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McBroom TJ, Torabian KA, Cherian NJ, Gillinov SM, Siddiq BS, Chaharbakhshi EO, Eberlin CT, Kucharik MP, Abraham PF, Martin SD. Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears. JSES Int 2024; 8:776-784. [PMID: 39035669 PMCID: PMC11258853 DOI: 10.1016/j.jseint.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. Methods A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. Results When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010). Conclusion Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.
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Affiliation(s)
- Trevor J. McBroom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kaveh A. Torabian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nathan J. Cherian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE, USA
| | - Stephen M. Gillinov
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bilal S. Siddiq
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Christopher T. Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Michael P. Kucharik
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL, USA
| | - Paul F. Abraham
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Scott D. Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Radhakrishnan R, Goh J, Tan AHC. Partial-thickness rotator cuff tears: a review of current literature on evaluation and management. Clin Shoulder Elb 2024; 27:79-87. [PMID: 37559523 PMCID: PMC10938024 DOI: 10.5397/cise.2022.01417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/12/2023] [Accepted: 03/12/2023] [Indexed: 08/11/2023] Open
Abstract
Rotator cuff disease is a common cause of shoulder pain for which partial-thickness rotator cuff tears occupy a significant proportion. Such tears are often difficult to diagnose and manage in the general clinic setting. A review of the available literature from well-known databases was performed in this study to provide a concise overview of partial-thickness rotator cuff tears to aid physicians in their understanding and management.
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Affiliation(s)
| | - Joshua Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Huang P, Tang X. Arthroscopic "Mini-Incision" Transtendon Repair of Shoulder Partial Articular-Sided Supraspinatus Tendon Avulsion. Arthrosc Tech 2023; 12:e2127-e2131. [PMID: 38196879 PMCID: PMC10772960 DOI: 10.1016/j.eats.2023.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/20/2023] [Indexed: 01/11/2024] Open
Abstract
Currently, the treatment of PASTA (partial articular-sided supraspinatus tendon avulsion) lesions includes arthroscopic transtendon and completion repair, but the shortcomings of both surgical techniques are obvious. We present a modified transtendon technique combining the transtendon with the mini-completion repair that is able to minimize the trauma from anchor implantation and add more intra-articular working access using a "mini-incision" on the supraspinatus tendon.
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Affiliation(s)
- Peiguan Huang
- Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Xiaojun Tang
- Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
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Springer B, Dreisbach R, Schatz KD, Kubista B, Waldstein W. Online Videos Regarding Relevant Postoperative Patient Information and Postoperative Rehabilitation After Arthroscopic Rotator Cuff Repair Provide Poor Information Quality, Accuracy, and Reliability. Arthroscopy 2023; 39:2443-2453.e2. [PMID: 37355180 DOI: 10.1016/j.arthro.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To evaluate the information quality, accuracy, and reliability of YouTube videos regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair. METHODS By use of The Onion Router (TOR) software and predefined search terms, 102 videos were assessed. Four scoring systems were used to evaluate included videos: (1) Journal of the American Medical Association (JAMA) benchmark criteria score; (2) Global Quality Score (GQS); (3) DISCERN score; and (4) a newly developed score, the Rotator Cuff Score (RCS). The RCS (0-30 points) was built based on the latest published evidence and guidelines from the American Academy of Orthopaedic Surgeons. Videos that scored up to 9 points were regarded as poor-quality videos. RESULTS Most of the included videos provided poor information quality, accuracy, and reliability. Videos that were uploaded by medically trained professionals showed significantly better results for all scores compared with commercial or personal-testimony videos (JAMA benchmark criteria score, P < .001; GQS, P < .001; DISCERN score, P = .001; and RCS, P = .001). Multivariate linear regression showed that the involvement of medically trained professionals was a significant predictor of better results for all scores (JAMA benchmark criteria score, β = 1.496 [P < .001]; GQS, β = 1.105 [P < .001]; DISCERN score, β = 11.234 [P < .001]; and RCS, β = 5.017 [P < .001]). Surprisingly, the like ratio was significantly higher for videos that were uploaded by non-medically trained individuals (P = .041). CONCLUSIONS The average information quality, accuracy, and reliability of YouTube videos regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair are poor. Videos from medically trained professionals provide significantly higher information quality; however, even these videos lack important information for a better understanding of arthroscopic rotator cuff repair. CLINICAL RELEVANCE Because of the lack of a peer-review process, available videos on YouTube regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair are of low quality, accuracy, and reliability. However, patients increasingly visit YouTube to gather medical knowledge. Physicians should enlighten patients about these findings and should be able to provide alternative sources of high-quality information.
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Affiliation(s)
- Bernhard Springer
- Department of Orthopaedic and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Robin Dreisbach
- Department of Orthopaedic and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Klaus-Dieter Schatz
- Department of Orthopaedic and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Bernd Kubista
- Department of Orthopaedics, Sanatorium Hera, Vienna, Austria
| | - Wenzel Waldstein
- Clinic for Orthopaedics Paulinenhilfe, Diakonie-Klinikum Stuttgart, Stuttgart, Germany.
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Yang Y, Hu D, Chen S, Guan S, Shang X. Transtendon technique versus repair after completion of the tear for articular-sided partial rotator cuff tear: a meta-analysis of comparative studies. J Orthop Surg Res 2023; 18:378. [PMID: 37217901 DOI: 10.1186/s13018-023-03831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Transtendon repair and repair after completion of the tear have been widely used to treat partial-thickness rotator cuff tears (PT-RCTs). The present study was aimed to compare the clinical outcomes and tendon integrity following arthroscopic repair of articular PT-RCTs using transtendon repair or repair after completion of the tear. METHODS We performed a systematic electronic database search on Cochrane Central Register of Controlled Trials, PubMed and Embase to identify articles equating articular-sided PT-RCTs repair. The randomized controlled clinical trials that met our criteria were evaluated for quality of methodology. The results obtained were further analyzed and correlated to present the benefits and drawbacks comparing the two surgical procedures. RESULT According to our inclusion and exclusion criteria, six articles were included in the present study. A total of 501 patients were analyzed as part of this study. The results indicated that both the surgical treatments provided excellent functional improvements and tendon integrity. However, no significant differences for the visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, range of motion, postoperative adhesive capsulitis, tendon integrity and patient satisfaction were found between the two cohorts (p > 0.05). CONCLUSIONS Both transtendon technique and repair after completion of the tear for articular-sided partial rotator cuff tear provide improvements in clinical outcome with a low complication rate and a high rate of healing.
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Affiliation(s)
- Yimeng Yang
- Department of Sports Medicine, Huashan Hospital, No. 12, Wulumuqi Zhong Road, Shanghai, 200040, China
- State Key Laboratory of Molecular Engineering of Polymers, Fudan University, Shanghai, China
| | - Dan Hu
- Department of Orthopedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, 215008, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, No. 12, Wulumuqi Zhong Road, Shanghai, 200040, China
| | - Shibing Guan
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
| | - Xiliang Shang
- Department of Sports Medicine, Huashan Hospital, No. 12, Wulumuqi Zhong Road, Shanghai, 200040, China.
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Effect of intraarticular pressure on glenohumeral kinematics during a simulated abduction motion: a cadaveric study. BMC Musculoskelet Disord 2023; 24:105. [PMID: 36750786 PMCID: PMC9906871 DOI: 10.1186/s12891-023-06127-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The current understanding of glenohumeral joint stability is defined by active restrictions and passive stabilizers including naturally-occurring negative intraarticular pressure. Cadaveric specimens have been used to evaluate the role of intraarticular pressure on joint stability, although, while the shoulder's negative intraarticular pressure is universally acknowledged, it has been inconsistently accounted for. HYPOTHESIS During continuous, passive humeral abduction, releasing the native intraarticular pressure increases joint translation, and restoring this pressure decreases joint translations. STUDY DESIGN Descriptive Laboratory Study. METHODS A validated shoulder testing system was used to passively abduct the humerus in the scapular plane and measure joint translations for seven (n = 7) cadaveric specimens. The pressure within the glenohumeral joint was measured via a 25-gauge needle during passive abduction of the arm, which was released and subsequently restored. During motion, the rotator cuff muscles were loaded using stepper motors in a force feedback loop and electromagnetic sensors were used to continuously measure the position of the humerus and scapula. Joint translation was defined according to the instant center of rotation of the glenohumeral head according to the recommendations by the International Society of Biomechanics. RESULTS Area under the translation versus abduction angle curve suggests that releasing the pressure within the capsule results in significantly less posterior translation of the glenohumeral head as compared to intact (85-90˚, p < 0.05). Posterior and superior translations were reduced after 70˚ of abduction when the pressure within the joint was restored. CONCLUSION With our testing system employing a smooth continuous passive motion, we were able to show that releasing intraarticular pressure does not have a major effect on the path of humeral head motion during glenohumeral abduction. However, both violating the capsule and restoring intraarticular pressure after releasing alter glenohumeral translations. Future studies should study the effect of simultaneous external rotation and abduction on the relationship between joint motion and IAP, especially in higher degrees of abduction. CLINICAL RELEVANCE Thoroughly simulating the glenohumeral joint environment in the cadaveric setting may strengthen the conclusions that can be translated from this setting to the clinic.
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Kim JH, Do WS, Lim JR, Yoon TH, Chun YM. Subscapularis tendon tears hidden by the medial biceps sling can be missed on arthroscopic examination. Arch Orthop Trauma Surg 2022; 143:3251-3258. [PMID: 36369526 DOI: 10.1007/s00402-022-04681-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION To investigate (1) the prevalence of "hidden lesions" and "non-hidden lesions" of subscapularis tendon tears requiring repair during arthroscopic examination that would be missed by a 30° arthroscope, but could be identified by a 70° arthroscope, from the standard posterior portal and (2) the correlation of preoperative internal rotation weakness and findings of magnetic resonance imaging (MRI) indicating hidden lesions. MATERIALS AND METHODS We retrospectively examined 430 patients who underwent arthroscopic subscapularis repair between was initially nonvisible with a 30° arthroscope but became visible only with a 70° arthroscope from the standard posterior portal. The preoperative and intraoperative findings of the hidden lesion group (n = 82) were compared with those of the non-hidden lesion group (n = 348). 2016 and 2020. A hidden lesion was defined as a subscapularis tendon tear requiring repair that preoperative internal rotation weakness was assessed using the modified belly-press test. Preoperative MR images were reviewed using a systemic approach. RESULTS The prevalence of hidden lesions was 19.1% (82/430). No significant difference was found in preoperative internal rotation weakness between the groups. Preoperative MRI showed a significantly lower detection rate in the hidden lesion group than in the non-hidden group (69.5% vs. 84.8%; P = 0.001). The hidden lesions were at a significantly earlier stage of subscapularis tendon tears than the non-hidden lesions, as revealed by the arthroscopic findings (Lafosse classification, degree of retraction; P = 0.003 for both) and MR findings (muscle atrophy, fatty infiltration; P = 0.001, P = 0.005, respectively). CONCLUSIONS Among the subscapularis tears requiring repair, 19.1% could be identified by a 70° arthroscope, but not by a 30° arthroscope, through the posterior portal. The hidden lesions showed a significantly lower detection rate on preoperative MRI than the non-hidden lesions. Thus, for subscapularis tears suspected on preoperative physical examination, the 70° arthroscope would be helpful to avoid a misdiagnosis.
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Affiliation(s)
- Joo-Hyung Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Woo-Sung Do
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Joon-Ryul Lim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea.
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Thangarajah T, Lo IK. Optimal Management of Partial Thickness Rotator Cuff Tears: Clinical Considerations and Practical Management. Orthop Res Rev 2022; 14:59-70. [PMID: 35250316 PMCID: PMC8893150 DOI: 10.2147/orr.s348726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/17/2022] [Indexed: 11/25/2022] Open
Abstract
Partial thickness rotator cuff tears have been diagnosed with increased frequency due to heightened awareness and an improvement in diagnostic modalities. When >50% of the tendon thickness has ruptured, intra-tendinous strain of the residual tendon increases. Surgery is generally confined to patients who have failed non-operative measures and have persistent symptoms. The rationale for repairing partial thickness tears lies in their limited self-healing capacity, and propensity to enlarge over time and progress to a full thickness defect. Although tear debridement and acromioplasty can improve pain and function, tear progression can occur, in addition to worse results being noted in bursal-sided defects. Several surgical strategies have been recommended but there is a lack of evidence to advocate one form of treatment over another. The aim of this narrative review is to discuss the treatment options for partial thickness tears of the rotator cuff.
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Affiliation(s)
- Tanujan Thangarajah
- Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Tanujan Thangarajah, Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada, Email
| | - Ian K Lo
- Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
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Xu J, Li Y, Ye Z, Wu C, Han K, Zheng T, Jiang J, Yan X, Su W, Zhao J. Biceps Augmentation Outperforms Tear Completion Repair or In Situ Repair for Bursal-Sided Partial-Thickness Rotator Cuff Tears in a Rabbit Model. Am J Sports Med 2022; 50:195-207. [PMID: 34779674 DOI: 10.1177/03635465211053334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is an ongoing debate on the treatment of bursal-sided partial-thickness rotator cuff tears (PTRCTs), including ideal repair techniques. Augmentation using a collagen patch has been introduced as a new surgical approach to treat PTRCTs, while the effect of autogenous biceps augmentation (BA) has not been investigated. PURPOSE To analyze the effects of BA on bursal-sided PTRCTs and compare its histological and biomechanical results with those of tear completion followed by repair and in situ repair (ISR). STUDY DESIGN Controlled laboratory study. METHODS Unilateral chronic PTRCTs were created in 96 mature New Zealand White rabbits, which were randomly divided into 4 groups: no repair, tear completion repair (TCR), ISR, and BA. A new bicipital groove was fabricated in BA for the biceps tendon that was transferred to augment the bursal-sided PTRCT repair. In each group, we sacrificed 6 rabbits for biomechanical testing of the whole tendon-to-bone complex (WTBC) and 6 for histological evaluation of bursal- and articular-sided layers at 6 and 12 weeks postoperatively. Healing responses between the biceps and new bicipital groove in the BA group were determined using histological analysis, and final groove morphologies were evaluated using micro-computed tomography. RESULTS The remaining tendon and enthesis in bursal-sided PTRCTs progressively degenerated over time. WTBCs of ISR exhibited a larger failure load than those of TCR, although better healing properties in the bursal-sided repaired site were achieved using TCR based on histological scores and superior articular-sided histological scores were observed using ISR. However, WTBCs of BA displayed the best biomechanical results and superior histological scores for bursal- and articular-sided regions. The new bicipital groove in BA remodeled over time and formed similar morphologies to a native groove, which provided a mature bone bed for transferred biceps tendon healing to augment bursal-sided PTRCTs. CONCLUSION BA achieved better biomechanical and histological results for repairing bursal-sided PTRCTs as compared with TCR and ISR. When compared with that of TCR, the WTBC of ISR exhibited a higher failure load, showing histological superiority in the articular-sided repair and inferiority in the bursal-sided repair. CLINICAL RELEVANCE BA may be an approach to improve bursal-sided PTRCT repair in humans, which warrants further clinical investigation.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yufeng Li
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ting Zheng
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Sella GDV, Silva LAD, Checchia CS, Marmille HC, Santili C, Miyazaki AN. Comparative Clinical Evaluation of Two Techniques of Arthroscopic Treatment of Partial Articular Rotator Cuff Tears. Rev Bras Ortop 2021; 56:726-732. [PMID: 34900100 PMCID: PMC8651439 DOI: 10.1055/s-0041-1729583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/01/2020] [Indexed: 10/25/2022] Open
Abstract
Objectives To evaluate the clinical results of patients submitted to arthroscopic treatment of partial lesion of the articular part of the rotator cuff by transtendon suture techniques and after completing the lesion and to compare the postoperative recovery time of the two techniques. Method Retrospective study based on the identification of all cases with partial lesion of the articular part of the rotator cuff submitted to arthroscopic treatment from October 1999 to December 2016 at the Shoulder and Elbow Group of our institution. Thirty-nine patients were included and divided into two groups: those who underwent the transtendon technique and those in whom the lesion was completed. The two groups were statistically similar. The respective medical records were analyzed as well as the identification of the applied technique, the postoperative results, and the related complications. The functional evaluation was performed using the score of the University of California at Los Angeles (UCLA). Results There was no statistically relevant difference between the groups, with a mean UCLA score of 32, and no difference in the time required for rehabilitation. Conclusion There was no difference between the clinical outcome of the patients, regardless of the technique used to repair the partial lesions of the articular part of the rotator cuff, with satisfactory results in 93% of the cases.
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Affiliation(s)
- Guilherme do Val Sella
- Grupo de Cirurgia de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Luciana Andrade da Silva
- Grupo de Cirurgia de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Caio Santos Checchia
- Grupo de Cirurgia de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Hector Carmona Marmille
- Grupo de Cirurgia de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Cláudio Santili
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Alberto Naoki Miyazaki
- Grupo de Cirurgia de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
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Song S, Lee SK, Kim JY. [Partial-Thickness Tear of Supraspinatus and Infraspinatus Tendon Revisited: Based on MR Findings]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:1366-1387. [PMID: 36238879 PMCID: PMC9431970 DOI: 10.3348/jksr.2021.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/03/2021] [Accepted: 10/18/2021] [Indexed: 12/05/2022]
Abstract
The interpretation of MRI of partial-thickness rotator cuff tears can be challenging. This review describes the anatomic considerations for diagnosing partial-thickness tears, especially supraspinatus and infraspinatus tendon and summarizes the classification of partial-thickness rotator cuff tears, as well as provides an overview on partial-thickness tears with delamination.
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Kjær BH, Magnusson SP, Henriksen M, Warming S, Boyle E, Krogsgaard MR, Al-Hamdani A, Juul-Kristensen B. Effects of 12 Weeks of Progressive Early Active Exercise Therapy After Surgical Rotator Cuff Repair: 12 Weeks and 1-Year Results From the CUT-N-MOVE Randomized Controlled Trial. Am J Sports Med 2021; 49:321-331. [PMID: 33471547 DOI: 10.1177/0363546520983823] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traumatic full-thickness rotator cuff tears are typically managed surgically, followed by rehabilitation, but the load progression to reach an optimal clinical outcome during postoperative rehabilitation is unknown. PURPOSE To evaluate whether there was a superior effect of 12 weeks of progressive active exercise therapy on shoulder function, pain, and quality of life compared with usual care. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Patients with surgically repaired traumatic full-thickness rotator cuff tears were recruited from 2 orthopaedic departments and randomized to progressive active exercise therapy (PR) or limited passive exercise therapy (UC [usual care]). The primary outcome was the change in the Western Ontario Rotator Cuff Index (WORC) score between groups from before surgery to 12 weeks after surgery. Secondary outcomes included changes in the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, pain, range of motion, and strength. Adverse events were registered during the intervention period. RESULTS A total of 82 patients were randomized to the PR (n = 41) or UC (n = 41) group. All 82 patients (100%) participated in the 12-week assessment and 79 in the 1-year follow-up. At 12 weeks, there was no significant difference between the groups in the change in the WORC score from baseline adjusted for age, sex, and center (physical symptoms: P = .834; sports and recreation: P = .723; work: P = .541; lifestyle: P = .508; emotions: P = .568). Additionally, there was no between-group difference for the secondary outcomes including the WORC score at 1 year and the DASH score, pain, range of motion, and strength at 12 weeks and 1 year. Both groups showed significant improvements over time in all outcomes. In total, there were 13 retears (16%) at 1-year follow-up: 6 in the PR group and 7 in the UC group. CONCLUSION PR did not result in superior patient-reported and objective outcomes compared with UC at either short- or long-term follow-up (12 weeks and 1 year). REGISTRATION NCT02969135 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Birgitte Hougs Kjær
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark.,Department of Sports Science and Clinical Biomechanics, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marius Henriksen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark.,The Parker Institute, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark
| | - Susan Warming
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark
| | - Eleanor Boyle
- Department of Sports Science and Clinical Biomechanics, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology, Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg Frederiksberg, Copenhagen, Denmark
| | - Ali Al-Hamdani
- Shoulder-Elbow Unit, Department of Orthopaedic Surgery, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Abstract
PURPOSE OF REVIEW This review presents epidemiology, etiology, management, and surgical outcomes of rotator cuff injuries in tennis players. RECENT FINDINGS Rotator cuff injuries in tennis players are usually progressive overuse injuries ranging from partial-thickness articular- or bursal-sided tears to full-thickness tears. Most injuries are partial-thickness articular-sided tears, while full-thickness tears tend to occur in older-aged players. The serve is the most energy-demanding motion in the sport, and it accounts for 45 to 60% of all strokes performed in a tennis match, putting the shoulder at increased risk of overuse injury and rotator cuff tears. Studies have shown deficits in shoulder range of motion and scapular dyskinesia to occur even acutely after a tennis match. First-line treatment for rotator cuff injuries in any overhead athlete consists of conservative non-operative management with appropriate rest, anti-inflammatory drugs, followed by a specific rehabilitation program. Operative treatment is usually reserved for older-aged players and to those who fail to return to play after conservative measures. Surgical options include rotator cuff debridement with or without tendon repair, biceps tenodesis, and labral procedures. Unlike rotator cuff repairs in the general population, repairs in the elite tennis athlete have less than ideal rates of return to sport to the same level of performance. Rotator cuff injuries are a common cause of pain and dysfunction in tennis players and other overhead athletes. The etiology of rotator cuff tears in tennis players is multifactorial and usually results from microtrauma and internal impingement in the younger athlete leading to partial tearing and degenerative full-thickness tears in older players. Surgical treatment is pursued in athletes who are still symptomatic despite an extensive course of non-operative treatment as outcomes with regard to returning to sport to the same pre-injury level are modest at best. Debridement alone is usually preferred over rotator cuff repairs for partial tears in younger players due to potential over-constraining of the shoulder joint and decreased rates of return to sport after rotator cuff repairs.
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Affiliation(s)
- Rami G. Alrabaa
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th Street, PH-11, New York, NY 10032 USA
| | - Mario H. Lobao
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th Street, PH-11, New York, NY 10032 USA
| | - William N. Levine
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th Street, PH-11, New York, NY 10032 USA
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15
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Oh JH, Lee YH, Lee TH, Jang SI, Kwon J. The Natural History of High-Grade Partial Thickness Rotator Cuff Tears: The Conversion Rate to Full Thickness Tears and Affecting Factors. Clin Orthop Surg 2020; 12:514-520. [PMID: 33274029 PMCID: PMC7683193 DOI: 10.4055/cios19167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/22/2020] [Indexed: 11/17/2022] Open
Abstract
Background Information regarding the progression of high-grade partial thickness rotator cuff tears (PTRCTs) is scarce. We aimed to assess the clinical outcome and the conversion rate to full thickness tears in patients with high-grade PTRCTs who underwent nonoperative treatment and to determine the factors associated with tear progression. Methods A total of 52 patients with high-grade PTRCTs, which were detected by magnetic resonance imaging or ultrasonography (USG), were treated conservatively between 2010 and 2017. They were followed up with USG at 6- to 12-month intervals for a mean of 34 months (range, 12–105 months). The average patient age was 57 years (range, 34–70 years), and 34 patients were women. Age, sex, body mass index, arm dominance, symptom duration, subscapularis tendon involvement, tear location, and trauma history were compared between patients with and without conversion to full thickness tears. Results A substantial percentage of high-grade PTRCTs progressed to full thickness tears (16/52, 30.8%). According to Kaplan-Meier analysis, the full thickness conversion rate was 30.8% at 3 years and 64% at 4 years. The full thickness conversion rate was higher in patients with subscapularis tendon involvement (p = 0.012). Conclusions A considerably large proportion of high-grade PTRCTs progressed to full thickness tears. Therefore, regular monitoring of tear progression should be considered after conservative treatment of high-grade PTRCTs, particularly in patients with subscapularis tendon involvement.
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Affiliation(s)
- Joo Han Oh
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ye Hyun Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul, Korea
| | - Tae Ho Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul, Korea
| | - Seok In Jang
- Department of Orthopedic Surgery, National Police Hospital, Seoul, Korea
| | - Jieun Kwon
- Department of Orthopedic Surgery, National Police Hospital, Seoul, Korea
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16
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Hirahara AM, Andersen WJ, Dooney T. Arthroscopic Knotless Rotator Cuff Repair With Decellularized Dermal Allograft Augmentation: The "Canopy" Technique. Arthrosc Tech 2020; 9:e1797-e1803. [PMID: 33294343 PMCID: PMC7695626 DOI: 10.1016/j.eats.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/05/2020] [Indexed: 02/03/2023] Open
Abstract
Repairability and clinical outcomes of full-thickness rotator cuff tears rely on tendon mobility, tissue quality, and subsequent tension on a repair. While repair of rotator cuff tears tend to yield excellent clinical results, poor tissue quality has been an important factor that has hampered successful outcomes. This Technical Note describes a double-row rotator cuff repair using a SpeedBridge configuration with dermal allograft "canopy" augmentation to bolster the repairable but thinned rotator cuff tissue. This technique employs a unique graft fixation strategy to simplify the procedure. This approach could provide surgeons with a great option when faced with mobile but thinned rotator cuff tissue.
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Affiliation(s)
- Alan M. Hirahara
- Private Practice Sacramento, California, U.S.A.,Address correspondence to Alan M. Hirahara, M.D., FR.C.S.C., 2801 K St., #330, Sacramento, CA 95816.
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17
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Quental C, Reis J, Folgado J, Monteiro J, Sarmento M. Comparison of 3 supraspinatus tendon repair techniques - a 3D computational finite element analysis. Comput Methods Biomech Biomed Engin 2020; 23:1387-1394. [PMID: 32787682 DOI: 10.1080/10255842.2020.1805441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Considering that optimal contact area and pressure at the tendon-bone interface are associated with better footprint repair and outcomes, the aim of this study was to compare the performance of standard double-row, transosseous equivalent (TOE), and partial articular supraspinatus tendon avulsion (PASTA) techniques for the treatment of full-thickness tears of the supraspinatus tendon using 3D finite element models. Loading consisted, alternately, in a preloading of 10 N and 20 N of the sutures. The footprint coverage of the standard double-row, TOE, and PASTA techniques was estimated to represent 19%, 30%, and 35%, respectively, of the repair area. The average contact pressures followed an opposite trend, i.e., the largest was estimated for the standard double-row technique, whereas the lowest was estimated for the PASTA technique. Despite the present study advancing the computational modelling of rotator cuff repair, and the results being consistent with the literature, its findings must be evaluated cautiously, bearing in mind its limitations.
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Affiliation(s)
- C Quental
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
| | - J Reis
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
| | - J Folgado
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
| | - J Monteiro
- Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - M Sarmento
- Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal
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18
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Zafra M, Uceda P, Muñoz-Luna F, Muñoz-López RC, Font P. Arthroscopic repair of partial-thickness articular surface rotator cuff tears: single-row transtendon technique versus double-row suture bridge (transosseous equivalent) fixation: results from a prospective randomized study. Arch Orthop Trauma Surg 2020; 140:1065-1071. [PMID: 32170453 DOI: 10.1007/s00402-020-03387-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND The purpose of this prospective study was to compare the clinical and structural findings following the arthroscopic repair of partial-thickness (exceeding 50%) articular-sided rotator cuff tears using either a single-row or a double-row suture bridge fixation. MATERIALS AND METHODS Fifty patients were included in this study. The patients were randomly placed into two groups: 25 underwent the single-row (Group I) and 25 a double-row suture bridge fixation (Group II). The clinical outcomes were assessed using ASES and Constant shoulder scores, both preoperatively and at the end of follow-up. The pain level was evaluated using the visual analogue scale (VAS), preoperatively, at 6 months and at the end of follow-up. All patients underwent preoperative MRI to identify the rotator cuff tear, and postoperatively at 12 months to evaluate tendon integrity. RESULTS The average follow-up was 32.5 months. The mean ASES scores increased from 35.9 to 96.7 in Group I and from 35.3 to 93.4 in Group II; the mean Constant shoulder scores increased from 55.6 to 97.8 in Group I and from 57.5 to 97.3 in Group II. There were no significant differences between the two groups. The average preoperative pain level decreased from 7.4 to 3 at 6 months and to 0.4 at the end of the Group I; and from 7.6 to 3 at 6 months and 0.8 in Group II. There was no significant difference between the two groups. At 12 months, the MRI assessments showed two retears in Group I (8%) and one retear in Group II (4%). CONCLUSION Arthroscopic repair of partial-thickness articular rotator cuff tears that exceed 50% of tendon thickness with a single-row transtendon repair or double-row suture bridge provides functional improvement and pain relief regardless of the repair technique used. There were no differences in clinical results between both techniques. LEVEL OF EVIDENCE Level II; prospective comparative study.
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Affiliation(s)
- Manuel Zafra
- Hospital Quirón, Instituto de Traumatología, Avda. del Aeropuerto, 14005, Córdoba, Spain
| | - Pilar Uceda
- Hospital Quirón, Instituto de Traumatología, Avda. del Aeropuerto, 14005, Córdoba, Spain. .,, Isla Hierro St Number 14, 14011, Córdoba, Spain.
| | | | - Rafael C Muñoz-López
- Hospital Quirón, Instituto de Traumatología, Avda. del Aeropuerto, 14005, Córdoba, Spain
| | - Pilar Font
- IMIBIC, Universidad de Córdoba, Córdoba, Spain
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19
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Pulatkan A, Anwar W, Ayık O, Bozdag E, Yildirim AN, Kapicioglu M, Tuncay I, Bilsel K. Tear Completion Versus In Situ Repair for 50% Partial-Thickness Bursal-Side Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model. Am J Sports Med 2020; 48:1818-1825. [PMID: 32298135 DOI: 10.1177/0363546520909854] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tear completion followed by repair (TCR) and in situ repair (ISR) have been widely used for bursal-side partial-thickness rotator cuff tears (PTRCTs). Both techniques have shown favorable results; however, controversy continues in terms of the best management. PURPOSE To compare the histological and biomechanical outcomes of these 2 techniques for 50% partial-thickness bursal-side rotator cuff tear repair in a rabbit model. STUDY DESIGN Controlled laboratory study. METHODS A total of 27 rabbits were used in this experimental study. Seven rabbits were sacrificed at the beginning of the study to form an intact tendon control group. A chronic 50% partial-thickness bursal-side tear model was created in 20 rabbits, and 5 rabbits were sacrificed for biomechanical testing of chronic partial-thickness tears (control group) without repair. In 15 rabbits, partial-thickness tears were repaired after 8 weeks. Partial-thickness tears in the right shoulders were completed to full thickness and repaired; in contrast, left shoulders were repaired in situ. All rabbits were euthanized 8 weeks after the repair. The tendons were tested biomechanically for ultimate failure, linear stiffness, and displacement. Histological evaluations of tendon-to-bone healing were performed via the modified Watkins score. RESULTS Macroscopically, all repaired tendons were attached to the greater tuberosity. The TCR group had a higher failure load than the ISR group, with mean values of 140.4 ± 13.8 N and 108.1 ± 16.6 N, respectively (P = .001). The modified Watkins score was significantly higher in the TCR group (23.5; range, 22-27) than in the ISR group (19.5; range, 16-22) (P = .009). CONCLUSION Both repair techniques are effective for 50% partial-thickness bursal-side rotator cuff tears; however, TCR yields significantly superior biomechanical and histological characteristics compared with ISR. CLINICAL RELEVANCE Tear completion and repair technique may increase tendon-to-bone healing and thereby reduce re-rupture rate in the partial thickness bursal side rotator cuff tears.
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Affiliation(s)
- Anil Pulatkan
- Department of Orthopedics and Traumatology, School of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Wasim Anwar
- FCPS Department of Orthopaedics, Medical Teaching Institute, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Omer Ayık
- Department of Orthopaedics and Traumatology, Fatih, Istanbul University Medical Faculty, School of Medicine, Istanbul, Turkey
| | - Ergun Bozdag
- Biomechanics Laboratory, Department of Mechanical Engineering, Istanbul Technical University, Taksim, Istanbul, Turkey
| | - Ayse Nur Yildirim
- Department of Pathology, Medeniyet University Goztepe Research and Training Hospital, Istanbul, Turkey
| | - Mehmet Kapicioglu
- Department of Orthopedics and Traumatology, School of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Ibrahim Tuncay
- Department of Orthopedics and Traumatology, School of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Kerem Bilsel
- Department of Orthopedics and Traumatology, School of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
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Trans-tendon suture bridge rotator cuff repair with tenotomized pathologic biceps tendon augmentation in high-grade PASTA lesions. Arch Orthop Trauma Surg 2020; 140:67-76. [PMID: 31616993 DOI: 10.1007/s00402-019-03285-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Indexed: 02/09/2023]
Abstract
PURPOSE The purpose of this study was to evaluate whether trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation improves mid-term clinical outcomes for high-grade partial articular-sided supraspinatus tendon avulsion (PASTA) lesions or not. METHODS A retrospective review of a consecutive series of arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation was conducted. Total 115 patients (44 men and 71 women) with minimum 2 years follow-up were enrolled in our study. Their mean age was 59.7 ± 7.6 (38-77) years and mean follow-up were 6.9 ± 2.5 (2 ~ 10) years. Clinical assessment and radiological outcomes using post-operative MRI were evaluated at last follow-up. RESULTS All these tears were high-grade PASTA lesions in which mean cuff tear size (exposed footprint) was anteroposterior length 15.7 ± 6.3 mm (5-25 mm) and mediolateral width 10.1 ± 3.6 mm 6.4 mm (5-16 mm). At last follow-up, mean pain VAS, ASES, UCLA, and SST scores were improved from pre-operative values of 5, 59, 21, and 7 to post-operative values of 1, 84.4, 29.5, and 9.4, respectively (p value < 0.001). ROM such as forward flexion, abduction, and internal rotation to the back were improved from a pre-operative mean of 148° (±24), 144° (±24), L2 (Buttock-T7) to a post-operative mean of 161° (±10), 160.0° (±12), and T12 (L3-T5), respectively (p value < 0.001). Follow-up MRI showed Sugaya classification type I in 24 patients (20.9%), type II in 78 patients (67.8%), type III in 11 patients (9.6%) and type 4 in 2 patients (1.7%) were found. As complications, shoulder stiffness was found in five patients, Popeye deformity in two patients and retear in two patients. Revision surgery of the retear was performed in 2 patients. At the last follow-up, 17% (20/115 patients) reported occasional discomfort at the extremes of range of motion during a heavy work or sports activities. CONCLUSIONS In high-grade PASTA lesions, arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation could be a useful treatment modality capable of preserving rotator cuff footprint, providing simultaneous biceps tenodesis, inducing better tendon healing and possibly preventing tendon buckling and residual pain of the conventional trans-tendon repair methods. These specific methods showed satisfactory outcomes and decreased residual shoulder discomfort (17%) at mid-term follow-up. LEVEL OF EVIDENCE Level IV, Retrospective case study.
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21
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Patient-Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full-Thickness Rotator Cuff Tears. Arthroscopy 2019; 35:2262-2271. [PMID: 31350082 DOI: 10.1016/j.arthro.2019.02.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 01/31/2019] [Accepted: 02/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To collect outcomes data on patients treated with a bioinductive collagen implant designed to induce rotator cuff healing in partial- and full-thickness cuff tears and to assess the safety and efficacy of the device. METHODS Fifteen surgeons in 15 centers in the United States enrolled patients between April 2016 and August 2017 and collected standardized outcomes data. Patients 21 years of age and older, able to read and speak English, and with partial- or full-thickness tears of the rotator cuff documented by magnetic resonance imaging were included in the study. Patients were assessed preoperatively with visual analogue scale (VAS), single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcomes measures. Postoperative assessment was made at 2, 6, and 12 weeks, 6 months, and 1 year. Patients underwent a standardized operative procedure with the implant. Patient demographics, comorbidities, tear types, and concomitant operative procedures were recorded. RESULTS Patients in both groups experienced statistically significant improvement in VAS, SANE, VR-12 PCS, ASES, and WORC scores (mean values 1.1, P < .001; 86.0, P < .001; 49.7, P < .001; 85.6, P < .001; and 84.4, P < .001 for partial tears and 1.2, P < .001; 80.7, P < .001; 45.7, P < .001; 83.8, P < .0001; and 80.1, P < .001 for full-thickness tears, respectively). For the partial tear group, average times for return to driving, work, and nonoverhead athletic activity were 14.6, 37.3, and 65.6 days, and for the full-thickness group, 24.5, 50.7, and 119.2 days, respectively. In the partial-thickness group, 84% and 83% of patients reported improvement in their VAS pain and ASES scores, respectively, that met or exceeded each measure's minimal clinically important difference. In the full-thickness group, 72% and 77% of the patients met or exceeded the minimal clinically important differences for VAS pain and ASES, respectively. CONCLUSION Outcomes after repair of partial- and full-thickness rotator cuff tears using a bioinductive implant show safety and efficacy at 1-year follow-up. LEVEL OF EVIDENCE Retrospective case series, level IV evidence.
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Transtendinous repair of partial articular sided supraspinatus tears is associated with higher rates of stiffness and significantly inferior early functional scores than tear completion and repair: A systematic review. Orthop Traumatol Surg Res 2018; 104:829-837. [PMID: 30036723 DOI: 10.1016/j.otsr.2018.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 04/28/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Transtendon repair (TTR) and tear completion and repair (TCR) are common repair techniques for partial thickness rotator cuff tears (PTRCTs). Previous systematic reviews have not demonstrated any advantage of either but have not specifically addressed early recovery. AIM To compare the outcomes of these two techniques in treating PTRCTs with respect to post-operative stiffness, delay in functional recovery and re-tear rates. MATERIAL AND METHODS A systematic review of the Medline and EMBASE database was performed in accordance with the PRISMA guidelines. Both cases series and comparative studies reporting functional outcomes, post-operative stiffness or re-tear rate after either TTR or TCR for PTRCTs were included. RESULTS The search strategy identified 21 studies (n=797); 4 comparative studies (n=214), 15 TTR (n=511) and 2 TCR case series (n=72). All four comparative studies included were randomised controlled trials. One RCT reported early outcomes and demonstrated significantly slower recovery in the TTR group at 3 months (ASES p=0.037, Constant score p=0.019 and pain p=0.001). Similarly, data from the case series suggested that the rate of post-operative stiffness was higher in the TTR group. All comparative studies demonstrated no significant difference at final follow up in terms of pain, range of motion or functional score. DISCUSSION The results of this systematic review suggest that transtendinous repairs are associated with more pain and worse function during the first 3 months. This suggests that tear completion and repair should be the preferred option, as comparative studies do not demonstrate any long-term advantage of transtendinous repair. LEVEL OF EVIDENCE II, systematic review.
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23
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Lo IK, Denkers MR, More KD, Nelson AA, Thornton GM, Boorman RS. Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment. Open Access J Sports Med 2018; 9:191-197. [PMID: 30271226 PMCID: PMC6149897 DOI: 10.2147/oajsm.s153236] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose The purpose of this study was to determine the clinical success rate of nonoperative treatment of partial-thickness rotator cuff tears (PT-RCTs), to determine baseline clinical factors predictive of outcome of nonoperative treatment of PT-RCTs, and to determine the imaging outcome of nonoperative treatment of PT-RCTs. Patients and methods All patients with a primary diagnosis of a PT-RCT were eligible for inclusion. Seventy-six patients (48 males, 28 females) with an average age of 52±10 years were included in the study. Patients were evaluated using a standardized format including clinical, imaging, and shoulder specific quality-of-life outcomes. Patients were assessed and treated either successfully nonoperatively or consented to undergo surgical intervention of their PT-RCT. Patients treated nonoperatively underwent follow-up by MRI arthrogram. Results Thirty-seven patients (49%) underwent nonoperative treatment. Logistic regression analysis indicated that the baseline variables of side (dominant or nondominant side involved), onset (traumatic or atraumatic), and thickness of tendon tear (<50% or >50%) were significant predictors of outcome. At a mean 46±7 months of follow-up, nonoperatively treated patients demonstrated a mean American Shoulder and Elbow Surgeons score of 85.1±16.0, and a Simple Shoulder Test score of 10.0±2.5. Overall, 76% of tears treated nonoperatively did not show a tear progression on anatomic imaging. Nine patients (24%) demonstrated tear progression, of which three patients (8%) demonstrated full-thickness tearing. Conclusion Nonoperative treatment was utilized in ~50% of the patients and resulted in improved clinical outcomes. Onset, shoulder involved, and thickness of the tear were predictive of the success of nonoperative treatment.
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Affiliation(s)
- Ian K Lo
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada,
| | - Matthew R Denkers
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Kristie D More
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada,
| | - Atiba A Nelson
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada,
| | - Gail M Thornton
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada,
| | - Richard S Boorman
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada,
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Kjær BH, Magnusson SP, Warming S, Henriksen M, Krogsgaard MR, Juul-Kristensen B. Progressive early passive and active exercise therapy after surgical rotator cuff repair - study protocol for a randomized controlled trial (the CUT-N-MOVE trial). Trials 2018; 19:470. [PMID: 30176943 PMCID: PMC6122575 DOI: 10.1186/s13063-018-2839-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/04/2018] [Indexed: 01/08/2023] Open
Abstract
Background Rotator cuff tear is a common cause of shoulder disability and results in patients predominantly complaining of pain and loss of motion and strength. Traumatic rotator cuff tears are typically managed surgically followed by ~ 20 weeks of rehabilitation. However, the timing and intensity of the postoperative rehabilitation strategy required to reach an optimal clinical outcome is unknown. Early controlled and gradually increased tendon loading has been suggested to positively influence tendon healing and recovery. The aim of this trial is therefore to examine the effect of a progressive rehabilitation strategy on pain, physical function and quality of life compared to usual care (that limits tendon loading in the early postoperative phase) in patients who have a rotator cuff repair of a traumatic tear. Methods The current study is a randomized, controlled, outcome-assessor blinded, multicenter, superiority trial with a two-group paralleled design. A total of 100 patients with surgically repaired traumatic rotator cuff tears will be recruited from up to three orthopedic departments in Denmark, and randomized to either a progressive early passive and active movement program or a limited early passive movement program (usual care). The primary outcome measure will be the change from pre-surgery to 12 weeks post-surgery in the Western Ontario Rotator Cuff Index questionnaire. Secondary outcomes include the Disabilities Arm, Shoulder and Hand questionnaire (DASH), range of motion, strength and tendon healing characteristics from ultrasound measurements at 12 months follow up. Discussion We hypothesized that patients who receive the progressive rehabilitation strategy will benefit more with respect to pain reduction, physical function and quality of life than those who receive care as usual. If this is confirmed our study can be used clinically to enhance the recovery of patients with traumatic rotator cuff tear. Trial registration ClinicalTrials.gov, NCT02969135. Registered on 15 November 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2839-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Birgitte Hougs Kjær
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark. .,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark.
| | - S Peter Magnusson
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Institute of Sports Medicine, Department of Orthopaedic Surgery M, Copenhagen Bispebjerg-Frederiksberg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susan Warming
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Marius Henriksen
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,The Parker Institute, Bispebjerg-Frederiksberg Hospital, Ndr. Fasanvej 57, DK-2000, Frederiksberg, Copenhagen, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology M51, Department of Orthopaedic Surgery, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark
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Gereli A, Kocaoglu B, Ulku TK, Silay S, Kilinc E, Uslu S, Nalbantoglu U. Completion repair exhibits increased healing characteristics compared with in situ repair of partial thickness bursal rotator cuff tears. Knee Surg Sports Traumatol Arthrosc 2018. [PMID: 29516123 DOI: 10.1007/s00167-018-4870-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Little information is available regarding the healing capacity of in situ and completion repair for the treatment of partial thickness rotator cuff tears. The purpose of the study was to analyze the healing characteristics of both techniques. METHODS Twenty-four adult Sprague-Dawley rats were operated. Partial thickness bursal side tears were created bilaterally at the supraspinatus tendons. Additional 6 rats were used as the sham group. The right shoulders were repaired in situ, and the left shoulders were repaired using the tear completion technique on the 10th day after detachment surgery. Rats were sacrificed on the 10th and 30th days after repair surgery. Type I collagen, the TNF-α concentrations, the number and diameter of fibroblasts, and neovascularization were examined at two different time points. RESULTS The collagen concentration (ng/mg total protein) was significantly increased in both groups at T1 and decreased in the in situ group, whereas completion repair continued to increase at T2 (P < 0.05). The mean fibroblast diameter in the completion repair group continued to increase at both time points (P < 0.05). Neovascularization was significantly increased with tear completion compared with in situ repair (P < 0.05) at T1. No significant (n.s.) differences regarding the TNF-α concentration (pg/mg total protein) were noted for both surgical techniques at T2 (P > 0.05). CONCLUSION Despite the concerns of detaching the intact tendon, the completion repair technique exhibited increased healing characteristics compared with the in situ technique. The reason for this finding might be the refreshing effect of debridement at the chronic degenerated tendon that could improve the healing response.
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Affiliation(s)
- Arel Gereli
- Department of Orthopedic Surgery, Faculty of Medicine, Acibadem Altunizade Hospital, Acibadem University, Yurtcan sok. No:1, 34662, Uskudar, Istanbul, Turkey
| | - Baris Kocaoglu
- Department of Orthopedic Surgery, Faculty of Medicine, Acibadem Altunizade Hospital, Acibadem University, Yurtcan sok. No:1, 34662, Uskudar, Istanbul, Turkey.
| | - Tekin Kerem Ulku
- Department of Orthopedic Surgery, Faculty of Medicine, Acibadem Altunizade Hospital, Acibadem University, Yurtcan sok. No:1, 34662, Uskudar, Istanbul, Turkey
| | - Sena Silay
- Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Evren Kilinc
- Department of Biophysics, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Serap Uslu
- Department of Histology and Embryology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ufuk Nalbantoglu
- Department of Orthopedic Surgery, Faculty of Medicine, Acibadem Altunizade Hospital, Acibadem University, Yurtcan sok. No:1, 34662, Uskudar, Istanbul, Turkey
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Liu JN, Garcia GH, Gowd AK, Cabarcas BC, Charles MD, Romeo AA, Verma NN. Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes. Curr Rev Musculoskelet Med 2018; 11:55-62. [PMID: 29330670 DOI: 10.1007/s12178-018-9459-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears. RECENT FINDINGS Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best. Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.
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Affiliation(s)
- Joseph N Liu
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA.
| | - Grant H Garcia
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
| | - Anirudh K Gowd
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
| | - Brandon C Cabarcas
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
| | - Michael D Charles
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
| | - Anthony A Romeo
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
| | - Nikhil N Verma
- Section of Sports Medicine, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 200, Chicago, IL, 60612, USA
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Vap AR, Mannava S, Katthagen JC, Horan MP, Fritz EM, Pogorzelski J, Millett PJ. Five-Year Outcomes After Arthroscopic Repair of Partial-Thickness Supraspinatus Tears. Arthroscopy 2018; 34:75-81. [PMID: 29100763 DOI: 10.1016/j.arthro.2017.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/17/2017] [Accepted: 07/21/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate clinical outcomes in patients who underwent arthroscopic repair of isolated partial-thickness rotator cuff tears (PTRCTs) of the supraspinatus tendon with a minimum follow-up period of 5 years. METHODS All patients who had undergone arthroscopic repair of isolated PTRCTs at least 5 years earlier were included. Preoperatively and postoperatively, the American Shoulder and Elbow Surgeons, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire), and Short Form 12 Physical Component Summary scores were collected, along with postoperative satisfaction (10-point scale) and return to activity. The associations between (1) patient age and outcome scores and (2) location of partial-thickness tear (articular vs bursal sided) and outcome scores were evaluated. Failure was defined as revision surgery of the rotator cuff repair. RESULTS The study included 24 shoulders (24 patients comprising 9 women and 15 men). Follow-up data were available on 20 shoulders (7 women and 13 men, 83% follow-up) at a mean of 6 ± 1 years postoperatively. The mean age at index surgery was 55 ± 11 years; 6 bursal- and 14 articular-sided tears were repaired. No patient required revision surgery. All scores significantly improved from preoperatively to postoperatively (P < .05); the median satisfaction rating (1, not satisfied; 10, completely satisfied) was 10 (range, 1-10). Neither patient age nor tear location correlated with outcome scores (P > .05). Seventeen patients indicated that they participated in previous recreational activity. Of these patients, 13 (76%) returned to the original level or a similar level of activity, 3 (18%) returned to activity at a lower level, and only 1 (6%) indicated an inability to return to activity. CONCLUSIONS Patients undergoing arthroscopic repair of PTRCTs can expect excellent clinical outcomes with low failure rates at midterm follow-up given that no patient progressed to revision rotator cuff repair during follow-up. The return-to-activity rate was very high after repair of isolated PTRCTs. Neither patient age nor tear location was associated with outcome scores. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Alexander R Vap
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A.; Department of Orthopaedic Surgery, Sports Medicine, Virginia Commonwealth University Hospital, Richmond, Virginia
| | - Sandeep Mannava
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A
| | - J Christoph Katthagen
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Department for Trauma, Hand- and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Marilee P Horan
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Erik M Fritz
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A..
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Hirahara AM, Andersen WJ. The PASTA Bridge: A Technique for the Arthroscopic Repair of PASTA Lesions. Arthrosc Tech 2017; 6:e1645-e1652. [PMID: 29416963 PMCID: PMC5795192 DOI: 10.1016/j.eats.2017.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/22/2017] [Indexed: 02/03/2023] Open
Abstract
PASTA (partial articular supraspinatus tendon avulsion) lesions of greater than 50% thickness are usually repaired, whereas those of less than 50% thickness receive subacromial decompression and debridement. However, tears of greater than 25% thickness of the tendon result in increased strain of the adjacent, intact tendon fibers. Re-creating the tendon footprint at the greater tuberosity is the goal of a repair. Transtendon repairs have been considered the gold standard in repair but have shown varying outcomes and are technically difficult procedures. This report details the PASTA bridge-a technique for the arthroscopic, percutaneous repair of PASTA lesions. The PASTA bridge uses a spinal needle to ensure the repair includes the leading edge of the good tissue and is at the appropriate angle and area. Most procedures use a knife or trocar blindly to access the joint to place anchors, which has the potential to damage surrounding tissues and result in poor anchor and suture placement. The PASTA bridge is a safe, reliable procedure that is easily reproducible and appropriate for surgeons of all experience levels and should be strongly considered when repairing PASTA lesions.
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Affiliation(s)
- Alan M. Hirahara
- Address correspondence to Alan M. Hirahara, M.D., F.R.C.S.C., 2801 K St, Ste 330, Sacramento, CA 95816, U.S.A.2801 K St, Ste 330SacramentoCA95816U.S.A.
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Osti L, Buda M, Andreotti M, Osti R, Massari L, Maffulli N. Transtendon repair in partial articular supraspinatus tendon tear. Br Med Bull 2017; 123:19-34. [PMID: 28910993 DOI: 10.1093/bmb/ldx023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/23/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Partial thickness rotator cuff tears (PTRCTs) are common, with an incidence between 17% and 37%, and a high prevalence in throwing athletes. Different surgical procedures are suggested when partial tears involve the articular portion of the rotator cuff, including arthroscopic debridement of the tear, debridement with acromioplasty, tear completion and repair, and lately transtendon repair. This systematic review describes the transtendon repair and examines indications, contraindications, complications and clinical outcome. SOURCE OF DATA We identified clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English and Italian concerning the clinical outcomes following treatment of partial articular supraspinatus tendon tear using transtendon surgical repair. AREAS OF AGREEMENT Eighteen studies fulfilled our inclusion criteria. All were published between 2005 and 2016, three were retrospective, and 15 prospective. The total number of patients was 507 with a mean age of 50.8 years. AREAS OF CONTROVERSY Tear completion and repair and transtendon repair alone produce similar results. GROWING POINTS Transtendon surgical repair allows to obtain good-excellent results in the treatment of partial articular supraspinatus tendon tears. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies are needed to produce clear guidelines in the treatment of partial articular supraspinatus tendon tears. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Leonardo Osti
- Unit of Arthroscopy and Sports Medicine, Hesperia Hospital, Via Arqua' 80/A, Modena, Italy
| | - Matteo Buda
- Department of Trauma and Orthopedic Surgery, University of Ferrara, Via Aldo Moro 8, Ferrara, Italy
| | - Mattia Andreotti
- Department of Trauma and Orthopedic Surgery, University of Ferrara, Via Aldo Moro 8, Ferrara, Italy
| | - Raffaella Osti
- Department of Trauma and Orthopedic Surgery, University of Ferrara, Via Aldo Moro 8, Ferrara, Italy
| | - Leo Massari
- Department of Trauma and Orthopedic Surgery, University of Ferrara, Via Aldo Moro 8, Ferrara, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy.,Centre for Sports and Exercise Medicine Queen Mary University of London Barts and The London School of Medicine and Dentistry, Mile End Hospital London, 275 Bancroft Road, London E1 4DG, UK
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In situ repair of partial articular surface lesions of the supraspinatus tendon. Rev Bras Ortop 2017; 52:303-308. [PMID: 28702388 PMCID: PMC5497015 DOI: 10.1016/j.rboe.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/21/2016] [Indexed: 11/22/2022] Open
Abstract
Objective To demonstrate the in situ repair technique of high-degree partial-thickness articular surface lesions of the supraspinatus tendon (SS). The procedure consists of the arthroscopic surgical repair of these lesions, without the need to complete the lesion, as occurs in traditional classical technique. A small incision is made in the longitudinal direction of the intact bursal fibers and where bone fixation anchors are introduced, which makes the procedure easier. These anchors are transferred to the tendon and thus enable the repair of the lesion. Methods 48 shoulders were operated in the period 2010–2015. The minimum follow-up was 12 months and maximum 60 months. Ages ranged from 38 years to 75 years (mean 54 years). They were indicated for the repair of high-degree symptomatic lesions and at least 30% intact superior bursal fibers of good quality. Results Patients were evaluated according to the UCLA criteria, the results were: 69% excellent, 17% good, 7% fair, and 7% poor. Fair results occurred in three patients with associated symptoms of polyarthralgia who remained with residual pain. Three patients developed postoperative joint stiffness (7%). Conclusion The procedure under study is safe and easy to reproduce. It shows high rates of positive results (86%). The opening made in the bursal side of the SS tendon allowed the arthroscope to remain in the subacromial space, making it easier to perform surgery.
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Vinanti GB, Rossato A, Scrimieri D, Petrera M. Arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion. Knee Surg Sports Traumatol Arthrosc 2017; 25:2151-2156. [PMID: 27106924 DOI: 10.1007/s00167-015-3953-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 12/15/2015] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the outcomes of arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion (PASTA) in a large study group. METHODS A retrospective review of prospectively collected data was conducted. One hundred and eighteen patients with PASTA lesion (grade A2-A3) who underwent arthroscopic transtendon repair were identified, of which 110 were eligible for the study. Ten patients were lost at final follow-up leaving a study group of 100 patients (52 male, 48 female). The average follow-up was 37 months (minimum 24 months, range 24-50, median 40). Mean age at the time of surgery was 50.4 (range 17-71, median 45). Patients were assessed before surgery and at 24-month follow-up, using the Simple Shoulder Test (SST), UCLA shoulder rating scale and the visual analogue scale (VAS). ROM was measured bilaterally and was evaluated before surgery, at 3-, 6- and 24-month follow-up. The satisfaction rate was calculated. Data were analysed using a paired Student's t test with 95 % confidence interval (significance p < 0.05). RESULTS Significant improvement in UCLA, SST and VAS score was observed. Fifty-four cases were rated excellent, 42 good, 2 fair, 2 poor according to the UCLA score. No significant differences in ROM were noted compared to the contra-lateral side (p < 0.001) at the 24-month follow-up. Eighteen patients presented with a stiff shoulder at the 3-month follow-up, but they recovered full ROM by the 6-month follow-up evaluation. CONCLUSIONS The arthroscopic transtendon repair of partial articular-sided rotator cuff tears is an effective procedure that leads to significant improvement in pain and shoulder function, with high patients' satisfaction rate, while the complication rate is low. This study demonstrated the effectiveness and safety of this technique in a large homogeneous study group. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Giovanni Battista Vinanti
- Gruppo Ospedaliero San Donato Foundation, Istituto Clinico San Rocco di Franciacorta, Via dei Sabbioni 24, 25050, Ome, Brescia, Italy.
| | - Alberto Rossato
- Gruppo Ospedaliero San Donato Foundation, Istituto Clinico San Rocco di Franciacorta, Via dei Sabbioni 24, 25050, Ome, Brescia, Italy
| | - Daniele Scrimieri
- Residency Program in Orthopaedic Surgery, University of Verona, Verona, Italy
| | - Massimo Petrera
- Department of Surgery, University of Toronto, Toronto, Canada
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Pinkowsky GJ, ElAttrache NS, Peterson AB, Akeda M, McGarry MH, Lee TQ. Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics. J Shoulder Elbow Surg 2017; 26:1152-1158. [PMID: 28359696 DOI: 10.1016/j.jse.2016.12.063] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 12/09/2016] [Accepted: 12/26/2016] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The objective of this study was to determine the biomechanical function of the rotator cable when a partial-thickness (>50%) tear is present. We compared intact specimens with partial tears of the anterior cable followed by partial anterior and posterior tears in regard to glenohumeral kinematics and translation. The hypothesis was that partial-thickness tears will lead to abnormal glenohumeral biomechanics, including glenohumeral translation and path of glenohumeral articulation. METHODS Five fresh frozen cadaveric shoulders with intact labrum, rotator cuff, and humerus were tested using a custom shoulder testing system in the scapular plane. Glenohumeral translation was measured after applying an anterior load of 30 N at different angles of external rotation. The path of glenohumeral articulation was measured by calculating the humeral head center with respect to the glenoid articular surface at 30°, 60°, 90°, and 120° of external rotation. RESULTS With an anterior force of 30 N, there was a significant increase in anterior and total translation at 30° of external rotation after the anterior cable was cut (P < .05). When the tear was extended to the posterior cable, there was a significant increase in anterior, inferior, and total translation at 30° and 120° of external rotation (P < .05). With respect to the path of glenohumeral articulation , the humeral head apex was shifted superiorly at 90° and 120° of external rotation after the posterior cable was cut (P < .05). CONCLUSION Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model.
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Affiliation(s)
| | | | - Alexander B Peterson
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Masaki Akeda
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA; Department of Orthopaedic Surgery, University of California, Irvine, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA; Department of Orthopaedic Surgery, University of California, Irvine, CA, USA
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Paim AE. Técnica de reparo in situ das lesões parciais da superfície articular do tendão do supraespinal. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Quental C, Folgado J, Monteiro J, Sarmento M. Full-thickness tears of the supraspinatus tendon: A three-dimensional finite element analysis. J Biomech 2016; 49:3962-3970. [DOI: 10.1016/j.jbiomech.2016.11.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 11/30/2022]
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Preservation of bursal-sided tendon in partial-thickness articular-sided rotator cuff tears: a novel arthroscopic transtendon anatomic repair technique. Arch Orthop Trauma Surg 2016; 136:1701-1708. [PMID: 27498108 DOI: 10.1007/s00402-016-2546-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The purpose of this study was to introduce a novel arthroscopic transtendon anatomic repair technique that spares the intact bursal-sided tendon in articular-sided partial-thickness rotator cuff tears (PTRCT) and to present shoulder functional outcomes in patients with symptomatic articular-sided PCRCT that involves more than 50 % of its thickness after arthroscopic repair using a novel technique. MATERIALS AND METHODS Eighteen patients with symptomatic articular-sided PCRCT involving more than 50 % of the tendon's thickness underwent arthroscopic repair using a devised technique. The devised technique restores only the torn articular portion of the rotator cuff at the anatomical footprint using a suture anchor, and preserves the integrity of the corresponding bursal-sided tendon by tying knots at the most lateral bursal side on the subacromial space. Clinical and functional outcome using ASES and Constant scores were evaluated. The structural integrity of the rotator cuff was evaluated by MRI at 6 months postoperatively. RESULTS Pain relief and shoulder functional outcomes were encouraging during the recovery phase after operation. ASES (preoperative 54.0 ± 10.3 to postoperative 92.6 ± 8.0), Constant score (61.2 ± 8.5-88.0 ± 5.3), VAS for pain (4.9 ± 2.6-0.6 ± 0.7) improved significantly after arthroscopic transtendon anatomic repair (p < 0.001). No patients had rotator cuff retears on 6-month MRI. No complications related to surgical procedures had occurred. CONCLUSION The devised technique of arthroscopic transtendon repair provided satisfactory functional outcomes without postoperative discomforts. This technique minimizes over-tightening of the articular layer and reduces tension mismatches between the articular and bursal layers, which are considered as important factors for improvement of postoperative shoulder motion.
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Ranalletta M, Rossi LA, Bertona AB, Atala NA, Tanoira I, Maignon G, Bongiovanni SL. Arthroscopic Transtendon Repair of Partial-Thickness Articular-Side Rotator Cuff Tears. Arthroscopy 2016; 32:1523-8. [PMID: 27039963 DOI: 10.1016/j.arthro.2016.01.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 12/12/2015] [Accepted: 01/15/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical outcomes and complications in a series of patients with painful partial articular cuff tears treated with the arthroscopic transtendinous repair with a minimum 2-year follow-up. METHODS Eighty patients with a mean age of 51 ± 5.4 years who had undergone an arthroscopic transtendon repair for a painful articular-sided rotator cuff tear with a minimum of 2-year follow-up were contacted. Clinical outcomes using a patient-based questionnaire, the University of California at Los Angeles score, the American Shoulder and Elbow Surgeons score, and the visual analog scale were evaluated. Postoperative complications were also assessed. RESULTS After arthroscopic repair, the University of California at Los Angeles scores improved from 13.6 to 31.5; the American Shoulder and Elbow Surgeons scores improved from 44.4 to 76.1; and the visual analog scale scores improved from 6.3 to 1.3 (P < .0001). A total of 92.5% of patients were satisfied with their results. Only 5 patients developed a postoperative adhesive capsulitis that responded favorably to physical therapy. Eleven patients had concurrent procedures performed at the time of surgery. We found no difference between these patients and those who had an isolated tendon repair. CONCLUSIONS Arthroscopic transtendon repair of partial-thickness articular-side rotator cuff tears is a reliable procedure that can be expected to produce satisfactory functional improvements and pain relief in most patients with a low rate of complications in the midterm follow-up. Concurrent procedures performed at the time of supraspinatus repair do not change functional outcomes. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Maximiliano Ranalletta
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Luciano Andrés Rossi
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Agustin Bernardo Bertona
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Nicolas Agustin Atala
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Tanoira
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gastón Maignon
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Santiago L Bongiovanni
- Department of Orthopedics and Traumatology, Prof. Dr. Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Matava M. Editorial Commentary: Your Surgical "Tool Box" Just Got a Little Bit Bigger. Arthroscopy 2016; 32:1529-30. [PMID: 27495859 DOI: 10.1016/j.arthro.2016.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 02/02/2023]
Abstract
There is currently no "gold standard" for the surgical repair of a partial-thickness rotator cuff tear. Ranalletta et al. have made a meaningful contribution to the orthopaedic literature with this study that reports the clinical outcomes of 80 patients who underwent arthroscopic transtendon repair of high-grade, articular-sided partial-thickness rotator cuff tears. At a mean follow-up of 62 months, they noted significant improvement in pain, range of motion, and a number of objective shoulder outcome measures. Perhaps most importantly, 92.5% rated their shoulder as "good" or "excellent." Unfortunately, we cannot definitively state whether or not these repairs actually healed given the lack of postoperative imaging, nor do we know the actual depth of these partial tears that can be difficult to objectively quantify. Despite these shortcomings, arthroscopic surgeons who treat rotator cuff disorders will be able to use this information in treating their patients irrespective of their preferred surgical technique. Future studies are needed to definitively determine which repair method, if any, is better.
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Arthroscopic Repair of Articular Surface Partial-Thickness Rotator Cuff Tears: Transtendon Technique versus Repair after Completion of the Tear-A Meta-Analysis. Adv Orthop 2016; 2016:7468054. [PMID: 27462471 PMCID: PMC4947639 DOI: 10.1155/2016/7468054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/08/2016] [Indexed: 11/17/2022] Open
Abstract
Articular surface partial-thickness rotator cuff tears (PTRCTs) are commonly repaired using two different surgical techniques: transtendon repair or repair after completion of the tear. Although a number of studies have demonstrated excellent clinical outcomes, it is unclear which technique may provide superior clinical outcomes and tendon healing. The purpose was to evaluate and compare the clinical outcomes following arthroscopic repair of articular surface PTRCT using a transtendon technique or completion of the tear. A systematic review of the literature was performed following PRISMA guidelines and checklist. The objective outcome measures evaluated in this study were the Constant Score, American Shoulder and Elbow Surgeons score, Visual Analogue Scale, physical examination, and complications. Three studies met our criteria. All were prospective randomized comparative studies with level II evidence and published from 2012 to 2013. A total of 182 shoulders (mean age 53.7 years; mean follow-up 40.5 months) were analyzed as part of this study. Both procedures provided excellent clinical outcomes with no significant difference in Constant Score and other measures between the procedures. Both procedures demonstrated improved clinical outcomes. However, there were no significant differences between each technique. Further studies are required to determine the long-term outcome of each technique.
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Ganal E, Ho CP, Wilson KJ, Surowiec RK, Smith WS, Dornan GJ, Millett PJ. Quantitative MRI characterization of arthroscopically verified supraspinatus pathology: comparison of tendon tears, tendinosis and asymptomatic supraspinatus tendons with T2 mapping. Knee Surg Sports Traumatol Arthrosc 2016; 24:2216-24. [PMID: 25739912 DOI: 10.1007/s00167-015-3547-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/18/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Quantitative MRI T2 mapping is a non-invasive imaging technique sensitive to biochemical changes, but no studies have evaluated T2 mapping in pathologic rotator cuff tendons. It was sought to evaluate the efficacy of T2 mapping in detecting differences in the supraspinatus tendon (SST) among patients with tendinosis, partial tears and minimally retracted full-thickness tears, relative to asymptomatic volunteers. METHODS The pathologic cohort consisted of two arthroscopically verified groups: tendinosis and a tear group of partial tears or minimally retracted full-thickness tears, and was compared to an asymptomatic cohort with no prior history of shoulder pathology. The SST was manually segmented from the footprint to the medial humeral head in the coronal and sagittal planes and divided into six clinically relevant subregions. Mean T2 values and inter- and intra-rater reliability were assessed. RESULTS In the anterolateral subregion, the tear group exhibited significantly higher mean T2 values (43.9 ± 12.7 ms) than the tendinosis (34.9 ± 3.9 ms; p = 0.006) and asymptomatic (33.6 ± 5.3 ms; p = 0.015) groups. In the posterolateral subregion, the tear group had higher mean T2 values (45.2 ± 13.7) than the asymptomatic group (34.7 ± 6.7; p = 0.012). Inter- and intra-rater reliability was mostly excellent (ICC > 0.75). CONCLUSION T2 mapping is an accurate non-invasive method to identify quantitatively early rotator cuff pathology. The lateral region in the coronal plane in particular may differentiate partial and small minimally retracted full-thickness tears from tendinosis and asymptomatic tendons. Understanding and being able to measure quantitatively the process of tendon degeneration and subsequent tearing may help clinicians to better predict at-risk groups and to stratify treatment options. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edmund Ganal
- The Steadman Clinic, 181 W Meadow Dr, Suite 400, Vail, CO, 81657, USA
| | - Charles P Ho
- Steadman Philippon Research Institute, 181 W Meadow Dr, Vail, CO, 81657, USA
| | - Katharine J Wilson
- Steadman Philippon Research Institute, 181 W Meadow Dr, Vail, CO, 81657, USA
| | - Rachel K Surowiec
- Steadman Philippon Research Institute, 181 W Meadow Dr, Vail, CO, 81657, USA
| | - W Sean Smith
- Steadman Philippon Research Institute, 181 W Meadow Dr, Vail, CO, 81657, USA
| | - Grant J Dornan
- Steadman Philippon Research Institute, 181 W Meadow Dr, Vail, CO, 81657, USA
| | - Peter J Millett
- The Steadman Clinic, 181 W Meadow Dr, Suite 400, Vail, CO, 81657, USA.
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Godinho GG, França FDO, Freitas JMA, Lago E Santos FM, Resende DS, Wageck JPZ, Portela SFB. Long-term functional evaluation of videoarthroscopic treatment of partial injuries of the rotator cuff. Rev Bras Ortop 2015; 50:200-5. [PMID: 26229917 PMCID: PMC4519643 DOI: 10.1016/j.rboe.2015.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 03/07/2014] [Indexed: 11/10/2022] Open
Abstract
Objective To compare the functional results from high and low-grade isolated partial lesions of the supraspinatus tendon of bursal and articular types, after arthroscopic treatment. Methods Sixty-four patients with isolated partial lesions of the supraspinatus tendon were evaluated. The mean length of follow-up was 76 months (range: 29–193). The mean age was 59 years (range: 36–82). The dominant side was affected in 44 patients (68.8%). There were 35 bursal lesions (54.7%) and 29 articular lesions (45.3%). We used the Ellman classification and characterized the lesions as low or high-grade according to whether they affected less than or more than 50% of the tendon thickness, respectively. Debridement was performed in 15 patients (23.5%), repair without completing the lesion in 11 (17%) and repair after completing the lesion in 38 (59.5%). The functional assessments on the patients were done using the Constant & Murley and UCLA scores. Results The mean Constant & Murley score among the patients with bursal lesions was 82.64 ± 6.98 (range: 59.3–99) and among those with articular lesions, 83.57 ± 7.58 (range: 66–95), while the mean UCLA score in the bursal lesions was 33.37 ± 2.85 (range: 21–35) and in the articular lesions, 32.83 ± 2.95 (range: 22–35). Conclusion Videoarthroscopic treatment of partial lesions of the rotator cuff presents good or excellent results when the low-grade lesions are debrided and the high-grade lesions are completed and repaired. These results are maintained over the long term, with a high satisfaction rate and few complications.
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Affiliation(s)
- Glaydson Gomes Godinho
- Hospital Ortopédico, Belo Horizonte, MG, Brazil ; Hospital Belo Horizonte, Belo Horizonte, MG, Brazil
| | | | - José Márcio Alves Freitas
- Hospital Ortopédico, Belo Horizonte, MG, Brazil ; Hospital Belo Horizonte, Belo Horizonte, MG, Brazil
| | | | - Danilo Santos Resende
- Hospital Ortopédico, Belo Horizonte, MG, Brazil ; Hospital Belo Horizonte, Belo Horizonte, MG, Brazil
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Kondratko-Mittnacht J, Lakes R, Vanderby R. Shear loads induce cellular damage in tendon fascicles. J Biomech 2015; 48:3299-305. [PMID: 26162546 DOI: 10.1016/j.jbiomech.2015.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/26/2015] [Accepted: 06/17/2015] [Indexed: 11/17/2022]
Abstract
Tendon is vital to musculoskeletal function, transferring loads from muscle to bone for joint motion and stability. It is an anisotropic, highly organized, fibrous structure containing primarily type I collagen in addition to tenocytes and other extracellular matrix components contributing to maintenance and function. Tendon is generally loaded via normal stress in a longitudinal direction. However, certain situations, including fiber breakage, enzymatic remodeling, or tendon pathology may introduce various degrees of other loading modalities, such as shear-lag at the fiber level, potentially affecting cellular response and subsequent function. Fascicles from rat tail tendon were dissected and placed in one of three paired groups: intact, single laceration, or double laceration. Each pair had a mechanically tested and control specimen. Single laceration fascicles contained one transverse laceration to mimic a partial tear. Double laceration fascicles had overlapping, longitudinally separated lacerations on opposite sides to cause intra-fascicular shear transfer to be the primary mechanism of loading. Elastic properties of the fascicle, e.g. peak load, steady state load, and stiffness, decreased from intact to single laceration to double laceration groups. Surprisingly, 45% of the intact strength was maintained when shear was the primary internal load transfer mechanism. Cellular viability decreased after mechanical testing in both laceration groups; cell death appeared primarily in a longitudinal plane where high shear load transfer occurred. This cell death extended far from the injury site and may further compromise an already damaged tendon via enzymatic factors and subsequent remodeling associated with cell necrosis.
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Affiliation(s)
- Jaclyn Kondratko-Mittnacht
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, 53705 WI, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, 53705 WI, USA
| | - Roderic Lakes
- Materials Science Program, University of Wisconsin-Madison, Madison, 53705 WI, USA; Department of Engineering Physics, University of Wisconsin-Madison, Madison, 53705 WI, USA
| | - Ray Vanderby
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, 53705 WI, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, 53705 WI, USA; Materials Science Program, University of Wisconsin-Madison, Madison, 53705 WI, USA.
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Matthewson G, Beach CJ, Nelson AA, Woodmass JM, Ono Y, Boorman RS, Lo IKY, Thornton GM. Partial Thickness Rotator Cuff Tears: Current Concepts. Adv Orthop 2015; 2015:458786. [PMID: 26171251 PMCID: PMC4480800 DOI: 10.1155/2015/458786] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/16/2015] [Indexed: 02/06/2023] Open
Abstract
Partial thickness rotator cuff tears are a common cause of pain in the adult shoulder. Despite their high prevalence, the diagnosis and treatment of partial thickness rotator cuff tears remains controversial. While recent studies have helped to elucidate the anatomy and natural history of disease progression, the optimal treatment, both nonoperative and operative, is unclear. Although the advent of arthroscopy has improved the accuracy of the diagnosis of partial thickness rotator cuff tears, the number of surgical techniques used to repair these tears has also increased. While multiple repair techniques have been described, there is currently no significant clinical evidence supporting more complex surgical techniques over standard rotator cuff repair. Further research is required to determine the clinical indications for surgical and nonsurgical management, when formal rotator cuff repair is specifically indicated and when biologic adjunctive therapy may be utilized.
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Affiliation(s)
- Graeme Matthewson
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Cara J. Beach
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Atiba A. Nelson
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Jarret M. Woodmass
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Yohei Ono
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Richard S. Boorman
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Ian K. Y. Lo
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
| | - Gail M. Thornton
- Department of Surgery, Section of Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada T2N 4Z6
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada V5Z 1M9
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Sun L, Zhang Q, Ge H, Sun Y, Cheng B. Which is the best repair of articular-sided rotator cuff tears: a meta-analysis. J Orthop Surg Res 2015; 10:84. [PMID: 26016477 PMCID: PMC4450842 DOI: 10.1186/s13018-015-0224-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 05/15/2015] [Indexed: 11/25/2022] Open
Abstract
Background Tear conversion followed by repair and trans-tendon techniques have been widely used for partial-thickness rotator cuff tears. Both of them showed favorable results with regard to the management of articular-sided partial-thickness rotator cuff tears (PTRCTs) of more than 50 % thickness. However, controversy continues with the best management. This study aims to compare the clinical outcomes between the two techniques. Methods The PubMed, Embase, and Cochrane library databases were searched for relevant studies published before October 1, 2014. Studies that clearly reported a comparison between the two procedures were selected. The American Shoulder and Elbow Surgeons scale (ASES) and the re-tear rate were evaluated. Statistical analysis was performed using the special meta-analysis software called “Comprehensive Meta Analysis”. Results Final meta-analysis after the full-text review included four studies about tear conversion followed by repair and seven studies about trans-tendon technique. The trans-tendon technique showed no significant difference with the tear conversion followed by repair technique with regard to the ASES scale (P = 0.69). But the re-tear rate (P < 0.05) was markedly lower in the trans-tendon technique group than the tear conversion and repair technique group. Conclusion In conclusion, the meta-analysis suggests that the trans-tendon technique is better than the tear conversion followed by repair technique with regard to the management of articular-sided PTRCTs of more than 50 % thickness in the re-tear rate aspect. Electronic supplementary material The online version of this article (doi:10.1186/s13018-015-0224-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lin Sun
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China. .,First Clinical Medical College, Nanjing Medical University, Nanjing, China.
| | - Qiang Zhang
- Department of Orthopedics, Changzhou No. 2 People's Hospital, Nanjing Medical University, Jiangsu, China.
| | - Heng'an Ge
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China.
| | - Yeqing Sun
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China.
| | - Biao Cheng
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China.
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Godinho GG, França FDO, Freitas JMA, Santos FMLE, Resende DS, Wageck JPZ, Portela SFB. Avaliação funcional em longo prazo do tratamento videoartroscópico das lesões parciais do manguito rotador. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Pensalfini M, Duenwald-Kuehl S, Kondratko-Mittnacht J, Lakes R, Vanderby R. Evaluation of global load sharing and shear-lag models to describe mechanical behavior in partially lacerated tendons. J Biomech Eng 2015; 136:091006. [PMID: 24845861 DOI: 10.1115/1.4027714] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/21/2014] [Indexed: 11/08/2022]
Abstract
The mechanical effect of a partial thickness tear or laceration of a tendon is analytically modeled under various assumptions and results are compared with previous experimental data from porcine flexor tendons. Among several fibril-level models considered, a shear-lag model that incorporates fibril-matrix interaction and a fibril-fibril interaction defined by the contact area of the interposed matrix best matched published data for tendons with shallow cuts (less than 50% of the cross-sectional area). Application of this model to the case of many disrupted fibrils is based on linear superposition and is most successful when more fibrils are incorporated into the model. An equally distributed load sharing model for the fraction of remaining intact fibrils was inadequate in that it overestimates the strength for a cut less than half of the tendon's cross-sectional area. In a broader sense, results imply that shear-lag contributes significantly to the general mechanical behavior of tendons when axial loads are nonuniformly distributed over a cross section, although the predominant hierarchical level and microstructural mediators for this behavior require further inquiry.
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Mihata T, McGarry MH, Ishihara Y, Bui CNH, Alavekios D, Neo M, Lee TQ. Biomechanical analysis of articular-sided partial-thickness rotator cuff tear and repair. Am J Sports Med 2015; 43:439-46. [PMID: 25512665 DOI: 10.1177/0363546514560156] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Articular-sided partial-thickness rotator cuff tears are common injuries in throwing athletes. The superior shoulder capsule beneath the supraspinatus and infraspinatus tendons works as a stabilizer of the glenohumeral joint. PURPOSE To assess the effect of articular-sided partial-thickness rotator cuff tear and repair on shoulder biomechanics. The hypothesis was that shoulder laxity might be changed because of superior capsular plication in transtendon repair of articular-sided partial-thickness rotator cuff tears. STUDY DESIGN Controlled laboratory study. METHODS Nine fresh-frozen cadaveric shoulders were tested by using a custom shoulder-testing system at the simulated late-cocking phase and acceleration phase of throwing motion. Maximum glenohumeral external rotation angle, anterior translation, position of the humeral head apex with respect to the glenoid, internal impingement area, and glenohumeral and subacromial contact pressures were measured. Each specimen underwent 3 stages of testing: stage 1, with the intact shoulder; stage 2, after creation of articular-sided partial-thickness tears of the supraspinatus and infraspinatus tendons; and stage 3, after transtendon repair of the torn tendons by using 2 suture anchors. RESULTS Articular-sided partial-thickness tears did not significantly change any of the shoulder biomechanical measurements. In the simulated late-cocking phase, transtendon rotator cuff repair resulted in decreased maximum external rotation angle by 4.2° (P = .03), posterior shift of the humeral head (1.1-mm shift; P = .02), decreased glenohumeral contact pressure by 1.7 MPa (56%; P = .004), and decreased internal impingement area by 26.4 mm(2) (65%; P < .001) compared with values in the torn shoulder. In the acceleration phase, the humeral head shifted inferiorly (1.2-mm shift; P = .03 vs torn shoulder), and glenohumeral anterior translation (1.5-mm decrease; P = .03 vs torn shoulder) and subacromial contact pressure (32% decrease; P = .004 vs intact shoulder) decreased significantly after transtendon repair. CONCLUSION Transtendon repair of articular-sided partial-thickness supraspinatus and infraspinatus tears decreased glenohumeral and subacromial contact pressures at time zero; these changes might lead to reduced secondary subacromial and internal impingements and consequently progression to full-thickness rotator cuff tear. However, repair of the tendons decreased anterior translation and external rotation and changed the positional relationship between the humeral head and the glenoid. CLINICAL RELEVANCE Careful attention should be paid to shoulder laxity and range of motion when transtendon repair is chosen to treat articular-sided partial-thickness rotator cuff tears, specifically in throwing athletes.
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Affiliation(s)
- Teruhisa Mihata
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan Katsuragi Hospital, Kishiwada, Japan Daiichi Towakai Hospital, Takatsuki, Japan
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA
| | - Yoko Ishihara
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA Department of Orthopedic Surgery, Tamanagayama Hospital, Nippon Medical School, Tokyo, Japan
| | - Christopher N H Bui
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA
| | - Damon Alavekios
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, California, USA University of California at Irvine, Irvine, California, USA
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Park SE, Panchal K, Jeong JJ, Kim YY, Kim JH, Lee JY, Ji JH. Intratendinous rotator cuff tears: prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears at midterm follow-up. Am J Sports Med 2015; 43:415-22. [PMID: 25389369 DOI: 10.1177/0363546514556741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intratendinous tears of the rotator cuff are rare, and little has been written about them. PURPOSE To investigate the prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair. STUDY DESIGN Case series; Level of evidence, 4. METHODS Included in the study were 33 patients (16 male, 17 female; mean age, 53.4 years) with arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair from March 2006 to July 2012. A history of trauma was found in 10 cases (30.3%). The dominant arm was involved in 26 cases (78.8%). The mean follow-up duration was 56 months. Preoperatively, a thorough physical examination was performed; at final follow-up, shoulder range of motion (ROM) in forward flexion, abduction, external rotation (ER) at the side, and internal rotation (IR) at the back was noted, and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analog scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded and compared with the preoperative data. Postoperative magnetic resonance imaging (MRI) was performed at 6 months to investigate rotator cuff healing status and repair integrity. RESULTS The prevalence of arthroscopically confirmed intratendinous tears was 4.7% among all arthroscopically treated partial-thickness rotator cuff tears. Impingement signs were positive in most of the patients (positive Hawkins-Kennedy test result in 78.8%, positive Neer sign in 66.7%, and either positive Hawkins-Kennedy test result or Neer sign in 84.8%). At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from a preoperative mean of 51.4, 18.9, 6.0, and 5.4, respectively, to a postoperative mean of 90.6, 32.9, 1.4, and 10.8, respectively (P < .001). According to the UCLA rating scale, outcomes were excellent in 17, good in 13, and fair in 3 cases. Shoulder ROM in forward flexion, abduction, ER at the side, and IR at the back improved from a preoperative mean of 135°, 129°, 25°, and L2, respectively, to a postoperative mean of 161°, 160°, 29°, and T10, respectively (P < .001 for all except ER). As per the Sugaya classification, on postoperative MRI, type I healing status was found in 10 (30.3%), type II in 18 (54.5%), and type III in 2 (6.1%) cases. None of the patients showed any evidence of retears. CONCLUSION Transtendon suture bridge repair yielded satisfactory clinical and radiological outcomes in patients with intratendinous rotator cuff tears.
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Affiliation(s)
- Sang-Eun Park
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Karnav Panchal
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jae-Jung Jeong
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Young-Yul Kim
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jong-Ho Kim
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Ju-Yeob Lee
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jong-Hun Ji
- Department of Orthopedic Surgery, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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Frisch KE, Marcu D, Baer GS, Thelen DG, Vanderby R. The influence of partial and full thickness tears on infraspinatus tendon strain patterns. J Biomech Eng 2015; 136:051004. [PMID: 24509523 DOI: 10.1115/1.4026643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 02/06/2014] [Indexed: 11/08/2022]
Abstract
Tears on the bursal and articular sides of the rotator cuff tendons are known to behave differently and strain is thought to play a role in this difference. This study investigates the effect of tear location on the changes in three strain measurements (grip-to-grip, insertion, and mid-substance tissue) in a sheep infraspinatus tendon model during axial loading. We introduced a 14 mm wide defect near the insertion from either the articular or bursal side of the tendon to three depths (3 mm, 7 mm & full) progressively. For each condition, tendons were sinusoidally stretched (4% at 0.5 Hz) while insertion and mid-substance strains were tracked with surface markers. For a fixed load, grip-to-grip strain increased significantly compared to intact for both cuts. Insertion strain increased significantly for the bursal-side defect immediately but not for the articular-side until the 66% cut. Mid-substance tissue strain showed no significant change for partial thickness articular-side defects and a significant decrease for bursal-side defects after the 66% cut. All full thickness cuts exhibited negligible mid-substance tissue strain change. Our results suggest that the tendon strain patterns are more sensitive to defects on the bursal side, and that partial thickness tears tend to induce localized strain concentrations in regions adjacent to the damaged tissue.
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50
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Lim TK, Park JH. Current Concept of Management of Partial-thickness Rotator Cuff Tear. Clin Shoulder Elb 2014. [DOI: 10.5397/cise.2014.17.4.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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