All-arthroscopic Repair Research Articles

All-Arthroscopic Repair of Arcuate Avulsion Fracture With Suture Anchor

Arcuate avulsion fractures are very rare but present pathologic posterolateral rotation instability. Untreated instability may lead to overload of the reconstructed posterior cruciate ligament (PCL) graft. Surgical treatment and clinical results have not yet been reported to our knowledge. This study presents the case of a 45-year-old man with PCL injury and an arcuate avulsion fracture of the fibular head. The dial test was positive preoperatively, and magnetic resonance imaging showed an “arcuate” sign. The avulsed bone fragment was reduced and fixed with a suture anchor by an all-arthroscopic technique. At the 1-year follow-up, the patient had resumed all his normal activities, including sports. He scored 1+ on the posterior drawer test, and external rotation was 1° less than that in his contralateral normal knee. Compared with the values in the contralateral normal knee, the posterior tibial translation was reduced from 15.5 mm preoperatively to 6.3 mm postoperatively. The postoperative magnetic resonance imaging and computed tomography scans showed that the reconstructed PCL graft and the osseous fragment of the styloid process of the fibular head attached to the popliteofibular ligament were reduced. This technical note describes an all-arthroscopic reduction and fixation technique of arcuate avulsed fracture of the fibular head.

Subscapularis Function and Structural Integrity After Arthroscopic Repair of Isolated Subscapularis Tears

Background: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date. Purpose: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears. Study Design: Case series; Level of evidence, 4. Methods: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair. Results: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test. Conclusion: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.

Outcomes of Arthroscopic Rotator Cuff Repair in Patients Aged 70 Years or Older

To evaluate outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. We identified 44 consecutive patients aged 70 years or older undergoing primary all-arthroscopic repair of symptomatic full-thickness tears of the rotator cuff. A minimum 2-year follow-up was performed by an independent examiner including range of motion and dynamometer strength testing, and shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and pain score on a visual analog scale were determined. Paired t tests were performed to compare preoperative and postoperative measures. Postoperative Constant-Murley scores were normalized with scores from age- and sex-matched healthy individuals. Of the patients, 39 (88.6%) were available for follow-up evaluation, with a mean age of 75.3 ± 4.2 years (range, 70.1 to 89.8 years) and a mean follow-up of 36.1 ± 9.9 months (range, 24.3 to 59.4 months). The American Shoulder and Elbow Surgeons score improved from 45.8 ± 16.6 (mean ± SD) to 87.5 ± 14.4 at final follow-up (P < .0001). The Simple Shoulder Test score improved from 3.9 ± 2.3 to 9.8 ± 2.5 (P < .0001). The pain score on the visual analog scale improved from 4.6 ± 2.2 to 0.5 ± 0.9 (P < .0001), and forward elevation increased from 114.8° ± 42.0° to 146.2° ± 33.2° (P = .0012). Mean age- and sex-matched normalized Constant-Murley scores ranged from 88.3% to 97.2% of normal in men and 81.7% to 88.8% of normal in women. Arthroscopic rotator cuff repair provides significant improvement in pain and function in carefully selected patients aged 70 years or older with symptomatic full-thickness rotator cuff tears and has a low complication rate. Level IV, therapeutic case series.

Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: Mini-open versus all-arthroscopic

The objective of this study was to determine mean cost and operative time differences between mini-open and all-arthroscopic rotator cuff repair techniques at surgical centers of low, intermediate, and high annual rotator cuff repair volume. The 2006 New York State Ambulatory Surgery Database (NY-SASD) was utilized. It represents 100% of all outpatient procedures performed in hospital-affiliated and freestanding surgical centers, containing 10,658,923 patients for 2006 alone. Only patients who had an arthroscopic acromioplasty and either open or arthroscopic rotator cuff repair were included, leaving 5,224 patients for the study. These were divided into 2 groups: the mini-open group (1,334) and the all-arthroscopic group (3,890). Surgical center volume data were divided into 3 groups: low volume (<75 rotator cuff repairs per year), intermediate volume (75-199 rotator cuff repairs per year), and high volume (200+ rotator cuff repairs per year). Patient age and gender were normally distributed within the 2 groups with no significant differences between them (P = .82 and P = .31, respectively). Operative time was significantly shorter in the mini-open group (103 minutes) compared to the all-arthroscopic group (113 minutes), P < .00001. Surgical charges were also significantly less in the mini-open group ($7,841) compared to the all-arthroscopic group ($8,985), P < .00001. Regardless of the repair method, high volume surgical centers were significantly more expensive when compared to low and intermediate volume centers, P < .00001. The mini-open rotator cuff repair technique requires significantly less operative time and is significantly less expensive than the all-arthroscopic repair. Regardless of the repair technique, high volume surgical centers cost significantly more than low and intermediate volume surgical centers.

Prospective analysis of arthroscopic rotator cuff repair: Subgroup analysis

The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome. A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P < .0001) and 92.65 +/- 11.36 at 2 years (P < 0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity. Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.

Training Resources in Arthroscopic Rotator Cuff Repair

Background: All-arthroscopic rotator cuff repair is becoming more commonly performed with recent improvements in implants, instrumentation, and techniques. This study evaluated the influence of different training resources for surgeons performing this procedure. Methods: A twenty-eight-item survey was created to evaluate the methods by which orthopaedic surgeons are trained in the skill of all-arthroscopic rotator cuff repair. We selected 2455 surgeons from the American Academy of Orthopaedic Surgeons web site who indicated that they performed shoulder surgery, arthroscopic surgery, and/or sports medicine as part of their practice. Using a 5-point Likert scale, the respondents rated the relative importance of different training resources, including the completion of a sports medicine or shoulder surgery fellowship, attendance at instructional courses, and practice on shoulder models, in contributing to their ability to perform arthroscopic rotator cuff repair. Results: Of the 2455 surveys sent, 1076 were returned (a response rate of 43.8%). Significantly more surgeons indicated that they performed arthroscopic repairs for a 2-cm tear compared with a 5-cm tear (p < 0.001). A younger age, higher volume of shoulder arthroscopies, and higher volume of rotator cuff repairs were all associated with significantly higher rates of preference for all-arthroscopic repairs compared with other types of repairs (p < 0.001). Compared with surgeons who received training in shoulder surgery during residency only, surgeons who had completed either shoulder or sports medicine fellowships were more likely to perform all-arthroscopic repairs. When ranking the relative importance of resources in the training for all-arthroscopic repair, the overall Likert scale scores were highest for a sports medicine fellowship (3.49), hands-on instructional courses (3.33), and practice in an arthroscopy laboratory on cadaver specimens (3.22). Likert scores were lowest for residency training (2.02), practice on artificial shoulder models (2.13), and Internet resources (2.25). Conclusion: The information from this survey may be used to direct the continually evolving training of surgeons in arthroscopic rotator cuff repairs.

Training Resources in Arthroscopic Rotator Cuff Repair

All-arthroscopic rotator cuff repair is becoming more commonly performed with recent improvements in implants, instrumentation, and techniques. This study evaluated the influence of different training resources for surgeons performing this procedure. A twenty-eight-item survey was created to evaluate the methods by which orthopaedic surgeons are trained in the skill of all-arthroscopic rotator cuff repair. We selected 2455 surgeons from the American Academy of Orthopaedic Surgeons web site who indicated that they performed shoulder surgery, arthroscopic surgery, and/or sports medicine as part of their practice. Using a 5-point Likert scale, the respondents rated the relative importance of different training resources, including the completion of a sports medicine or shoulder surgery fellowship, attendance at instructional courses, and practice on shoulder models, in contributing to their ability to perform arthroscopic rotator cuff repair. Of the 2455 surveys sent, 1076 were returned (a response rate of 43.8%). Significantly more surgeons indicated that they performed arthroscopic repairs for a 2-cm tear compared with a 5-cm tear (p < 0.001). A younger age, higher volume of shoulder arthroscopies, and higher volume of rotator cuff repairs were all associated with significantly higher rates of preference for all-arthroscopic repairs compared with other types of repairs (p < 0.001). Compared with surgeons who received training in shoulder surgery during residency only, surgeons who had completed either shoulder or sports medicine fellowships were more likely to perform all-arthroscopic repairs. When ranking the relative importance of resources in the training for all-arthroscopic repair, the overall Likert scale scores were highest for a sports medicine fellowship (3.49), hands-on instructional courses (3.33), and practice in an arthroscopy laboratory on cadaver specimens (3.22). Likert scores were lowest for residency training (2.02), practice on artificial shoulder models (2.13), and Internet resources (2.25). The information from this survey may be used to direct the continually evolving training of surgeons in arthroscopic rotator cuff repairs.

Structural Integrity and Clinical Outcomes After Arthroscopic Repair of Isolated Subscapularis Tears

Isolated tears of the subscapularis occur less commonly than those involving the superior and posterior components of the rotator cuff. The purpose of the present study was to evaluate the structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. A prospective study of seventeen consecutive patients who were managed with an all-arthroscopic repair of the subscapularis tendon was performed. The study group included thirteen men and four women who had an average age of forty-seven years at the time of surgery. The average interval from the onset of symptoms to the time of surgery was twenty-four months. Thirteen tears were traumatic, and four were degenerative. Seven patients had a tear involving the superior third of the tendon, six had a tear involving the superior two-thirds of the tendon, and four had complete separation of the subscapularis from its insertion on the lesser tuberosity. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the Constant and University of California at Los Angeles scoring systems, and all patients had postoperative computed tomographic arthrography studies to evaluate the structural integrity of the repair. The average duration of follow-up was twenty-nine months. When the preoperative findings were compared with the most recent findings, the average relative Constant score had improved from 58% to 96% (p < 0.05), the average University of California at Los Angeles score had improved from 16 to 32 points (p < 0.05), the average pain score had improved from 5.9 to 13.5 points (p < 0.05), the average forward flexion had improved from 146 degrees to 175 degrees (p < 0.05), the average external rotation had improved from 50 degrees to 60.3 degrees (p < 0.05), the average internal rotation had improved from the level of the sacrum to L1-L2 (p < 0.05), and the average abduction strength had improved from 7.4 to 15.6 points (p < 0.05). The structural integrity of the repair was completely intact in fifteen patients and was partially reruptured in two patients on the basis of computed tomographic arthrography. Progression of fatty infiltration of the subscapularis was not observed in any patient. Subjectively, twelve patients were very satisfied with the result, four were satisfied, and one was not satisfied. Arthroscopic repair of an isolated subscapularis tear can yield marked improvements in shoulder function, can significantly reduce pain, and can result in a durable structural repair. Therapeutic Level IV.

All-Arthroscopic Versus Mini-Open Rotator Cuff Repair: A Retrospective Review With Minimum 2-Year Follow-up

To compare the clinical outcomes of patients undergoing all-arthroscopic versus mini-open rotator cuff repair. In addition, ultrasound was used to assess the integrity of the repair. A total of 38 patients who had undergone all-arthroscopic repair and 33 patients who had undergone mini-open repair with minimum 2-year follow-up were evaluated. All patients completed the American Shoulder and Elbow Surgeons' Scoring Survey (ASES), the Simple Shoulder Test, the L'Insalata Scoring Survey, and visual analog scales for pain. Physical examination, including strength testing and ultrasound evaluation to determine the integrity of the rotator cuff, was performed. No statistical difference in ASES scores was noted between patients who had all-arthroscopic repair versus mini-open repair, and 24% of all-arthroscopic repairs and 27% of mini-open repairs showed recurrent defects on ultrasound at follow-up. This difference was not statistically significant. Patients with an original tear larger than 3 cm were 7 times more likely to have a recurrent defect at follow-up. Patients with persistent defects had statistically significant deficits in strength on forward elevation and external rotation when compared with those with a normal shoulder. However, no difference was observed with regard to pain or outcome scores between patients with intact repairs and those with persistent defects. No difference in clinical outcomes was found between patients with rotator cuffs repaired arthroscopically and those repaired with use of a mini-open technique. Level III, retrospective comparative study.

All-arthroscopic versus mini-open repair of small or moderate-sized rotator cuff tears: a protocol for a randomized trial [NCT00128076

BackgroundRotator cuff tears are the most common source of shoulder pain and disability. Only poor quality studies have compared mini-open to arthroscopic repair, leaving surgeons with inadequate evidence to support optimal, minimally-invasive repair.Methods/DesignThis randomized, multi-centre, national trial will determine whether an arthroscopic or mini-open repair provides better quality of life for patients with small or moderate-sized rotator cuff tears. A national consensus meeting of investigators in the Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS Canada) identified this question as the top priority for shoulder surgeons across Canada. The primary outcome measure is a valid quality-of-life scale (Western Ontario Rotator Cuff (WORC)) that addresses 5 domains of health affected by rotator cuff disease. Secondary outcomes will assess rotator cuff functionality (ROM, strength, Constant score), secondary dimensions of health (general health status (SF-12) and work limitations), and repair integrity (MRI). Outcomes are measured at baseline, at 6 weeks, 3, 6, 12, and 24 months post-operatively by blinded research assistants and musculoskeletal radiologists. Patients (n = 250) with small or medium-sized cuff tears identified by clinical examination and MRI who meet eligibility criteria will be recruited. This sample size will provide 80% power to statistically detect a clinically important difference of 20% in WORC scores between procedures after controlling for baseline WORC score (α = 0.05). A central methods centre will manage randomization, data management, and monitoring under supervision of experienced epidemiologists. Surgeons will participate in either conventional or expertise-based designs according to defined criteria to avoid biases from differential surgeon expertise. Mini-open or all-arthroscopic repair procedures will be performed according to a standardized protocol. Central Adjudication (of cases), Trial Oversight and Safety Committees will monitor trial conduct. We will use an analysis of covariance (ANCOVA), where the baseline WORC score is used as a covariate, to compare the quality of life (WORC score) at 2 years post-operatively. As a secondary analysis, we will conduct the same statistical test but will include age and tear size as covariates with the baseline score. Enrollment will require 2 years and follow-up an additional 2 years. The trial will commence when funding is in place.DiscussionThese results will have immediate impact on the practice behaviors of practicing surgeons and surgical trainees at JOINTS centres across Canada. JOINTS Canada is actively engaged in knowledge exchange and will publish and present findings internationally to facilitate wider application. This trial will establish definitive evidence on this question at an international level.

A Comparison of Arthroscopic and Open Rotator Cuff Repair

The purpose of this study was to compare the results of all-arthroscopic repair of full-thickness rotator cuff tears including massive tear with those of open repair. Nonrandomized control study. We evaluated 100 consecutive patients (100 shoulders) who were treated for full-thickness rotator cuff tears either by all-arthroscopic (50 patients) or open repair (50 patients). The mean age was 57 years (range, 24 to 78 years). The mean follow-up period was 49 months (range, 25 to 83 months). Of all the patients, 7 had a small tear, 63 a medium tear, 17 a large tear, and 13 a massive tear; in the arthroscopic group, 5 had a small tear, 28 a medium tear, 9 a large tear, and 8 a massive tear. The results of the arthroscopic and open groups were compared using the shoulder rating scale of the University of California at Los Angeles (UCLA) and the Japanese Orthopaedic Association (JOA). The 2 groups were statistically similar in terms of age, gender, trauma incidence, tear size, duration of symptoms, and preoperative shoulder scores. The UCLA and JOA scores improved significantly in both groups postoperatively. Outcomes and the postoperative UCLA and JOA scores were not significantly different between the 2 groups. The postoperative UCLA and JOA scores in patients with a large-to-massive tear were significantly lower than those with a small-to-medium tear, but outcomes were not statistically different between the arthroscopic and open groups depending on the tear size. The percentage of satisfactory results of arthroscopic and open repair for small-to-medium tears was 97.0% and 94.6%, respectively. Those of arthroscopic and open repair for large-to-massive tears was 82.4% and 76.9%, respectively. Arthroscopic repair of small-to-massive tears had outcomes equivalent to those of open repair. Outcomes in patients with large-to-massive tears were inferior to those in patients with small-to-medium tears, regardless of repair method. Level III, case-control study.

관절경 보조 소절개 봉합술을 이용한 회전근 개 파열의 치료 - 5∼8년 추시 결과 -

Purpose: To report our experience of treatment of rotator cuff tear and evaluate the mid-term outcome. Materials and Methods: We have performed 50 cases of mini-open rotator cuff repair from March 1996 to March 1999. Male to female ratio was 34：16, the average age 46.5(23∼57) years old, mean follow-up period was 78(62∼93) months. All-arthroscopic repair and open repair cases were excluded. Mean symptomatic period was 12.5(6∼38) months, operation was indicated in cases of no improvement by 6 months of conservative management. Preoperative simple radiographs and Magnetic resonance arthrography were obtained in all cases. We also observed the inflammation, synovitis, thickness of tear and associated pathology intraoperatively. We evaluated pain, function, and range of motion by UCLA score. Results: Overall UCLA score was mean 29.5 points. Excellent 25, good 18, poor 7 cases. Mean pain score was improved 2.6 to 7.5, 44 cases(88%) were improved and 6 cases(12%) were not improved. Mean functional score was improved 3.4 to 8.5, and activity at follow up, 25 cases(50%) were same, 8 cases(14%) were above, 17 cases(34%) were below compared with preoperative level. Mean active forward flexion was preoperative 112° to postoperative 160°, forward flexion strength was improved 3.8 to 4.7. 43 cases(86%) of patients were satisfied at the result, 7 cases(14%) were not satisfied or aggravated. Results: Mini-open rotator cuff repair was effective method in treating rotator cuff tear.

All-arthroscopic versus mini-open rotator cuff repair: long-term follow-up (SS-10)

All arthroscopic repair has previously been shown to show equivalent short-term outcome and decreased morbidity compared to mini-open repair. Concerns have remained however about both the technical difficulty and long-term outcome of all-arthroscopic repair. From 1/96 to 3/99 501 patients were the subjects of an earlier report in 2000 on the preliminary results contrasting all arthroscopic repair and mini open repair. Two hundred twenty one of these had moderate or large tears or other diagnoses and were excluded, leaving 280 patients for review. 126 chose an all-arthroscopic repair versus 154 with an open repair. These patients were re-reviewed four years later to form the basis of this study. Follow-up averaged 84.3 months for the arthroscopic and 95.8 for open with a minimum of six years. Age, gender, associated findings at surgery, and duration of surgery were not significantly different between the two groups. There were two manipulations and two reoperations for failed repair in the open group (3%) in the early study; one additional repair in the open group failed at longer follow-up. One patient had a loose anchor (1%) using second-generation anchors and better technique. Two patients had early failed repairs and an additional two failed later with a total reoperation rate of 4% (p = ns). Final outcomes as measured by ASES, UCLA and SST scores were not statistically different. All arthroscopic repair is shown to offer a significant reduction in perioperative morbidity over mini open repair. Mid-range follow-up continues to show equivalent outcomes between the two techniques. While the anatomic outcome of the two techniques at mid to long-term follow-up remains unknown, clinical results between the two techniques remains the same. All arthroscopic repair has previously been shown to show equivalent short-term outcome and decreased morbidity compared to mini-open repair. Concerns have remained however about both the technical difficulty and long-term outcome of all-arthroscopic repair. From 1/96 to 3/99 501 patients were the subjects of an earlier report in 2000 on the preliminary results contrasting all arthroscopic repair and mini open repair. Two hundred twenty one of these had moderate or large tears or other diagnoses and were excluded, leaving 280 patients for review. 126 chose an all-arthroscopic repair versus 154 with an open repair. These patients were re-reviewed four years later to form the basis of this study. Follow-up averaged 84.3 months for the arthroscopic and 95.8 for open with a minimum of six years. Age, gender, associated findings at surgery, and duration of surgery were not significantly different between the two groups. There were two manipulations and two reoperations for failed repair in the open group (3%) in the early study; one additional repair in the open group failed at longer follow-up. One patient had a loose anchor (1%) using second-generation anchors and better technique. Two patients had early failed repairs and an additional two failed later with a total reoperation rate of 4% (p = ns). Final outcomes as measured by ASES, UCLA and SST scores were not statistically different. All arthroscopic repair is shown to offer a significant reduction in perioperative morbidity over mini open repair. Mid-range follow-up continues to show equivalent outcomes between the two techniques. While the anatomic outcome of the two techniques at mid to long-term follow-up remains unknown, clinical results between the two techniques remains the same.

Surgical treatment of rotator cuff tears

Rotator cuff pathology remains a significant cause of pain and disability in the general population. Arthroscopy has better defined the normal and pathologic appearance of the rotator cuff and complex anatomy that dictates its function. Diagnosis is made efficiently by physical examination, magnetic resonance imaging, and more recently by ultrasonographic means, which have been used to study the natural history of tears. The transformation from open to mini-open techniques in the early-to mid-1990s is nearly complete. For most tear patterns follow-up studies show reliable and durable satisfactory results (overall 80 to 96%). Promising results are also reported in older patient populations. Improved methods are being developed for the treatment of massive tears, those involving multiple tendons, and tears occurring in poor-quality tissues. The roles of patient age and acromioplasty upon rotator cuff repair are being challenged. In addition, the evolution of all-arthroscopic repair techniques provides a theoretical advantage in terms of tension-free repairs that are less invasive yet more anatomic. Long-term results are still lacking.