Background: Increased age, larger tear size, and more advanced fatty degeneration of the rotator cuff musculature have been correlated with poorer healing rates after rotator cuff repair. Platelets are an endogenous source of growth factors present during rotator cuff healing.
Hypothesis: Augmentation of rotator cuff repairs with platelet-rich fibrin matrix (PRFM) may improve the biology of rotator cuff healing and thus improve functional outcome scores and retear rates after repair.
Study Design: Cohort study; Level of evidence, 3.
Methods: Rotator cuff tears at risk for retear were prospectively identified using an algorithm; points were assigned for age (50-59 years = 1; 60-69 years = 2; >70 years = 3), anterior-to-posterior tear size (2-2.9 cm = 0; 3-3.9 cm = 1; >4 cm = 2), and fatty atrophy (Goutallier score 0-2 = 0; Goutallier score 3-4 = 1). Three points were required for enrollment. Arthroscopic rotator cuff repair was performed with the addition of PRFM. Preoperative and 1-year postoperative magnetic resonance imaging (MRI) and functional outcome scores were obtained. Imaging and functional outcomes were compared with historical controls meeting the same enrollment criteria.
Results: Sixteen and 21 patients were enrolled in the PRFM and control groups, respectively. Mean age (65 ± 7 and 65 ± 9 years; P = .89), tear size (3.8 ± 1.1 and 3.9 ± 1.1 cm; P = .79), and median Goutallier scores (2 and 3; P = .18) were similar between the PRFM and control groups, respectively. Retear rates (56.2% vs 38.1%) were statistically significantly higher (P = .024) in the PRFM group compared with controls. Functional outcome scores postoperatively were not significantly improved compared with controls. Complications included 2 infections in the PRFM group.
Conclusion: The augmentation of at-risk rotator cuff tears with PRFM did not result in improved retear rates or functional outcome scores compared with controls.
Background: A hooked-type acromion has been suspected to correlate with higher rotator cuff tear or impingement syndrome. However, correlation of acromial shape after acromioplasty with the rotator cuff retears and clinical results has not been studied before.
Purpose: To assess the shape of the acromion after arthroscopic acromioplasty and to see if there is any relation with the rotator cuff retears and clinical results.
Study Design: Case series; Level of evidence, 4.
Methods: One hundred consecutive patients who underwent acromioplasty using a posterior cutting block technique accompanied by rotator cuff repair were included in this study. The decision was made to perform acromioplasty intraoperatively after confirmation of external impingement. Postoperative acromial shape was evaluated according to whether the acromion was flat, curved, or hooked on coronal and sagittal planes on magnetic resonance imaging (MRI) at a mean 13.4 months after surgery. Retear rates and clinical scores were compared between the hooked acromion and the others on postoperative MRI.
Results: Preoperatively, only 29 patients had a hooked acromion on either coronal or sagittal plane MRI. After acromioplasty of those 100 patients, 23 still showed a hooked acromion. Twenty-six of 29 preoperatively hooked acromions were changed to nonhooked acromions, and 20 of 23 postoperatively hooked acromions had been nonhooked acromions preoperatively. No difference was found in the retear rate with respect to the postoperative acromial shape. Clinically, the American Shoulder and Elbow Surgeons (ASES) score was not different between the hooked acromion and the other group (82 vs 85, P = .099). However, the Constant score of the hooked acromion group was lower than that of the other group (74 vs 85, P = .036). Ninety-four of 100 patients were contacted again for the evaluation of the ASES score at a mean 36.5 months (range, 29-45 months) and showed no difference between the hooked acromion and the other group (87 vs 87, P = .903).
Conclusion: Even with a standard posterior cutting block technique during acromioplasty, 23% of patients still showed a hooked acromion after arthroscopic acromioplasty. Using the signs of coracoacromial ligament impingement as an indication for acromioplasty might lead to hooked acromions postoperatively, which were nonhooked acromions preoperatively. However, the retear rate showed no difference according to the postoperative acromial shape.
Background: Despite advances in arthroscopic repair of rotator cuff tears, recurrent tears after repair of large and massive tears remain a significant clinical problem. The primary objective of this study was to define the timing of structural failure of surgically repaired large and massive rotator cuff tears by serial imaging with ultrasound. The secondary objective of this study was to investigate the association between recurrent tears and clinical outcome after rotator cuff repair.
Hypothesis: Recurrent tear after arthroscopic repair of large rotator cuff tears is more likely to occur late (>3 months) in the postoperative period and will be associated with inferior clinical outcome scores.
Study Design: Cohort study; Level of evidence, 3.
Methods: Twenty-two consecutive patients with large (>3 cm) rotator cuff tears underwent arthroscopic repair with a standardized technique. Serial ultrasound examinations were performed at 2 days, 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. Western Ontario Rotator Cuff (WORC) Index scores were also collected at these time points.
Results: Nine (41%) of the 22 arthroscopically repaired rotator cuff tears demonstrated recurrent tears. Seven of the 9 retears occurred within 3 months of surgery, and the other 2 occurred between 3 and 6 months. No retears occurred after 6 months. At 24-month follow-up, WORC scores favoring intact rotator cuffs over retears approached statistical significance (mean WORC intact 123.9 vs retear 659.8; P = .07).
Conclusion: Recurrent rotator cuff tears are not uncommon after arthroscopic repair of large and massive tears. These recurrent tears appear to occur more frequently in the early postoperative period (within the first 3 months) and are associated with inferior clinical outcomes.
Background: The prognostic factors associated with structural outcome after arthroscopic rotator cuff repair have not yet been fully determined.
Hypothesis: The hypothesis of this study was that bone mineral density (BMD) is an important prognostic factor affecting rotator cuff healing after arthroscopic cuff repair.
Study Design: Cohort study; Level of evidence, 3.
Methods: Among 408 patients who underwent arthroscopic repair for full-thickness rotator cuff tear between January 2004 and July 2008, 272 patients were included whose postoperative cuff integrity was verified by computed tomography arthrography (CTA) or ultrasonography (USG) and simultaneously who were evaluated by various functional outcome instruments. The mean age at the time of operation was 59.5 ± 7.9 years. Postoperative CTA or USG was performed at a mean 13.0 ± 5.1 months after surgery, and the mean follow-up period was 37.2 ± 10.0 months (range, 24-65 months). The clinical, structural, and surgery-related factors affecting cuff integrity including BMD were analyzed using both univariate and multivariate analysis. Evaluation of postoperative cuff integrity was performed by musculoskeletal radiologists who were unaware of the present study.
Results: The failure rate of rotator cuff healing was 22.8% (62 of 272). The failure rate was significantly higher in patients with lower BMD (P < .001); older age (P < .001); female gender (P = .03); larger tear size (P < .001); higher grade of fatty infiltration (FI) of the supraspinatus, infraspinatus, and subscapularis (all P < .001); diabetes mellitus (P = .02); shorter acromiohumeral distance (P < .001); and associated biceps procedure (P < .001). However, in the multivariate analysis, only BMD (P = .001), FI of the infraspinatus (P = .01), and the amount of retraction (P = .03) showed a significant relationship with cuff healing failure following arthroscopic rotator cuff repair.
Conclusion: Bone mineral density, as well as FI of the infraspinatus and amount of retraction, was an independent determining factor affecting postoperative rotator cuff healing. Further studies with prospective, randomized, and controlled design are needed to confirm the relationship between BMD and postoperative rotator cuff healing.
Background: Partial rotator cuff tears are being diagnosed more often because of high-resolution magnetic resonance imaging (MRI). Articular-side partial tears are much more common than bursal-side tears, and all-inside or PASTA repairs that preserve the bursal tissue have gained popularity. In contrast, there have been few reports about preserving the articular tissue during bursal tear repair.
Purpose: To report clinical and radiological results of bursal-side partial-thickness rotator cuff tear (PTRCT) repair with preservation of as much of the intact articular-side tendon as possible.
Study Design: Case series; Level of evidence, 4.
Methods: From May 2006 to March 2008, 109 patients with PTRCT underwent arthroscopic repair. Among them, 38 consecutive patients who received a full-layer repair on the bursal side for greater than 50% thickness PTRCT were retrospectively evaluated. All repairs were performed with a technique that preserved intact articular fibers. To assess the outcome, pain visual analog scale (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score were evaluated at final follow-up. Postoperative MRI at least 6 months after surgery was evaluated for repair integrity.
Results: All 38 patients (21 men and 17 women) were available for final follow-up. The mean age at surgery was 50.8 years (range, 30-58 years), and the mean follow-up time was 26.9 months (range, 24-41 months). There were 21 right shoulders and 17 left shoulders, for which the mean time from the onset of symptoms to surgery was 47.0 months (±83.3 months). The PVAS improved from 5.2 (±2.5) to 1.6 (±1.5), and mean ASES and Constant scores improved from 53.1 (±20.4) and 59.9 (±15.3) to 87.2 (±9.4) and 83.2 (±12.0), respectively. Postoperative MRI was available in 33 patients at a mean 8.2 months after surgery. Twenty-nine shoulders (87.9%) had an intact repaired tendon, while 3 patients had shown partial-thickness delaminated retears, and 1 patient demonstrated a full-thickness retear on postoperative MRI.
Conclusion: For bursal-side PTRCT, clinical outcomes and tendon healing showed good results at a minimum 2 years after surgery, with minimal damage to intact articular tendon fibers on postoperative MRIs.
Background: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date.
Purpose: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears.
Study Design: Case series; Level of evidence, 4.
Methods: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair.
Results: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test.
Conclusion: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.
Background
The suture-bridging technique is a new arthroscopic technique to repair rotator cuff tears. Biomechanical advantages compared with double-row fixations have been described.
Hypothesis
The authors hypothesized that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation.
Study Design
Case series; Level of evidence, 4.
Methods
Fifty-one consecutive patients, with a median age of 62 years (range, 37–76 years), who had undergone an arthroscopic suture-bridging repair of an isolated supraspinatus tendon tear were evaluated in this prospective study 4, 12, and a median of 24 months postoperatively. Subjective and functional outcome was assessed using the simple shoulder test and Constant score. With magnetic resonance imaging 12 months postoperatively, the tendon integrity and potential predictors of failures were evaluated.
Results
The simple shoulder test scores improved significantly from 9 points (range, 1–12 points) at 4 months, to 12 points (range, 1–12 points) at 12 months, and 12 points (range, 5–12 points) at 24 months postoperatively. The Constant score increased significantly from preoperative 64% (range, 37%–92%) to 82% (range, 36%–100%) at 4 months, 96% (range, 49%–100%) at 12 months, and 96% (range, 64%–100%) at 24 months postoperatively. Magnetic resonance imaging 12 months after surgery showed retears in 28.9%. Two different types of retears could be observed: insufficiently healed and medially retorn supraspinatus tendons. The Constant score did not differ significantly between the groups with retears and intact repairs. A patient age of more than 60 years was found to influence tendon healing significantly.
Conclusion
The hypothesis, that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation, could not be confirmed. The functional outcome after the new suture-bridging technique was good and comparable with the reported results after double-row repair from the literature. A structural failure of tendon repair was not identical to clinical failure.
