the other groups (P < .001) at 12 weeks.

CONCLUSION

Three-dimensionally printed rhPTH-soaked nanofiber sheet fixation can promote tendon-to-bone healing of chronic RCT.

Quantitative Magnetic Resonance Imaging measurement of muscle atrophy and fatty degeneration after arthroscopic rotator cuff repair

BACKGROUND

It is unclear whether muscle atrophy (MA) and fatty degeneration (FD) have improved after arthroscopic rotator cuff repair (ARCR). Therefore, the objective of this study was to perform quantitative magnetic resonance imaging (MRI) measurement to evaluate MA and FD before and after surgery. Correlations of clinical outcome with changes in MA and FD were also analyzed.

MATERIALS AND METHODS

From March 2013 to March 2017, 40 patients who had no re-tear up to 1 year after ARCR were enrolled. MA and FD of supraspinatus muscle before surgery, at 3 days after surgery, and at 1 year after surgery were measured quantitatively in conventional Y-view and supraspinatus origin-view (SOV). Measurement items were muscle area (mm²), occupation ratio (%), fatty infiltration (FI, %), and fatty degenerative area (mm²). Postoperative clinical outcomes were measured at 1 year after ARCR. Correlation between measure values and outcome scores were analyzed.

RESULTS

Inter-measurement reliability was high (ICC = 0.933, Cronbach-α = 0.963). There was no significant change in MA in conventional Y-view at 1 year after surgery (Occupation ratio, p = 0.2770; MA, p = 0.3049) or in SOV (MA, p = 0.5953). FI and fat area measured with the conventional method on Y-view and showed significant differences (p = 0.0001). However, FI and fat area measured with the modified method on Y-view and SOV showed no significant difference (all p > 0.05). Postoperative clinical outcomes showed significant improvement compared to preoperative ones (p = 0.0001). However, there was no significant correlation between FD and FA (p = 0.653).

CONCLUSION

Quantitative MRI measurement was shown to be a reliable and valid method. MA and FD do not improve after ARCR considering postoperative anatomical changes of supraspinatus at 1-year follow-up. FD of the supraspinatus in conventional Y-view, but not in SOV, showed a significant change at 1 year postoperatively. MA showed no significant improvement. There was no correlation between improvement in clinical scores and changes in FD and MA.

Association between functional outcome scores and MRI-based structural integrity after rotator cuff repair: a prospective cohort study

PURPOSE

Natural history of rotator cuff tears is poorly understood. Repair of rotator cuff tears has shown to improve functional outcomes in full-thickness tears. However, high re-tear rates have been reported in literature, which does not correlate with poorer outcomes. Primary aim of this study was to explore association between functional outcome scores and structural integrity of rotator cuff, using magnetic resonance imaging (MRI)-based grading.

METHODS

Patients with MRI-proven full-thickness rotator cuff tears, undergoing mini-open rotator cuff repair, were assessed for shoulder abduction strength and functional outcome scores before the surgery and 2 years after the procedure. Association between functional outcome scores and MRI grading for rotator cuff healing (Sugaya grading) was analyzed.

RESULTS

A total of 38 patients (18 females and 20 males), with a mean age of 50.6 years (SD: 10.9), were included in the study. Mean duration of symptoms was 6.05 months (SD: 4.2). On postoperative MRI, healing of the cuff was categorized as Sugaya grade 1 in 12 patients, grade 2 in 20 patients and grade 3 in 6 patients. Higher Sugaya grades (T: 13.48, p: 0.001) and grades of fatty degeneration (T: 14.05, p: 0.001) were found to be associated with longer duration of symptoms. Improvement in shoulder abduction strength correlated negatively with the duration of symptoms (r: -0.39, p: 0.01). There was a significant improvement in functional outcome scores after the surgery. There was no association between postoperative structural integrity of the repaired tendon (Sugaya grading) and functional outcome scores.

CONCLUSION

Early repair of rotator cuff results in better functional outcomes and shoulder strength. The findings from this study suggest there is a dissociation between MRI-based grades of healing of repaired rotator cuff and function of the shoulder.

STUDY DESIGN

Level II, Prospective cohort study.

Functional and Structural Outcomes After Retears of Arthroscopically Repaired Large and Massive Rotator Cuff Tears

Background:

Most studies have shown acceptable clinical results in patients with large or massive tears treated by arthroscopic rotator cuff repair (ARCR); however, the effects of retears after surgery in these patients remain unknown.

Purpose:

To evaluate functional and structural outcomes after retears of large and massive rotator cuff tears treated by ARCR.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 196 consecutive patients with large to massive rotator cuff tears underwent physical examination and magnetic resonance imaging before and after ARCR at 6, 12, and 24 months. Of these, 9 patients were lost at 6 months after surgery. Therefore, 187 patients were followed up for 24 months after surgery; 148 patients showed no postsurgical ruptures. Consequently, the remaining 39 patients with postsurgical ruptures were included in this study (mean age at surgery, 64.2 ± 8.7 years). Functional outcome measures comprised the University of California, Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcome measures consisted of the global fatty degeneration index (GFDI), mediolateral tear size, and residual tendon attachment area as evaluated by our own scoring system.

Results:

The mean UCLA and JOA scores significantly improved from 16.3 ± 3.9 and 63.2 ± 10.7 preoperatively to 27.9 ± 5.5 (P < .0001) and 84.5 ± 9.4 (P < .0001) at final follow-up, respectively. The mean mediolateral tear size (P = .03, .02, and .02, respectively) and residual tendon attachment area (P = .04, .03, and .04, respectively) significantly improved from preoperatively to 6, 12, and 24 months postoperatively. The correlation analysis between the functional and structural variables confirmed significant associations between the residual tendon attachment area, the JOA and UCLA scores at 24 months postoperatively, and the preoperative GFDI (r = –0.81 to 0.78).

Conclusion:

The residual tendon attachment area after a retear was significantly larger at 24 months after surgery than before surgery. In addition, significant associations were confirmed between preoperative fatty degeneration, the residual tendon attachment area, and functional outcomes after a retear. These results may explain why functional outcomes significantly improved even after retears in this series.

Massive Rotator Cuff Repair: Banana SutureLasso Double-Row Fixation

Massive rotator cuff tears have always been a worrisome situation to every orthopaedic surgeon. Patients' functional demands are increasing with time, and this is why we aim to offer them the best options to preserve their quality of life. We found that using the Banana SutureLasso (Arthrex) has made this type of surgery much easier. We think that with the Banana SutureLasso (Arthrex) we have more access to the medial part of the rotator cuff, and that we can grab both the deep and superficial layers of the tendons while diminishing the risk of laceration. We combined an X-suture with a double-row fixation using a Corkscrew (Arthrex) on the humeral tuberosity and a SwiveLock (Arthrex) screw on lateral side of the humerus. We used only 3 portals with an extra parking portal. Another advantage is that we can adjust the sutures so they would be perpendicular to both ends of the tear. Our technique is simple, safe, and reproducible.

Treatment of Large and Massive Rotator Cuff Tears: Does Infraspinatus Muscle Tear Affect Repair Integrity?

Background

Clinical outcomes and prognosis of large and massive rotator cuff tears are known to be unpredictable not only in degeneration of the rotator cuff, but also due to a high rate of retear.

Methods

Totally, 81 patients who had undergone arthroscopic rotator cuff repair from May 2008 to February 2016 were evaluated in our study. Clinical and functional evaluations were performed with the Constant score and the University of California, Los Angeles (UCLA) score, as well as full physical examination of the shoulder. All patients were confirmed to have magnetic resonance imaging (MRI) of tendon healing at least 1 year postoperatively.

Results

The average age at the time of surgery was 65 years (range, 47–78 years). The average duration of postoperative time in which a follow-up MRI was performed was 36.1 months (range, 12–110 months). Large tears were present in 48 cases (59.3%) and massive tears in 33 cases (40.7%). Overall, there were 33 retear cases (40.7%). All the average clinical outcome scores were significantly improved at the last follow-up (p<0.001), although repair integrity was not maintained. Compared to type A, types C, and D of the Collin’s classification showed significantly higher retear rates (p=0.036).

Conclusions

Arthroscopic rotator cuff repair yields improved clinical outcomes and a relatively high degree of patient satisfaction, despite the repair integrity not being maintained. Involvement of the subscapularis muscle or infraspinatus muscle had no effect on the retear rate.

Adverse effects of xenogenic scaffolding in the context of a randomized double-blind placebo-controlled study for repairing full-thickness rotator cuff tears

PURPOSE

The purpose of the study was to compare the safety and efficacy of autologous mesenchymal stem cells (MSCs) embedded in a xenogenic scaffold for repairing the supraspinatus tendon.

METHODS

This was a randomized, double-blind and placebo-controlled trial evaluating patients with full-thickness rotator cuff tears (Eudra-CT, 2007-007630-19). Effectiveness was evaluated using the Constant score and a visual analogue pain scale (VAS). Constant score has four domains including pain (15 possible points), activities of daily living (20 possible points), mobility (40 possible points), and strength (25 possible points). Scores range from 0 points (most disability) to 100 points (least disability). The structural integrity of the repaired tendon was assessed by magnetic resonance imaging (MRI) according to Patte and Thomazeau classification criteria. The primary study end point was an improvement in the Constant score by 20 points at one year compared to initial assessment.

RESULTS

The trial was stopped due to adverse effects observed in both groups. Only thirteen patients were included and analyzed. The Constant questionnaire showed a significant improvement in the MSC treatment group compared with the preoperative data (p = 0.0073). Secondary outcome measures were similar in both groups.

CONCLUSIONS

Our study showed preliminary inconclusive clinical outcomes in the patients treated with MSCs. Adverse events revealed the need for further approaches using scaffolds of a different nature or perhaps no scaffolds, in the context of small joints.

TRIAL REGISTRATION

Eudra-CT, 2007-007630-19 . Registered on 30 January 2008.

LEVEL OF EVIDENCE

A Level 1 of evidence treatment study.

Effect of Recombinant Human Parathyroid Hormone on Rotator Cuff Healing After Arthroscopic Repair

PURPOSE

To assess the effect of teriparatide, a recombinant human parathyroid hormone, on rotator cuff healing after arthroscopic repair compared with patients who were not treated with teriparatide.

METHODS

This was a prospective propensity-matched study. Thirty-one patients who underwent arthroscopic rotator cuff repair for tears >2 cm in size between January 2015 and June 2016 were recruited (group I). Daily subcutaneous injections of teriparatide 20 μg were administered for 3 months following surgery. In the same period, propensity score matching (1-to-4) was performed to generate an untreated control group undergoing rotator cuff repair alone (group II) with the same tear size. Magnetic resonance imaging evaluation of tendon healing was performed at least 1 year postoperatively, as well as the range of shoulder motion, American Shoulder and Elbow Surgeons score, Constant score, and simple shoulder test.

RESULTS

There was no significant difference of the retraction size, the anterior to posterior dimension of torn rotator cuff, or the preoperative bone mineral density in groups I and II (P = .78, .87, and .96, respectively). The rate of retear was significantly lower in group I than in group II (16% vs 33.9%; P = .04). Range of motion and functional scores were not significantly different between the 2 groups (P > .05).

CONCLUSIONS

Teriparatide, a recombinant human parathyroid hormone, can be a systemic treatment option that significantly enhances the tendon-to-bone healing after arthroscopic rotator cuff repair for patients with rotator cuff tears >2 cm.

LEVEL OF EVIDENCE

Level III, case-control study.

Mid-term clinical outcome following rotator cuff repair using all-suture anchors

BACKGROUND

Symptomatic rotator cuff tears can cause significant pain and functional disturbance, with associated financial ramifications. Non-surgical management should always be considered initially, however if recalcitrant to these measures surgical intervention may involve open, arthroscopic-assisted mini-open or arthroscopic rotator cuff repairs. The use of trans-osseous sutures and suture anchors has been reported with good results, with no significant differences if the repair remains intact or recurrent tears occur. The role of traditional suture anchors has been assessed clinically and biomechanically, however there have been reports of pull out, anchor material found within joint and concerns with the amount of bone loss. The all suture anchor (ASA) is proposed to address these concerns with encouraging cadaveric, biomechanical results to date.

METHODS

The two senior authors performed 31 arthroscopic rotator cuff repairs using ASA with a double row technique at the two study centres'. The patients were reviewed in clinic at one month, three months, 6 months and a year postoperatively. The patients were assessed with the Constant score and clinical range of motion of the shoulder in abduction, forward flexion, external rotation and internal rotation. The surgical technique and rehabilitation was the same for both surgeons.

RESULTS

At a mean follow up of 10.2 months (range 3-12 months) the mean constant score was 77.1 (range 35-90), with a mean abduction of 139.6° (range 30-180°), external rotation of 43.4° (range 20-80°), and internal rotation to lumbar vertebrae 3-4 (range buttock to lumbar vertebra 1). There has been one re-rupture to date.

CONCLUSIONS

The functional and clinical results in our study are comparable to those reported in literature using standard anchors.

Subacromial Local Anesthetics Do Not Interfere With Rotator Cuff Healing After Arthroscopic Repair

BACKGROUND

Subacromial pain pumps are used for analgesia after arthroscopic rotator cuff surgery. However, there is controversy about myotoxic or tendinotoxic effects of local anesthetics.

HYPOTHESIS

Ropivacaine administered via a subacromial pain pump would have no adverse effect on rotator cuff tendon healing, fatty degeneration, strength, or functional outcomes after arthroscopic repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study continues follow-up of patients enrolled in the authors' 3 published prospective studies regarding pain control after arthroscopic rotator cuff repair. In total, 118 patients who underwent rotator cuff repair and returned for evaluation at least 1 year postoperatively were divided into 3 groups: patients who received continuous subacromial ropivacaine infusion (group 1, n = 33), those who received patient-controlled subacromial ropivacaine infusion (group 2, n = 30), and those who received other pain control modalities (intravenous patient-controlled analgesia and/or interscalene block; group 3, n = 55). At least 1 year postoperatively, tendon healing and changes in global fatty degeneration index (GFDI) were estimated through computed tomographic arthrography, magnetic resonance imaging, or ultrasonography. Changes in isokinetic muscle performance test (IMPT) were calculated and functional outcomes evaluated, including visual analog scales (VASs) for pain and satisfaction, American Shoulder and Elbow Surgeons score, and Constant score.

RESULTS

At final follow-up, there were no differences in pain VAS (group 1, 1.1 ± 2.3; group 2, 1.3 ± 1.9; group 3, 0.9 ± 1.7; P = .88), satisfaction VAS (group 1, 8.3 ± 2.4; group 2, 8.7 ± 1.5; group 3, 8.0 ± 2.1; P = .64), American Shoulder and Elbow Surgeons score (group 1, 79.5 ± 10.5; group 2, 81.1 ± 6.9; group 3, 75.7 ± 7.6; P = .34), or Constant score (group 1, 81.8 ± 8.7; group 2, 77.6 ± 9.3; group 3, 78.2 ± 8.4; P = .31). Among the 3 groups, there were no significant differences in healing rates (group 1, 72.7%; group 2, 73.3%; group 3, 70.9%; P = .83) and no differences in changes of GFDI (group 1, 0.45; group 2, 0.62; group 3, 0.41; P = .79), and IMPT (abduction: group 1, 113.0%; group 2, 121.5%; group 3, 120.1%; P = .73; external rotation: group 1, 112.1%; group 2, 121.6%; group 3, 111.7%; P = .71; internal rotation: group 1, 118.2%; group 2, 118.0%; group 3, 118.1%; P = .95). When data were reanalyzed with 2 groups (group 1 + 2 vs group 3), there were no significant differences in functional scores, healing rates, or changes in GFDI and IMPT ( P > .05).

CONCLUSION

Current data suggest that myotoxicity of subacromial ropivacaine administered via pain pump may be reversible or may not be so severe as to interfere with tendon healing and cause muscle degeneration and thus may not affect postoperative function.

Tape Versus Suture in Arthroscopic Rotator Cuff Repair: Biomechanical Analysis and Assessment of Failure Rates at 6 Months

BACKGROUND

Rotator cuff retears after surgical repair are associated with poorer subjective and objectives clinical outcomes than intact repairs.

PURPOSE

The aims of this study were to (1) examine the biomechanical differences between rotator cuff repair using No. 2 suture and tape in an ovine model and (2) compare early clinical outcomes between patients who had rotator cuff repair with tape and patients who had repair with No. 2 suture.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

Biomechanical testing of footprint contact pressure and load to failure were conducted with 16 ovine shoulders using a tension band repair technique with 2 different types of sutures (No. 2 suture [FiberWire; Arthrex] and tape [FiberTape; Arthrex]) with the same knotless anchor system. A retrospective study of 150 consecutive patients (tape, n = 50; suture, n = 100) who underwent arthroscopic rotator cuff repair by a single surgeon with tear size larger than 1.5 × 1 cm was conducted. Ultrasound was used to evaluate the repair integrity at 6 months postsurgery.

RESULTS

Rotator cuff repair using tape had greater footprint contact pressure (mean ± standard error of the mean, 0.33 ± 0.03 vs 0.11 ± 0.3 MPa; P < .0001) compared with repair using No. 2 sutures at 0° abduction with a 30-N load applied across the repaired tendon. The ultimate failure load of the tape repair was greater than that for suture repair (217 ± 28 vs 144 ± 14 N; P < .05). The retear rate was similar between the tape (16%; 8/50) and suture groups (17%; 17/100).

CONCLUSION

Rotator cuff repair with the wider tape compared with No. 2 suture did not affect the retear rate at 6 months postsurgery, despite having superior biomechanical properties.

The Clinical Effect of a Rotator Cuff Retear: A Meta-analysis of Arthroscopic Single-Row and Double-Row Repairs

BACKGROUND

The clinical effect of a retear after rotator cuff repair remains unclear. While some studies have indicated clinical deficits due to a retear, others have stated that a retear does not detrimentally affect outcomes.

PURPOSE

To conduct a meta-analysis comparing clinical outcomes between intact and retorn rotator cuffs after arthroscopic repair.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search using the terms "arthroscopic," "rotator cuff," "repair," "retear," "re-tear," "defect," "single-row," "double-row," "clinical outcomes," and "functional outcomes" was conducted. Article inclusion criteria were an adequate description of the surgical technique, stratification of outcomes by intact rotator cuff versus retear with a minimum of 1 year of follow-up, and documentation of the presence/absence of a full-thickness retear using imaging. Exclusion criteria were isolated subscapularis tears/repairs, labral repairs, infections, postoperative fractures, insufficient data or statistical indications, and postoperative data not stratified by retear versus intact rotator cuff. A meta-analysis was performed using a random-effects model on variables that had comparisons from at least 3 studies. Single-row (SR) and double-row (DR) studies were analyzed both separately and together in an "all arthroscopic repairs" (AAR) comparison. The calculated effect was considered significant at a P value <.05.

RESULTS

Within the SR group, patients with a rotator cuff retear had a significantly lower Constant score (mean difference [95% CI], -6.79 [-8.94 to -4.65]; P < .001) and lower University of California, Los Angeles (UCLA) score (-3.21 [-5.27 to -1.15]; P = .002) but not higher pain (0.071 [-0.34 to 0.49]; P = .739). Within the DR group, patients with a rotator cuff retear had a significantly lower Constant score (mean difference [95% CI], -9.35 [-12.2 to -6.50]; P < .001), lower American Shoulder and Elbow Surgeons (ASES) score (-12.1 [-17.1 to -7.26]; P < .001), lower UCLA score (-3.07 [-4.85 to -1.29]; P < .001), higher pain (0.622 [0.19 to 1.05]; P = .005), and lower abduction strength ( P < .001). In the AAR comparison, patients with a retear had a significantly lower Constant score (mean difference [95% CI], -7.56 [-9.55 to -5.57]; P < .001), lower ASES score (-10.1 [-15.5 to -4.64]; P < .001), lower UCLA score (-3.00 [-4.47 to -1.53]; P < .001), and lower abduction strength (in kg·f) (-3.32 [-4.53 to -2.12]; P < .001) but not higher pain (0.332 [-0.014 to 0.680]; P = .060).

CONCLUSION

Patients with a full-thickness rotator cuff retear exhibited significantly lower clinical outcome scores and strength compared with patients with an intact or partially torn rotator cuff.

Single-versus double-row arthroscopic rotator cuff repair in massive tears

Background

It is a challenge for orthopaedic surgeons to treat massive rotator cuff tears. The optimal management of massive rotator cuff tears remains controversial. Therefore, the goal of this study was to compare arthroscopic single- versus double-row rotator cuff repair with a larger sample size.

Material/Methods

Of the subjects with massive rotator cuff tears, 146 were treated using single-row repair, and 102 were treated using double-row repair. Pre- and postoperative functional outcomes and radiographic images were collected. The clinical outcomes were evaluated for a minimum of 2 years.

Results

No significant differences were shown between the groups in terms of functional outcomes. Regarding the integrity of the tendon, a lower rate of post-treatment retear was observed in patients who underwent double-row repair compared with single-row repair.

Conclusions

The results suggest that double-row repair is relatively superior in shoulder ROM and the strength of tendon compared with single-row repair. Future studies involving more patients in better-designed randomized controlled trials will be required.

Correlation of clinical symptoms and function with fatty degeneration of infraspinatus in rotator cuff tear

PURPOSE

The aim of this study was to analyse the correlation of clinical symptoms and function with the fatty degeneration of the infraspinatus in rotator cuff tears.

METHODS

A total of 152 patients who had rotator cuff tears was enroled retrospectively. The infraspinatus muscle was divided into two compartments according to the bundle of fibres, and the patients were divided into four groups that reflected fatty degeneration. The muscle strength of the shoulder and clinical symptoms was investigated.

RESULTS

The severity of the rotator cuff tear and retraction increased with fatty degeneration of both the superior and inferior parts in the infraspinatus muscles. Because of the increasing fatty degeneration of the superior part of the infraspinatus, the shoulder strength index (SSI) of abduction had poor results. Additionally, as the fatty degeneration of the inferior part of the infraspinatus increased, the SSI of abduction and external rotation had worse results.

CONCLUSIONS

Fatty degeneration of the superior part of the infraspinatus has no correlation with the power of external rotation but has a negative correlation with the power of abduction. Moreover, fatty degeneration of the inferior part of the infraspinatus has a negative correlation with both the power of abduction and external rotation.

LEVEL OF EVIDENCE

Retrospective study, Level IV.

Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review

PURPOSE

The purpose of this systematic review was to detect the reliability of the currently available magnetic resonance imaging measurements used in the evaluation of repaired rotator cuff.

METHODS

Search was performed using major electronic databases from their inception to February 2014. All studies reporting post-operative magnetic resonance assessment after rotator cuff repair were included. After the identification of available magnetic resonance criteria, reliability studies were further analysed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

One hundred and twenty studies were included in the review. Twenty-six different criteria were identified. Ten studies reported inter-observer reliability, and only two assessed intra-observer reliability of some of the identified criteria. Structural integrity was the most investigated criterion. The dichotomized Sugaya's classification showed the highest reliability (k = 0.80-0.91). All other criteria showed moderate to low inter-observer reliability. Tendon signal intensity and footprint coverage showed a complete discordance. Intra-observer reliability was high for the presence of structural integrity, and moderate to low for all other criteria. Methodological quality was high only for one study and moderate for three studies.

CONCLUSIONS

Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. Reliability of most of them has not been analysed yet. With the data available, only the presence of structural integrity showed good intra- and inter-observer agreement.

LEVEL OF EVIDENCE

Systematic review of descriptive and qualitative studies, Level IV.