Intraoperative Determinants of Rotator Cuff Repair Integrity An Analysis of 500 Consecutive Repairs

Sports Medicine and Shoulder Service, St George Hospital Campus, University of New South Wales, Sydney, Australia.
The American Journal of Sports Medicine (Impact Factor: 4.36). 10/2012; 40(12). DOI: 10.1177/0363546512462677
Source: PubMed


BACKGROUND:Rotator cuff repair has a relatively high (20%-90%) chance of retears. Patients with an intact rotator cuff 6 months after surgery have better subjective and objective outcomes at 6 months and 2 years after rotator cuff repair than those who do not have an intact repair. PURPOSE:The aim of this study was to determine if, and if so which, intraoperative factors predict an intact repair 6 months after rotator cuff repair. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:The study consisted of a cohort of 500 consecutive patients who had an arthroscopic rotator cuff repair performed by a single surgeon and an ultrasound evaluation using standard protocols of the repair 6 months after surgery. Exclusion criteria included previous fracture or shoulder surgery, incomplete or partial rotator cuff repair, and concomitant arthroplasty. Rotator cuff tear size was measured intraoperatively and mapped. The quality of the tendon, tendon mobility, and repair quality were assessed and ranked based on predetermined scales (1-4) and recorded on a specifically designed form. Logistic regression analysis was performed, with cuff integrity at 6-month follow-up as the dependent variable and tear/repair factors as the independent variables. RESULTS:The overall postoperative retear rate was 19% at 6 months. The best predictor of rotator cuff integrity was preoperative tear size (correlation coefficient, r = 0.33; P < .001). Patients with small (≤2 cm(2)) rotator cuff tears were least likely to have retears (retear rate, 10%). As the tear size increased, the retear rate increased in a linear fashion: ≤2 cm(2) (10%), 2 to 4 cm(2) (16%), 4 to 6 cm(2) (31%), 6 to 8 cm(2) (50%), and >8 cm(2) (57%). Other surgeon-ranked intraoperative assessments did correlate with retears, but the correlations were relatively weak: repair quality (r = -0.17; P < .001), tendon mobility (r = -0.15; P < .001), and tendon quality (r = -0.14; P < .01). Regression analysis showed that the retear rate at 6-month follow-up was best predicted from the preoperative tear size and the surgeon-ranked repair quality: chance of retear = 0.38 + (0.02 × tear size in cm(2)) - (0.08 × repair quality). Tendon quality and tendon mobility did not contribute significantly to this prediction. CONCLUSION:Tear size was the best intraoperative predictor of repair integrity after rotator cuff repair, with tears less than 2 cm(2) twice as likely to heal than tears greater than 6 cm(2).

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Available from: George A C Murrell, Feb 11, 2014
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    • "In this context, it should be noted that there are no global tears (medial-to-lateral diameter of torn rotator cuff greater than 5 cm) in our series because we use an open multiple muscle transfer technique for such tears. Because retear rates are proportional to tear size in other studies [10, 20] and were in our series, exclusion of patients with such large tears could explain our low retear rate. Therefore, it is meaningless to simply compare the overall retear rates in our series with those reported by others whose series had a different distribution of tear size. "
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    ABSTRACT: Although arthroscopic anchor suturing is commonly used for rotator cuff repair and achieves good results, certain shortcomings remain, including difficulty with reoperation in cases of retear, anchor dislodgement, knot impingement, and financial cost. In 2005, we developed an anchorless technique for arthroscopic transosseous suture rotator cuff repair. After acromioplasty and adequate footprint decortication, three K-wires with perforated tips are inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint using a customized aiming guide. After pulling the rotator cuff stump laterally with a grasper, three K-wires are threaded through the rotator cuff and skin. Thereafter, five Number 2 polyester sutures are passed through three bone tunnels using the perforated tips of the K-wires. The surgery is completed by inserting two pairs of mattress sutures and three bridging sutures. We investigated the retear rate (based on MR images at least 1 year after the procedure), total score on the UCLA Shoulder Rating Scale, axillary nerve preservation, and issues concerning bone tunnels with this technique in 384 shoulders in 380 patients (174 women [175 shoulders] and 206 men [209 shoulders]). Minimum followup was 2 years (mean, 3.3 years; range, 2-7 years). Complete followup was achieved by 380 patients (384 of 475 [81%] of the procedures performed during the period in question). The remaining 91 patients (91 shoulders) do not have 1-year postsurgical MR images, 2-year UCLA evaluation or intraoperative tear measurement, or they have previous fracture, retear of the rotator cuff, preoperative cervical radiculopathy or axillary nerve palsy, or were lost to followup. Retears occurred in 24 patients (24 shoulders) (6%). The mean overall UCLA score improved from a preoperative mean of 19.1 to a score of 32.7 at last followup (maximum possible score 35, higher scores being better). Postoperative EMG and clinical examination showed no axillary nerve palsies. Bone tunnel-related issues were encountered in only one shoulder. Our technique has the following advantages: (1) reoperation is easy in patients with retears; (2) surgical materials used are inexpensive polyester sutures; and (3) no knots are tied onto the rotator cuff. This low-cost method achieves a low retear rate and few bone tunnel problems, the mean postoperative UCLA score being comparable to that obtained by using an arthroscopic anchor suture technique. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 07/2013; 471(11). DOI:10.1007/s11999-013-3148-7 · 2.77 Impact Factor
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    ABSTRACT: Rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. No surgical technique has proved to be superior. Despite surgery, about 20% of patients experience retears, more likely occurring in those with larger tears.
    Primary care 12/2013; 40(4):889-910. DOI:10.1016/j.pop.2013.08.006 · 0.74 Impact Factor
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    ABSTRACT: Study Design Systematic literature review. Objectives To perform a systematic literature review on prognostic factors for successful recovery after arthroscopic rotator cuff repair. Background Rotator cuff lesions is a common shoulder disorder with a prevalence ranging from 13% in people over 50 years to more than 50% in people older than 80 years. Several factors can affect the extent to which a person recovers after the surgical repair of a rotator cuff tear. More knowledge about these prognostic factors may lead to a better understanding of why the recovery process is successful in some patients but not in others. Methods A systematic literature search from 1995 to November 2013 was performed to identify studies reporting prognostic factors for successful recovery after arthroscopic rotator cuff repair. Results A total of 455 studies were initially identified. Ten studies were included in the review. A total of 12 prognostic factors were identified as predisposing to better recovery. These factors could be divided into 4 categories: demographic factors (younger age, male gender), clinical factors (higher bone mineral density, absence of diabetes mellitus, higher level of sports activity, greater preoperative range of motion, absence of obesity), factors related to cuff integrity (smaller sagittal size of the cuff lesion, less retraction of the cuff, less fatty infiltration, no multiple tendon involvement), and factors related to the surgical procedure (no concomitant biceps or acromioclavicular joint procedures). Conclusion Knowledge and understanding of prognostic factors should be used in the decision making process concerning arthroscopic rotator cuff repair to offer better care to patients. Level of Evidence Prognostic, level 2a. J Orthop Sports Phys Ther, Epub 22 January 2014. doi:10.2519/jospt.2014.4832.
    01/2014; 44(3). DOI:10.2519/jospt.2014.4832
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