Article

Surgical Repair of Chronic Rotator Cuff Tears: A Prospective Long-Term Study

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Abstract

Rotator cuff disease or injury is one of the most frequently seen orthopaedic conditions, and surgical repair of rotator cuff tears is a common procedure. A prospective analysis of the operation, with consistent assessment of patient characteristics, variables associated with the rotator cuff tear and repair techniques, and outcome factors, was performed. One hundred and five shoulders with a chronic rotator cuff tear underwent open surgical repair and acromioplasty between 1975 and 1983. The patients were followed for an average of 13.4 years (range, two to twenty-two years). There were sixteen small tears, forty medium tears, thirty-eight large tears, and eleven massive tears. The tears were repaired directly (seventy-two tears), by V-Y plasty (twelve), by tendon transposition (twenty), or by reinforcement with a fascia lata graft (one). The long head of the biceps had been previously torn in eleven shoulders and was tenodesed in three other shoulders. In fifty-six shoulders, the distal part of the clavicle was excised for treatment of degenerative arthritic changes, often associated with osteophyte formation. Satisfactory pain relief was obtained in ninety-six shoulders (p < 0.0001). There was significant improvement in active abduction (p < 0.001) and external rotation (p < 0.007) as well as in strength in these directions of movement (p < 0.03 and p < 0.002, respectively). At the latest follow-up evaluation, the result was rated as excellent for sixty-eight shoulders, satisfactory for sixteen, and unsatisfactory for twenty-one. Tear size was the most important determinant of outcome with regard to active motion, strength, rating of the result, patient satisfaction, and need for a reoperation. Older age, less preoperative active motion, preoperative weakness, distal clavicular excision, and a transposition repair technique were all associated with larger tear size. There were eight reoperations; five were for rerepair of a persistent or recurrent rotator cuff tear. Standard tendon repair techniques combined with anterior acromioplasty, postoperative limb protection, and monitored physiotherapy can produce consistent and lasting pain relief and improvement in range of motion. Improving the results of this procedure will depend upon the development of new techniques to address the active motion and strength deficiencies following repair of massive rotator cuff tears.

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... [1][2][3][4] A massive tear is a tear with a diameter of 5 cm or greater or a complete tear of 2 or more tendons. 5 The size and reparability of a tear are not always related: A massive tear is not necessarily irreparable, and an irreparable tear is not necessarily massive. 6 RCTs may be small or large; they have a progressive pattern in most cases. ...
... 13,14 Recently, the LHBT was used for superior capsular reconstruction (SCR). 15 This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint. The technique combines many procedures, each of which can be solely used for the treatment of irreparable and massive RCTs. ...
... [1][2][3][4] A massive tear is a tear with a diameter of 5 cm or greater or a complete tear of 2 or more tendons. 5 The size and reparability RECONSTRUCTION OF ROTATOR CUFF TEAR e459 of a tear are not always related: A massive tear is not necessarily irreparable, and an irreparable tear is not necessarily massive. 6 ...
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Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT’s origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.
... However, it is difficult to compare clinical results of subacromial decompression or acromioplasty because surgical techniques differ from surgeon to surgeon. Most orthopaedists concentrate on the anterior acromion [7][8][9][10][11] , whereas others perform the acromioplasty on the inferior surface [8][9][10] , the lateral side 11 , or the medial side 8,12 . The crucial part of acromion which should be removed or decompressed during the procedures have not been determined accurately. ...
... However, it is difficult to compare clinical results of subacromial decompression or acromioplasty because surgical techniques differ from surgeon to surgeon. Most orthopaedists concentrate on the anterior acromion [7][8][9][10][11] , whereas others perform the acromioplasty on the inferior surface [8][9][10] , the lateral side 11 , or the medial side 8,12 . The crucial part of acromion which should be removed or decompressed during the procedures have not been determined accurately. ...
... However, it is difficult to compare clinical results of subacromial decompression or acromioplasty because surgical techniques differ from surgeon to surgeon. Most orthopaedists concentrate on the anterior acromion [7][8][9][10][11] , whereas others perform the acromioplasty on the inferior surface [8][9][10] , the lateral side 11 , or the medial side 8,12 . The crucial part of acromion which should be removed or decompressed during the procedures have not been determined accurately. ...
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To find out which structure is crucial for the formation of shoulder impingement syndrome with the purpose of directing surgical procedures of subacromial decompression and discussing whether it is necessary to manage acromioclavicular joint during operation and how to do it properly. Methods: This was a retrospective study. Clinical data and preoperative computed tomography (CT) images were collected from patients who were diagnosed with rotator cuff tears between January 2017 and August 2019 (sample size: 46) and those who were diagnosed without rotator cuff tears between March 2018 and August 2019 (sample size: 44) in our institution, respectively. Three-dimensional models of shoulders were established by multiplanar reconstruction of CT scans and measurements were performed on these models. The parameters such as the acromial length and width, the axial tilt, and the distance from acromial margin to glenoid plane were measured in an adjusted axial plane, and the critical shoulder angle and the spatial volume under acromioclavicular joint were measured in an adjusted coronal plane. The demographic characteristics, the acromial morphology and the spatial volume under acromioclavicular joint were compared to find significant differences between the two groups. The association between the axial tilt and the distance from acromial margin to glenoid plane was evaluated by an ordinary least squares linear regression. Results: The patients with rotator cuff tears consisted of 16 males and 30 females, among which 30 right shoulders and 16 left shoulders were included. The patients without rotator cuff tears consisted of 28 males and 16 females, among which 15 right shoulders and 29 left shoulders were involved. Significant differences between the groups were found in the acromial width (3.332 cm vs 3.111 cm), the axial tilt (33.765° vs 23.829°), the critical shoulder angle (32.630° vs 30.363°), the distance from anterior 3 cm of lateral acromial margin (range, 2.476 cm-3.302 cm vs 1.993 cm-3.089 cm), and anterior 0.9 cm of medial acromial margin (range, 0.967 cm-2.369 cm vs 0.668 cm-1.993 cm) to glenoid plane, and the spatial volume under acromioclavicular joint (1.089 cm vs 1.446 cm) in the two groups. No significant differences were found in the age (60.0 years vs 58.3 years) or the acromial length (4.187 cm vs 4.184 cm). Significant association was revealed by linear regression analysis between the axial tilt and the distance from anterior two-thirds of lateral acromial margin to glenoid plane, and similar association was also found in the anterior half of medial margin. Conclusion: Anterior two-thirds of lateral acromial margin, anterior half of medial acromial margin, and inferior aspect of acromioclavicular joint are crucial structures and need to be fully decompressed when treating patients with rotator cuff tears.
... We chose to modify a small locking plate (a shortened PHILOS plate, HS-A-BU0173-029, China; Fig. 4D) to fix the fractures, in line with guidelines for the surgical treatment of displaced fractures of the HGT [16]. All operations were performed by the senior author (Shijie-Fu). ...
... This is a useful approach for areas in which patients cannot afford high medical expenses and/or have insufficient health insurance and is also beneficial because the insertion angle can be adapted to increase biomechanical strength following fixation of osteoporotic fractures; a subject which warrants further study. However, compression screws may cause damage to fracture fragments [7,16,24]. (ii) Type II (single-fragment with medium size RCT) fractures should be fixed using screws combined with suture anchors under arthroscopic guidance. This method is widely used to treat PHFs as the tendon-bone interface fragment is fixed and satisfactory clinical results can be achieved [16,18]. ...
... (ii) Type II (single-fragment with medium size RCT) fractures should be fixed using screws combined with suture anchors under arthroscopic guidance. This method is widely used to treat PHFs as the tendon-bone interface fragment is fixed and satisfactory clinical results can be achieved [16,18]. (iii) Type III (multi-fragment) fractures should be fixed using a suture bridge or small locking plate to provide stable fixation and early return to function. ...
Article
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Background Split fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method. Methods We created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCT) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed. Results The mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicate that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment. Conclusions Biomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.
... It is thought that delayed rehabilitation protocols can prevent situations that may adversely affect tendon healing such as micro-motion and cavity formation in the repair area. However, delayed joint motion may increase the risk of joint stiffness after surgery and potentially delay the return of shoulder function (9). Because of these conflicting findings, there is no definitive consensus on the initiation of a rehabilitation after RCR (3). ...
... The DR protocol after RCR is preferred due to the concern that early movement may adversely affect tendon healing from micro-movement and cavity formation in the repair area. However, delayed motion can increase the risk of joint stiffness after surgery and potentially delay the return of shoulder function (9). Some studies have indicated that the ER protocol after arthroscopic RCR increases the risk of re-tear, especially in patients with large tears between 3 cm and 5 cm (21,22). ...
Article
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Aim: The aim of this study was to determine and compare the effects of early and delayed passive joint rehabilitation protocol on functional and quality of life outcomes in patients following arthroscopic rotator cuff repair (RCR). Material and Methods: A total of 202 patients who underwent arthroscopic RCR were included into the study. Ninety eight patients who started the rehabilitation program just after the arthroscopic RCR were comprised as early rehabilitation (ER) group, while 104 patients whose shoulder joint motion was not allowed for 3 weeks after surgery as delayed rehabilitation (of complications such as re-tear, frozen shoulder and infection that developed during the follow-up period. Both rehabilitation protocols were found to have a similar effect on patient-reported outcomes. Conclusion: At a mean follow-up time of 13 months, early and delayed onset postoperative rehabilitation programs are associated with similar functional and quality of life outcomes, and complication rates. Therefore, DR can be preferred primarily in patients with large tears. ER can be an option for the patients with small tears who has anticipation of early return to work and daily life.
... Their prevalence is estimated at 24% in patients between 40 to 60 years of age and increases up to 54% in patients older than 60 years [3][4][5]. 10-40% are reported to be massive tears, a term used to describe a tear of a diameter of more than 5 cm [6] or a tear of two or more tendons [7]. Conservative measures such as physical therapy, oral pain medication, or subacromial infiltration are first-line treatment options for patients with low physical demands [2,8]. ...
... The choice of the best surgical treatment option is influenced by tissue quality, concomitant osteoarthritis and patient-specific factors, such as age and activity level [9,10]. The repair of a torn rotator cuff is the favored treatment option and leads to good to excellent clinical results in arthroscopic [11][12][13][14][15] and open procedures [6,16,17]. ...
Article
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Objectives: To evaluate the clinical and radiographic outcome of low-demand patients with massive rotator cuff tears undergoing arthroscopic debridement in mid- and long-term follow-up, as well as the rate of conversion to reverse shoulder arthroplasty. Methods: We performed a retrospective analysis of 19 patients with a mean age at surgery of 68 years (range, 55-80 years) from a previously described consecutive cohort and after a mean follow up of 47 month (FU1) and 145 month (FU2). The functional outcome was evaluated with the VAS score, the American Shoulder and Elbow Surgeons (ASES) score, and the age- and gender-adjusted Constant (aCS) score. The radiographic outcome was classified according to the Hamada classification. Non-parametric analyses were carried out with the Mann-Whitney U for independent samples and the Wilcoxon signed-rank test for related samples. Results: Five patients (26%) developed symptomatic cuff tear arthropathy and underwent reverse shoulder arthroplasty after a mean time of 63 months (range, 45-97 months). These patients were excluded from further analyses. The mean VAS score of the remaining 14 patients at FU1 was significantly lower compared to preoperatively (P = .041), while there were no significant differences between the VAS score at FU1 and FU2 (P = 1.0). The ASES score of the affected shoulder at FU1 was significantly higher compared to prior to surgery (P = .028), while there were no significant differences between the scores of the affected shoulder between FU1 and FU2 (P = .878). While the ASES score of the contralateral shoulder at FU1 was significantly higher than the score of the affected shoulder (P = .038), there were no significant differences in the ASES scores of the affected and the healthy shoulder at FU2 (P = .575). The evaluation of the aCS produced similar results. A progression of the Hamada grade was documented in 6 patients. Conclusions: Arthroscopic debridement is a safe and valid option for low-demand middle-age or elderly patients with symptomatic massive rotator cuff tears, leading to a significant pain relief and significantly improved functional outcome at mid- and long-term follow up. However, about a quarter of the patients in our cohort had to undergo reverse shoulder arthroplasty due to symptomatic cuff tear arthropathy. Furthermore, some of the remaining patients continued to undergo radiographic progression. This might be due to the natural history of their disease and/or the surgical procedure, and the clinical relevance of this finding should be evaluated in further studies.
... Of all patients, 51 patients were finally included in this retrospective study, and they attended a minimum clinical follow-up of 24 months. According to the classification criteria proposed by Cofield [21], there were 22 cases of a small tear (0-1 cm), 69 cases of a medium tear (1-3 cm), and 11 cases of a large tear (3-5 cm). Patients were divided into 2 groups. ...
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Background: Bilateral rotator cuff tears are not uncommon and the timing of the surgical treatment of both shoulders is debated. In the present study, we aimed to compare the clinical outcomes of patients who underwent single-stage or staged bilateral arthroscopic rotator cuff repair. Methods: From March 2013 to May 2018, a retrospective review on all patients who underwent bilateral arthroscopic rotator cuff repair at our department was performed. Patients were separated into 2 groups: single-stage and staged. The minimum follow-up period was 2 years. The visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, Constant-Murley (Constant) score, the range of motion (ROM) of the shoulder and the hospitalization costs were evaluated for comparison between the two groups before and after the operation. Differences between groups were assessed using t-tests and ANOVA. Results: All 51 patients completed follow-up of 2 years, single stage (n = 24) and staged group (n = 27). There was no significant difference in the VAS, ASES, UCLA and Constant scores between the single-stage group and the staged group before the operation. Postoperative clinical scores were significantly improved in both groups (P < 0.05). All outcome scores were significantly different between the two groups at 6 months postoperatively, and the staged scored better than the single-stage (P < 0.05). At 12, 18, and 24 months after the operation, the outcome scores were not significantly different between the two groups. At follow-up, the ROM of the shoulder was not significantly different between the two groups. In the single-stage group, the outcome scores and ROM were similar for both shoulders and comparable to the staged group. We also found significant cost savings in the single-stage group (4440.89 ± 130.55 USD) compared to the staged group (5065.73 ± 254.76 USD) (p < 0.05). Conclusions: Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months. Moreover, good outcomes were observed on both sides of the single-stage group.
... M assive rotator cuff tears are defined as defects of >5 cm or involving two or more tendons. 1 Size and repairability are not mutually exclusive and a massive tear is not necessarily irreparable. 2 Warner defined irreparability as the inability to achieve a direct repair of the native tendon to the humerus despite adequate soft tissue mobilization. ...
Article
Large and massive rotator cuff tears are not always reparable and present a difficult clinical problem. If surgery is warranted surgical options range from arthroscopic debridement, partial repairs, degradable spacers, tendon transfers, and more superior capsular reconstruction. The rotator cable is formed by the deep layer of the coracohumeral ligament and the crescent structure running from the anterior insertion site of the supraspinatus to the inferior border of the infraspinatus. The role of the rotator cable is not clear but seems to play a role in reducing tendon stress and influence glenohumeral kinematics. In this laboratory-based cadaver study the anterior cable was reconstructed with semitendinosus allograft treating large "irreparable" rotator cuff defects. Reconstruction resulted in reduced superior migration and subacromial contact forces without inhibiting range of motion.
... Classificação por tamanho da lesãoBastantes estudos trazem a preferência pela abordagem cirúrgica em relação ao tratamento não cirúrgico[54,64,65], mesmo sem muita comprovação científica[10,66]. O tratamento dito conservador, apesar desse apresentar melhora funcional em alguns pacientes[34,[36][37][38][39]65,67], traz consigo muitos riscos para a cicatrização e remodelamento do tendão, como infiltração gordurosa, atrofia muscular, retração de tendão, entre outros[10,50,54,68,69], ou até mesmo progressão da lesão com degeneração do Algumas das características a serem levadas em conta, além desses riscos, são idade, atividade, cronicidade da lesão, o tamanho da mesma e seu comprometimento. Algumas Constant scores, elevação e abdução pós reparo, enquanto o outro grupo trouxe elevação no Constant score e na rotação externa. ...
Article
Introdução: A articulação do ombro é composta por um conjunto de músculos formando o manguito rotador, dentre suas principais funções estão estabilizar e gerar força nos movimentos do membro superior. Quando ocorre uma lesão aguda – em alguma das estruturas que o compõe – essa é conduzida de forma cirúrgica, em sua maioria. Contudo ainda é bastante discutido quando deve ser feita essa abordagem para que o desfecho do paciente seja o mais favorável possível. Objetivos: Analisar e comparar do ponto de vista funcional, pacientes com rotura traumática do manguito rotador que tenham sido submetidos ao reparo artoscópico em diferentes tempos após a lesão, por meio de avaliação clínica e escores funcionais. Métodos: Um estudo que avaliou 50 pacientes com rotura traumática do manguito rotador, submetidos ao tratamento cirúrgico artroscópico no Hospital HOME, Brasília-DF, no período de jan/2011 até dez/2017. Na avaliação dos pacientes foi realizada uma entrevista clínica, uma avaliação funcional e biomecânica, englobando responder os escores funcionais (UCLA e Constant). Foram separados em grupos de pacientes abordados em diferentes tempos: Grupo 1A (nos primeiros 3 meses após a lesão), Grupo 1B (no intervalo de 3 a 6 meses após a data da lesão) e Grupo 2 (após o sexto mês pós lesão) – e comparado os resultados. Resultados: Dentre os resultados encontrados, temos que em todos os grupos há diminuição da dor pós cirurgia, a média do score UCLA foi semelhante nos grupos estudados, com o 1B sendo o de maior pontuação, e o score Constant-Murley acompanhou esse resultado. Quando comparado em relação ao membro contralateral de forma direta, o grupo 1A foi superior na elevação gônio e na rotação externa gônio, o grupo 1B foi superior na rotação interna gônio e não houve alteração de força de elevação, força de rotação externa e de força de rotação interna com relevância estatística entre os grupos. Quando avaliado a diferença entre o membro operado e o contralateral, foi observado que não há significância estatística que justificaria por si a abordagem em um dos intervalos propostos. Conclusões: Apesar da amplitude de movimento não indicar um melhor tempo para a abordagem da lesão, o intervalo de 3 a 6 meses pós lesão, Grupo 1B, apresenta melhor desempenho nos scores funcionais que avaliam também a satisfação do sujeito a respeito da intervenção feita, o que pode justificar sua superioridade.
... 7,8,16,27 Repair failure is often related to factors such as patient age, tear size and chronicity, muscle atrophy, tendon quality, repair technique, and postoperative rehabilitation. 9,10,17,20,29,38 For more common tear patterns that typically involve small-to medium-sized tears, the failure rates range from 5% to 36%. 9,26,31 Therefore, improved repair strategies are needed that provide both mechanical stability and augmentation of the intrinsic tendon healing process. ...
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Background The rate of retear after primary rotator cuff failure remains unacceptably high (up to 36% for small- to medium-sized tears). Augmentation of cuff repair with scaffold devices has been reported to improve healing after cuff repair. Purpose/Hypothesis To describe the surgical technique of using an interpositional nanofiber scaffold during rotator cuff repair and report on a retrospective series of patients regarding functional outcomes and postoperative healing on magnetic resonance imaging (MRI). We hypothesized that augmentation of cuff repair with an interpositional scaffold would result in a high rate of tendon healing and excellent functional outcomes. Study Design Case series; Level of evidence, 4. Methods A total of 33 patients underwent arthroscopic rotator cuff repair augmented with a nanofiber, bioresorbable polymer patch secured as an inlay between the tendon and underlying bone. Patients were evaluated preoperatively and postoperatively with the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) shoulder score, and active range of motion (ROM) measurements. Postoperative MRI was used to evaluate repair status. Results At a minimum follow-up of 6 months, the patients showed significant improvement on SST and ASES scores ( P < .0001 for both). ROM in forward flexion, abduction, internal rotation, and external rotation significantly improved at 6 months postoperatively ( P < .05 for all). MRI at an average of 11 months postoperatively showed healing in 91% of patients; one patient had a recurrent tear with transtendon failure, and another patient had retear at the insertional site. The patch was not visible on postoperative imaging, suggesting complete resorption in all patients. No adverse events were associated with the patch. Conclusion Our results demonstrate the preliminary safety and efficacy of a novel, bioresorbable synthetic scaffold for rotator cuff repair. The use of the scaffold resulted in a 91% tendon healing rate and significant improvements in functional and patient-reported outcome measures. The results are promising for improving the current unacceptably high rate of rotator cuff repair failure.
... Restoring an anatomic footprint of the tendon is one of the crucial factors that leads to a good outcome. 2 Furthermore, an anatomic repair of the rotator cuff tendon is one of the few factors under the surgeon's control. Accurate knowledge of the footprint anatomy helps diagnose and treat the partial tears of the rotator cuff tendons and helps in recognizing the tear's pattern and accurately planning the surgical repair. ...
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Newer studies challenged the traditionally held belief that the supraspinatus inserts on the entire superior facet and the infraspinatus is attached on the entire middle facet of the greater tuberosity. They showed that the infraspinatus tendon is thicker anteriorly and can be differentiated from the posterior part of the supraspinatus. Hence, the newer studies showed that the supraspinatus attached in a much smaller area than previously thought, and infraspinatus occupied the lateral part of the superior facet of the greater tuberosity. This review aimed to present all the older and current knowledge of the rotator cuff insertion and discuss how this knowledge may affect the surgical repair of the rotator cuff tendons. Our review has synthesized and compared the differences and similarities between the older and the newer knowledge about the footprint anatomy of the cuff tendons and the capsule attachment. We have also highlighted how the newer knowledge impacts the way we treat the tears of the rotator cuff tendons. Level of evidence Review of basic science studies.
... Dislocation of the LHBT has been regarded as being associated with large or massive RCTs or an evolution of subluxation. 23 Four types of dislocation have been described: inside subscapularis, intra-articular dislocation with subscapularis tear, intra-articular dislocation with subscapularis-transverse ligament tear, and extraarticular dislocation. In our series, 6 patients with LHBT dislocations were found; in 4 cases, a large RCT was associated with an extra-articular dislocation with an empty groove; in the remaining patients, a subscapularis tear and a consequent intra-articular dislocation were diagnosed. ...
Article
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Purpose To evaluate the association between rotator cuff tear (RCT) size and long head biceps tendon (LHBT) pathology. Methods We retrospectively enrolled 202 consecutive patients (114 women and 88 men with mean age at surgery of 62.14 years [SD, 7.73]) who underwent arthroscopic rotator cuff repair for different sized full-thickness RCTs. LHBT pathology was evaluated considering the presence of inflammation, section alteration, loss of integrity, dislocation, dynamic instability, and absence. The site of LHBT pathology was evaluated considering 3 portions: (1) the insertional element; (2) the free intra-articular portion; (3) the part that enters the intertubercular groove. Statistics were evluated. Results The LHBT was absent in 22 cases (10.9%): 2, 4, 15, and 1 patients with small, large, massive, and subscapularis RCTs, respectively. A significant correlation was found between the prevalence of LHBT absence and massive RCTs (P < .001). In 53 patients (26%), there was a healthy LHBT; a healthy LHBT was present in 47%, 20% and 8% of small, large and massive RCTs, respectively. A significant correlation between LHBT inflammation, section alteration, loss of integrity, and RCT severity was found (P < .001, P < .001, and ). The insertional portion was the most involved (57% of cases); RCT severity was significantly associated with the number of involved portions (P < .001). Conclusions Shoulder LHBT pathology is associated with increasing rotator cuff tear size. Clinical Relevance Surgeons should be aware that biceps pathology is particularly prevalent in patients with larger RTCs.
... Arthroscopic surgery is regarded as the "gold standard" to treat rotator cuff injury due to its advantages including smaller incisions and fewer complications [12]. However, for patients with large-area rotator cuff injury, factors including injury area [13], patient age [14], injury time [15], tendon quality [16], tendon atrophy and fatty infiltration [17][18][19], as well as removal of suture anchor after surgery, rupture of suture materials, slippage of surgical knot, tendon cutting, or tears in a new position [20,21] may cause problems in the tendon-bone interface, such as difficulty in healing or formation of fibrovascular scar tissue interface. As a result, the new fibrous vascular tissue lacks the gradient mineral distribution and continuity of collagen fiber [22], and cannot recover to the original tissue structure and biomechanical properties, leading to the failure rate of rotator cuff repair between 20% and 95% [2,23,24]. ...
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Based on the published animal studies, we systematically evaluated the outcomes of various materials for rotator cuff repair in animal models and the potentials of their clinical translation. 74 animal studies were finally included, of which naturally derived biomaterials were applied the most widely (50.0%), rats were the most commonly used animal model (47.0%), and autologous tissue demonstrated the best outcomes in all animal models. The biomechanical properties of naturally derived biomaterials (maximum failure load: WMD 18.68 [95%CI 7.71–29.66]; P = 0.001, and stiffness: WMD 1.30 [95%CI 0.01–2.60]; P = 0.048) was statistically significant in the rabbit model. The rabbit model showed better outcomes even though the injury was severer compared with the rat model.
... Previous studies on rotator cuff outcomes have not made a distinction between gender and sex, and some have not even provided any data regarding either factor. Others have conducted secondary analyses with patient "gender" examined for its role in outcomes [7][8][9][10][11][12][13][14][15] with little commentary on the significance of any related findings. This may be understandable because gender was not the primary focus of any of the foregoing studies. ...
Article
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Background Although rotator cuff syndrome is common and extensively studied from the perspective of producing healed tendons, influence of gender on patient-reported outcomes is less well examined. As activity and role demands may vary widely between men and women, clarity on whether gender is an important factor in outcome would enhance patient education and expectation management. Our purpose was to determine if differences exist in patient-reported outcomes between men and women undergoing rotator cuff surgery. Methods One hundred forty-eight participants (76 W:72 M) aged 35–75 undergoing surgery for unilateral symptomatic rotator cuff syndrome were followed for 12 months after surgery. Demographics, surgical data, and the Western Ontario Rotator Cuff (WORC) scores were collected. Surgery was performed by two fellowship-trained shoulder surgeons at a single site. Results There were no gender-based differences in overall WORC score or subcategory scores by 12 months post-op. Pain scores were similar at all time points in men and women. Women were more likely to have dominant-arm surgery and had smaller rotator cuff tears than men. Complication rates were low, and satisfaction was high in both groups. Conclusion Patient gender doesn’t appear to exert an important effect on patient-reported rotator cuff outcomes in this prospective cohort. Further work examining other covariates as well as the qualitative experience of going through rotator cuff repair should provide greater insight into factors that influence patient-reported outcomes.
... While there is abundant literature reporting the results for surgical treatment of full thickness rotator cuff tears [9,10,[12][13][14][15][16][17], controversy exists around the timing for surgical repair of acute rotator cuff tears. The threshold of progression from an acute tear to a subacute tear to chronic cuff degeneration is not well defined [1,18,19] and the importance of time to repair is still inconclusive. ...
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IntroductionThe purpose of this study was to determine if delay (before or after 4 months) in repairing a symptomatic traumatic rotator cuff tear affected clinical outcome, re-rupture rates and use of interpositional dermal grafts.Methods This was a case matched (age + tear size) series of patients who underwent an early (≤ 4 months) or delayed (> 4 months) rotator cuff repair following a traumatic tear. If a direct repair could not be achieved a dermal interposition graft was used. Outcomes were collected at a median time of 30 months post-operatively using the Oxford, Constant and EQ5D scores.ResultsTwenty patients underwent rotator cuff repair within 4 months (1–4) of injury. Twenty age and cuff tear size—matched patients were identified who had undergone a delayed repair (4.1–24 months) after injury. We found no significant difference (p > 0.05) in patient reported outcomes scores between the early and delayed repair. [Oxford scores; Early 43(13–48), Delayed 45 (31–48); Constant scores; Early 73 (21–94), Delayed 73.5 (44–87); EQ5D; Early 0.75 (0.25–1), Delayed 0.77 (0.4–1)]. Time to full recovery was significantly longer (14 vs 33.8 months) for the delayed repair group (P > 0.05).When cuff tears were subdivided into < 3 cm tears or ≥ 3 cm tears, no significant difference outcome scores were founds. However, use of dermal interposition graft was 44% in delayed group for tears ≥ 3 cm. No grafts were used in early repair group. There was one symptomatic re-tear in our series which was in the early repair group.Conclusion When compared to the delayed repair group, patients that underwent early repair of traumatic rotator cuff tears had shorter time of recovery, and less need for allograft augmentation for tears 3 cm or greater. However, at mid-term follow-up, this study found no difference in patient reported outcomes following early versus delayed repair of traumatic rotator cuff tears.Level of evidence: 3
... The degree of atrophy and the amount of fatty degeneration in the SSP muscle bellies was assessed on sagittal T1 images and was graded from 0 to 4 using the Goutallier classification (Goutallier et al., 1994). RCT size was assessed based on the largest dimension and was graded as small (<1 cm), medium (1-3 cm), large (3-5 cm), or massive (≧5 cm) (Cofield et al., 2001). Four patients had small RCTs; nine patients had medium RCTs. ...
Article
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Introduction: This study aimed to compare the effect of the load of the upper limb on the stiffness of supraspinatus muscle regions during isometric shoulder abduction in the scapular plane in healthy individuals and patients with a rotator cuff tear. Materials and methods: Thirteen male patients were scheduled for arthroscopic rotator cuff repair, and 13 healthy male individuals were recruited. The movement task involved 30° isometric shoulder abduction in the scapular plane. The tasks included passive abduction, abduction with half-weight of the upper limb (1/2-weight), and full weight of the upper limb (full-weight). The stiffness of the supraspinatus muscle (anterior superficial, anterior deep, posterior superficial, and posterior deep regions) was recorded using ultrasound shear-wave elastography. Results: The stiffness of the anterior superficial region on the affected side was significantly lower than that on the control side for the 1/2-weight and full-weight tasks. The stiffness of the anterior deep, posterior superficial, and posterior deep regions was not affected. Discussion: This is the first study that investigated the mechanical effects of different loads on different supraspinatus muscle regions in rotator cuff tear patients. Our results indicate that the anterior superficial region in rotator cuff tear patients was mainly responsible for reduced active stiffness. This might be because this region contributes to force exertion and exhibits atrophy in rotator cuff tears. Hence, the anterior superficial region could be a focal point of quantitative dysfunction evaluation of the supraspinatus muscle in the case of a rotator cuff tear.
... The retracted rotator cuff may alter the course of the SSN, leading to a traction injury of the nerve [21]. The rotator cuff tears are classified into four categories according to Cofield: small tear < 1 cm, medium tear 1-3 cm, large tear 3-5 cm, and massive tear > 5 cm [22]. Lädermann et al. used a simple method (A-B-C-D) to classify the tear patterns: Type A: bone involvement; Type B:full thickness tendon lesion; Type C: musculotendinous junction leision; Type D: muscle insufficiency [23]. ...
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Purpose In the present study, we aimed to determine whether decompression of suprascapular nerve (SSN) at the spinoglenoid notch could lead to a better functional outcome for the patients who underwent repairment of rotator cuff due to posterosupeior massive rotator cuff tear (MRCT) and suprascapular neuropathy. Methods A total of 20 patients with posterosuperior MRCT and suprascapular neuropathy were analyzed in the present work. The preoperative magnetic resonance imaging (MRI) showed rotator cuff tear in supraspinatus and infraspinatus. All patients underwent arthroscopic rotator cuff repair. Patients were divided into two groups (group A: non-releasing, group B: releasing) according to whether the SSN at the spinoglenoid notch was decompressed. The modified University of California at Los Angeles shoulder rating scale (UCLA) and visual analog scale (VAS) questionnaire were adopted to assess the function of the affected shoulder preoperatively and 12 months after the operation. Electromyography (EMG) and nerve conduction study (NCS) were used to evaluate the nerve condition. Patients underwent MRI and EMG/NCS at 6 months after operation and last follow-up. Results All patients were satisfied with the treatment. MRI showed that it was well-healed in 19 patients at 6 months after the operation. However, the fatty infiltration of supraspinatus and infraspinatus was not reversed. Only one patient in the non-releasing group showed the retear. The retear rate of group A and group B were 30% (3/10) and 20% (2/10) respectively at 12 months after the operation. One patient undergoing SSN decompression complained of discomfort in the infraspinatus area. His follow-up EMG after 6 months showed fibrillation potentials (1+) and positive sharp waves (1+) in the infraspinatus. The other patients’ EMG results showed no abnormality. The postoperative UCLA and VAS scores were improved in both groups, and there was no significant difference in the follow-up outcomes between the two groups. Conclusions Patients with postersuperior MRCT and suprascapular neuropathy, decompression of suprascapular nerve at spinoglenoid notch didn’t lead to a better functional outcome with the repairment of rotator cuff. Arthroscopic rotator cuff repair could reverse the suprascapular neuropathy. Level of evidence Level III.
... The tear size was measured along the anterior-posterior (AP) and medial-lateral (ML) length [14]. According to the classi cation criteria proposed by Co eld [15], there were 22 cases of a small tear (0-1 cm), 69 cases of a medium tear (1-3 cm), and 11 cases of a large tear (3-5 cm). At 6, 12, and 24 months postoperatively, routine postoperative MRI was performed. ...
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Background: In the present study, we aimed to compare the clinical outcomes of patients who underwent single-stage or staged bilateral arthroscopic rotator cuff repair. Methods: From March 2013 to May 2018, a retrospective review on all patients who underwent bilateral arthroscopic rotator cuff repair at our department was performed. There were 24 patients in the single-stage group and 27 patients in the staged group. The minimum follow-up period was 2 years. The visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, Constant-Murley (Constant) score, and the range of motion (ROM) of the shoulder were evaluated for comparison between the two groups before and after the operation. Moreover, the hospitalization costs in the two groups were also recorded. Results: All 51 patients were available throughout follow-up. There was no significant difference in the VAS score (P=0.424), ASES score (P=0.325), UCLA score (P=0.170), and Constant score (P=0.275) between the single-stage group and the staged group before the operation. Postoperative clinical scores were significantly improved in both groups. The VAS score, ASES score, UCLA score, and Constant score were significantly different between the two groups at 6 months postoperatively (P<0.05). At 12, 18, and 24 months after the operation, the VAS score, UCLA score, Constant score, and ASES score were not significantly different between the two groups. At follow-up, the ROM of the shoulder was not significantly different between the two groups. Besides, there was a significant difference in hospitalization costs between the two groups (P<0.05). Furthermore, there was no significant difference in the VAS score, UCLA score, Constant score, ASES score, and ROM between the first surgery and second surgery in the single-stage group postoperatively. Conclusion: Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-up. Moreover, good outcomes were observed on both sides of the single-stage group.
... The degree of atrophy and the amount of fatty degeneration in the SSP muscle bellies was assessed on sagittal T1 images and was graded from 0 to 4 using the Goutallier classification [20]. RCT size was assessed based on the greatest dimension and graded as either small (< 1 cm), medium (1-3 cm), large (3-5 cm), or massive (≧ 5 cm) [21]. Three patients had a small RCT and five patients had a medium RCT. ...
Article
PurposeThis study aimed to investigate the time-course changes in the active stiffness of the supraspinatus muscle after arthroscopic rotator cuff repair.Methods Eight male patients (mean age 61.5 ± 9.4 years) who underwent arthroscopic rotator cuff repair for small to medium tears were recruited for this study. Movement tasks included 30° shoulder isometric abduction and maximal voluntary isometric contraction of shoulder abduction in the scapular plane. The stiffness of the supraspinatus (anterior superficial, anterior deep, posterior superficial, and posterior deep regions), upper trapezius, and middle deltoid muscles in bilateral shoulders was recorded using ultrasound shear wave elastography. For each subject, the measurement was performed preoperatively and 3, 6, and 12 months postoperatively.ResultsThe stiffness of the affected anterior superficial region of the supraspinatus muscle 12 months postoperatively was significantly higher than that measured preoperatively and 3 months postoperatively (p < 0.05); it was significantly higher at 6 months postoperatively than at 3 months postoperatively (p < 0.05). Further, the maximal voluntary isometric contraction had significantly improved 12 months postoperatively compared to that measured preoperatively and 3 months postoperatively (p < 0.05). The stiffness of the affected upper trapezius and middle deltoid muscles 12 months postoperatively was significantly lower than that preoperatively (p < 0.05).Conclusion The maximal voluntary isometric contraction 12 months postoperatively possibly increased because of improvement in the active stiffness of the anterior superficial region. Active stiffness of the anterior superficial region may improve 6 months rather than 3 months postoperatively because of the different stages of muscle force, structural repair tendon strength, and remodeling.
... In the German healthcare system, patients with shoulder problems often present initially to a general practitioner or general orthopedic doctor with no special training regarding the shoulder. Subscapularis (SSC) tendon tears are especially difficult to diagnose for non-specialized doctors and are often missed early on, leading to a delay in therapy [1]. Therefore, the written report from the radiologist is very important in terms of referring patients to specialist shoulder surgeons. ...
Article
Introduction Rotator cuff tears are one of the most common reasons for shoulder pain, and patients often present initially to general practitioners. However, subscapularis tears are especially difficult to diagnose and hence adequate therapy is often delayed. General practitioners or non-specialist orthopedic surgeons need reliable MRI findings to allow timely referral of patients to shoulder specialists. The purpose of this study was to determine the validity of the written MRI report of patients with arthroscopically proven subscapularis tendon tears. Method In this retrospective study, 97 patients (mean age 62.4 ± 10 years, 63 men) who underwent arthroscopic subscapularis repair between April 2013 and January 2015 by two experienced shoulder surgeons and who underwent a preoperative 1.5 T MRI study were included. All of these patients had high-field strength (i. e., ≥ 1.5 T) standard MRI scans performed within 4–164 (mean 57.4 ± 38.4) days before their arthroscopic procedures. Results and Conclusion Subscapularis tendon tears, verified by arthroscopy, were correctly identified in only 37 of 97 cases in the written report of the preoperative MRI. This resulted in an overall low sensitivity of 38.1 %. Correctly predicted lesions were as follows: Fox and Romeo I 29.4 % (5/17 patients), Fox and Romeo II 20 % (7/35 patients), Fox and Romeo III 46.7 % (14/30 patients) and Fox and Romeo IV 73.3 % (11/15 patients). In contrast, concurrent supraspinatus tendon tears were identified correctly in 88.2 % of patients (60/68 cases, sensitivity 88.2 %, specificity 96.5 %). Preoperative written radiology reports provided by a heterogeneous group of 39 presumably non-MSK-specialized radiologic centers do not reliably detect subscapularis tendon tears and are not sufficient for guiding patients to specialist centers. Compared to other rotator cuff injuries, this study shows difficulties in the correct diagnosis of subscapular tendon injuries. However, this is necessary to provide patients with timely therapy. It can be assumed that MRI review by musculoskeletal-specialized radiologists would more often than not lead to the correct diagnosis. Key Points: Citation Format
... The maximum length from anterior to posterior and from medial to lateral of the RCT was measured using a ruler. The tear size was also classified using the system reported by Cofield et al. [25]: small (< 1 cm), medium (1 to < 3 cm), large (3 to < 5 cm), or massive (≥ 5 cm). The following criteria of the rotator cuff tendon status described by Collin et al. [26] were used to evaluate soft tissue quality: good soft tissue quality was defined as satisfactory rotator cuff tissue with normal quality and thickness, moderate soft tissue quality was defined as a firm tendon with at least half its normal thickness, and poor soft tissue quality was defined as a soft or friable tendon with less than one-half its normal thickness. ...
Article
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Background Discriminating traumatic rotator cuff tears (RCTs) from degenerative RCTs is sometimes difficult in elderly patients because the prevalence of asymptomatic RCTs increases with age. Little intraoperative information is available on the characteristics of traumatic and degenerative RCTs in elderly patients. The purpose of this study was to compare the arthroscopic findings and histological changes of the coracoacromial ligament (CAL) between traumatic and degenerative RCTs in elderly patients. Methods Forty-two shoulders of 42 patients aged ≥ 65 years underwent arthroscopic rotator cuff repair. Nineteen patients had traumatic full-thickness RCTs (Group T), and 23 had degenerative full-thickness RCTs (Group D). The quality of the rotator cuff tissue and the condition of the long head of the biceps were examined. The grade of CAL was evaluated both arthroscopically and histologically. The stiffness of the musculotendinous unit was calculated by measuring the force and displacement using a tensiometer. The arthroscopic and histological findings of the two groups were compared. Results Although the mean tendon displacement was comparable, the stiffness was different between Group T and Group D (0.56 ± 0.31 and 1.09 ± 0.67 N/mm, respectively; p < 0.001). Both arthroscopic and histological analysis of the CAL showed that the degenerative changes in the CAL were milder in Group T than in Group D ( p < 0.001 and p < 0.001, respectively). There was a moderate positive correlation between the arthroscopic findings of CAL degeneration and the histopathological changes in this ligament (r = 0.47, p = 0.002). Conclusions Traumatic RCTs were characterized by preserved elasticity of the musculotendinous unit and milder CAL degeneration compared with degenerative RCTs even in elderly patients.
Article
Background Numerous surgical options are available for the management of massive irreparable rotator cuff tears, but there are no current definitive guidelines concerning the optimal treatment modality. The purpose of this study was to evaluate the efficacy and safety of a biodegradable subacromial spacer (InSpace) implantation in patients with irreparable rotator cuff tears. Methods A retrospective study was conducted involving 47 patients treated with the InSpace balloon between 2016 and 2018. Shoulder function was assessed using Constant Score. Pain was scored using a visual analogue scale, with scores ranging from 0 to 10. Results At an average follow-up of 24.6 months (range 12–38), the Constant Score had improved from 39.4 to 71.5 points (p < 0.0001). The range of motion, a main component of Constant Score, was improved after two years, from 27.6 to 42.2 points (p < .001). The visual analogue scale score decreased from 6.32 at baseline to a mean score of 2.7 points (p < 0.0001). Discussion Arthroscopic deployment of the InSpace device was found to be a safe, reliable treatment option in patients with painful irreparable rotator cuff tears, with meaningful improvement in shoulder function without serious complications.
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The musculoskeletal system is essential for maintaining posture, protecting organs, facilitating locomotion, and regulating various cellular and metabolic functions. Injury to this system due to trauma or wear is common, and severe damage may require surgery to restore function and prevent further harm. Autografts are the current gold standard for the replacement of lost or damaged tissues. However, these grafts are constrained by limited supply and donor site morbidity. Allografts, xenografts, and alloplastic materials represent viable alternatives, but each of these methods also has its own problems and limitations. Technological advances in three-dimensional (3D) printing and its biomedical adaptation, 3D bioprinting, have the potential to provide viable, autologous tissue-like constructs that can be used to repair musculoskeletal defects. Though bioprinting is currently unable to develop mature, implantable tissues, it can pattern cells in 3D constructs with features facilitating maturation and vascularization. Further advances in the field may enable the manufacture of constructs that can mimic native tissues in complexity, spatial heterogeneity, and ultimately, clinical utility. This review studies the use of 3D bioprinting for engineering bone, cartilage, muscle, tendon, ligament, and their interface tissues. Additionally, the current limitations and challenges in the field are discussed and the prospects for future progress are highlighted.
Article
Purpose: High-grade partial thickness rotator cuff tears (i.e., those involving at least 50% of the tendon thickness) are especially challenging to treat and various treatment strategies have been described. Prior studies have demonstrated equivalent outcomes between in situ tear fixation and tear completion repair techniques. However, it is unknown how repair of completed high-grade partial thickness tears to full tears compares to repair of full-thickness tears. The purpose of this study was to compare clinical outcome measures at least 1 year postoperatively between patients who had completion of a high-grade partial thickness supraspinatus tear to a full-thickness tear (PT) and those who had an isolated full-thickness supraspinatus tear (FT). The hypothesis of this study was equivalent retear rates as well as equivalent clinical and patient-reported outcomes between the two groups. Methods: A retrospective review of 100 patients who underwent isolated arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of 1 year follow-up was performed. Patients were separated into two groups based on their treatment: 56 had completion of a partial thickness supraspinatus tear to full-thickness tear with repair (PT) and 44 had isolated full-thickness supraspinatus repairs (FT). The primary outcome was rotator cuff retear, which was defined as a supraspinatus retear requiring revision repair. Secondary outcomes were patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV), range of motion (ROM) and strength in forward flexion (FF), external rotation (ER), and internal rotation (IR). Results: There was a significantly lower rate of retear between the PT versus FT groups (3.6% vs. 16.3%, p = 0.040). There were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all n.s.). Discussion: The data from this study demonstrated that the PT group had a significantly lower retear rate at 1 year follow-up than the FT group, while PROs, ROM, and strength were similar between the two groups. Patients with PT supraspinatus tears can have excellent outcomes, equivalent to FT tears, after completion of the tear, and subsequent repair with low retear rates. These findings may aid the treating surgeon when choosing between in situ fixation of the PT supraspinatus tear or completion of the tear and subsequent repair, as it allows the treating surgeon to choose the procedure based on comfort and experience level. Level of evidence: Level III.
Article
Rotator cuff tears (RCTs) are a common cause of disability and pain in the adult population. Despite the successful repair of the torn tendon, the delay between the time of injury and time of repair can cause muscle atrophy. The goal of the study was to engineer an electroconductive nanofibrous matrix with an aligned orientation to enhance muscle regeneration after rotator cuff (RC) repair. The electroconductive nanofibrous matrix was fabricated by coating Poly(3,4-ethylenedioxythiophene): poly(styrenesulfonate) (PEDOT:PSS) nanoparticles onto the aligned poly(ε-caprolactone) (PCL) electrospun nanofibers. The regenerative potential of the matrix was evaluated using two repair models of RCTs include acute and sub-acute. Sprague-Dawley rats (n=39) were randomly assigned to 1 of 8 groups. For the acute model, the matrix was implanted on supraspinatus muscle immediately after the injury. The repair surgery for the sub-acute model was conducted 6 weeks after injury. The supraspinatus muscle was harvested for histological analysis two and six weeks after repair. The results demonstrated the efficacy of electrical and topographical cues on the treatment of muscle atrophy in vivo. In both acute and sub-acute models, the stimulus effects of topographical and electrical cues reduced the gap area between muscle fibers. This study showed that muscle atrophy can be alleviated by successful surgical repair using an electroconductive nanofibrous matrix in a rat RC model.
Article
Background With the increasing number of patients undergoing arthroscopic rotator cuff repair (ARCR), postoperative pain control in these patients has become an important issue. We investigated and compared post-operative pain relief with intravenous acetaminophen (IA) and interscalene brachial plexus block (IBPB) after ARCR. Methods This prospective study involved 66 consecutive patients who underwent ARCR in 2019–2020 at our hospital. Overall, 23 and 43 shoulders were assigned to the IA and IBPB groups, respectively. We evaluated the visual analog scale (VAS) pain scores at rest, during activity, and at night for the first 72 h postoperatively. We compared the results statistically between the groups. A p-value <0.05 was considered statistically significant. Results VAS scores for night pain in the IBPB group were significantly lower than those in the IA group for the first 24 h postoperatively (p = 0.017). In contrast, the same scores were significantly lower in the IA group than in the IBPB group at 72 h postoperatively (p = 0.024). Other scores were not significantly different between the groups. Conclusions IBPB provides superior night pain control during the first 24 h postoperatively, and IA provides superior night pain control at 72 h postoperatively. However, there were no significant differences in other pain scores between the two groups.
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Background The irreparability of rotator cuff repair is generally determined during surgery. We have been performing partial repairs for rotator cuff tears that are deemed irreparable with primary repair. The aim of this study is to report, for the first time, the long-term postoperative outcome of our partial repair method, and to clarify the criteria for the irreparability of primary repair. Methods The UCLA score, radiographical findings, and MRI findings of 156 shoulders that underwent rotator cuff repair (primary repair, 126 shoulders; partial repair, 30 shoulders) were retrospectively evaluated at preoperative and > 10-year postoperative follow-up (mean evaluation time, 11.5 ± 1.0 years). Osteoarthritic (OA) changes were evaluated by radiographical findings, and the cuff integrity (Sugaya classification) and fatty infiltration (Goutallier classification) were evaluated by MRI findings. These evaluations were compared between a primary repair group and partial repair group. Results Although no significant difference was observed between pre- and postoperative findings for the UCLA score, the strength of forward flexion was significantly lower at 10 years postoperatively in the partial repair group. Preoperative image evaluation showed no significant difference in OA changes between the two groups; however, fatty infiltration showed significantly greater progression in the partial repair group than the primary repair group. At > 10-year postoperative follow-up, the OA changes, cuff integrity, and fatty infiltration showed significantly greater progression in the partial repair group compared to the primary repair group. Although the long-term outcome of the partial repair group was inferior to that of the primary repair group in imaging evaluations, good functional outcome of the shoulder joint was maintained. Conclusion Our results suggested that partial repair could be an effective treatment option for irreparable rotator cuff tear. In terms of the feasibility of primary repair, the cut-off value for preoperative fatty infiltration was Stage 2; thus, we believe that primary repair should be performed for cases with Stage 2 fatty infiltration or lower, and partial repair should be performed for cases with Stage 3 fatty infiltration stage 3 or higher. However, manual workers and athletes with Stage 3 fatty infiltration or higher should be advised in advance that mild muscle weakness may remain after surgery.
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Background Degenerative and traumatic changes to the rotator cuff can result in massive and irreparable rotator cuff tears (RCTs). Purpose/Hypothesis The study objective was to conduct a biomechanical comparison between a small, incomplete RCT and a large, complete RCT. We hypothesized that the incomplete supraspinatus (SS) tear would lead to an incremental loss of abduction force and preserve vertical position of the humeral head, while a complete SS tear would cause superior humeral migration, decrease functional deltoid abduction force, and increase passive range of motion (ROM). Study Design Controlled laboratory study. Methods Six cadaveric shoulders were evaluated using a custom testing apparatus. Each shoulder was subjected to 3 conditions: (1) intact/control, (2) 50%, full-thickness, incomplete SS tear, and (3) 100%, complete SS tear. Deltoid abduction force, superior humeral head migration, and passive ROM were measured in static conditions at 0°, 30°, and 60° of glenohumeral abduction, respectively. Results The intact SS resulted in a mean deltoid abduction force of 2.5, 3.3, and 3.8 N at 0°, 30°, and 60° of abduction, respectively. Compared with the intact shoulder, there was no significant difference in mean abduction force seen in the incomplete tear, while the force was significantly decreased by 52% at 30° of abduction in the complete tear ( P = .009). Compared with the incomplete tear, there were significant decreases in abduction force seen in the complete tear, by 33% and 48% (0.9 N and 1.1 N) at 0° and 30° of abduction, respectively ( P = .04 and .004). The intact configuration experienced a mean superior humeral head migration of 1.5, 1.4, and 1.1 mm at 0°, 30°, and 60° of abduction, respectively. The complete tear resulted in a superior migration of 3.0 and 4.4 mm greater than the intact configuration at 0° and 30° of abduction, respectively ( P = .001). There was a 5° and 10° increase in abduction ROM with 50% and 100% tears, respectively ( P = .003 and .03). Conclusion An incomplete SS tear does not significantly alter the biomechanics of the shoulder, while a large, complete SS tear leads to a significant superior humeral migration, a decreased deltoid abduction force, and a mild increase in passive ROM. Clinical Relevance Our findings demonstrate the effects of large SS tears on key biomechanical parameters, as they progress from partial tears.
Article
The shoulder joint is vulnerable for injuries following trauma and in the context of sporting activities. Degenerative rotator cuff disease is also a common entity. Conservative therapy is often not indicated or does not lead to the desired success, so surgical intervention is necessary. Routine follow-ups, but also persistent complaints, delayed healing, or recurrent trauma, usually need postoperative imaging of the shoulder. The choice of the adequate imaging modality and technique is important to reach the correct diagnosis. Additionally, knowledge of the most common surgical procedures, as well as typical normal findings and expected pathologies on different imaging modalities, is crucial for the radiologist to play a relevant role in the postoperative diagnostic process. This article addresses postoperative imaging after rotator cuff repair, shoulder arthroplasty, and surgery for shoulder stabilization with an emphasis on computed tomography and magnetic resonance imaging.
Article
Introduction Indications for reverse total shoulder arthroplasty (RTSA) have expanded over recent years. Whilst cuff tear arthropathy is an accepted indication, the results of its use in those without arthritis is not clear. The aim of this article is to review the literature on RTSA for massive rotator cuff tears without associated arthritis. Methods A systematic review search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to find all studies with clinical outcomes on RTSA performed for massive irreparable rotator cuff tears (MIRCT) without arthritis. Results Of the 160 studies produced by the search, a detailed analysis found 11 articles to be included in this review. There was variability in the implant style used and the outcome measures utilised, but all studies found improvement in the outcome following RTSA. Many studies advised judicious use following high complication rates, and caution was advised in those patients with pre-operatively preserved active forward elevation. Conclusion The available evidence suggests that RTSA is a reliable option in older patients with persistent pain and lack of function following MIRCT even without arthritis. However, as outcomes are not significantly worse following failed rotator cuff repair, joint preserving options in the younger age group should be carefully considered in light of the relatively high complication rate associated with RTSA. Level of evidence IV.
Article
Objective The purpose of this guide is to illustrate an arthroscopic rotator cuff repair (RCR) with two techniques for biologically enhanced patch augmentation.IndicationsMassive rotator cuff tears (> 5 cm) and revision RCR.ContraindicationsActive joint or systemic infection; severe fatty muscle atrophy; severe glenohumeral arthropathy; American Society of Anesthesiologists Physical Status (ASA PS) IV.Surgical techniqueDermal allograft patch augmented with concentrated bone marrow aspirate (cBMA), platelet-rich plasma (PRP) and platelet-poor plasma (PPP); or Regeneten patch augmented with bursa, PRP, PPP, and autologous thrombin.Postoperative managementA 30° abduction sling for 6 weeks; unrestricted active-assisted external rotation and forward elevation after 12 weeks; focus on restoration of scapular stability and strength.ResultsA total of 22 patients received revision massive RCR using a dermal allograft patch enhanced with cBMA and PRP with a mean follow-up of 2.5 years (1.0–5.8 years). There was a significant improvement in the preoperative Simple Shoulder Test (SST). There was also a trend towards improved pain and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. In this cohort, 45% reached the minimal clinically important difference (MCID), 41% achieved substantial clinical benefit (SCB), and 32% had a patient-acceptable symptomatic state (PASS) for the ASES score. Preliminary data using the Regeneten patch technique with bursa, PRP, PPP, and autologous thrombin was prospectively collected in five patients between 05/2020 and 03/2021 at the author’s institution. Mean follow-up was 6.5 ± 1.3 (6–8 months). There was an improvement from preop to postop in pain, ASES, SANE, Constant–Murley (CM) score and active range of motion.
Article
Purpose: Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes. Methods: Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed. Results: This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups. Conclusion: The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR. Level of evidence: III.
Article
Objective: To evaluate if deep learning is a feasible approach for automated detection of supraspinatus tears on MRI. Materials and methods: A total of 200 shoulder MRI studies performed between 2015 and 2019 were retrospectively obtained from our institutional database using a balanced random sampling of studies containing a full-thickness tear, partial-thickness tear, or intact supraspinatus tendon. A 3-stage pipeline was developed comprised of a slice selection network based on a pre-trained residual neural network (ResNet); a segmentation network based on an encoder-decoder network (U-Net); and a custom multi-input convolutional neural network (CNN) classifier. Binary reference labels were created following review of radiologist reports and images by a radiology fellow and consensus validation by two musculoskeletal radiologists. Twenty percent of the data was reserved as a holdout test set with the remaining 80% used for training and optimization under a fivefold cross-validation strategy. Classification and segmentation accuracy were evaluated using area under the receiver operating characteristic curve (AUROC) and Dice similarity coefficient, respectively. Baseline characteristics in correctly versus incorrectly classified cases were compared using independent sample t-test and chi-squared. Results: Test sensitivity and specificity of the classifier at the optimal Youden's index were 85.0% (95% CI: 62.1-96.8%) and 85.0% (95% CI: 62.1-96.8%), respectively. AUROC was 0.943 (95% CI: 0.820-0.991). Dice segmentation accuracy was 0.814 (95% CI: 0.805-0.826). There was no significant difference in AUROC between 1.5 T and 3.0 T studies. Sub-analysis showed superior sensitivity on full-thickness (100%) versus partial-thickness (72.5%) subgroups. Data conclusion: Deep learning is a feasible approach to detect supraspinatus tears on MRI.
Thesis
Due to its unique anatomy and biomechanics, the shoulder shows some distinctive patterns while ageing. Several controversies are ongoing in the field of imaging, clinical testing, and existing and trending treatments for ageing patients with shoulder pain. Part 1 is an MRI study about osteoarthritis of the outer collar bone joint. Part 2 of the thesis has several studies about the function of rotator-cuff tendons and the evaluation of surgical techniques. One of these analyses shoulder movements of patients with a torn rotator cuff compared to a control group. Several specific movement patterns were shown including hyperactivity of the biceps muscle. If non-operative treatment of rotator cuff tears fails, and the tendon can not be repaired, a dissection of the biceps tendon with key-hole surgery can be a solution. After surgery, the majority of the patients gain function and have less pain. This biceps tendon, which runs partially through the shoulder joint, can be used as a graft in rotator cuff surgery. Based on the literature this seems to be a good option. Based on these results a novel technique is developed to use the biceps tendon as an enforcement of the rotator cuff during arthroscopic surgery. Clinical results are described in a pilot study. Part 3 describes several trends in the Netherlands on the treatment of shoulder pain after the publication of the guideline in 2016. The results of this thesis will help caregivers to give patients with shoulder pain the best treatment
Article
Background An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques. Material and methods The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants. Results A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0–56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5). Conclusion Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.
Article
Background: Shoulder pain is a common musculoskeletal complaint in the general population, mostly in the elderly. Among them, the rotator cuff problems are found to be most common causes. The treatment of rotator cuff pathology has progressed from open repair, first described by Codman in 1911 to arthroscopy assisted “mini open” techniques, to all arthroscopic repair techniques, first reported by Johnson who used metal staples while E.M. Wolf pioneered the first completely arthroscopic repair using suture anchors in 1990. The purpose of this study is to evaluate the functional outcome following all arthroscopic repairs of full-thickness rotator cuff tears with suture anchors. Materials and Methods: A prospective study was done for 24 shoulders in 24 patients treated for full-thickness rotator cuff tear by all-arthroscopic repair between February 2014 and September 2015 and followed until May 2018. The results were evaluated using the University of California at Los Angeles (UCLA) shoulder scoring system. Patients younger than 18 and over 80 and also those with bony lesion were excluded from the study as were those which might have confounded the outcome were excluded. Results: Among the 24 patients, the UCLA clinical scores were excellent in 12 patients, good in 9 patients, fair in 2 patients, and poor in 1 patient. The average UCLA score was 31.84. Conclusion: All-arthroscopic repair is an excellent treatment option for full-thickness rotator cuff tears, although with a steep learning curve.
Article
Background The purpose of this study was to compare the efficacy of tranexamic acid versus placebo after arthroscopic rotator cuff repair. Methods This prospective, double-blind, and randomized study involved 66 patients who consecutively underwent arthroscopic rotator cuff repair from 2020 to 2021 at our hospital. Thirty-three shoulders each were randomly assigned to the tranexamic acid and control groups. In the former group, 1000 mg of tranexamic acid (20 mL) was administered intravenously 10 min before surgery and the same volume of normal saline (20 mL) was administered intravenously in the control group. We evaluated visual clarity; visual analog scale pain scores at rest, during activity, and at night; the circumference and diameter of the shoulder joint in the groups before and after the surgery at 1, 2, and 3 days, and 1 week; estimated perioperative blood loss; and operative time. Visual clarity was rated using a numeric rating scale from grade 1 (poor) to grade 3 (clear) every 15 min throughout the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. Results Visual clarity was found to be significantly better in the tranexamic acid group, with a greater percentage of grade 3 visual clarity (75.6 ± 11.2% vs 68.1 ± 13.4%, p = 0.045). The visual analog scale scores at rest and at night in the control group were significantly lower than those in the tranexamic acid group for 1 week postoperatively (13.8 ± 14.8 vs 5 ± 9.3, p = 0.008, 36.1 ± 23.3 vs 19.3 ± 24, p = 0.012). The circumference and diameter of the shoulder joint, estimated perioperative blood loss, and operative time were not significantly different between the two groups. Conclusion Intravenous administration of tranexamic acid is an alternative way to improve visual clarity in arthroscopic rotator cuff repair; however, there are no other significant differences compared to the administration of placebo.
Chapter
Subscapularis failure and insufficiency after prior repair surgery represent a difficult problem. Although one option is revision to reverse shoulder prosthesis, in many cases of a young, active patient, other options should be considered. The problem of subscapularis failure after surgery becomes even more debilitating in the setting of a failed shoulder arthroplasty. Pectoralis major tendon transfer and latissimus dorsi tendon transfer remain a reasonable salvage option to address this difficult problem, with reliable improvements in pain, range of motion, and patient satisfaction and functional outcomes.
Article
Introduction The aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigation Methods Journal Citation Index was searched to find articles using the search terms pertaining to “rotator cuff repair”. All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade. Results All the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade's most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade. Conclusion There are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.
Article
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In this paper, we have evaluated the clinical efficacy of rotator cuff surgery combined with Chinese medicine Buyang Huanwu Decoction (adding medicine) in the treatment of patients with rotator cuff injury. For this purpose, sixty patients with rotator cuff injury and shoulder arthroscopic surgery were selected in this hospital (where 57 cases were finally screened). The patients were divided into a control group (28 cases) and a study group (29 cases) by the envelope method. The control group received conventional treatment after the operation, whereas the study group was combined with Buyang Huanwu Decoction after the operation. The clinical efficacy of the two groups, particularly after treatment, was compared in terms of self-care ability and Constant–Murley scores before and after treatment, that is, 4 w, 8 w, and 12 w. The total effective rate of treatment in the study group was significantly higher than that of the control group after 4 weeks of treatment (P<0.05). There was no significant difference in the FIM self-care scores of the two groups before treatment (P>0.05). In the study group patients, after treatment for 4 w and 8 w, the FIM self-care score was significantly improved (P<0.05). The FIM self-care score of the patients in the study group, after 12 w of treatment, had no significant difference compared with the control group (P>0.05). The Constant–Murley scores of the two groups were compared before treatment where no significant difference is observed (P>0.05) and the Constant–Murley score of the study group patients was significantly higher than that of the control group, after 4 w and 8 w treatment (P<0.05). Additionally, Constant–Murley score of the study group was not significantly higher than that of the control group after 12 w of treatment difference (P>0.05). The proposed combined treatment program has value of promotion and implementation in the clinical treatment of patients with rotator cuff injury.
Chapter
The objective of this chapter is to define further the clinical value of moment arms and provide a descriptive approach based on experimental investigation into the calculation of moment arm for the rotator cuff muscles spanning the glenohumeral joint during abduction. With the advent of imaging techniques quantifying the muscle torque capacity can be a reliable tool for clinical assessment of RC repairs as well as GH joint arthroplasty. Joint kinematics and muscle force estimation are essential for quantification of patient outcome and rehabilitation. Methods used in the calculation of moment arms usually referred to as the geometric approach and excursion method are directly related through principle of virtual work and moment equations where both require a center of rotation and a measureable distance to the line of action of the muscle force or simply the rate of change in the excursion of the muscle force length. In this chapter experimental data is provided for two muscles supraspinatus and subscapularis, respectively where a combination of a 3D model and digitized points along the tendons attachment and insertion surface area are used in the analysis.
Article
Background: In shoulders with irreparable massive rotator cuff tears (RCTs) with high-grade fatty degeneration (Goutallier stage 3 or 4) of the supraspinatus tendon and low-grade fatty degeneration (Goutallier stage 1 or 2) of the infraspinatus tendon (ISP), arthroscopic patch grafting (PG) has been reported as superior to partial repair (PR) regarding the ISP retear rate at short-term to midterm follow-up. However, the longer term outcomes are unclear. Purpose: To compare clinical and structural outcomes in the PG and PR groups at a minimum of 7 years postoperatively. Study design: Cohort study; Level of evidence, 3. Methods: We evaluated 24 patients in the PG group and 24 patients in the PR group. We primarily used the Constant score for clinical outcomes and performed magnetic resonance imaging for structural outcomes in the PG and PR groups. The risk factors for a retear of the ISP were identified by univariate and multivariate (forward stepwise selection method) logistic regression analyses. We primarily compared values at midterm follow-up (<4 years) with values at the final follow-up (minimum 7 years) for each patient. Results: The mean midterm and final follow-up times for the PG group were 41.0 and 95.1 months, respectively, compared with 35.7 and 99.3 months, respectively, for the PR group. We found significant differences for the midterm and final follow-up Constant total scores in the PG and PR groups (midterm follow-up: 79.1 vs 69.9, respectively [P = .001]; final follow-up: 76.0 vs 65.3, respectively [P = .006]) and in the Constant strength scores (midterm follow-up: 14.6 vs 8.5, respectively [P < .001]; final follow-up: 13.1 vs 8.3, respectively [P = .001]). Treatment group (PR) was a significant predictor of an ISP retear in the logistic regression analysis (odds ratio, 3.545; P = .043). Conclusion: Patients with low-grade massive RCTs treated with PG or PR improved significantly in terms of clinical outcomes at the midterm and final follow-up time points. However, Constant scores were significantly better in the PG group at the final follow-up.
Preprint
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Background: Split fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method. Methods: We created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCTs) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed. Results: The mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicates that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment. Conclusions: Biomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.
Article
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Background Bigliani types of acromion and critical shoulder angle (CSA) have been implicated as indicators of rotator cuff disease. A sharpened inferolateral edge of acromion (termed as Sharpened Lateral Acromion Morphology or SLAM sign) is frequently observed in anteroposterior radiographs of the glenohumeral joint in patients with rotator cuff tears (RCT). We aimed to evaluate the association of the SLAM sign with RCT in comparison to high CSA (≥ 35°) and Bigliani type 3 (hooked) acromion. Methods A cohort of 100 consecutive patients undergoing non-arthroplasty surgery for RCT and 106 patients with primary frozen shoulder were matched manually in 1:1 ratio based on age and gender to yield study population with 50 patients in each group. The two groups were compared for the presence of the SLAM sign, high CSA, and type 3 acromion on the radiographs. Results All the three parameters were found more prevalent in the RCT group than the frozen shoulder group (SLAM, 46% vs 0; high CSA, 60% vs 40%; type 3 acromion, 18% vs 4%) (P < 0.05). The SLAM sign showed stronger correlation with RCT than high CSA and type 3 acromion (Ps = 0.562 vs 0.220 vs 0.224 respectively). Conclusion The SLAM sign is a simple and easily identifiable radiological predictor of rotator cuff disease.
Article
Purpose Examine SCR outcomes after minimum 2-year follow-up and determine risk factors predictive of outcomes. Methods Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable RCT met inclusion criteria; minimum 2-year follow-up was obtained on 32 patients (80% follow-up). Patient demographics and pre-operative clinical findings were collected. Post-operative data including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected. Results The Hamada score was ≤ 2 in 88% with average AH interval distance of 6.8 mm. Pre-operatively 6 patients had ER lag (19%) and 6 had pseudoparalysis (19%). Intra-operative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31-degree increase; p=0.007) and strength in all planes (all p<0.05). Patient-reported outcomes significantly improved (ASES 34-point increase; VAS 2.9-point decrease; SANE 48-point increase; all p<0.05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 post-operative falls; 1 persistent severe pain; 1 persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n=6) had significant improvement in post-op FE (28 vs 154 degrees; p<0.0001) and SANE score (p=0.016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n=12), significant improvement was seen in post-op FE (108 vs 158 degrees; p=0.019) and patient-reported outcome scores (p<0.005). In patients converted from SCR to rTSA (n=3) there were no distinguishing characteristics present. Conclusion Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant post-op improvement in FE and patient-reported outcomes.
Article
A dor no ombro constitui uma apresentação clínica comum e os distúrbios do manguito rotador (MR) são considerados a principal causa desse tipo de dor, além de causar sintomas como fraqueza muscular e perda de amplitude de movimento articular do ombro, que podem resultar em restrições das atividades diárias. O reparo artroscópico das lesões do MR apresenta-se como solução para os pacientes sintomáticos, com resultados satisfatórios em até 93% dos pacientes. O objetivo do estudo foi determinar quais fatores prognósticos, de forma independente, influenciaram os desfechos clínicos do reparo artroscópico do MR. Trata-se de um estudo transversal, retrospectivo, com 144 pacientes. Foram utilizados teste de correlação e regressão multivariada para analisar os seguintes conjuntos de variáveis: 1) Avaliação pré-operatória; 2) Variáveis intrínsecas ao paciente, relacionadas à lesão, relacionadas ao procedimento e 3) Avaliação funcional pós-operatória. Os resultados avaliados pelas escalas funcionais UCLA e Constant Murley apresentaram 131 (91,61%) pacientes com resultados excelentes e bons e 89 (72,02%) com resultados excelentes, bons e satisfatórios, respectivamente. Houve redução significativa da dor pós-operatória (p2,2 x 10–16). A idade apresentou correlação com o tamanho da lesão, em que pacientes com idade mais avançada apresentaram lesões maiores (p=0,01). Após a aplicação das regressões multivariadas as seguintes variáveis estiveram correlacionadas com piores resultados clínicos: dislipidemia (p=0,04), obesidade (p=0,026), idade (p=0,04), membro dominante operado (p=0,04). Fixação completa das lesões (p=0,019) e lesão do supraespinhal (p=0,032) estiveram relacionadas com melhores resultados clínicos. Pode-se concluir que o reparo artroscópico das lesões do manguito rotador apresentou resultados satisfatórios de acordo com as escalas funcionais utilizadas. Dislipidemia, membro dominante operado, fixação completa da lesão, obesidade, lesão do supraespinhal e idade foram fatores preditores associados aos resultados clínicos.
Article
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Thirteen patients with 14 large rotator cuff tears were operated on using carbon fiber to cover the defect. The median follow-up time was 4 years. In 11, 1, and 2 cases the results were respectively excellent or good, fair, and poor. In 2 cases where the carbon fiber was anchored to the major tuberosity, a bone cyst was seen, but it did not influence the result. A carbon fiber tow application combined with Neer's anterior acromioplasty seems useful in the reconstruction of large tears of the rotator cuff.
Article
Impingement on the tendinous portion of the rotator cuff by the coracoacromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurface of the anterior process of the acromion and this area may also show erosion and eburnation. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coracoacromial ligament. The impingement may also involve the tendon of the long head of the biceps and if it does, it is best to decompress the tendon and remove any osteophytes which may be in its groove, but to avoid transplanting the biceps tendon if possible. Hypertrophic lipping at the acromio-clavicular joint may impinge on the supraspinatus tendon when the arm is in abduction and, if the lip is prominent, this joint should be resected. These are the principles of anterior acromioplasty.
Article
A review of 30 patients who underwent a primary repair of their rotator cuff 10 years previously was performed. The average age of the patients at the time the operation was performed was 51 years (range 20 to 65 years). Twenty-seven men and three women were reviewed. An acromioplasty was performed in all patients. No patient had a distal clavicle excision. There were 12 small, 11 medium, five large, and two massive tears. A significant decrease in pain after surgery and a return to preinjury activities occurred in 82% of the patients. Subjective results were excellent or good in 70% of the patients. Good or excellent results were achieved in 80% of the 25 patients with objective data. In the overall results (subjective and objective), 64% of the patients had a good or excellent outcome. By Neer's criteria, 72% satisfactory results were achieved. No significant prognostic indicators were identified in this study, although a trend toward better results occurred in patients less than 55 years old and in those patients with smallor medium-sized tears. The findings of this study confirm the view that the results of rotator cuff repairs do not deteriorate, with follow-up extending to 10 years.
Article
Sixty-one patients had operative repair of a massive rotator cuff tear and were followed an average of 7 years (range 3 to 13 years). The mean age of the patients was 62 years; there were 40 male and 21 female patients. All patients had significant pain, 31 patients had insidious onset of pain, and 30 patients recalled a traumatic event. Preoperatively, average active forward elevation was 88°, and average active external rotation was 27°. Forty-nine (80%) patients had marked atrophy of the supraspinatus and infraspinatus muscles. All patients had subacromial decompression as well as mobilization and transposition of rotator cuff tendons with tendon repair to bone. Fifty-two (85%) patients had satisfactory results, with 32 (52%) rated excellent and 20 (33%) rated good. Nine (15%) patients had unsatisfactory results, with four (7%) rated fair and five (8%) rated poor. Ninety-two percent of patients had satisfactory pain relief. The mean gain in forward elevation was 76%, and in active external rotation it was 30°. Adequate pain relief and the ability to raise the arm above the horizontal plane were achieved in 56 (92%) patients. Two patients tore their rotator cuff again after significant trauma.
Article
In a prospective study, 87 consecutive patients with 88 chronic, full-thickness tears of the rotator cuff were randomly assigned to either open surgical tendon repair and anterior acromioplasty (50 shoulders) or arthroscopic debridement and subacromial decompression (38 shoulders). All patients were reexamined 2 to 5 years after the operation with the University of California at Los Angeles 35-Point Scale for Pain and Function of the Shoulder. The average ratings were 30.5 (rotator cuff repair) and 25.1 (arthoscopic debridement/decompression) for each group. The open surgical repair group faired significantly better than the arthroscopic debridement group (p = .0028). Thirteen required subsequent procedures, four with tendon repair and nine with decompression. Five in the decompression group experienced cuff tear arthropathy. Surgical repair of full-thickness rotator cuff tears provided results superior to those of arthroscopic debridement and subacromial decompression.
Article
Two hundred and seventy six patients with 292 symptomatic full thickness rotator cuff tears were examined. Of 214 patients with 227 symptomatic tears seen prior to surgical intervention, 22 (14%) subsequently were operated upon by the authors. Pain, weakness in shoulder elevation, and crackling and popping in the shoulder were the 3 most common symptoms of full thickness tears. Selective supraspinatus or infraspinatus atrophy, palpable cuff tear, and palpable crepitus on passive shoulder rotation were the 3 most common signs of the full thickness cuff tear. The criteria for operative intervention are delineated. Arthrography was a valuable objective method of demonstrating the full thickness cuff tear, but the size of the tear did not necessarily correlate with the arthrogram. Saber cut incision with deltoid detachment, excision of the subdeltoid bursa and coracoacromial ligament, and downward traction on the freely draped arm afforded excellent visualization for mobilization and repair of the torn cuff. Vertical acromionectomy was unnecessary. Poor postoperative results were due to inadequate exposure, limited anterior deltopectoral incisions, vertical acromionectomies, preoperative limitation of passive motion, and poor patient selection. The course of full thickness cuff tears managed nonoperatively is outlined; 59% of the patients had excellent to good results. With proper patient selection, operative repair of full thickness cuff tears, including massive avulsions, is a worthwhile procedure for the patient. Eighty four per cent of the patients selected for surgery by the authors' criteria obtained excellent or good results.
A prospective study was done on 73 patients who underwent surgical repair of a rotator cuff tear. The patients were divided into four groups according to the active shoulder flexion and the trophism of the rotator cuff muscles: group A--range of motion > 100 degrees; group B--ROM 60-100 degrees; group C--ROM < 60 degrees; group D--ROM < 100 degrees and significant muscle hypotrophy. The rotator cuff tears were classified into four groups at surgery according to size: grade I measured < 2 cm; grade II measured 2-4 cm, grade III measured > 4 cm but was reparable; and grade IV was irreparable. The results were evaluated after an average follow-up of 2.3 years and correlated to several factors including the preoperative clinical assessment, the size of the lesion, the type of lesion (tear or detachment), and the mechanism of injury (traumatic or atraumatic). Seventy-three percent of the cases had satisfactory results. The preoperative clinical assessment and the size of the tear were the most important indicators of the final outcome. The proportion of satisfactory results underwent a progressive decline from group A (88%) to group D (14%) and from grades I and II (88% and 89%, respectively) to grade III (56%) and grade IV (none). Rotator cuff repair is almost always successful in patients with more than 60 degrees of active arm flexion and either small or medium-size tears. Less than two-thirds of the patients with major tears and less than 60 degrees of motion achieve satisfactory results. Failure is highly probable in irreparable tears and in the presence of significant hypotrophy of the rotator cuff muscles.
Article
Thirty-eight shoulders of 36 patients with incomplete rotator cuff tears surgically repaired were evaluated, with an average follow-up period of 4.9 years. The average age at operation was 52.2 years. Three types of incomplete tears were identified: superficial (12 shoulders), intratendinous (three), and deep surface tears (23). Full-thickness cuff involving the lesion was resected and repaired by side-to-side suture (13 shoulders), side-to-bone suture (eight), fascial patch grafting (16), or side-to-bone suture with fascial patch grafting (one). The overall results were satisfactory in 31 shoulders (82%). The results were not affected by the tear types, operative methods, or follow-up period. The patients with poor results were associated with major complications other than rotator cuff tears or with insufficient resection of the damaged cuff. When the full-thickness cuff involving the lesion is completely resected and repaired, long-term satisfactory results can be anticipated in a high percentage of patients regardless of tear types.
Article
Using 26 cadaver shoulders, we produced a standard defect in the supraspinatus tendon and performed one of three types of repair. Their strength was found by testing in tension the force required to produce a gap of 3 mm, then 6 mm, and finally total disruption of the repair. The use of a polyethylene patch to spread the forces over the lateral bone surface and of extra sutures to grasp the tendon end raised by 2.6 times the load at which a 3 mm gap in the repair occurred and by 1.7 times the load to failure.
Article
Sixteen irreparable, massive rotator cuff tears were treated with latissimus dorsi transfer and reviewed after an average of 33 months. There were no neurovascular complications or infections. Pain relief was satisfactory in 94% of the shoulders at rest and in 81% on exertion. Flexion was 83 degrees preoperatively and 135 degrees postoperatively. The functional value of the shoulder averaged 73% of an age- and gender-adjusted normal score. For the 12 shoulders with a functional subscapularis, it averaged 82%; for those four without a functioning subscapularis, 48%. If the subscapularis was torn and could not be adequately repaired, latissimus dorsi transfer was of no value. In cases with good subscapularis function but irreparable defects in the external rotator tendons, restoration of approximately 80% of normal shoulder function was obtained, indicating that latissimus dorsi transfer is a safe and valuable alternative for the treatment of this specific type of irreparable rotator cuff tear.
Article
We evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. We correlated the functional result with the integrity of the cuff, as determined by ultrasonography. Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect. The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Arthroscopic subacromial decompression has become an accepted treatment for patients with impingement syndrome; however, its use for full-thickness rotator cuff tears is controversial. We observed 25 patients with full-thickness rotator cuff tears treated by arthroscopic subacromial decompression and cuff debridement alone with a minimum of 1 year follow-up observation. Based on the University of California at Los Angeles shoulder rating, 84% of the cases were rated as excellent or good. There was significant improvement in pain, function, motion, and strength. Eighty-eight percent of the patients were satisfied with the procedure. Although all tear sizes improved significantly, smaller tears fared better than larger tears. The preliminary results of arthroscopic subacromial decompression with cuff debridement compare favorably to open techniques of rotator cuff repair with or without acromioplasty and should be considered in selected patients with full-thickness rotator cuff tears.
Article
Thirty-one patients with arthroscopically documented partial thickness rotator cuff tears treated by arthroscopic debridement of the lesion were retrospectively reviewed. The patients had had symptoms for an average of 20.5 months prior to surgery. Twenty-two of these 31 shoulders also had bursoscopy, with 18 having arthroscopic subacromial decompression. The results were graded by both the UCLA Shoulder Rating Scale and Neer's criteria. Twenty-six (84%) of the patients had satisfactory results with the remaining 5 (16%) patients having unsatisfactory results. A classification system for the size and location of partial thickness rotator cuff tears is presented. The lesion size did not affect the result. Repeat arthroscopy in three patients demonstrated no further deterioration of their rotator cuff. The results with and without subacromial decompression were similar. The need for subacromial decompression is best determined by the arthroscopic finding of a bursal side tear.
Article
A retrospective review is reported on 68 patients with 72 full-thickness rotator-cuff tears treated surgically. Duration of symptoms before surgery averaged 18 months (range, one month to ten years). Tears of the rotator cuff were divided into small (12 shoulders), medium (26 shoulders), large (17 shoulders), and massive (17 shoulders). Rotator-cuff tears were repaired by use of a bony trough in 88% of patients. All patients were treated with decompression acromioplasty. In addition, an acromioclavicular arthroplasty was performed in 29 patients. Forty-seven men and 21 women with an average age of 58 years (range, 31-76 years) were followed for an average of 24 months (range, nine to 57 months). Excellent results are reported in 46 shoulders, good in 20, fair in four, and poor in two. The size of tear and duration of symptoms did not significantly affect results.
Article
We reexamined 97 of 116 shoulders operated on for rotator cuff lesions after an average follow-up time of 37 months. Seventy percent had a good or excellent clinical result, and 14 percent were graded as poor. Upon ultrasonographic examination of the 97 shoulders, 37 had a normal rotator cuff, 31 had thinning and/or hyperdensity, and 29 had a complete rupture of the cuff. Patients with concomitant anterior acromioplasties did better than those without. There was a poor correlation between clinical and ultrasonographic results. We recommend that rotator cuff tears should be closed only if this can be achieved without undue tension. If extensive tissue mobilization or coverage with alloplastic material or with regional muscle flaps is required, the lesion should be debrided and left open, and only an anterior acromioplasty should be performed.
Article
Ten patients with painful, massive (greater than 5 cm), complete rotator cuff tears involving primarily the supraspinatus were treated with arthroscopic acromioplasty and rotator cuff debridement. All patients except one had normal active motion and strength preoperatively. All patients had roentgenographically normal acromiohumeral distance and an anterior-inferior acromial osteophyte. The goal was to obtain pain relief without loss of motion of strength. This was accomplished in all patients. This study shows that normal shoulder function is possible with a massive unrepaired tear of the rotator cuff. Normal function in the face of an unrepaired cuff tear can occur only if there is a balance of two important force couples, one in the coronal plane and the other in the transverse plane. This balance depends upon the functional integrity of the anterior cuff, the posterior cuff, and the deltoid. In patients whose cuff tears satisfy these anatomic and biomechanical criteria, the achievement of pain relief through arthroscopic debridement and decompression seems to be all that is necessary for normal pain-free function.
Article
The surgical pathology and clinical results of 78 reconstructions of chronic rotator cuff tears were reviewed retrospectively. The predominant complaint preoperatively was chronic pain with impaired shoulder function, resistant to repeated conservative treatment. Results according to a functional assessment were excellent or satisfactory in 71% of the patients, unsatisfactory in 12%, and failed in 17%. Relief of pain including night pain and pain with activity was obtained. Surgery should include a thorough exploration of the rotator cuff and the adjacent tissues. Accompanying problems, including biceps tendon disorders or impingement factors, must be recognized and treated at the time of the reconstruction procedure. Repair of the torn rotator cuff and treatment of concomitant lesions are effective operative procedures when symptoms are persistent and fail to respond to conservative treatment.
Article
This paper reports the conclusions from a clinical, radiological and mathematical analysis of 126 patients with rotator cuff ruptures who were treated by operation. There were 83 men and 43 women. The mean age was 53.4 years and the average follow-up period was 3.5 years. According to a new method of scoring, an acceptable result was achieved in 78% of cases (excellent in 29%, good in 23%, and fair in 26%). The chi-square and the two tailed t-tests indicated that the following preoperative or operative variables influenced the results significantly: time away from work before operation (p<0.001); operative delay (p<0.001); the number of operations on the rotator cuff (p<0.001); atrophy of the spinati muscles (p<0.001); degenerative changes of the greater tuberosity (p<0.001); the heaviness of the patient's work (p<0.005); the extent of the resection of the acromion (p<0.005) and indication for operation (pain, lack of motion or both) (p<0.025). According to regression and covariance analyses, these factors independently influenced the final outcome. The following variables did not significantly predict or influence the operative result: age of the patient; sex; conjoined lesions; the size of the rupture; the site of the rupture or detachment of the deltoid.
Article
In fifty patients who had fifty tears of the rotator cuff that had been repaired, we correlated the preoperative findings by history, physical examination, and radiography with the operative findings, the difficulty of the repair, and the results after an average follow-up of 3.5 years. The results, which were rated on the basis of pain, function, range of motion, strength, and satisfaction of the patient, were satisfactory in 84 per cent and unsatisfactory in 16 per cent. The correlations of the preoperative findings with the results showed that pain and functional impairment, the primary indications for repair, were significantly relieved. The longer the duration of pain was preoperatively, the larger the cuff tear and the more difficult the repair were. The strength of abduction and of external rotation before repair was of prognostic value: the greater the weakness, the poorer the result. The poorest results were in patients with strength ratings of grade 3 or less. Limitation of active motion preoperatively was also of prognostic value: in patients who were unable to abduct the shoulder beyond 100 degrees preoperatively, there was an increased risk of a poor result. An acromiohumeral distance of seven millimeters or less (measured on the anteroposterior radiograph) suggested a larger tear and the likelihood that after repair there would be less strength in flexion, less active motion, and lower scores. Single or double-contrast arthrography was not consistently accurate in estimating the size of the tear. After so-called watertight repair and anterior acromioplasty, successful results can be anticipated in a high percentage of patients.
Article
Rotator cuff disease is a common and important source of shoulder symptoms. The cuff mechanism functions not only to stabilize the shoulder but also to provide power and perhaps assist with the maintenance of joint nutrition. The pathogenesis of rotator cuff disease is associated with aging; repetitive use or injury; tendon hypovascularity; and, seemingly most important, subacromial tendon impingement. There is a large spectrum of pathological changes within this disease category. Non-operative therapy may be effective, but it is not as consistently successful as was formerly believed. Early surgical treatment should be considered for the rare acute injury that produces a large rotator-cuff defect and loss of active abduction. Long-term non-operative treatment is desirable for almost all patients with tendon inflammation. When surgical treatment is undertaken, an anterosuperior approach is most useful. Anterior acromioplasty should always be considered. Resection of the distal part of the clavicle or bicipital tenodesis is indicated only when acromioclavicular arthritis or substantial wear or instability of the biceps tendon is present. The size and shape of the tendon tears vary greatly. The most direct and simple repair technique seems to be the best - progressing from direct tendon repair to repair to bone, to transposition of local tissue, to grafting. Postoperative support should vary according to need. Physiotherapy after surgery seems to be quite important. Failures of surgical repair that are associated with rotator cuff retearing have a fair to poor prognosis after a second tendon repair. Advanced rotator-cuff disease may rarely be associated with the development of severe glenohumeral arthritis resulting in a combination of lesions that is very difficult to treat.
Article
In a retrospective study of 74 shoulders in 73 patients treated at the Geisinger Medical Center between January 1951 and March 1972, the diagnosis of tear of the rotator cuff was confirmed by surgical repair in 65 shoulders and by arthrography in 9. According to a described rating system, the results in the 65 surgically treated shoulders at the end of convalescence (from 2.8 to 21.6 mth after surgery) were excellent or good in 69% and fair or poor in 31%, while in the 46 shoulders reevaluated from 18 mth to 20 yr after surgery the results were excellent or good in 74% and fair or poor in 26%. Sex, age, occupation, and a traumatic onset had little or no influence on the result. The results were better if preoperative roentgenograms were normal or if the tear was partial; while results tended to be worse if there were calcific deposits in the cuff, if the acromion was not reattached after acromionectomy, and if the repair necessitated suturing the proximal cuff into a trough cut in the humeral head. The result at 6 to 9 mth was not likely to change subsequently.
Article
The results of 63 operative repairs of chronic tears of the rotator cuff in 61 patients are reviewed retrospectively; the mean follow-up was 32.7 months. Fifty-four patients presented with symptoms of persistent pain and seven patients with gross loss of movement. All the patients had failed to respond to conservative treatment. Results were assessed in terms of relief of pain, restoration of movement, the patients' ability to return to work and whether they were satisfied with the results. Overall, a good result in terms of relief of pain was achieved in 40 shoulders. In 31 shoulders (30 with pain and one without pain) the operation included particular measures to decompress the subacromial space; 26 of the patients achieved relief of pain which was significantly better than in those patients whose operation did not include a decompression. The complications and failures are discussed. It is suggested that operative repair of the chronically torn rotator cuff of the shoulder is a worthwhile operation and that the operation should include an adequate decompression of the subacromial space.
Article
Subscapularis transposition into a supraspinatus or supraspinatus and infraspinatus rotator cuff defect has been overlooked as a method of tendon repair. The surgical technique for this type of repair, with or without the concomitant use of a glenohumeral resurfacing prosthesis, is described. Postoperatively, the extremity is supported in a position that does not allow stress to be placed on a repair until healing has occurred. Generally, physical therapy is begun early and continued for many months. In the present series, satisfactory relief of pain was achieved in 22 of the 26 patients. Active abduction in the plane of the scapula averaged 120 degrees for patients with rotator cuffs repair and prosthetic replacement and 130 degrees for those with rotator cuff repair alone. Twelve patients gained more than 30 degrees active abduction, and four lost this amount of motion, or greater, as compared with preoperative capabilities. In two of the 26 patients, the rotator cuff repair was completely disrupted during the acute postoperative period. Twenty-five of the 26 patients were satisfied with the surgical procedure. This type of repair seems to be a secure repair, bring healthy tendon tissue into an area of tendon degeneration and loss of tissue substance. As such, it satisfies the basic surgical principles of achieving repair with healthy tissue that is not under tension. The results compare favorably with those reported in the literature on rotator cuff repair and further suggest that this technique is an acceptable alternative for repairing large or massive rotator cuff tears that have tendon substance loss. However, this technique should not be used for smaller tears, for which more simple techniques are more adequate, because if a retear occurs during the postoperative period, the cuff detect might be quite large, with significant pain postoperatively and functional limitations resulting.
Article
A modified Neer acromioplasty, subacromial decompression, and débridement of massive, irreparable lesions of the supraspinatus and infraspinatus tendons was performed in fifty-seven patients. Fifty patients (fifty-three shoulders) were followed for an average of six and one-half years. The average age of the patients was sixty years (range, thirty-eight to seventy-four years). The results, as rated on the basis of pain, function, range of motion, strength, and satisfaction of the patient, were satisfactory in forty-four shoulders (83 per cent) and unsatisfactory in nine (17 per cent). A favorable outcome was observed in shoulders in which both the anterior portion of the deltoid muscle and the long head of the biceps tendon were intact and in which a previous acromioplasties or operations on the rotator cuff had been performed. An unsatisfactory outcome was observed in shoulders in which the anterior part of the deltoid muscle was weak or absent or in which a previous acromioplasty and attempted repair of the rotator cuff had been performed. The active forward flexion of the shoulder improved from an average of 105 degrees preoperatively to an average of 140 degrees postoperatively. The results of the present study suggest that, with proper rehabilitation, adequate decompression of the subacromial space, anterior acromioplasty, and débridement of massive tears of the rotator cuff can lead to the relief of pain and the restoration of shoulder function.
Article
One hundred thirty-six patients with impingement syndrome and rotator cuff disease who were treated nonoperatively from 1987 to 1991 were reviewed to identify findings at initial presentation that correlated with final outcome. Mean followup was 20 months (range, 6-41 months). All patients received initial conservative treatment. The results were analyzed in 2 groups. Group I consisted of the entire 136 patients with a minimum 6-month followup. Group II consisted of a subgroup of 68 patients with at least an 18-month followup. The overall results in Group I were 66% excellent and good and 34% fair and poor. For Group II, the overall results were 76% excellent and good and 24% fair and poor. For the Group II patients, a distribution of clinical findings at the 6-month followup demonstrated only 46% excellent and good results, indicating that the clinical result improves significantly as followup duration increased. Patient characteristics and prognostic factors that were associated with an unfavorable clinical outcome included a rotator cuff tear > 1 cm2, a history of pretreatment clinical symptoms for > 1-year duration, and significant functional impairment at initial presentation. Factors not associated with clinical outcome included patient age, occupation, gender, associated instability, dominance, chronicity of onset, active range of motion, or specific treatment modalities. Early operative intervention is recommended for patients with poor prognostic factors to avoid a protracted clinical course.
Article
One hundred eighty-seven patients (189 shoulders) were treated surgically between 1970 and 1992 for massive rotator cuff tears using either a tendon-to-tendon repair or the McLaughlin procedure. The age of the patients ranged from 20 to 86 years; 95% of them were 45 years or older. The average followup was 6 years 9 months. Excellent or good functional results were attained in 93% of patients. Thirty-three percent of those who underwent tendon to tendon repair complained of pain after overuse compared with only 18% who had the McLaughlin Procedure.
Article
Between May 1988 and May 1990, 44 patients with Stage II impingement were randomized into open and arthroscopic treatment groups. Forty-one patients were available for final follow-up in May 1991: 22 in the open group, 19 in the arthroscopic group. Comparisons of pain, function, motion, and strength were made preoperatively and at 2, 6, 12, 26, and 52 weeks postoperatively. Final analysis showed that the main benefits of arthroscopic acromioplasty were evident in the first 3 months postoperatively. Arthroscopic patients regained flexion and strength more rapidly than did open patients, had shorter hospitalizations, used less narcotics, and returned more quickly to both work and activities of daily living. By 3 months postoperatively, open patients tended to "catch up" with arthroscopic patients, and further recovery was equivalent. In both groups, full recovery took at least 1 year for the majority of patients and in both groups at 1 year > 90% of patients achieved a satisfactory result. Because of its medical and economic advantages for both the patient and the health-care system, we conclude that arthroscopic acromioplasty should become the procedure of choice for patients with impingement syndrome refractory to conservative treatment.
Article
Seventy-one patients who had shoulder impingement syndrome were managed operatively with a modified Neer acromioplasty: thirty-seven, who had an intact rotator cuff, had a modified acromioplasty, and thirty-four, who had a torn cuff, had a modified acromioplasty and repair of the cuff. In the classic anterior acromioplasty as described by Neer, emphasis is placed on resection of the inferior prominence of the acromion. We believe that the removal of only the inferior prominence is insufficient, as often too much of the anterior aspect of the acromion protrudes beyond the anterior border of the clavicle. This portion of the acromion continues to irritate the subacromial bursa and the rotator cuff and to produce symptoms of impingement. Our modified acromioplasty is done in two steps: the portion of the acromion that projects anteriorly beyond the anterior border of the clavicle is resected vertically and then an anteroinferior acromioplasty is performed. We studied the results in patients who had been operated on by the senior one of us and who had been followed clinically for a minimum of two years. At the most recent follow-up visit, no difference in terms of pain and function was found between the patients who had had the modified acromioplasty only (Group I) and the patients who had had the modified acromioplasty and repair of the rotator cuff (Group II); thirty-three (89 per cent) of the patients in Group I and thirty (88 per cent) of those in Group II had a good or excellent result.
Article
Twenty-five patients with rotator cuff tears had bilateral isokinetic shoulder strength evaluations after a pain-relieving subacromial lidocaine injection. Shoulder strength testing was repeated at six months and again at 12 months after rotator cuff surgery. Strength was recorded as a ratio of peak torques comparing the operative with the nonoperative shoulder. Preoperative strength averaged 37%, 36%, and 33% for abduction, external rotation, and forward flexion. Six-month postoperative strength increased to 68%, 76%, and 66% for abduction, external rotation, and forward flexion, respectively. Twelve-month postoperative strength increased to 104%, 142%, and 97% for abduction, external rotation, and forward flexion. Shoulders with rotator cuff tears demonstrate major objective signs of weakness. Shoulder pain obscures objective evaluation of weakness. Preoperative strength can be accurately measured after subacromial lidocaine injection. Shoulder strength is significantly improved by rotator cuff repair. (C) Lippincott-Raven Publishers.
Article
Fifty consecutive patients completed standardized questionnaires regarding general health status as well as function of the shoulder before and an average of thirteen months after arthroscopic repair of a full-thickness tear of the rotator cuff. Comparison of the preoperative and postoperative responses to the questions demonstrated highly significant improvements in the patient's assessment both of general health and of function of the shoulder. The Short Form-36 (SF-36) General Health Survey revealed significant improvements in the most recent follow-up scores compared with the preoperative scores with regard to physical functioning (p = 0.0001), role-physical (p = 0.0001), bodily pain (p = 0.0001), vitality (p = 0.0001), social functioning (p = 0.0001), role-emotional (p = 0.006), mental health (p = 0.0213), and physical component summary (p = 0.0001). The University of California at Los Angeles (UCLA) Shoulder Score, the Constant Shoulder Score, and the American Shoulder and Elbow Surgeons (ASES) Shoulder Index showed significant improvements in all postoperative total and component scores (p = 0.0001). Most importantly, all three shoulder-rating systems demonstrated significant improvements in the postoperative scores for pain and function (p = 0.0001). While a general health status instrument such as the SF-36 can document the impact of an orthopaedic condition on a patient as well as the results of treatment, a more complete representation of the patient's condition requires the use of region-specific self-assessment questionnaires and evaluation by a physician.
Article
Eighty-five percent to 95% of patients who undergo primary surgical repair of full-thickness rotator cuff tears have a significant decrease in shoulder pain and improvement in shoulder function. The results of surgery are dependent on the surgical technique, the extent of pathologic changes in the rotator cuff, and the postoperative rehabilitation protocol. Preoperative factors associated with a less favorable result are the size of the tear, the quality of the tissues, the presence of a chronic rupture of the long head of the biceps tendon, and the degree of preoperative shoulder weakness. Surgical factors associated with a less favorable result include inadequate acromioplasty, residual symptomatic acromioclavicular arthritis, inadequate rotator cuff tissue mobilization, deltoid detachment or denervation, and failure of rotator cuff healing. Clinical evaluation and preoperative imaging of the shoulder will improve patient selection and counseling. Meticulous surgical technique and postoperative rehabilitation will optimize the final result.
MS Departments of Orthopedic Surgery
  • Robert H Cofield
  • Md Parvizi
  • Duane M Ilstrup
  • M Charles
  • Rowland
Robert H. Cofield, MD Javad Parvizi, MD, FRCS Duane M. Ilstrup, MS Charles M. Rowland, MS Departments of Orthopedic Surgery (R.H.C. and J.P.) and Biostatistics (D.M.I. and C.M.R.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
Ultrasonographic 3-year follow-up of 97 cases
  • N Wülker
  • C Melzer
  • C S Wirth
Wülker N, Melzer C, Wirth CS. Shoulder surgery for rotator cuff tears. Ultrasonographic 3-year follow-up of 97 cases. Acta Orthop Scand. 1991;62:142-7.