Intact Repairs Research Articles

Differences in Clinical Outcomes Between Patients With Retear After Supraspinatus Tendon Repair and Those With Intact Repair at 5-Year Follow-up

Background: It is well known that rotator cuff repair is associated with an overall retear rate of 21% to 26%. However, a cuff retear may not necessarily be associated with poor clinical outcomes. Hypothesis: There would be no difference in clinical outcomes between patients with a cuff retear and those with an intact repair at a midterm follow-up of 5 years. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted involving patients who received arthroscopic complete repair of the supraspinatus tendon between January 2009 and December 2017. Patients who did not have a postoperative magnetic resonance imaging (MRI) scan or who had a follow-up of <5 years were excluded. Clinical outcomes, including the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion (FF) of the involved shoulder were assessed at the 2-year and 5-year follow-up points. Results: The study group included 105 patients with a mean follow-up of 85 months. MRI scans were performed at a mean of 20 months. Fourteen full-thickness cuff retears and 91 intact repairs were identified using postoperative MRI scans. Significant improvement in VAS score, ASES score, and FF were found between the preoperative assessment and the 2 designated follow-up points (2 years and 5 years) in both the cuff retear and the intact repair groups (P < .001). The VAS and ASES scores at the 2-year follow-up for the intact repair group were 1.8 ± 2.0 and 80.7 ± 18.1, respectively. The corresponding values for the retear group were 2.3 ± 2.2 and 71.9 ± 19.5, respectively. No significant difference was found between the 2 groups in the VAS and ASES scores at the 2-year follow-up. However, patients with an intact repair had a better VAS score (1.4 ± 1.8; P = .049) and ASES score (81.7 ± 17; P = .019) than those with a cuff retear at the 5-year assessment (3.0 ± 2.8 and 67.1 ± 22.9, respectively). In the intact repair group, 91% of patients achieved the minimal clinically important difference for the 5-year VAS score, compared with 54% in the cuff retear group (P < .001). The corresponding values for the 5-year ASES score were 80% and 54%, respectively (P = .044). FF measurements at the 5-year follow-up in patients with intact repair and those with a cuff retear were 161°± 23° and 144°± 37°, respectively (P = .059). Continuous improvement in VAS score and FF between the 2-year and 5-year follow-up was observed in the intact repair group (P = .005 and P = .04, respectively). Conclusion: The patients with an intact repair had better VAS and ASES scores compared with those who had a cuff retear at a midterm follow-up of 5 years. Between the 2-year and the 5-year follow-up, some further improvement was observed in the VAS score and FF in the intact repair group.

Clinical outcomes of medialized single-row repair with fascia lata graft augmentation for large and massive rotator cuff tears

A high postoperative retear rate after arthroscopic rotator cuff repair (ARCR) of large and massive tears remains a problem. This study evaluated rotator cuff integrity after ARCR with fascia lata graft augmentation for large and massive rotator cuff tears and compared clinical outcomes between patients with intact repairs and retears. Forty-five patients with rotator cuff tears who could not undergo primary repair due to tendon retraction underwent arthroscopic medialized single-row repair with fascia lata graft augmentation. The patients' minimum follow-up was 2 (2-9) years. Supraspinatus cuff integrity was evaluated postoperatively by magnetic resonance imaging. We compared the clinical outcomes of patients with intact repairs vs. retears based on the University of California-Los Angeles (UCLA), Constant, and Japanese Orthopaedic Association (JOA) scores. We also evaluated their range of motion (ROM) and muscle strength. Retears were observed in 11 of 45 patients. UCLA, Constant, and JOA scores significantly improved postoperatively compared to preoperatively in the intact repair (all P<.001) and retear (all P<.036) groups. The intact repair group had significantly higher Constant (75.6 [mean]±9.9 [SD] vs. 69.8±7.9; P=.026) and JOA (94.4±6.9 vs. 89.8±5.9; P=.041) scores than the retear group. Forward elevation, abduction, and the strengths of abduction and external rotation significantly improved in the intact repair group (all P<.003) but not in the retear group (all P>.05). The intact repair group had significantly higher postoperative forward flexion (165°±15° vs. 154°±23°; P=.036), abduction (164°±17° vs. 151°±26°; P=.029), and abduction strength (3.5±2.2 kg vs. 2.3±1.2 kg; P=.017) than the retear group. In the intact repair group (n=34), Sugaya type I:II ratio differed significantly between postoperative 3 months (2:32) and 24 months (24:10) (P<.001). Repaired tendon thickness did not decrease significantly between 3 months (7.1 mm) and 2 years (6.9 mm) (P=.543). ARCR with fascia lata graft augmentation of large and massive rotator cuff tears showed a 24.4% retear rate but significantly improved the clinical scores, ROMs, and muscle strength with excellent cuff integrity in the intact repair group. However, the differences in the Constant and UCLA scores between the intact repair and retear groups were under the minimal clinically important difference, and their clinical significance is uncertain. Our results confirm that ARCR with fascia lata graft augmentation improves patients' postoperative outcomes if the repair site is maintained postoperatively.

Comparative sensitivity and accuracy of 24vs.18 MHz ultrasound probes for the diagnosis of flexor tendon repair integrity.

To determine whether a 24 MHz transducer significantly improves sensitivity, specificity and accuracy in evaluating flexor tendon repair integrity compared with an 18 MHz transducer. One hundred and twelve cadaveric digits were randomised to an intact repair or simulated 'failed' repair, and to a two- or eight-strand repair of a flexor digitorum profundus laceration. A blinded sonologist evaluated specimens in static mode using 18 and 24 MHz transducers. Gaps were remeasured after scanning, and final gap width recorded. McNemar's exact test calculated differences between sensitivity, specificity and accuracy, and chi-squared test to compare sensitivity, specificity and accuracy between number of strands (2 vs. 8) and repair gap (≥4 mm). The 24 MHz transducer had higher sensitivity (81 vs. 59%), lower specificity (67 vs. 70%) and higher overall accuracy (74 vs. 64%), than the 18 MHz transducer. The difference for sensitivity was significant (P = 0.011), but not differences for specificity and overall accuracy (P > 0.05). Pearson's correlation (r = 0.61) demonstrated a moderate-to-strong positive correlation between measured and true gap sizes. Increased number of suture strands (2 vs. 8) did not impair sensitivity, specificity nor accuracy. Ultrasound may tend to overestimate gap width, and a slight risk that some intact repairs, or those with small, clinically insignificant gaps may undergo surgical exploration that may not be indicated. A 24 MHz transducer is a more sensitive and accurate transducer for assessing flexor tendon repair integrity and measuring small gaps.

Comparative Accuracy of 1.5T MRI, 3T MRI, and Static Ultrasound in Diagnosis of Small Gaps in Repaired Flexor Tendons: A Cadaveric Study

We hypothesized that magnetic resonance imaging (MRI) would more accurately diagnose small gaps (<6 mm) after flexor tendon repair than static ultrasound (US) and that suture artifact would negatively impair accuracy. A laceration of the flexor digitorum profundus was created in 160 fresh-frozen cadaveric digits and randomized to either an intact repair (0-mm gap) or repairs using a locked 4-strand suture repair with either 4-0 Prolene, Ethibond, or and gaps of 2, 4,or 6 mm; or no suture in which 2-, 4-, or 6-mm gaps were created without a suture crossing the repair site. We performed 1.5T and 3T MRI and static US studies; gap widths were estimated by radiologists blinded to suture presence and true gap widths. The 1.5 and 3.0T MRI had a lower mean error than US for gap sizes 0 and 2 mm. All 3 modalities performed similarly for 4- and 6-mm gaps. Documentation of imaging artifact worsened error, and odds of seeing artifacts were 1.72 higher with MRI than with US. Suture did not worsen artifact nor impair accuracy for any of the 3 modalities. When no suture was used, all 3 modalities significantly overestimated the true gap. MRI is most accurate for small gaps less than 4 mm. Although all modalities overestimated gap sizes in specimens with a 0-mm gap (intact tendon repair), mean overestimation (<2 mm) was not clinically relevant. Ultrasound overestimated 2-mm gaps (clinically intact repairs), whereas MRIs did not. We recommend MRI for evaluation of gaps after flexor tendon repair. The 1.5T has slightly better sensitivity and specificity for distinguishing clinically intact (gap < 3 mm) from clinically impaired (gap > 3 mm) repairs than the 3T. Accurate diagnosis of intact repairs or small gaps (<3 mm) might prevent unnecessary exploration or allow modification of rehabilitation protocols. Diagnosis of clinically relevant gaps (3-6 mm) may allow for earlier revision surgery before significant tendon retraction and adhesions develop, possibly necessitating a staged reconstruction.

Comparative Sensitivity and Specificity of Static and Dynamic High-Resolution Ultrasound in Diagnosis of Small Gaps in Repaired Flexor Tendons: A Cadaveric Study

To compare the sensitivity and specificity of high-resolution static and dynamic ultrasound (US) for diagnosing intact repairs and small, clinically relevant gaps (≥4 mm) in repaired flexor digitorum profundus tendons within zone 2 and, secondarily, to evaluate the effect of suture artifact from 3 commonly used suture types. Eighty-eight fresh-frozen cadaveric digits (thumbs excluded) were randomized to either an intact repair (0-mm gap) or repairs using a locked 4-strand suture repair with either 4-0 Prolene, Ethibond, or FiberWire and gaps of 2, 4, or 6 mm and no suture in which 2-, 4-, or 6-mm gaps were created without a suture crossing the repair site. Gap widths were estimated by a blinded musculoskeletal ultrasonographer in static and dynamic modes. Both static and dynamic modalities tended to overestimate actual gap sizes. For the suture gaps, both modalities had poor sensitivity (29% static; 42% dynamic) for accurately diagnosing a clinically intact repair (<4 mm), but better specificity (83% static; 75% dynamic) for diagnosing a clinically failed repair (≥4-mm gap). Although suture presence decreased the sensitivity of gap width measurement for both modalities, no differences were seen between suture types. Static and dynamic US have poor sensitivity for diagnosing clinically intact repairs (gaps < 4 mm) because they typically overestimate gap size. The ability to diagnose failed repairs (gap ≥ 4 mm), based on greater specificity, is much better, but still suboptimal. Based on a receiver operating characteristic analysis cutoff of 5 mm, if a gap of 5 mm or larger is identified with US when evaluating a zone 2 flexor digitorum profundus tendon repair, a failed repair is likely in about 80% of cases. A gap measurement of less than 5 mm may miss a high percentage of repairs that are clinically failed.

A case series of recurrent myotendinous rotator cuff tears repaired and augmented with dermal allograft: clinical outcomes at two years

We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound. Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist. Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study.

The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3–37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.

Early postoperative repair status after rotator cuff repair cannot be accurately classified using questionnaires of patient function and isokinetic strength evaluation

This study investigated if patients with an intact tendon repair or partial-thickness retear early after rotator cuff repair display differences in clinical evaluations and whether early tendon healing can be predicted using these assessments. We prospectively evaluated 60 patients at 16weeks after arthroscopic supraspinatus repair. Evaluation included the Oxford Shoulder Score, 11-item version of the Disabilities of the Arm, Shoulder and Hand, visual analog scale for pain, 12-item Short Form Health Survey, isokinetic strength, and magnetic resonance imaging (MRI). Independent t tests investigated clinical differences in patients based on the Sugaya MRI rotator cuff classification system (grades 1, 2, or 3). Discriminant analysis determined whether intact repairs (Sugaya grade 1) and partial-thickness retears (Sugaya grades 2 and 3) could be predicted. No differences (P<.05) existed in the clinical or strength measures. Although discriminant analysis revealed the 11-item version of the Disabilities of the Arm, Shoulder and Hand produced a 97% true-positive rate for predicting partial thickness retears, it also produced a 90% false-positive rate whereby it incorrectly predicted a retear in 90% of patients whose repair was intact. The ability to discriminate between groups was enhanced with up to 5 variables entered; however, only 87% of the partial-retear group and 36% of the intact-repair group were correctly classified. No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16weeks. An intact repair or partial-thickness retear could not be accurately predicted. Our results suggest that correct classification of healing in the early postoperative stages should involve imaging.

Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries

Abdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA. Data were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination. Of 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P< .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P< .0001) and for women compared with men (66.3% vs 59.0%; P< .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery. Despite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs.

Changes in Abdominal Aortic Aneurysms Rupture and Short-Term Mortality, 1995-2008: A Retrospective Observational Study

Conclusion: Decreases in mortality from abdominal aortic aneurysm (AAA), both from rupture and short-term repair, are likely related to the introduction and expansion of endovascular aneurysm repair (EVAR). Summary: EVAR was approved by the U.S. Food and Drug Administration in 1999 and has resulted in lower perioperative mortality and morbidity, as documented in three large randomized trials and in the U.S. Medicare population. Decreased morbidity and mortality associated with EVAR, combined with widespread use of abdominal imaging studies, has resulted in more aneurysms being detected than in the past and more aneurysms being repaired. The authors' hypothesis was that increased rates of detection and elective repair of AAA, in combination with increasing use of EVAR, should be associated with decreased short-term AAA-related mortality. To test their hypothesis, they identified Medicare beneficiaries undergoing elective AAA repair and patients hospitalized with a ruptured AAA (rAAA) from 1995 to 2008. They then calculated standardized annual rates of AAA-related deaths from elective repair or rupture. During the study period, 338,278 patients underwent intact AAA repair, and there were 69,653 patients with rAAA, of whom 47,524 underwent repair. Repairs of intact AAAs increased substantially in those aged >80 years (57.7 to 92.3 per 100,000, P < .001) but decreased in those aged 65 to 74 years (81.8 to 68.9, P < .001). By 2008, 77% of all intact repairs and 31% of all rAAA repairs were performed with EVAR (P < .001). Operative mortality declined for intact repair (4.9% to 2.4%, P < .001) and for rAAA repair (44.1% to 36.3%, P < .001). Short-term AAA-related deaths decreased by more than half (26.1 to 12.1 per 100,000, P < .001), with the greatest decline occurring in those aged >80 years (53.7 to 27.3, P < .001). Comment: The results presented here parallel those presented earlier this year in the British Journal of Surgery (Anjum A, et al. Br J Surg 2012;99:637-45) documenting overall decreasing mortality from AAA. The current study focused primarily on procedurally related deaths. Use of the Medicare database, however, cannot completely dissect all of the factors that may be related to a decrease in AAA mortality. For example, it is certainly possible that aneurysms discovered incidentally may be detected when a higher proportion are potentially treated by EVAR. In addition, comorbidities in patients with incidentally discovered AAAs may be different than in those whose AAAs were discovered on physical examination or were associated with symptoms. The Medicare database also does not examine the effect of decreasing smoking rates on overall AAA-related mortality. It is very probable there are epidemiologic and procedurally related, as well as sociality related factors, that are all contributing to a decline of mortality related to AAA.

Changes in Abdominal Aortic Aneurysm Rupture and Short-Term Mortality, 1995–2008

To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). Previous epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method, and its use has expanded to more than 75% of elective AAA repairs. We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995 to 2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. A total of 338,278 patients underwent intact AAA repair during the study period. There were 69,653 patients with AAA rupture, of whom 47,524 underwent repair. Intact repair rates increased substantially in those older than 80 years (57.7-92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8-68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for both intact (4.9%-2.4%, P < 0.001) and ruptured (44.1%-36.3%, P < 0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1-12.1 per 100,000, P < 0.001), with the greatest decline occurring in those older than 80 years (53.7-27.3, P < 0.001). A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients older than 80 years.

Older Patients Benefited Most From EVAR

Older Patients Benefited Most From EVAR

Long-term outcome and structural integrity following open repair of massive rotator cuff tears

Background:Surgical repair of massive rotator cuff tears is associated with less favorable clinical results and a higher retear rate than repair of smaller tears, which is attributed to irreversible degenerative changes of the musculotendinous unit.Materials and Methods:During the study period, 25 consecutive patients with a massive rotator cuff tear were enrolled in the study and the tears were repaired with an open suture anchor repair technique. Preoperative and postoperative clinical assessments were performed with the Constant score, the simple shoulder test (SST) and a pain visual analog scale (VAS). At the final follow-up, rotator cuff strength measurement was evaluated and assessment of tendon integrity, fatty degeneration and muscle atrophy was done using a standardized magnetic resonance imaging protocol.Results:The mean follow-up period was 70 months. The mean constant score improved significantly from 42.3 to 73.1 points at the final follow-up. Both the SST and the pain VAS improved significantly from 5.3 to 10.2 points and from 6.3 to 2.1, respectively. The overall retear rate was 44% after 6 years. Patients with an intact repair had better shoulder scores and rotator cuff strength than those with a failed repair, and also the retear group showed a significant clinical improvement (each P<0.05). Rotator cuff strength in all testing positions was significantly reduced for the operated compared to the contralateral shoulder. Muscle atrophy and fatty infiltration of the rotator cuff muscles did not recover in intact repairs, whereas both parameters progressed in retorn cuffs.Conclusions:Open repair of massive rotator tears achieved high patient satisfaction and a good clinical outcome at the long-term follow-up despite a high retear rate. Also, shoulders with retorn cuffs were significantly improved by the procedure. Muscle atrophy and fatty muscle degeneration could not be reversed after repair and rotator cuff strength still did not equal that of the contralateral shoulder after 6 years.Level of evidence:Level IV

Vascularity of the Rotator Cuff After Arthroscopic Repair: Characterization Using Contrast-Enhanced Ultrasound (SS-36)

Robust vascularity is present at the anchor site in the greater tuberosity three months after arthroscopic rotator cuff repair. Blood supply for the tendon-bone interface comes from the tuberosity. Persistent defects are common after rotator cuff repair; this suggests that the biology of tendon-bone healing in rotator cuff repair is suboptimal. To date, there has been limited in-vivo assessment of vascularity of the shoulder after rotator cuff repair. This study aims to characterize the vascularity of the rotator cuff tendon/bone interface after arthroscopic repair using contrast enhanced ultrasound. After obtaining Institutional Review Board approval, 13 patients (mean age:58.5) were enrolled in the study. Patients underwent arthroscopic single row rotator cuff repair with suture anchors (average 2 anchors doubly loaded with #2 nonabsorbable suture) of supraspinatus tears that averaged 2 cm x 1.25 cm in size. The patients then underwent lipid microsphere (Definity, 10μL/kg, Bristol Myers Squibb) contrast-enhanced shoulder ultrasound examinations three months after rotator cuff repair with images obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to optimally visualize the blood flow to the shoulder. Qualitative and quantitative analysis of blood flow was performed using ultrasound imaging quantification and analysis software (QLAB; Philips, Andover, MA). Table 1 summarizes the vascularity data in the three regions of interest in intact repairs. A robust vascular response was seen at the anchor site in the greater tuberosity three months after rotator cuff repair. Comparatively little blood flow was observed in the rotator cuff tendon. Exercise recruited blood flow to all three regions of interest. 10 of 13 repairs were completely intact on ultrasound examination. Blood flow was diminished at the anchor site in repairs with a persistent defect. This study quantifies in vivo vascularity of the rotator cuff three months after arthroscopic repair. Three conclusions can be drawn from these data. 1) The rotator cuff is relatively avascular after repair at three months. 2) A robust vascular response occurs at the suture anchor site in the greater tuberosity. This suggests that the blood supply for healing of the tendon-bone interface after rotator cuff repair comes from the bony side. An intact repair may be necessary to foster angiogenesis at the repair site. 3) Exercise recruits blood flow to both the greater tuberosity and rotator cuff. This study is limited in that only one time point was considered. However, these data suggest that the repaired rotator cuff tendon is relatively avascular and that the blood supply to the tendon bone interface comes from the tuberosity.

Arthroscopic Repair of Massive “Irreparable” Tears of the Rotator Cuff Using Double Interval Slides: Clinical And Magnetic Resonance Imaging Results (SS-43)

The objective of this study was to examine the clinical and anatomical outcomes following arthroscopic double interval slides in the repair of massive, otherwise “irreparable” rotator cuff tears. 11 patients were evaluated clinically and with MRI at a minimum 12 months post-operative. Double interval slides resulted in improved shoulder specific quality of life scores (post-operative versus pre-operative) and improved forward flexion. Active external rotation demonstrated no significant change. Anatomically, 55% of patients demonstrated massive re-tearing on MRI, 18% demonstrated a thin though grossly intact repair, and 27% showed a robust repair. Some chronic massive rotator cuff tears are irreparable using standard mobilization techniques. The double interval slide releases the interval between the supraspinatus and rotator interval (i.e. the anterior interval slide) and the interval between the supraspinatus and infraspinatus (i.e. the posterior interval slide) allowing repair of some massive “irreparable” rotator cuff tears. The purpose of this study was to review the clinical and MRI results following arthroscopic rotator cuff repair of massive “irreparable” rotator cuff tears using double interval slides. Eleven patients (5 females, 6 males; mean age 57.5 +/- 8 years) with massive, contracted, immobile rotator cuff tears that were irreparable using standard mobilization techniques, but reparable using arthroscopic double interval slides, were reviewed. The mean duration of symptoms was 16 +/- 12 months with 9 primary and 2 revision procedures. All patients had massive tears of the rotator cuff isolated to the supraspinatus and infraspinatus. All tears were irreparable using standard releases including capsular release but were reparable using a double interval slide mobilization technique and standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by an independent observer, the ASES shoulder index and the Simple shoulder test (SST). All patients were evaluated by MRI interpreted by a musculoskeletal trained radiologist. Paired two-tailed t-tests were used to determine significant differences between preoperative and postoperative scores and unpaired t-tests were used to determine significant differences between intact and re-ruptured repairs. A p<0.05 was considered statistically significant. At a mean follow-up of 21 +/- 10 months (range: 12-42 months), 10 of 11 patients were satisfied with surgery and would have surgery again. The ASES shoulder index increased from a mean of 41.5 +/- 18.3 preoperatively to a mean of 79.1 +/- 17.4 post-operatively (p< 0.0001) and the SST increased from 2.8 +/- 2.6 out of 12 preoperatively to 8.8 +/− 2.7 out of 12 post-operatively (p< 0.0001). The mean active forward elevation increased significantly from 119.5 o +/- 45.2o to 152.7o +/- 23.0o (p=0.05). However, the mean active external rotation did not significantly change (preop= 38.2o +/- 17.1o; postop= 32.3o +/- 17.4o; p=0.5). MRI demonstrated that 6 patients (55%) had massive re-tearing of the rotator cuff to its original size, 2 had a thin but grossly intact repair and 3 had a thick and robust repair. Patients with intact repairs had significantly more external rotation strength on manual muscle testing (p=0.002) and trended toward improved ASES scores (ASES= 87 versus 72; p=0.15) but was not significantly different. The current early results suggest that rotator cuff repair using the double interval slide can provide significantly improved subjective and objective results even in the presence of a re-torn rotator cuff. Furthermore, although 55% of patients had massive re-tearing of the rotator cuff to its original size, 5 of 11 patients had at least some tissue connecting the rotator cuff to bone with some evidence for improved results. Level of Evidence Level IV case series.