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Oklaz EB, Ahmadov A, Aral F, Tosun MF, Ayas İH, Kanatli U. Repair of Isolated Subscapularis Tears With Concurrent Biceps Tenodesis Using a Single Anchor Results in Satisfactory Clinical Outcomes: Minimum 2-Year Follow-Up. Arthroscopy 2024:S0749-8063(24)00554-1. [PMID: 39128678 DOI: 10.1016/j.arthro.2024.07.026] [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: 02/28/2024] [Revised: 07/15/2024] [Accepted: 07/15/2024] [Indexed: 08/13/2024]
Abstract
PURPOSE To investigate the clinical outcomes of patients treated with isolated subscapularis tear repair and biceps tenodesis using a single anchor. METHODS Patients diagnosed with subscapularis tear and who underwent arthroscopic surgery by a single surgeon between February 2017 and January 2022 were evaluated retrospectively. Inclusion criteria were patients who underwent repair of isolated subscapularis tear along with tenodesis for long head of the biceps tendon pathologies such as SLAP lesion, instability, partial tear, or tenosynovitis, with a minimum follow-up of 24 months. Assessment included active and passive range of motion, single-assessment numeric evaluation (SANE), visual analog scale (VAS), Constant-Murley score (CMS), and specific subscapularis and biceps tests. Improvements were analyzed using minimum clinically important difference (MCID) values. RESULTS A total of 20 patients were included. The mean age was 48.5 ± 7 years, and the follow-up period was 43.1 ± 12.7 months. Significant improvements were observed at the final follow-up in active forward flexion, active abduction, active internal rotation, as well as VAS, SANE, and CMS (P < .001). The MCID analysis showed that 100% of patients met the MCID for CMS, 90% for SANE, and 100% for VAS. CONCLUSIONS In the presence of an isolated subscapularis tear associated with long head of the biceps tendon pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor. Most patients (>90%) achieved the MCID for the CMS, SANE, and VAS, indicating significant clinical improvement and satisfactory patient outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ethem Burak Oklaz
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - Asim Ahmadov
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Furkan Aral
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Muhammed Furkan Tosun
- Department of Orthopaedics and Traumatology, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - İnci Hazal Ayas
- Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Gazi University, Ankara, Turkey
| | - Ulunay Kanatli
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Turkey
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Garg AK, Meena A, Farinelli L, D'Ambrosi R, Tapasvi S, Braun S. Partial subscapularis tear: State-of-the-art. J ISAKOS 2024:S2059-7754(24)00126-3. [PMID: 38909905 DOI: 10.1016/j.jisako.2024.06.009] [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: 03/08/2024] [Revised: 06/06/2024] [Accepted: 06/17/2024] [Indexed: 06/25/2024]
Abstract
The subscapularis (SSC) muscle is a crucial anterior glenohumeral stabilizer and internal rotator of the shoulder joint. The partial tears of the SSC might result from traumatic injury or intrinsic degeneration. Partial SSC tears can range in severity and be classified into different categories based on the location of the tear, size of the lesion, and associated pathology. The tear usually begins from the superolateral margin in the first facet and propagates downwards. It is frequently associated with biceps pathology or anterosuperior lesions. These tears are now increasingly recognized as distinct pathology that requires specific diagnostic and management approaches. The current management approaches are shifting towards operative, as partial SSC tears are increasingly recognized as a distinct pathology. At present, there is no consensus regarding the timing of repair, but the relative tendency of the SSC to retract much faster than other rotator cuff muscles, and difficulty in mobilization, advocates an early repair for SSC irrespective of the lesion size. An associated biceps pathology can be treated with either tenotomy (biceps delamination/erosion) or tenodesis. The techniques of partial SSC repair are constantly improving. There is no reported difference in use of 2-anchor-based conventional single-row (SR), a 3-anchor-based interconnected double-row technique, or a 2-anchor-based interconnected hybrid double-row construct in the repair construct. However, the 2-anchor-based interconnected double-row provides an advantage of better superolateral coverage with leading-edge protection, as it helps in placing the superolateral anchor superior and lateral to the original footprint. A timely intervention and restoration of the footprint will help restore and rehabilitate the shoulder. Future directions should prioritise injury prevention, early diagnosis with clinic-radiological cues and targeted interventions to mitigate risk.
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Affiliation(s)
- Ankit Kumar Garg
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Amit Meena
- Division of Orthopedics, Shalby Multi-Specialty Hospital, Jaipur, India; Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Innsbruck, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria.
| | - Luca Farinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Riccardo D'Ambrosi
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy; Università degli Studi di Milano, Dipartimento di Scienze Biomediche per la Salute, Milan, Italy
| | | | - Sepp Braun
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Innsbruck, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
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Dey Hazra RO, Dey Hazra ME, Hanson JA, Rutledge JC, Horan MP, Rupp MC, Millett PJ. Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes. J Shoulder Elbow Surg 2024; 33:832-840. [PMID: 37659702 DOI: 10.1016/j.jse.2023.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon. METHODS Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded. RESULTS In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear. CONCLUSION Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.
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Affiliation(s)
- Rony-Orijit Dey Hazra
- Steadman Philippon Research Institute, Vail, CO, USA; Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Maria E Dey Hazra
- Steadman Philippon Research Institute, Vail, CO, USA; Private Practice, Dr. Ulf Kuhlee, Berlin, Berlin, Germany
| | | | | | | | - Marco-Christopher Rupp
- Steadman Philippon Research Institute, Vail, CO, USA; Department of Orthopaedic Sports Medicine, Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter J Millett
- Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA.
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Kilic AI, Zuk NA, Ardebol J, Pak T, Menendez ME, Denard PJ. Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up. Orthop J Sports Med 2024; 12:23259671241229429. [PMID: 38390399 PMCID: PMC10883133 DOI: 10.1177/23259671241229429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/06/2023] [Indexed: 02/24/2024] Open
Abstract
Background Few studies have reported clinical outcomes and tendon healing rates after arthroscopic isolated subscapularis (SSC) repair (AISR). Purpose/Hypothesis The primary purpose of this study was to evaluate clinical outcomes and tendon healing after AISR. It was hypothesized that AISR would result in satisfactory clinical outcomes along with a high rate of tendon healing at the midterm follow-up. The secondary purpose was to assess the influence of tear size and muscle atrophy on SSC tendon healing and patient-reported outcomes. It was hypothesized that both would be negatively correlated with healing but would have no effect on clinical outcomes . Study Design Case series; Level of evidence, 4. Methods A retrospective analysis was conducted on prospectively collected data for 77 patients who underwent primary AISR between 2011 and 2021 at a single institution, with a minimum 2-year postoperative follow-up for all patients. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Shoulder Value (SSV), and the visual analog scale for pain. Repair techniques and concomitant procedures were also collected. SSC tendon healing was evaluated via ultrasound at the final follow-up. Linear regression analysis was performed to determine factors affecting SSC healing. Results The mean follow-up was 58.1 ± 3.3 months. ASES scores significantly improved from 41.5 to 81.6, and the SSV improved from 38.2 to 80.5 (P < .01 for both). Among the 40 patients (51.9%) who underwent postoperative ultrasound, 87.5% showed complete tendon healing. There were no significant differences in outcome scores between healed and unhealed tendons. Increased muscle atrophy and larger tears were correlated with failure of SSC healing (β = -0.285 [P = .015] and β = -0.157 [P = .045], respectively). Conclusion Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. Smaller tear sizes with less muscle atrophy were correlated with improved tendon healing. However, even when the tendon incompletely healed, the procedure improved functional outcomes.
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Affiliation(s)
| | | | | | - Theresa Pak
- Oregon Shoulder Institute, Medford, Oregon, USA
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Kirchner F, Ono Y, Albers S, Junker M, Fal MF, Kircher J. Arthroscopic subscapularis repair using the subscapularis interlocking (SICK)-stitch technique leads to restoration of clinical function with low complication and revision rates. JSES Int 2024; 8:67-74. [PMID: 38312275 PMCID: PMC10837738 DOI: 10.1016/j.jseint.2023.10.010] [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: 02/06/2024] Open
Abstract
Background The purpose of this study is to determine the mid-term outcome after arthroscopic subscapularis tendon (SCP) reconstruction using the subscapularis interlocking (SICK)-stitch technique. The hypotheses are that arthroscopically repaired SCP lesions using the SICK-stitch show a good restoration of shoulder function with low complication and failure rates. Methods This is a retrospective monocentric study of n = 199 patients (n = 106 female) with arthroscopically treated SCP tears with the interlocking (SICK) stitch technique from July 2013 to October 2018. Inclusion criteria: minimum follow-up of 2 years. Exclusion criteria: irreparable and massive cuff tears, osteoarthritis, and fractures. The postoperative assessment consisted of the range of motion, constant score, simple shoulder test, simple shoulder value, disability of the shoulder and arm score, short form 12, and patient satisfaction. Results Mean age was 61 years (25-83); n = 4 (2%) patients were lost to follow-up with mean follow-up time of 63.6 months (36-96). Additional supraspinatus tendon lesions (n = 147) were repaired in n = 101 cases. SCP grading (n = 69) (35% traumatic) (Fox/Romeo): n = 113 grade II, n = 71 grade III, n = 11 grade IV. A positive preoperative lift-off test (n = 132, 68%) was corrected in n = 124 (94%) of cases. Ninety seven percent of patients would undergo surgery again with a mean satisfaction score of 14.4/15. Results at final follow-up (data: mean pre; post; P value): lexion (130; 166; .001), abduction (123;159; .001), external rotation (35;82; .001), internal rotation (52; 68; .07), constant score (50; 82; .001), disability of the shoulder and arm score (40; 19; .001), simple shoulder test (5; 10; .001), and simple shoulder value (44; 83; .001) significantly improved. The mean physical health scale short form 12 was 46 (24-63) and 51 (15-66) for mental health. Age, body mass index, SCP-grading, and supraspinatus tendon repair did not significantly affect any outcome parameter. Three (1.5%) patients underwent revision surgery, of which 1 (0.5%) had an infection. Conclusion Two years after arthroscopic SCP repair using the SICK-stitch technique, we observed excellent restoration of clinical function with low complication and revision rates. The SICK-stitch technique thus represents a good and reliable therapeutic option for the arthroscopic repair of SCP lesions.
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Affiliation(s)
- Florian Kirchner
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany
| | - Yohei Ono
- Hokkaido Shoulder Clinic, Obihiro, Hokkaido, Japan
| | - Sebastian Albers
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany
| | - Marius Junker
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany
| | - Milad Farkhondeh Fal
- Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Jörn Kircher
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany
- Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Kim SC, Kim HG, Park JH, Kim JS, Kim JI, Yoo JC. Arthroscopic Repair of Large Subscapularis Tear Over the First Facet. Am J Sports Med 2023; 51:3383-3392. [PMID: 37849244 DOI: 10.1177/03635465231203702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND Long-term studies on arthroscopic repair of large subscapularis (SSC) tears over the first facet with or without supraspinatus (SSP) tear are limited. PURPOSE To assess the structural and clinical outcomes of arthroscopic repair of large SSC tears using magnetic resonance imaging (MRI) and identify the factors related to SSC retear and poor outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS This study involved 109 patients (84.0 ± 36.2 months of follow-up) who underwent arthroscopic repair of large SSC tears (Yoo and Rhee classification type III [n = 81] or IV [n = 28]) between 2011 and 2019. All patients underwent MRI at 6.1 ± 0.4 months after surgery, and 79 of 109 patients (72.5%) were followed up over 7 years. Clinical outcomes (active range of motion, functional scores, and belly press strength) and final poor clinical outcomes (reoperation, osteoarthritic change, and poor clinical outcome) were recorded. SSP tear size, rotator cuff atrophy and fatty infiltration (Goutallier classification), SSC tendon integrity (intact, intermediate, definite tear), and SSP tendon integrity (Sugaya classification) were evaluated by MRI. RESULTS The overall SSC retear rate was 8.3% (9/109) (type III, 2/81 [2.5%]; type IV, 7/28 [25.0%]; P < .001). SSC Goutallier grade 4 showed a higher retear rate than grade 3 (7/33 [21.2%] vs 2/33 [6.1%]; P = .149). A large SSP tear (in millimeters) (odds ratio [OR], 1.5; P = .003), SSC Goutallier grade 4 (OR, 10.8; P = .047), and SSP Goutallier grade 3 or 4 (OR, 0.02; P = .013) were independent factors for SSC retear. Clinical outcomes, except for external rotation, were poorer in patients with SSC retear than in those without retear. Final poor clinical outcomes were observed in 27 of 79 patients (34.2%); female sex (OR, 7.7; P = .007), SSC retear (OR, 8.2; P = .025), and SSP retear (OR, 4.7; P = .031) were independent factors. CONCLUSION Arthroscopic repair of large SSC tears has shown promising structural outcomes for type III tears but not type IV tears. SSC retear was affected by SSC atrophy, as well as SSP tear size and atrophy. Approximately one-third of the final poor clinical outcomes could be predicted, and SSC retear, SSP retear, and female sex were associated with long-term poor clinical outcomes, underscoring the importance of carefully selecting patients for arthroscopic repair of large SSC tears.
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Affiliation(s)
- Su Cheol Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Gon Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Hun Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Soo Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji In Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Chul Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Martinho T, Zbinden J, Ono Y, Amiri A, Collin P, Lädermann A. Long Head of the Biceps Pediculated Autograft Augmentation of Arthroscopic Subscapularis Repair. Arthrosc Tech 2023; 12:e1391-e1398. [PMID: 37654870 PMCID: PMC10466290 DOI: 10.1016/j.eats.2023.04.008] [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: 02/08/2023] [Accepted: 04/12/2023] [Indexed: 09/02/2023] Open
Abstract
Subscapularis (SSc) repairs are not free of failure and continues to pose a challenging problem. Although various biological and structural augmentation methods are available for the posterosuperior rotator cuff, few options have been explored for the anterior one. In the Technical Note, we describe an all-arthroscopic technique in which we use the long head of the biceps tendon (LHBT) as a pediculated autograft to reinforce an SSc repair. After SSc repair and LHBT tenodesis, the intra-articular portion of the LHBT is placed on the upper part of the SSc tendon at the rotator interval. Repurposing the otherwise-discarded tendon brings several biological and mechanical advantages at a lower cost without donor-site morbidity.
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Affiliation(s)
- Tiago Martinho
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Yohei Ono
- Hokkaido Shoulder Clinic, Hokkaido, Japan
| | - Arash Amiri
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | | | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Zheng W, Weng R, Wu X, Liu Z, Liao Z, Chen S, Zheng S, Yi Z, Huang X, Wei H. Clinical efficacy and tendon integrity of patients with subscapularis tear by the technique of arthroscopic single external row repair. Front Med (Lausanne) 2023; 10:1167158. [PMID: 37564049 PMCID: PMC10411732 DOI: 10.3389/fmed.2023.1167158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Background With the development of arthroscopic technology and equipment, arthroscopy can effectively repair the tear of the subscapular muscle. However, it is difficult to expose the subscapular muscle and operate it under a microscope. In this study, the SwiveLock® C external row anchor under arthroscopy was applied to repair the tear of the subscapular muscle in a single row, which is relatively easy to operate with reliable suture and fixation, and its efficacy was evaluated. Purpose This study aimed to assess the clinical efficacy and the tendon integrity of patients who had subscapularis tears by adopting the single-row repair technique with a SwiveLock® C external row anchor. Methods Patients who had the subscapular muscle tear either with or without retraction were included, and their follow-up time was at least 1 year. The degree of tendon injury was examined by magnetic resonance imaging (MRI) and confirmed by arthroscopy. The tendon was repaired in an arthroscopic manner by utilizing the single-row technique at the medial margin of the lesser tuberosity. One double-loaded suture SwiveLock® C anchor was applied to achieve a strong fixation between the footprint and tendon. The range of motion, pain visual simulation score, American Shoulder and Elbow Surgeons (ASES) score, and Constant score of shoulder joint were evaluated for each patient before the operation, 3 months after the operation, and at least 1 year after the operation. Results In total, 110 patients, including 31 males and 79 females, with an average age of 68.28 ± 8.73 years were included. Arthroscopic repair of the subscapular tendon with SwiveLock® C external anchor can effectively improve the range of motion of the shoulder joint. At the last follow-up, the forward flexion of the shoulder joint increased from 88.97 ± 26.33° to 138.38 ± 26.48° (P < 0.05), the abduction range increased from 88.86 ± 25.27° to 137.78 ± 25.64° (P < 0.05), the external rotation range increased from 46.37 ± 14.48° to 66.49 ± 14.15° (P < 0.05), and the internal rotation range increased from 40.03 ± 9.01° to 57.55 ± 7.43° (P < 0.05). The clinical effect is obvious. The constant shoulder joint score increased from 40.14 ± 15.07 to 81.75 ± 11.00 (P < 0.05), the ASES score increased from 37.88 ± 13.24 to 82.01 ± 9.65 (P < 0.05), and the visual analog scale score decreased from 5.05 ± 2.11 to 1.01 ± 0.85 (P < 0.05). In the 6th month after the operation, two cases (1.81%) were confirmed to have re-tears via MRI. Conclusion In this study, we repaired the subscapularis muscle with a single-row technique fixed by SwiveLock® C anchor and FiberWire® sutures and evaluated its efficacy. The results showed that the clinical effect of single-row arthroscopic repair was satisfactory and that reliable tendon healing could be achieved.
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Affiliation(s)
- Weipeng Zheng
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Rui Weng
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Xiaohang Wu
- Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Zhijun Liu
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Zhihao Liao
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Sheng Chen
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Suming Zheng
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Zhiyong Yi
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Xudong Huang
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
| | - Hewei Wei
- The Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China
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Ghasemi SA, McCahon JA, Yoo JC, Toussaint B, McFarland EG, Bartolozzi AR, Raphael JS, Kelly JD. Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:201-208. [PMID: 37588429 PMCID: PMC10426670 DOI: 10.1016/j.xrrt.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Several classifications have been proposed for subscapularis tendon tearing (SCTs); however, there remains a poor agreement between orthopedic surgeons regarding the diagnosis and management of these lesions. Distinguishing the various tear patterns and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment. Purpose The purpose of this study was to outline the current literature regarding SCT classification and treatment and conduct a survey among shoulder and elbow surgeons to identify the approaches regarding surgical decision-making for these injuries. Methods In this systematic review, we analyzed 12 articles regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. In addition, 4 international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1161 ASES members. One hundred sixty five surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in 4 parts including indications/contraindications, treatment plan, and the factors affecting outcomes in the survey. Results Classification criteria were extremely variable with differing recommendations and descriptions of tear morphology; most were based on tear size, associated shoulder pathology, or lesser tuberosity footprint exposure. Considering the multiple classification systems and the overall poor agreement regarding SCT management, our study found that the most widely agreed upon (more than 80%) statements included early surgery is advised for traumatic SCT, chronic degenerative SCT (without fatty infiltration) associated with acute supraspinatus tear is a candidate for repair, and rotator cuff arthropathy is a contraindication for SCT repair. Conclusion Our study was able to identify both patient and tear characteristics that are well agreed upon among surgeons in the treatment of these injuries. Lafosse classification is generally widely accepted; however, it needs to be improved by some additions. Continued collaboration among surgeons is needed to establish an acceptable and broadly applicable classification system for the management of these injuries.
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Affiliation(s)
- S. Ali Ghasemi
- Department of Orthopaedic Surgery, Einstein Healthcare Network, Philadelphia, PA, USA
| | | | - Jae Chul Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Bruno Toussaint
- Department of Orthopaedic Surgery, Clinique Générale, Annecy, France
| | - Edward G. McFarland
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | | - James S. Raphael
- Department of Orthopaedic Surgery, Einstein Healthcare Network, Philadelphia, PA, USA
| | - John D. Kelly
- Department of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Eckers F, Loske S, Ek ET, Müller AM. Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review. J Clin Med 2023; 12:1713. [PMID: 36902499 PMCID: PMC10003213 DOI: 10.3390/jcm12051713] [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: 12/17/2022] [Revised: 02/05/2023] [Accepted: 02/18/2023] [Indexed: 02/23/2023] Open
Abstract
Rotator cuff (RC) tears are among the most common musculoskeletal disorders and can be associated with pain, weakness, and shoulder dysfunction. In recent years, there have been significant advances with regard to the understanding of rotator cuff disease and its management. With technological improvements and advanced diagnostic modalities, there has been much progress as to improved understanding of the pathology. Similarly, with advanced implant designs and instrumentation, operative techniques have evolved. Furthermore, refinements in postoperative rehabilitation protocols have improved patient outcomes. In this scoping review, we aim to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight recent advances in its management.
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Affiliation(s)
- Franziska Eckers
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
- Melbourne Orthopaedic Group, Melbourne, VIC 3181, Australia
| | - Stefan Loske
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Melbourne, VIC 3181, Australia
- Department of Surgery, Monash University, Melbourne, VIC 3168, Australia
| | - Andreas M. Müller
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
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11
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Camenzind RS, Martin Becerra J, Tondelli TO, Gossing L, Serane-Fresnel J, Lafosse T, Lafosse L. Correlation between preoperative clinical examination and intraoperatively found subscapularis tendon tear. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:373-379. [PMID: 35006313 DOI: 10.1007/s00590-021-03197-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/29/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Analyze the diagnostic value for subscapularis (SSC) tendon tears, their correlation between pain and strength on clinical tests, and compare them with intraoperative arthroscopic findings to prove their diagnostic value. METHODS 110 consecutive patients undergoing arthroscopic rotator cuff repair were reviewed and allocated to isolated SSC (n = 39) and combined anterosuperior tendon tear (n = 71) groups and analyzed. Preoperative clinical testing included belly press (BPT), bear hug (BHT), lift-off (LOT), palm-up (PUT), and Jobe test (JT). All tests were performed in two categories: pain (in 4 categories: 0, 5, 10, and 15) and strength (from 0 to 5). The tendon tears were intraoperatively reviewed and classified. RESULTS Mean age was 59 years (SD 10). The sensitivity of the BHT was 88.2% and 74.5% for BPT, while specificity was only 41.9% for BHT and 45% for BPT. Sensitivity of JT was 90.5% and 87.5% for PUT, while specificity was only 41% for JT and 28.2% for PUT. A low positive correlation for an intraoperative SSC lesion and the strength of BPT (Spearman rank correlation - 0.425; p value < 0.0001) and the strength of BHT ( - 0.362; p value = 0.001) could be found. With linear regression analysis estimated by ordinary least squares, a correlation between BPT strength and surgical grade of SSC lesion (- 0.528; 95% CI, - 0.923 to - 0.133; pvalue < 0.01) was found. CONCLUSION The BHT showed a higher sensitivity for a SSC lesion, while the BPT had a higher correlation between preoperative testing, most notably internal rotation strength, and intraoperative surgical grade of the SSC tendon lesion. LEVEL OF EVIDENCE Level II, Prospective cohort study for Diagnostic tests.
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Affiliation(s)
- Roland Stefan Camenzind
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Javier Martin Becerra
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- Ortomove, Centro Medico ABC, Av carlos graef Fernández 154 consultorio 0071, Santa Fe Cuajimalpa, 05300, Mexico City, Mexico
| | - Timo O Tondelli
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Louis Gossing
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- Department of Orthopaedic Surgery, Braine-l'Alleud-Waterloo Hospital, Centre Hospitalier Interregional Edith Cavell (CHIREC), Braine-l'Alleud, Belgium
| | - Julien Serane-Fresnel
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- IECEM - Research Unit, Polyclinique Saint Côme, Compiègne, France
| | - Thibault Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
| | - Laurent Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
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12
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Themessl A, Wagner T, Rupp MC, Degenhardt H, Woertler K, Hatter KA, Imhoff AB, Siebenlist S, Pogorzelski J. "Functional outcomes and MRI-based tendon healing after (antero-) superior rotator cuff repair among patients under 50 years: retrospective analysis of traumatic versus non-traumatic rotator cuff tears". BMC Musculoskelet Disord 2023; 24:52. [PMID: 36670374 PMCID: PMC9862981 DOI: 10.1186/s12891-023-06174-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Rotator cuff tears among patients under 50 years either result from an adequate trauma or are considered non-traumatic due to work-related or athletic overuse. The impact of these different mechanisms on postoperative functional outcomes and tendon healing has not yet been fully understood. Therefore, it was the purpose of this study to investigate the influence of etiology of (antero-)superior rotator cuff tears on postoperative outcomes and the healing rates after arthroscopic rotator cuff repair in a young patient population. METHODS Patients under 50 years who underwent arthroscopic rotator cuff repair between 2006-2017 for an anterosuperior rotator cuff tear with a minimum follow up of 24 months were included in this study. Revision surgeries or reconstructive concomitant procedures other than long head of the biceps tenodesis were excluded. Patients were divided into two groups according to the etiology of their rotator cuff tear (traumatic vs. non-traumatic). Demographic and outcome scores including the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score (CS), bilateral strength measurements and postoperative tendon integrity evaluated on magnetic resonance imaging (MRI) were assessed and compared between both groups. RESULTS The mean follow up for this study was 55.6 months (24 - 158). Twenty-one patients (50.0%) had a traumatic RCT and 21 patients (50.0%) had a non-traumatic tear. Outcome scores did not differ significantly between groups. Strength measurements of the supraspinatus revealed significantly decreased force of the affected side as opposed to the contralateral side (p = 0.001), regardless of etiology. Retear rates were similar in both groups (37.5% and 33.3%, p = n.s.). Cuff integrity at follow-up was not predictive of superior scores or strength. CONCLUSION Surgical treatment of traumatic and non-traumatic RCT yields good clinical results in patients under the age of 50. The etiology of the rotator cuff tear did not significantly affect postoperative outcomes or healing rates. About one third of the patients suffered from a retear postoperatively, however retears were not predictive of inferior outcomes at midterm follow-up. STUDY DESIGN Level III. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Alexander Themessl
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Timon Wagner
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Marco-Christopher Rupp
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Hannes Degenhardt
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Klaus Woertler
- grid.6936.a0000000123222966Department of Radiology, Technical University of Munich, Munich, Germany
| | - Kate A. Hatter
- grid.189509.c0000000100241216Department of Surgery/ Emergency Medicine, Duke University Hospital, Durham, NC USA
| | - Andreas B. Imhoff
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sebastian Siebenlist
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Jonas Pogorzelski
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
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13
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Cuéllar A, Cuéllar A, Seijas R, Barra M, Cuéllar R. [Translated article] Analysis of the results and adverse factors of arthroscopic repair of degenerative subscapular lesions. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:T319-T327. [DOI: 10.1016/j.recot.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/14/2021] [Indexed: 10/17/2022] Open
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14
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Endell D, Child C, Freislederer F, Moroder P, Scheibel M. [Treatment of subscapularis tendon lesions]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:731-740. [PMID: 35943549 DOI: 10.1007/s00113-022-01221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
The further development of minimally invasive techniques in recent years, enables adequate intraoperative visualization, mobilization and stable reconstruction even of larger subscapularis tears resulting in good to excellent clinical and structural results. Chronic tears of the subscapularis tendon with high grade muscle atrophy and advanced fatty infiltration can be treated with a muscle tendon transfer (e.g. pectoralis major or latissimus dorsi transfer). If pseudoparalysis and/or signs of anterosuperior decentration of the humeral head or defect arthropathy are present, in most cases a reverse shoulder arthroplasty represents the only surgical option.
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Affiliation(s)
- David Endell
- Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz.
| | - Christopher Child
- Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz
| | - Florian Freislederer
- Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz
| | - Philipp Moroder
- Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz
| | - Markus Scheibel
- Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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15
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Huang J, Cheng J, Tang S, Shi B, Liu G, Xie G. Arthroscopic Subscapularis Tendon Repair Using the Mason-Allen Technique. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:431-434. [PMID: 33782934 DOI: 10.1055/a-1387-8079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Arthroscopic rotator cuff repair has recently been popularized for treating tears. In a biomechanical trial, the Mason-Allen stitch improved the fixation quality of poorly vascularized tendons. The use of this technique involving the subscapularis tendon remains rare. The aim of this study was to evaluate the clinical outcomes of Mason-Allen technique repaired subscapularis tendons. METHODS A retrospective research of collected data from 98 patients with subscapularis tears who had undergone arthroscopic repair between May 2015 and December 2018. There were 75 males and 23 females. The mean age was 56.4 ± 9.6 years and the mean follow-up was 12.5 ± 4.0 months. The visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Constant-Murley score were used to analyze shoulder function. An MRI was performed to assess the integrity of the repair. RESULTS Patients had significantly less pain and a better active range of motion compared with preoperative levels. VAS improved significantly from a preoperative mean of 3.42 to a postoperative mean of 1.91. ASES increased significantly from the preoperative mean of 43.6 to the postoperative mean of 74.5. Seven cases suffered from retears, which were confirmed by an MRI examination. CONCLUSION Arthroscopic rotator cuff repair with the Mason-Allen method resulted in a decreased level of pain and satisfied function recovery.
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Affiliation(s)
- Junqi Huang
- Orthopedics, Mianyang Central Hospital, Mianyang, China
| | - Jiajia Cheng
- Orthopedics, Mianyang Central Hospital, Mianyang, China
| | - Shitian Tang
- Orthopedics, Mianyang Central Hospital, Mianyang, China
| | - Bo Shi
- Orthopedics, Mianyang Central Hospital, Mianyang, China
| | - Gang Liu
- Orthopedics, Mianyang Central Hospital, Mianyang, China
| | - Gangtai Xie
- Orthopedics, Mianyang Central Hospital, Mianyang, China
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Xiao M, Cohen SA, Cheung EV, Sherman SL, Abrams GD, Freehill MT. Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e1193-e1201. [PMID: 35747639 PMCID: PMC9210385 DOI: 10.1016/j.asmr.2022.01.009] [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: 07/28/2020] [Accepted: 01/24/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies. Methods A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale. Results Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%). Conclusion Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears. Clinical Relevance Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.
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Affiliation(s)
- Michelle Xiao
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Samuel A. Cohen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Emilie V. Cheung
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Seth L. Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Geoffrey D. Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Michael T. Freehill
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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17
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Subscapularis Tears: Evolution in Treatment Options. J Am Acad Orthop Surg 2022; 30:485-492. [PMID: 35294403 DOI: 10.5435/jaaos-d-21-00155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Subscapularis tears occur more commonly than previously reported. Owing to the importance of the subscapularis in shoulder function, strong consideration should be given to repairing a full-thickness subscapularis tear when present. Historically, subscapularis repairs were done through a deltopectoral approach with good results. More recently, arthroscopic techniques have been developed with similar outcomes. When tears of the subscapularis are irreparable, reconstructive options, including tendon transfers, capsular reconstruction, and reverse shoulder arthroplasty, exist and continue to evolve.
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18
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Chellamuthu G, Sundar S, Rajan DV. Current concepts review in the management of subscapularis tears. J Clin Orthop Trauma 2022; 28:101867. [PMID: 35494488 PMCID: PMC9043658 DOI: 10.1016/j.jcot.2022.101867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.
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Affiliation(s)
- Girinivasan Chellamuthu
- Corresponding author. Ortho One Orthopaedic Speciality Centre, Singanallur, Coimbatore, 641005, Tamil Nadu, India.
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19
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van der List JP, Kok LM, Alta TDW, van der List MPJ, van Noort A. Role of Delay Between Injury and Surgery on the Outcomes of Rotator Cuff Repair: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 51:1328-1339. [PMID: 35099309 DOI: 10.1177/03635465211069560] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of rotator cuff repair (RCR) are influenced by several well-described factors, but the role of delay from injury to surgery on the outcomes is not clear. PURPOSE To assess the role of delay to surgery on the outcomes of RCR in the literature. STUDY DESIGN Systematic review with meta-analysis; Level of evidence, 4. METHODS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. All studies assessing outcomes after RCR-either retear rates or patient-reported outcome measures (PROMs)-and reporting delay to surgery were identified through June 2021 in PubMed, Embase, and Cochrane. Inclusion criteria consisted of traumatic injuries, mean age <65 years, minimum 6-month follow-up, and assessment of retear rates with radiologic examination or reporting of PROMs. Random-effect models were used to assess outcomes, reported in odds ratio (OR) or mean difference (MD) with 95% CIs. RESULTS A total of 8118 patients were included from 33 studies, with a mean age of 59 years (range, 53-64) and mean follow-up of 3.0 years (range, 0.5-8.2), among whom 53% were male and 74% had dominant-side injury. Patients undergoing surgery >3 months after injury did not have significantly higher retear rates (OR, 1.1 [95% CI, 0.5 to 3.1]; P = .700), lower Constant-Murley score (MD, -6.2 [95% CI, -16.4 to 4.1]; P = .240), or lower ASES score (American Shoulder and Elbow Surgeons; MD, -12.9 [95% CI, -26.0 to -0.2]; P = .050) compared with those having surgery within 3 months. Similarly, delaying surgery for 6 months did not result in higher retear rates (OR, 1.7 [95% CI, 0.8 to 3.7]; P = .190) or lower PROMs. Delaying surgery for 1 year, however, led to an increased likelihood of retear when compared with <1 year (OR, 2.9 [95% CI, 2.1 to 4.0]; P < .001), and this was similar for the 2-year cutoff (OR, 5.9 [95% CI, 1.1 to 32.1]; P = .040). It was also noted that patients with an intact cuff at follow-up had a mean 3.9 months' shorter time from injury to surgery than patients with retear (95% CI, 1.0-6.8 months; P = .009). CONCLUSION This systematic review with meta-analysis found that delaying rotator cuff surgery for 3 to 6 months did not lead to higher retear rates or inferior PROMs as compared with undergoing earlier surgery. However, delaying surgery for ≥1 year clearly resulted in higher retear rates after RCR. This study is limited by relying on retrospective studies, and larger prospective studies are needed to confirm these findings. REGISTRATION CRD42021240720 (PROSPERO).
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.,Department of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura M Kok
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Tjarco D W Alta
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | | | - Arthur van Noort
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
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20
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Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review. Arthroscopy 2022; 38:159-173.e6. [PMID: 34052379 DOI: 10.1016/j.arthro.2021.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings. METHODS A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis. RESULTS The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all). CONCLUSION Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row. LEVEL OF EVIDENCE Level IV, systematic review of Level II-IV studies.
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21
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Yoon TH, Kim SJ, Choi YR, Cho JT, Chun YM. Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears. Am J Sports Med 2021; 49:3952-3958. [PMID: 34652226 DOI: 10.1177/03635465211047485] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study. PURPOSE To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair. STUDY DESIGN Case series, Level of evidence, 4. METHODS This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon's full-thickness tear was made during the revision procedure. RESULTS At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%). CONCLUSION Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.
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Affiliation(s)
- Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Cho
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Rayos Del Sol S, Guzman A, Shin Yin SS, Gardner B, Bryant S, Chakrabarti MO, McGahan PJ, Chen JL. Single-Portal, Single-Anchor Repair of a Superior Third Subscapularis Tear Using a Self-Punching Knotless Soft Suture Anchor. Arthrosc Tech 2021; 10:e2079-e2085. [PMID: 34504746 PMCID: PMC8416967 DOI: 10.1016/j.eats.2021.05.003] [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: 04/21/2021] [Accepted: 05/14/2021] [Indexed: 02/03/2023] Open
Abstract
Numerous techniques exist for arthroscopic subscapularis repair with varying degrees of complexity based on tear morphology, all of which have established satisfactory outcomes in function and patient satisfaction. Arthroscopic subscapularis repair can require several working portals and suture anchors, increasing both technical complexity and operative time. This Technical Note describes an arthroscopic repair of a superior one-third subscapularis tear using a self-punching knotless soft suture anchor through a single anterior working portal. Thus, we offer a unique approach to arthroscopic repair of superior one-third subscapularis tears that is time-saving, reproducible, and highly efficient while minimizing iatrogenic damage and postoperative complications.
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Affiliation(s)
- Shane Rayos Del Sol
- Address correspondence to Shane Rayos Del Sol, Advanced Orthopaedics and Sports Medicine, 450 Sutter St., Ste. 400, San Francisco, CA 94108, U.S.A.
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Björnsson Hallgren HC, Holmgren T. Good outcome after repair of trauma-related anterosuperior rotator cuff tears-a prospective cohort study. J Shoulder Elbow Surg 2021; 30:1636-1646. [PMID: 33069905 DOI: 10.1016/j.jse.2020.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterosuperior rotator cuff tears with a displaced long head of the biceps tendon are most often trauma-related, and patients with these conditions often present with severe pain and shoulder dysfunction. Repair of the subscapularis and supraspinatus and a biceps tenodesis or a tenotomy are the recommended treatments based on retrospective studies. The aim of this study was to prospectively evaluate clinical and structural treatment outcome in a cohort of trauma-related anterosuperior injuries in patients with previously healthy shoulders. MATERIALS AND METHODS Patients seeking care for a suspected rotator cuff injury after shoulder trauma were screened according to a protocol including clinical examination, baseline scoring with Western Ontario Rotator Cuff Index (WORC) and numeric rating scale of pain, ultrasound, and magnetic resonance imaging (MRI). Those with anterosuperior injuries were offered surgical treatment, structured postoperative physiotherapy, and inclusion in the present study with 1-year follow-up, including MRI, baseline scores, Constant-Murley score, and Patient Global Impression of Change. Thirty-three patients (78% men) with a mean age of 59 (40-76) years were included. RESULTS All patients had a biceps pulley lesion, a displaced biceps tendon, and incomplete full-thickness subscapularis and supraspinatus tears. Six patients declined surgery. At follow-up, the operated patients reached a median WORC score of 86% and a median change from baseline to follow-up of 50% (P = .0001). Pain decreased (P = .0001) at rest, at night, and during activity. The median Constant-Murley score was 86% of the contralateral nonoperated shoulder, 58% of the contralateral abduction strength recovered after surgery, and 86% reported that they were recovered or much improved. All repairs and tenodeses healed except for 2 supraspinatus tendons. The 6 nonoperated patients reached a median WORC score of 90, a change in the median value from baseline to follow-up of 31, but reported more pain, and a smaller proportion considered themselves as recovered or much improved. In all patients, the 1-year MRIs had signal changes in the upper muscular portion of subscapularis, consistent with fatty infiltration, regardless of operative or nonoperative treatment. CONCLUSION Anterosuperior rotator cuff injury with an associated pulley lesion and displaced long head of the biceps tendon may be treated successfully with surgery as the majority of patients in our cohort clinically recovered or were much improved without pain after a year. With a 1-year perspective, nonoperatively treated patients may also reach a reasonable clinical outcome. Independently of treatment or tendon healing, residual subscapularis muscle injury was seen, which may have long-term implications.
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Affiliation(s)
- Hanna C Björnsson Hallgren
- Department of Orthopaedics in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Theresa Holmgren
- Department of Orthopaedics in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Cuéllar A, Cuéllar A, Seijas R, Barra ME, Cuéllar R. Analysis of the results and adverse factors of arthroscopic repair of degenerative subscapular lesions. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 66:319-327. [PMID: 34172411 DOI: 10.1016/j.recot.2021.03.006] [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: 10/29/2020] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To carry out a review of degenerative subscapularis ruptures (SSC) after their arthroscopic repair and to evaluate whether the results are comparable in terms of pain and function to those of younger patients with traumatic ruptures. METHODS The data of 80 SSC tears of the 660 rotator cuff tears operated on by the same team of surgeons from June 2008 to June 2018 were retrospectively reviewed. The clinical data of the surgical indications were collected: age, gender, laterality, intervention delay, associated pathologies, location of pain, value of the Visual Analogue Scale (VAS) and the Constant-Murley test (CMT); surgical data were also collected: type and size of lesion, associated biceps injury and associated surgical procedure, coracoid stenosis and associated surgical procedure, number and type of anchors used. A statistical study was performed with multiple linear regression test, parametric tests (Student's t or ANOVA) and non-parametric tests. RESULTS Of 80 patients, 36 were women (45%) and 44, men (55%); mean age 61years (range 47 to 81); mean delay of surgery 3.5months (range 1 to 6); right shoulder affected in 46 cases (57.5%), left in 34 (42.5%); 22 (27.5%) were isolated lesions, 58 (72.5%) were associated with supraspinatus rupture (SE). The mean improvement was 5.0 points in terms of the VAS and 39.9 points on average in the CMT. New breakage rate, 1.25%. Adverse factors: size of the tear, delay in intervention, women. Patients with type I-B rupture have a better overall result in the CMT than types I-A and III. The longer the delay, the worse results are observed, both for the VAS and the CMT. Women present worse and statistically significant results both in the VAS (P=.00) and in the CMT (P=.01). CONCLUSIONS Excellent and good results have been obtained in this group of patients, but there are adverse factors such as the size of the tear, the duration of the symptoms and the association of other pathologies, especially in women.
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Affiliation(s)
- A Cuéllar
- Policlínica Gipuzkoa Quirón-Salud, Donostia-San Sebastián, España.
| | - A Cuéllar
- Policlínica Gipuzkoa Quirón-Salud, Donostia-San Sebastián, España
| | - R Seijas
- Hospital Quirón-Salud, Barcelona, España
| | - M E Barra
- Departamento de Fisioterapia, Universidad Internacional de Cataluña, Sant Cugat del Vallès, Barcelona, España
| | - R Cuéllar
- Policlínica Gipuzkoa Quirón-Salud, Donostia-San Sebastián, España
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Cigolotti A, Biz C, Lerjefors E, de Iudicibus G, Belluzzi E, Ruggieri P. Medium- to long-term clinical and functional outcomes of isolated and combined subscapularis tears repaired arthroscopically. Arch Med Sci 2021; 17:1351-1364. [PMID: 34522265 PMCID: PMC8425253 DOI: 10.5114/aoms.2020.97714] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 11/24/2019] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The purpose of this study was twofold. First, the efficacy of arthroscopic repair in patients with full thickness, isolated subscapularis tendon tears (I-STTs) or combined subscapularis tendon tears (C-STTs) involving the rotator cuff tendons was evaluated. Second, the outcomes between these two groups were compared. The influence of age and gender on the cohort clinical outcomes was also analysed. Our hypothesis was that satisfactory functional results could be obtained arthroscopically in both groups without any influence of age or gender. MATERIAL AND METHODS Seventy-nine patients were enrolled: 15 with I-STTs and 64 with C-STTs. The clinical outcomes were assessed using Constant and Disabilities of the Arm, Shoulder and Hand (DASH) scores, Numeric Rating Scale (NRS) for pain and Visual Analogue Scale (VAS) for satisfaction. The subscapularis strength was assessed using a comparative dynamometric bear-hug test. Group outcomes were compared, including statistical analysis. RESULTS For each group, there were no differences regarding the subscapularis strength of the operated and non-operated shoulders. A comparison of the post- with the pre-operative outcomes showed an increase in the Constant score and a decrease in the NRS. Comparing the two groups, we found no difference in strength of the operated and non-operated shoulders, but a significant difference in relation to pre-operative Constant score and pre-operative NRS. Age was negatively correlated with both pre-operative and post-operative Constant scores. No association was found between gender and the outcomes, although the DASH score was higher in women. CONCLUSIONS Arthroscopic repair of STTs provided functional restoration, pain relief and patient satisfaction in both groups. Age and gender did not affect the clinical outcomes achieved by arthroscopic STT repair.
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Affiliation(s)
- Augusto Cigolotti
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
| | - Carlo Biz
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
| | - Erik Lerjefors
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
- Orthopaedic Clinic, NU Hospital Group, NÄL Hospital Trollhättan and Uddevalla Hospital, Trollhättan, Sweden
| | - Gianfranco de Iudicibus
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
| | - Elisa Belluzzi
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
- Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Pietro Ruggieri
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, Padova, Italy
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Chauvet T, Haritinian E, Baudin F, Collotte P, Nové-Josserand L. The Invisible MGHL Test: Diagnostic Value and Benefits for the Repair of Retracted Subscapularis Tears. Am J Sports Med 2020; 48:2144-2150. [PMID: 32551821 DOI: 10.1177/0363546520929695] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Some full-thickness subscapularis tendon tears and partial tears of the deep layer are difficult to characterize, leading to misdiagnosis. PURPOSE To evaluate the association between displacement of the middle glenohumeral ligament (MGHL) and retracted tears of the subscapularis tendon as a possible test to improve diagnosis. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Videos (N = 100) recorded during arthroscopic rotator cuff repair involving a torn subscapularis tendon were analyzed retrospectively to assess the association between the MGHL test (nonvisibility of the MGHL) and other objective anatomic criteria. The invisible MGHL test was defined as positive if the MGHL was initially nonvisible in the beach-chair position and appeared only when the subscapularis tendon was pulled back into position by using a 30° arthroscope from the standard posterior portal. The parameters considered during the initial exploration were (1) visibility of the horizontal part of the subscapularis tendon; (2) visibility of the MGHL in its usual position, crossing the superior border of the subscapularis tendon; (3) exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear); and (4) complete or partial exposure of the lesser tuberosity of the humerus. Tendon retraction was evaluated in 3 stages according to the Patte classification. RESULTS The invisible MGHL test result was positive in 45% of cases. It was positive in 6% of cases (2 of 31) when there was no subscapularis tendon retraction and in 62% of cases (43 of 69) when there was partial or complete retraction (P < .001). The invisible MGHL test was significantly associated with the width of the tear (P < .001) and exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear, P = .0002). After repair, the MGHL was visible in its anatomic position in 96% of cases. CONCLUSION A positive invisible MGHL test is an alternative indication of subscapularis tendon retraction, and the relocation of the MGHL can also be used after repair to assess the proper anatomic repositioning of the subscapularis tendon.
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Affiliation(s)
- Thomas Chauvet
- Ramsay Générale de Santé, Jean Mermoz Private Hospital, Centre Orthopédique Santy, Lyon, France
| | - Emil Haritinian
- Carol Davila University of Medicine and Pharmacy, Foişor Orthopaedic Hospital, Bucharest, Romania
| | | | - Philippe Collotte
- Ramsay Générale de Santé, Jean Mermoz Private Hospital, Centre Orthopédique Santy, Lyon, France
| | - Laurent Nové-Josserand
- Ramsay Générale de Santé, Jean Mermoz Private Hospital, Centre Orthopédique Santy, Lyon, France
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Liu Y, Lafosse L, Opsomer G, Villain B, Kempf JF, Collin P. Ten-year clinical and magnetic resonance imaging evaluation after repair of isolated subscapularis tears. JSES Int 2020; 4:913-918. [PMID: 33345234 PMCID: PMC7738443 DOI: 10.1016/j.jseint.2020.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hypothesis The purpose was to evaluate long-term clinical outcomes and tendon structural integrity after repair of isolated subscapularis (SSC) tendon tears. Methods Sixty-one patients who underwent repair of isolated SSC tears were evaluated. The mean interval from symptom onset to surgery was 5.3 months. Shoulder function was investigated using the Constant score and Subjective Shoulder Value (SSV). Structural integrity of the repair and quality of the repaired tendon were assessed using magnetic resonance imaging. Independent preoperative factors affecting clinical outcomes, including patient sex, age, smoking habits, injections, dominant shoulder, profession, and tear onset (chronic vs. traumatic), were evaluated. Results A total of 35 patients (9 women and 26 men; mean age, 54 years) were included at the final 10-year follow-up because 21 patients were lost to follow-up and 5 underwent reoperations. The mean Constant score improved from 55.1 points preoperatively to 75.4 points postoperatively (P = .001). The postoperative SSV was 80.9, and the retear rate was 12.9%. Postoperative fatty infiltration increased in 26% of the patients with grades 3-4, but it was not related to lower clinical outcomes. Multivariable regression analysis revealed no correlation among the preoperative factors, including sex, age, smoking habits, injections, dominant shoulder, profession, and tear onset, and the postoperative Constant score, SSV, and tendon healing. Conclusion At a mean of 10 years after repair of isolated SSC tears, clinical results were satisfactory and functional improvement was maintained in the long term. Severe fatty infiltration increased with time, but it was not related to clinical outcomes and the retear rate.
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Affiliation(s)
- Yulei Liu
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, China
| | - Laurent Lafosse
- Department of Orthopaedic Surgery, Alps Surgery Institute, Clinique General Annecy, Annecy, France
| | - Gaëtan Opsomer
- Department of Orthopaedic Surgery, Alps Surgery Institute, Clinique General Annecy, Annecy, France
| | - Benoit Villain
- Department of Orthopaedic Surgery, Alps Surgery Institute, Clinique General Annecy, Annecy, France
| | | | - Phillipe Collin
- Centre of Shoulder Surgery, Saint-Gregoire Private Hospital Center, Institut Locomoteur de l'Ouest Saint Gregoire (Vivalto Sante), Saint Gregoire, France
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Agarwalla A, Puzzitiello RN, Leong NL, Allison B, Romeo AA, Forsythe B. Primary Arthroscopic Repair of a Traumatic Isolated Subscapularis Tendon Rupture in an Adolescent Patient. Orthopedics 2020; 43:e182-e186. [PMID: 32003841 DOI: 10.3928/01477447-20200129-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/14/2019] [Indexed: 02/05/2023]
Abstract
Subscapularis tendon tears in the pediatric population are most commonly associated with an avulsion fracture of the lesser tuberosity. Isolated subscapularis tendon ruptures are infrequently reported. According to previous reports, the diagnosis of subscapularis tendon injuries in pediatric patients is often delayed and management is typically conservative. When operative management is indicated, an open deltopectoral approach has been used and may include concomitant open reduction and internal fixation of the lesser tuberosity. The authors report the case of a healthy 15-year-old boy who had an isolated subscapularis tendon rupture. During operative management, labral tape sutures were passed through the subscapularis tendon at the junctions of the inferior one-third and superior two-thirds, along with the superior one-third and inferior two-thirds. Both suture limbs were implanted with a 4.75-mm polyetheretherketone suture anchor within the inferior one-third and superior one-third of the lesser tuberosity footprint. A mini-open subpectoral biceps tenodesis was also performed through an axillary incision. By 8 months postoperatively, the patient exhibited normal function with full range of motion and was allowed to return to sport-related activity. [Orthopedics. 2020;43(3):e182-e186.].
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Meshram P, Rhee SM, Park JH, Oh JH. Comparison of Functional and Radiological Outcomes of Tears Involving the Subscapularis: Isolated Subscapularis Versus Combined Anterosuperior Rotator Cuff Tears. Orthop J Sports Med 2020; 8:2325967119899355. [PMID: 32118080 PMCID: PMC7029597 DOI: 10.1177/2325967119899355] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Few studies have compared the clinical and radiological characteristics and outcomes in isolated subscapularis (SSC) and combined anterosuperior (AS) rotator cuff tears (RCTs). Furthermore, risk factors for retear after SSC repair and the effect of preoperative fatty degeneration require further evaluation. Purpose: To compare the functional and radiological outcomes of isolated SSC with combined AS RCTs after arthroscopic repair and to determine the risk factors for SSC retear in these 2 groups. Study Design: Cohort study; Level of evidence, 3. Methods: Data from 30 patients in the isolated SSC group were compared with data from 110 patients in the combined AS group. All patients underwent primary arthroscopic rotator cuff repair between 2010 and 2016. Clinical outcomes were assessed through use of the visual analog scale for pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test at a mean follow-up of 26.7 months (range, 24-96 months). SSC tendon integrity was examined via magnetic resonance imaging, computed tomography arthrogram, or ultrasonography at least 1 year after surgery. Results: The isolated SSC group had a greater proportion of males and the patients were younger compared with the combined AS group (both P < .050). The incidence of trauma was high but not significantly different between groups (56.7% vs 40.9%; P = .180). Clinical outcome measures and radiological outcomes in terms of retear were not statistically different between both groups (16.7% vs 8/5%; P = .337). The optimal cutoff values for the risk of SSC tendon retear in both groups were 19-mm retraction and 16-mm superoinferior dimension (P = .048). Unfavorable preoperative fatty degeneration of the SSC muscle (grades 3 and 4) was a significant risk factor for retear (odds ratio, 9.8; P < .001). Conclusion: Isolated SSC and combined AS RCTs were comparable except for patient age and sex; both had a high incidence of traumatic history. The current data suggest that the risk factors for retear after SSC repair in RCTs involving the SSC were tear size greater than 19 mm of retraction and unfavorable fatty degeneration (grade 3 or higher) of the SSC muscle.
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Affiliation(s)
- Prashant Meshram
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Sung-Min Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Joo Hyun Park
- Department of Orthopaedic Surgery, Bundang Jaesaeng Hospital, Seongnam-si, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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Reifenrath J, Wellmann M, Kempfert M, Angrisani N, Welke B, Gniesmer S, Kampmann A, Menzel H, Willbold E. TGF-β3 Loaded Electrospun Polycaprolacton Fibre Scaffolds for Rotator Cuff Tear Repair: An in Vivo Study in Rats. Int J Mol Sci 2020; 21:E1046. [PMID: 32033294 PMCID: PMC7036781 DOI: 10.3390/ijms21031046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 12/21/2022] Open
Abstract
Biological factors such as TGF-β3 are possible supporters of the healing process in chronic rotator cuff tears. In the present study, electrospun chitosan coated polycaprolacton (CS-g-PCL) fibre scaffolds were loaded with TGF-β3 and their effect on tendon healing was compared biomechanically and histologically to unloaded fibre scaffolds in a chronic tendon defect rat model. The biomechanical analysis revealed that tendon-bone constructs with unloaded scaffolds had significantly lower values for maximum force compared to native tendons. Tendon-bone constructs with TGF-β3-loaded fibre scaffolds showed only slightly lower values. In histological evaluation minor differences could be observed. Both groups showed advanced fibre scaffold degradation driven partly by foreign body giant cell accumulation and high cellular numbers in the reconstructed area. Normal levels of neutrophils indicate that present mast cells mediated rather phagocytosis than inflammation. Fibrosis as sign of foreign body encapsulation and scar formation was only minorly present. In conclusion, TGF-β3-loading of electrospun PCL fibre scaffolds resulted in more robust constructs without causing significant advantages on a cellular level. A deeper investigation with special focus on macrophages and foreign body giant cells interactions is one of the major foci in further investigations.
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Affiliation(s)
- Janin Reifenrath
- Department of Orthopaedic Surgery, Hannover Medical School, Anna–von–Borries Str. 1–3, 30625 Hannover, Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
| | - Mathias Wellmann
- Department of Orthopaedic Surgery, Hannover Medical School, Anna–von–Borries Str. 1–3, 30625 Hannover, Germany
| | - Merle Kempfert
- Department of Orthopaedic Surgery, Hannover Medical School, Anna–von–Borries Str. 1–3, 30625 Hannover, Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
| | - Nina Angrisani
- Department of Orthopaedic Surgery, Hannover Medical School, Anna–von–Borries Str. 1–3, 30625 Hannover, Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
| | - Bastian Welke
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic Surgery, Hannover Medical School, Haubergstraße 3, 30625 Hannover, Germany
| | - Sarah Gniesmer
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
- Clinic for Cranio–Maxillo–Facial Surgery, Hannover Medical School, Carl–Neuberg–Straße 1, 30625 Hannover, Germany
| | - Andreas Kampmann
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
- Clinic for Cranio–Maxillo–Facial Surgery, Hannover Medical School, Carl–Neuberg–Straße 1, 30625 Hannover, Germany
| | - Henning Menzel
- Institute for Technical Chemistry, Braunschweig University of Technology, Hagenring 30, 38106 Braunschweig, Germany
| | - Elmar Willbold
- Department of Orthopaedic Surgery, Hannover Medical School, Anna–von–Borries Str. 1–3, 30625 Hannover, Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625 Hannover, Germany
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Gniesmer S, Brehm R, Hoffmann A, de Cassan D, Menzel H, Hoheisel AL, Glasmacher B, Willbold E, Reifenrath J, Ludwig N, Zimmerer R, Tavassol F, Gellrich NC, Kampmann A. Vascularization and biocompatibility of poly(ε-caprolactone) fiber mats for rotator cuff tear repair. PLoS One 2020; 15:e0227563. [PMID: 31929570 PMCID: PMC6957163 DOI: 10.1371/journal.pone.0227563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/20/2019] [Indexed: 12/22/2022] Open
Abstract
Rotator cuff tear is the most frequent tendon injury in the adult population. Despite current improvements in surgical techniques and the development of grafts, failure rates following tendon reconstruction remain high. New therapies, which aim to restore the topology and functionality of the interface between muscle, tendon and bone, are essentially required. One of the key factors for a successful incorporation of tissue engineered constructs is a rapid ingrowth of cells and tissues, which is dependent on a fast vascularization. The dorsal skinfold chamber model in female BALB/cJZtm mice allows the observation of microhemodynamic parameters in repeated measurements in vivo and therefore the description of the vascularization of different implant materials. In order to promote vascularization of implant material, we compared a porous polymer patch (a commercially available porous polyurethane based scaffold from Biomerix™) with electrospun polycaprolactone (PCL) fiber mats and chitosan-graft-PCL coated electrospun PCL (CS-g-PCL) fiber mats in vivo. Using intravital fluorescence microscopy microcirculatory parameters were analyzed repetitively over 14 days. Vascularization was significantly increased in CS-g-PCL fiber mats at day 14 compared to the porous polymer patch and uncoated PCL fiber mats. Furthermore CS-g-PCL fiber mats showed also a reduced activation of immune cells. Clinically, these are important findings as they indicate that the CS-g-PCL improves the formation of vascularized tissue and the ingrowth of cells into electrospun PCL scaffolds. Especially the combination of enhanced vascularization and the reduction in immune cell activation at the later time points of our study points to an improved clinical outcome after rotator cuff tear repair.
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Affiliation(s)
- Sarah Gniesmer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
| | - Ralph Brehm
- Institute for Anatomy, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Andrea Hoffmann
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
- Department of Orthopedic Surgery, Laboratory for Biomechanics and Biomaterials, Graded Implants and Regenerative Strategies, Hannover Medical School, Hannover, Germany
| | - Dominik de Cassan
- Institute for Technical Chemistry, Braunschweig University of Technology, Braunschweig, Germany
| | - Henning Menzel
- Institute for Technical Chemistry, Braunschweig University of Technology, Braunschweig, Germany
| | - Anna Lena Hoheisel
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
- Institute of Multiphase Processes, Leibniz University Hannover, Hannover, Germany
| | - Birgit Glasmacher
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
- Institute of Multiphase Processes, Leibniz University Hannover, Hannover, Germany
| | - Elmar Willbold
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Janin Reifenrath
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Nils Ludwig
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Ruediger Zimmerer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - Frank Tavassol
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - Nils-Claudius Gellrich
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Kampmann
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
- NIFE—Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Hannover, Germany
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Repair failure increases the risk of developing secondary glenohumeral osteoarthritis: A long-term follow-up after open repair of large subscapularis tendon tears. Orthop Traumatol Surg Res 2019; 105:1529-1533. [PMID: 31732397 DOI: 10.1016/j.otsr.2019.09.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 08/21/2019] [Accepted: 09/17/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The subscapularis musculotendinous unit provides a stabilizing effect on the glenohumeral joint and thus, enables normal active range of motion. As pathologies of the subscapularis tendon (SSC) are diagnosed with increased regularity, treatment strategies and their long-term consequences are of relevant interest. Therefore, the primary objective of this retrospective case series was to evaluate clinical and radiological long-term results after open repair of large SSC tears. HYPOTHESIS Repair failure negatively influences clinical outcomes and the progression of secondary glenohumeral osteoarthritis (OA). METHODS Between 1998 and 2007, 24 patients with traumatic large (Lafosse III and IV) SSC tears were treated with an open transosseous repair technique. Of those, 20 patients (83%) with a mean age of 55±8 years (range, from 31 to 68 years) at the time of surgery were subjected to a long-term follow-up after a mean of 14±3 years (range, from 10 to 18 years). The Subjective Shoulder Value (SSV), the Constant Score (CS), the University of California at Los Angeles (UCLA) Shoulder Score, and the American Society for Shoulder and Elbow Surgeons (ASES) Score were obtained. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity. The progression of secondary glenohumeral OA from pre- to postoperative was analyzed using the collective instability arthropathy (CIA) score. RESULTS One patient (5%) had to undergo revision surgery due to a symptomatic re-tear of the SSC tendon. Besides that, the mean SSV of the affected shoulder was 83%±12, the CS 78±10, the UCLA 32±2, and the ASES 89±14 points, respectively. MRI revealed a re-tear of the SSC tendon in 4 patients (29%). On the affected shoulder, glenohumeral OA progressed significantly from pre- (CIA, 0.3±0.5) to postoperative (CIA, 1.7±0.9; p=0.003) and was significantly associated with repair failure (p=0.040). CONCLUSION Open repair of large SSC tears yielded good clinical long-term results. Nevertheless, repair failure was common and, in the further course, negatively affected clinical outcomes and the progression of secondary glenohumeral OA. LEVEL OF EVIDENCE IV; retrospective case series.
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Willbold E, Wellmann M, Welke B, Angrisani N, Gniesmer S, Kampmann A, Hoffmann A, Cassan D, Menzel H, Hoheisel AL, Glasmacher B, Reifenrath J. Possibilities and limitations of electrospun chitosan‐coated polycaprolactone grafts for rotator cuff tear repair. J Tissue Eng Regen Med 2019; 14:186-197. [DOI: 10.1002/term.2985] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 09/27/2019] [Accepted: 10/17/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Elmar Willbold
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
| | - Mathias Wellmann
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
| | - Bastian Welke
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
| | - Nina Angrisani
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
| | - Sarah Gniesmer
- Clinic for Cranio‐Maxillo‐Facial SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
| | - Andreas Kampmann
- Clinic for Cranio‐Maxillo‐Facial SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
| | - Andrea Hoffmann
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
| | - Dominik Cassan
- Institute for Technical ChemistryBraunschweig University of Technology Braunschweig Germany
| | - Henning Menzel
- Institute for Technical ChemistryBraunschweig University of Technology Braunschweig Germany
| | - Anna Lena Hoheisel
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
- Institute for Multiphase ProcessesLeibniz University Hannover Hannover Germany
| | - Birgit Glasmacher
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
- Institute for Multiphase ProcessesLeibniz University Hannover Hannover Germany
| | - Janin Reifenrath
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic SurgeryHannover Medical School Hannover Germany
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE)Hannover Medical School Hannover Germany
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Hasler A, Boyce G, Schallberger A, Jost B, Catanzaro S, Gerber C. Arthroscopic repair of isolated subscapularis tears: clinical outcome and structural integrity with a minimum follow-up of 4.6 years. J Shoulder Elbow Surg 2019; 28:2171-2180. [PMID: 31279720 DOI: 10.1016/j.jse.2019.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/23/2019] [Accepted: 03/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND After isolated subscapularis repair, improvement in shoulder function has been reported at short-term review. The purpose of this study was to determine whether arthroscopic subscapularis repair provides durable improvement in objective and subjective shoulder function with a low structural retear rate. METHODS All patients treated with arthroscopic repair of an isolated subscapularis tear between August 2003 and December 2012 with a minimum follow-up period of 4.6 years were identified from our database. A number of patients in our study cohort underwent a prior complete midterm assessment, which allowed a subgroup analysis to detect changes in structural integrity and corresponding function. Clinical and radiographic outcomes, including outcomes on conventional radiography and magnetic resonance imaging or ultrasound, were assessed. RESULTS The study enrolled 36 shoulders with a mean patient age of 57.7 years (range, 31-75 years; standard deviation, 10.6 years). The mean follow-up period was 8.6 years (range, 4.6-13.9 years; standard deviation, 2.44 years). Internal rotation to the thoracic vertebrae was achieved in 94% of cases and was significantly improved (P < .001) compared with the preoperative situation. The mean relative Constant score improved from 68% preoperatively to 93% at final follow-up (P < .001). Magnetic resonance imaging evaluation showed a rerupture rate of 2.7% (1 of 36 shoulders). Twenty patients underwent previous complete midterm assessment (mean, 2.9 years; range, 1-4.5 years), with comparisons between midterm and long-term follow-up showing comparable results without statistically significant deterioration. CONCLUSIONS Functional and subjective improvements in shoulder function are maintained at a mean follow-up of more than 8 years after isolated subscapularis repair and are associated with a low structural failure rate of the repair.
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Affiliation(s)
- Anita Hasler
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland.
| | - Glenn Boyce
- Department of Orthopaedics, University Hospital Bendigo Health, Bendigo, VIC, Australia
| | - Alex Schallberger
- Department of Orthopaedics and Traumatology, Hospital Interlaken, Unterseen, Switzerland
| | - Bernhard Jost
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sabrina Catanzaro
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
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Monroe EJ, Flores SE, Chambers CC, Zhang AL, Feeley BT, Lansdown DA, Ma CB. Patient-Reported Outcomes After Isolated and Combined Arthroscopic Subscapularis Tendon Repairs. Arthroscopy 2019; 35:1779-1784. [PMID: 31060759 DOI: 10.1016/j.arthro.2019.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze minimum 2-year postoperative patient-reported outcomes of a large group of patients after arthroscopic subscapularis (SSc) repair with respect to surgical findings and concurrent procedures. METHODS Patients who underwent arthroscopic SSc repair from January 2010 to April 2016 completed the Patient-Reported Outcomes Measurement Information System for Upper Extremity (PROMIS-UE) test and postoperative visual analog scale pain score. Medical records were reviewed for the preoperative visual analog scale pain score and surgical findings. SSc tears were considered partial or complete. Concomitant pathology and treatment of the supraspinatus (SS), infraspinatus (IS), and biceps tendon were recorded. We compared preoperative variables and outcomes between isolated partial SSc repair, partial SSc with SS and/or IS repair, isolated complete SSc repair, and complete SSc with SS and/or IS repair. RESULTS One hundred forty-five shoulders were included with an average age of 62.0 ± 9.8 years and average follow-up period of 52.2 ± 19.5 months. A significant reduction in the pain score occurred, from 4.8 (95% confidence interval [CI], 4.4-5.2) to 0.9 (95% CI, 0.6-1.1) (P < .001), with a mean postoperative PROMIS-UE score of 50.7 (95% CI, 49.5-52.0). Most SSc tears were partial with SS and/or IS repair (44.1%). Isolated partial SSc tears (29.9%), complete SSc tears with SS and/or IS repair (20.1%), and isolated complete SSc tears (5.9%) were less common. A significant difference in the mean postoperative PROMIS-UE score was not found between groups (P = .609). Biceps tendon pathology was significantly more common in complete SSc tears than partial SSc tears (P < .001), but there was no difference in the rate of biceps intervention (P = .110) or the PROMIS-UE score based on biceps intervention (P = .471). CONCLUSIONS We observed significant improvements in pain and patient-reported outcomes in line with population means for a large group of patients after SSc tendon repair. Importantly, outcomes were similar despite the size of SSc tear or concurrent SS and/or IS repairs. Biceps pathology was common, and neither its presence nor its treatment influenced postoperative patient outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Emily J Monroe
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A..
| | - Sergio E Flores
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Caitlin C Chambers
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
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A Superolaterally Placed Anchor for Subscapularis "Leading-Edge" Refixation: A Biomechanical Study. Arthroscopy 2019; 35:1306-1313.e1. [PMID: 30902534 DOI: 10.1016/j.arthro.2018.11.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/25/2018] [Accepted: 11/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare a conventional single-row (SR) repair technique and 2 double-row (DR) repair techniques to restore and protect the superolateral aspect of the subscapularis (SSC) tendon and ensure SSC leading-edge reconstruction in a cadaveric model. METHODS The native footprint was measured in 15 pairs of human cadaveric shoulders (N = 30) with a mean age of 67.2 years. According to the Fox-Romeo classification, a 25% defect or 50% defect in a superior-inferior direction was created. Specimens were mounted onto a servohydraulic test system to analyze contact variables at 0° and 20° of abduction with a force-controlled ramped program up to 50 N. In addition, each specimen was cyclically loaded (10-100 N, 300 cycles). The tears were repaired with 1 of 3 constructs: a 2-anchor medially based conventional SR construct, a 2-anchor-based hybrid DR construct, or a 3-anchor-based DR construct. The outcome variables were ultimate tensile load, displacement, and pressurized footprint coverage. RESULTS All reconstructions resulted in stable constructs with peak loads exceeding 450 N (P = .68). The overall displacement during cyclic loading was between 1.2 and 3.0 mm (P = .70). A significant difference was seen when the 2 arm positions of 0° and 20° of abduction were compared, showing a constant reduction of pressurized footprint coverage with the arm abducted (P = .01). Analyzing footprint coverage with respect to the region of interest-the leading edge of the SSC-we observed a significant difference between the SR construct and a construct using a superolaterally placed anchor (25% defect, P = .01; 50% defect, P = .01), whereas no statistical differences were detectable between the hybrid DR construct and the DR construct. CONCLUSIONS The leading edge of the SSC tendon can best be restored by using a superolateral anchor, whereas no statistical difference in load to failure in comparison with an SR construct or with the addition of a third anchor was detectable. CLINICAL RELEVANCE The SSC is critical for proper shoulder function. Without an increase in the number of implants, a significantly better footprint reconstruction can be achieved by placing an anchor superior and lateral to the native footprint area close to the entrance of the bicipital groove.
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Histologic characteristics of the subscapularis tendon from muscle to bone: reference to subscapularis lesions. J Shoulder Elbow Surg 2019; 28:959-965. [PMID: 30711396 DOI: 10.1016/j.jse.2018.11.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although subscapularis tendon lesions seem to differ from those of the supraspinatus tendon, the features they have in common suggest that the subscapularis tendon may also have 2 distinct layers. Our aim was therefore to characterize the histologic structure of the subscapularis tendon from its humeral insertion point to the musculotendinous junction. MATERIAL AND METHODS A histologic study was performed on 10 autopsy samples. The subscapularis tendon was extracted in one piece from the musculotendinous junction to the humeral insertion point and was prepared using standard (hematoxylin-eosin-saffron) staining. RESULTS Histologic analysis revealed 2 fibrous layers, distinguishable by the orientation of the collagen bundles. The deep layer was thinner and composed of parallel longitudinal collagen fibers inserting onto the lesser tuberosity flush with the cartilage. The superficial layer was thicker and composed of interdigitated collagen bundles inserting onto the lesser and the greater tuberosity after splitting into 2 bands, 1 lining the floor of the bicipital groove, and the other extending over the long head of the biceps tendon across the groove. Each layer formed an independent musculotendinous junction in the subscapularis muscle. CONCLUSIONS The subscapularis tendon is composed of 2 distinct fibrous layers, just like the supraspinatus tendon, but arranged differently. The superficial layer of the subscapularis tendon passes across the bicipital groove and forms a fibrous ring around the long head of the biceps tendon that stabilizes the latter in the bicipital groove. These results explain some of the specific features of subscapularis tears described in the literature, namely, delamination and biceps subluxation.
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Abstract
Rotator cuff disease encompasses a broad spectrum of injury and pathology with an increasing incidence with age. Pain with overhead activity, localizing to the deltoid region, and loss of active range of motion of the shoulder are among the most common presenting symptoms. Treatment options are dependent on the extent of disease and patient symptoms, and may range from physical therapy to surgical repair using a variety of possible techniques. Tear thickness, size, and morphology frequently dictate the repair techniques that are used, such as margin convergence, anterior and posterior interval slides, and mobilization of the rotator interval and supraspinatus with a subscapularis repair. Establishing and maintaining a low-tension repair is important in optimizing tendon healing after surgery. Superior capsule reconstruction is an emerging treatment strategy for massive, otherwise irreparable cuff tears, though more long-term evidence is necessary to fully evaluate this option.
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Willinger L, Lacheta L, Beitzel K, Buchmann S, Woertler K, Imhoff AB, Scheiderer B. Clinical Outcomes, Tendon Integrity, and Shoulder Strength After Revision Rotator Cuff Reconstruction: A Minimum 2 Years' Follow-up. Am J Sports Med 2018; 46:2700-2706. [PMID: 30084649 DOI: 10.1177/0363546518786006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The retear rate after primary rotator cuff (RC) reconstruction is high and commonly leads to poorer clinical outcomes and shoulder function. In the case of primary failure, revision RC reconstruction (RCR) has become increasingly important to re-create RC integrity and improve outcomes. To date, clinical and structural outcomes after RCR have not been sufficiently investigated and described at midterm follow-up. Hypothesis/Purpose: The purpose was to evaluate the clinical and radiological outcomes after revision RCR. It was hypothesized that revision RCR significantly improves clinical outcomes and that the outcomes positively correlate with tendon integrity on magnetic resonance imaging (MRI). STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent revision RCR between 2008 and 2014 were retrospectively evaluated with a minimum follow-up of 2 years. Outcomes were assessed by a clinical examination, a visual analog scale for pain (VAS), the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Tendon integrity was determined using 3-T MRI and graded according to the Sugaya classification. RESULTS Thirty-one of 40 patients (77.5%) were available for the final assessment at a mean follow-up of 50.3 ± 20.4 months. Clinical outcome scores significantly improved from preoperatively to postoperatively for the CS (39.7 ± 16.7 to 65.1 ± 19.7; P < .001), ASES (44.2 ± 17.7 to 75.2 ± 24.8; P < .001), and DASH (68.6 ± 15.1 to 21.5 ± 19.1; P < .001). The VAS score decreased from 6.1 ± 1.8 preoperatively to 1.3 ± 1.8 at final follow-up ( P < .001). MRI demonstrated a retear rate of 55.5%. No differences in CS, ASES, and DASH scores were detected between patients with an intact repair and failure. Abduction strength was not significantly different in patients with an intact repair and retears (55.5 N vs 44.0 N, respectively, P = .52). CONCLUSION Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing. Therefore, tendon integrity was not correlated with better clinical outcomes after revision RCR at final follow-up.
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Affiliation(s)
- Lukas Willinger
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lucca Lacheta
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefan Buchmann
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Orthopaedisches Fachzentrum Weilheim-Garmisch-Starnberg-Penzberg, Weilheim, Germany
| | - Klaus Woertler
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bastian Scheiderer
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Altintas B, Buckley PS, Millett PJ. Editorial Commentary: Arthroscopic Subscapularis Repair: Bridging Successful Tendon Healing and Improved Patient Outcomes. Arthroscopy 2018; 34:2549-2551. [PMID: 30173795 DOI: 10.1016/j.arthro.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 02/02/2023]
Abstract
Open repair has been regarded as the gold standard for the treatment of subscapularis tendon tears. However, recent studies on newer arthroscopic techniques and published results of arthroscopic repair have shown promising results. As such, there exists a growing interest in understanding the best fixation technique to obtain successful functional and patient-reported clinical outcomes. While the literature shows superior outcomes after double-row repair for posterosuperior rotator cuff tears compared with single-row repair, the evidence is inconclusive for subscapularis tears. We believe that arthroscopic double-row transosseous equivalent repair of full-thickness subscapularis tears leads to superior clinical outcomes with higher healing rates and will become the standard of care in the future.
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Jungmann PM, Gersing AS, Woertler K, Dietrich TJ, Baum T, Baumann F, Bensler S. Reliable semiquantitative whole‐joint MRI score for the shoulder joint: The shoulder osteoarthritis severity (SOAS) score. J Magn Reson Imaging 2018; 49:e152-e163. [DOI: 10.1002/jmri.26251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/22/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Pia M. Jungmann
- Department of NeuroradiologyUniversity Hospital Zurich, University of Zurich Zurich Switzerland
- Department of RadiologyTechnical University of Munich Munich Germany
| | | | - Klaus Woertler
- Department of RadiologyTechnical University of Munich Munich Germany
| | - Tobias J. Dietrich
- Radiology and Nuclear MedicineKantonsspital St. Gallen St. Gallen Switzerland
| | - Thomas Baum
- Department of NeuroradiologyTechnical University of Munich Munich Germany
| | - Frederic Baumann
- Clinical and Interventional AngiologyUniversity Hospital Zurich, University of Zurich Zurich Switzerland
| | - Susanne Bensler
- Institute of RadiologyCantonal Hospital Baden Baden Switzerland
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Elena N, Woodall BM, Mac Hale WP, McGahan PJ, Pathare NP, Shin EC, Chen JL. Single Portal Technique for Subscapularis Tendon Repair. Arthrosc Tech 2018; 7:e645-e649. [PMID: 29955570 PMCID: PMC6020394 DOI: 10.1016/j.eats.2018.02.014] [Citation(s) in RCA: 8] [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: 01/25/2018] [Accepted: 02/17/2018] [Indexed: 02/03/2023] Open
Abstract
The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported. Ideally less operative time, less scarring, and postoperative pain would be the expected benefits, but no study has compared the long-term outcome of these 2 procedures yet. To maximize possible improvements, we would like to present an arthroscopic technique: a subscapularis tendon repair performed with the aid of an angled suture passer and using a single anterior working portal.
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Affiliation(s)
- Nicholas Elena
- Address correspondence to Nicholas Elena, M.D., Advanced Orthopaedics & Sports Medicine, 450 Sutter Street, Suite 400, San Francisco, CA 94108, U.S.A.
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Jeong JY, Pan HL, Song SY, Lee SM, Yoo JC. Arthroscopic subscapularis repair using single-row mattress suture technique: clinical results and structural integrity. J Shoulder Elbow Surg 2018; 27:711-719. [PMID: 29054384 DOI: 10.1016/j.jse.2017.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rupture of the subscapularis (SSC) tendon, isolated or combined, is rare, and the treatment modalities are controversial. The purpose of this study was to evaluate, by magnetic resonance imaging (MRI), the clinical outcomes and structural integrity of the SSC tendon after all-arthroscopic repair with single-row mattress suture for isolated or combined SSC tendon tears. METHODS This study included 68 patients who underwent all-arthroscopic repair using single-row mattress suture for isolated or combined SSC tendon tears between April 2011 and January 2013. The patients were evaluated by the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant shoulder score, and SSC muscle strength measurement. MRI was used for assessment of the postoperative integrity of the SSC tendon. RESULTS With a mean follow-up of 29.5 ± 4.0 months, the preoperative Constant shoulder and American Shoulder and Elbow Surgeons scores were 50.3 ± 21.0 and 46.6 ± 18.3, respectively, which improved at the last follow-up to 75.7 ± 16.6 and 81.3 ± 18.1, respectively, with statistical significance (P < .001). Belly-press and bear-hug test results showed some improvement in the last follow-up (>2 years) compared with the presurgical state (P = .125 and .650). A statistically significant SSC muscle strength deficit persisted in the postoperative state (P = .015). MRI evaluation showed a retear rate of 8.8%. CONCLUSIONS Arthroscopic repair of isolated or combined SSC tears with the single-row mattress suture technique results in significant clinical improvements and enduring tendon integrity, although SSC strength remains reduced from that on the normal side.
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Affiliation(s)
- Jeung Yeol Jeong
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hai-Le Pan
- Department of Orthopaedic Surgery, The Affiliated No. 2 Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Seung Yeop Song
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Min Lee
- Division of Sports Medicine, Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
| | - Jae Chul Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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