Partial Rotator Cuff Repair Research Articles

Paper #60 - Partial rotator cuff repair in massive rotator cuff tears: long-term follow-up

Paper #60 - Partial rotator cuff repair in massive rotator cuff tears: long-term follow-up

The “Pull-Over” Technique for Arthroscopic Superior Capsular Reconstruction

The management of irreparable rotator cuff tears is a difficult problem to deal with. The options include nonoperative route with anterior deltoid exercises, debridement with or without long head of biceps tenotomy, partial rotator cuff repair, tuberoplasty, muscle transfer, patch augmentation, biodegradable spacers, and reverse shoulder arthroplasty. None of these options are without their limitations. In recent years, arthroscopic superior capsular reconstruction has gained popularity as an alternative technique to address irreparable rotator cuff tears. Arthroscopic superior capsular reconstruction, however, is technically difficult. The purpose of this technical note is to describe a simple and reproducible technique for this procedure that addresses some of the challenges involved.

Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up

A subset of patients with massive irreparable rotator cuff tears present with retained overhead elevation and pain as their primary complaint. Our aim was to evaluate the outcomes of partial arthroscopic rotator cuff repair with biceps tenotomy and to report the failure rate of this procedure for patients with >5 years of follow-up. Thirty-four patients underwent partial rotator cuff repair and biceps tenotomy for treatment of a massive rotator cuff tear. Patients had preoperative active forward elevation >120° and no radiographic evidence of glenohumeral arthritis. Patients were followed up clinically and radiographically, and 28 patients had a minimum of 5 years of follow-up. Failure was defined as an American Shoulder and Elbow Surgeons score of <70, loss of active elevation >90°, or revision to reverse shoulder arthroplasty during the study period. Patients demonstrated improvements in average preoperative to postoperative American Shoulder and Elbow Surgeons scores (46.6 to 79.3 [P < .001]) and Simple Shoulder Test scores (5.7 to 9.1 [P < .001]) along with decrease in visual analog scale for pain scores (6.9 to 1.9 [P < .001]). No significant change in forward elevation (168° to 154° [P = .07]), external rotation (38° to 39° [P = 1.0]), or internal rotation (84% to 80% [P = 1.0]) was identified; 36% of patients had progression of the Hamada stage. The failure rate was 29%; 75% of patients were satisfied with their index procedure. Partial rotator cuff repair and biceps tenotomy for patients with massive irreparable rotator cuff tears with retained overhead elevation and pain as the primary complaint produced reasonable outcomes at midterm follow-up of at least 5 years.

Arthroscopic Partial Rotator Cuff Repair in the Management of Massive Rotator Cuff Tears: Long-term Follow-up

Arthroscopic Partial Rotator Cuff Repair in the Management of Massive Rotator Cuff Tears: Long-term Follow-up

Paper #10 - Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: mid-term outcomes with a minimum 5 years of follow-up

Paper #10 - Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: mid-term outcomes with a minimum 5 years of follow-up

Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears in young patients are a particular challenge for the orthopaedic surgeon. Surgical treatment options include debridement, partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and reverse total shoulder arthroplasty. Recently, reconstruction of the superior glenohumeral capsule using a fascia lata autograft has been suggested to reduce superior glenohumeral translation and restore superior stability. Promising clinical results have been reported in 1 case series of 23 patients, indicating that superior capsular reconstruction may be a promising tool to manage massive irreparable rotator cuff tears. This article describes our preferred technique for arthroscopic superior capsule reconstruction.

Treatment options for irreparable postero-superior cuff tears in young patients.

Rotator cuff tears (RCTs) occur more commonly with advanced age, with most rotator cuff abnormalities in patients less than 30 years old being painful tendinoses or partial-thickness RCTs. Irreparable postero-superior cuff tears has been reported as frequent as 7% to 10% in the general population, and the incidence of irreparable RCTs in young patients is still unknown. Several surgical procedures have been proposed for young patients with irreparable postero-superior RCTs, such as rotator cuff debridement, partial rotator cuff repair, biceps tenotomy/tenodesis, rotator cuff grafting, latissimus dorsi tendon transfer, and reverse shoulder arthroplasty. After being thoroughly investigated in open surgery, arthroscopic techniques for latissimus dorsi tendon transfer have been recently described. They have been shown to be an adequate option to open surgery for managing irreparable postero-superior RCTs refractory to conservative management.

Isolated subscapularis repair for massive rotator cuff tear.

The best surgical treatment for an irreparable rotator cuff tear is controversial. In such cases, partial rotator cuff repair, primarily involving the posterior cuff in most reports, has been shown to be beneficial. The authors retrospectively investigated 41 patients who underwent arthroscopic subscapularis-only repair and greater tuberoplasty between April 2003 and August 2009 for massive 3-tendon cuff tears with irreparable supraspinatus and infraspinatus tendons after 3 months of conservative management was unsuccessful. Twenty-five patients (61%) underwent biceps tenotomy, and the remaining 39% had preexisting biceps tenotomy or rupture. The patients were assessed with American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Of the 41 patients, 34 (83%) were available for a follow-up telephone questionnaire after a minimum of 12 months (mean, 35 months; range, 12-84 months). Mean ASES and SANE scores were 76% and 63%, respectively. Mean postoperative passive range of motion was 156° of forward flexion and 39° of external rotation. Of the patients queried, 74% (25 of 34) were able to actively raise their arms above shoulder level. For those with a positive belly-press test result preoperatively, 22 of 27 patients had a negative test result postoperatively. A total of 3 complications (7.3%) occurred. Workers' compensation claim was a strong predictor of lower shoulder scores. Arthroscopic subscapularis-only repair and greater tuberoplasty may offer a promising and safe method for treating massive rotator cuff tears when the supra-spinatus and infraspinatus tendons are irreparable. Workers' compensation claim may predict lower outcome scores.

Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder.

The management of patients with irreparable rotator cuff tears remains a challenge for orthopaedic surgeons with the final treatment option in many algorithms being either a reverse shoulder arthroplasty or a tendon transfer. The long term results of these procedures are however still widely debated, especially in younger patients. A variety of arthroscopic treatment options have been proposed for patients with an irreparable rotator cuff tear without the presence of arthritis of the glenohumeral joint. These include a simple debridement with or without a biceps tenotomy, partial rotator cuff repair with or without an interval slide, tuberplasty, graft interposition of the rotator cuff, suprascapular nerve ablation, superior capsule reconstruction and insertion of a biodegradable spacer (Inspace) to depress the humeral head. These options should be considered as part of the treatment algorithm in patients with an irreparable rotator cuff and could be used as either as an interim procedure, delaying the need for more invasive surgery in the physiologically young and active, or as potential definitive procedures in the medically unfit. The aim of this review is to highlight and summarise arthroscopic procedures and the results thereof currently utilised in the management of these challenging patients.

Results of Arthroscopic Partial Repair of Large Retracted Rotator Cuff Tears

To evaluate the midterm results of partial rotator cuff repair using the Constant score and the acromiohumeral radiographic measurement. Thirty-eight patients with a mean age of 65 years and a large retracted rotator cuff tear (at least 2 tendons) were included in the study. Patients underwent clinical examination, standard radiography, and isometric strength testing at a mean follow-up of 47 months. The rotator cuff tears were classified as posterosuperior, anterosuperior, or global tears (≥3 tendons), and an arthroscopic partial repair was performed. The mean Constant score significantly increased from 56 points before surgery to 71 points after surgery (P=.041); the mean age- and sex-adjusted Constant score significantly improved from 63% to 90% at a mean follow-up of 47 months after arthroscopic partial rotator cuff repair (P= .003); and the subcategories pain and activity significantly improved (P= .001, P= .014, respectively). The active range of motion improved from 133° of flexion and 111° of abduction before surgery to 163° of forward flexion and 156° of abduction after surgery (P < .001). However, the active range of external rotation decreased from 44° before surgery to 36° after surgery. Further, there was a trend toward a decrease in the mean acromiohumeral distance from 7.0 mm before surgery to 5.6 mm after surgery. The abduction strength did not significantly improve after surgery (4.2 kg before surgery and 4.8 kg after surgery; P= .116). An arthroscopic partial repair of the rotator cuff is an effective tool to improve the Constant score by restoring active forward flexion and abduction and through pain relief. Further, we found that a pathologically decreased acromiohumeral distance cannot be reversed by a partial rotator cuff repair. Level IV, therapeutic case series.

Intraoperative Determinants of Rotator Cuff Repair Integrity

Background: Rotator cuff repair has a relatively high (20%-90%) chance of retears. Patients with an intact rotator cuff 6 months after surgery have better subjective and objective outcomes at 6 months and 2 years after rotator cuff repair than those who do not have an intact repair. Purpose: The aim of this study was to determine if, and if so which, intraoperative factors predict an intact repair 6 months after rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: The study consisted of a cohort of 500 consecutive patients who had an arthroscopic rotator cuff repair performed by a single surgeon and an ultrasound evaluation using standard protocols of the repair 6 months after surgery. Exclusion criteria included previous fracture or shoulder surgery, incomplete or partial rotator cuff repair, and concomitant arthroplasty. Rotator cuff tear size was measured intraoperatively and mapped. The quality of the tendon, tendon mobility, and repair quality were assessed and ranked based on predetermined scales (1-4) and recorded on a specifically designed form. Logistic regression analysis was performed, with cuff integrity at 6-month follow-up as the dependent variable and tear/repair factors as the independent variables. Results: The overall postoperative retear rate was 19% at 6 months. The best predictor of rotator cuff integrity was preoperative tear size (correlation coefficient, r = 0.33; P < .001). Patients with small (≤2 cm2) rotator cuff tears were least likely to have retears (retear rate, 10%). As the tear size increased, the retear rate increased in a linear fashion: ≤2 cm2 (10%), 2 to 4 cm2 (16%), 4 to 6 cm2 (31%), 6 to 8 cm2 (50%), and >8 cm2 (57%). Other surgeon-ranked intraoperative assessments did correlate with retears, but the correlations were relatively weak: repair quality (r = −0.17; P < .001), tendon mobility (r = −0.15; P < .001), and tendon quality (r = −0.14; P < .01). Regression analysis showed that the retear rate at 6-month follow-up was best predicted from the preoperative tear size and the surgeon-ranked repair quality: chance of retear = 0.38 + (0.02 × tear size in cm2) – (0.08 × repair quality). Tendon quality and tendon mobility did not contribute significantly to this prediction. Conclusion: Tear size was the best intraoperative predictor of repair integrity after rotator cuff repair, with tears less than 2 cm2 twice as likely to heal than tears greater than 6 cm2.

次修復不能な腱板広範囲断裂に対する鏡視下腱板部分修復術の MRI 評価

次修復不能な腱板広範囲断裂に対する鏡視下腱板部分修復術の MRI 評価

Partial Rotator Cuff Repair in Massive Rotator Cuff Tears: Long-Term Follow-Up (SS-17)

Introduction Surgical options for the patient with a massive rotator cuff tear remain limited. Tendon transfers offer significant perioperative morbidity, and procedures such as interval tendon slides have raised concerns about the vascularity of the remaining tendon, with a recent study showing only 25% of patients with interval slides had solid healing on MRI follow-up. Xenograft and allograft patches have shown significant complications and mixed results. Burkhart (1994) and others pioneered the concept of partial rotator cuff repairs as an arthroscopic-assisted procedure, with good preliminary results. The procedure is however difficult, especially to access the infraspinatus and subscapularis from a deltoid split. Presented here is the first report of all-arthroscopic partial rotator cuff repair in the treatment of massive, unrepairable rotator cuff tears. Methods Eighty patients with large or massive rotator cuff tears were evaluated. All patients were Thomazeau class 2 to 3 for atrophy, and Goutallier class 2 to 4 for fatty infiltration. All patients had primary closure attempted; interval slides or other heroic techniques were avoided. If solid closure without tension could not be obtained by primary repair, but a portion of the cuff could be solidly reapproximated, partial rotator cuff repair with acromioplasty, preserving the coracoacromial ligament, was performed. All patients were reexamined, with UCLA, SST, and ASES scores obtained, and follow-up radiographs and MRI scans were obtained and compared to preoperative studies. Results Sixty five patients had repair of the infraspinatus only, with 15 patients combined infraspinatus and subscapularis. Follow-up was a minimal of 24 months (average 40.7 months). Good or excellent results were obtained in 88% of cases based on UCLA scores, with SST scores averaging 10.11 and ASES scores 86.2. No complications occurred, specifically no hardware issues, infections, or neurologic injuries. All procedures were performed successfully as an outpatient procedure. Pain scores showed the most significant decrease, with functional scores based on ASES and Constant scores showed less improvement. External rotation strength improved 1.2 grades. No patient developed anterosuperior instability, and no patients developed cuff tear arthropathy. Radiographs at final follow-up showed no evidence of vertical migration. MRI scanning showed no progression of atrophy and interval healing of the repaired segment in 68%. Conclusion Good results can be obtained with arthroscopic partial rotator cuff repair for large and massive rotator cuff tears. Arthroscopic exposure of the rotator cuff is much simpler that with mini-open technique, and direct suturing of the available tendons is possible without damaging the deltoid. While not approaching the results of complete arthroscopic repair, this technique represents a reasonable, low-morbidity salvage option for the patient with a rotator cuff tear that is not primarily repairable.

Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair

BackgroundThe surgical treatment of massive rotator cuff tears (RCT) is still controversial and can be based on a variety of different surgical repair methods. This study investigated the effectiveness of arthroscopic debridement or arthroscopic partial repair in patients with massive RCT.Materials and methodsThis prospective, randomized study involved forty-two patients with massive RCT (fatty infiltration stage 3 or 4) treated with either arthroscopic partial repair or arthroscopic debridement were selected to detect possible differences in functional outcome. Both groups were matched according to age and gender. Patients were examined before, and 16 ± 3 and 24 ± 2 months after surgery. The status of the rotator cuff repair was determined using ultrasonographic evaluation.ResultsRegardless of the treatment group, postoperative results demonstrated highly significant improvements compared with preoperative values in most parameters. The overall Constant score in the partial repair group was superior to the outcome in the debridement group (P < 0.01, F = 8.561), according to better results in abduction (P < 0.01, F = 13.249), activity (P < 0.01, F = 21.391) and motion (P < 0.01, F = 4.967). All treatment groups had similar pain relief (P = 0.172, F = 1.802) and satisfaction, reflected in equal values of disabilities of the arm, shoulder and hand (DASH) score (P = 0.948, F = 0.004). Ultrasonography revealed structural failure of the partial rotator cuff repair in 52% at final follow-up.ConclusionsDuring the follow-up period all patients in our series had good or satisfactory outcome after rotator cuff surgery. Regardless of high rates of structural failure of the partial rotator cuff repair, the results of arthroscopic partial rotator cuff repair demonstrated slightly better functional outcome than debridement.

The Incidence of Early Metallic Suture Anchor Pullout After Arthroscopic Rotator Cuff Repair

The purpose of this study was to identify the incidence of metallic suture anchor pullout after arthroscopic rotator cuff repair and determine the impact of tear size on the risk of pullout. A retrospective review of 269 patients (550 metallic suture anchors) who underwent arthroscopic rotator cuff repair between January 2006 and January 2009 was conducted. Inclusion criteria included patients aged 18 years or older, a minimum of 6 weeks' radiographic follow-up, and the use of 1 or more metallic suture anchors for partial or complete rotator cuff repair. The mean age of the cohort at the time of surgery was 55 years (range, 29 to 86 years), and there were 189 men and 80 women. Early anchor pullout occurred in 6 patients (9 anchors). The overall incidence of early metallic suture anchor pullout in this cohort was 2.4% (95% confidence interval, 0.5% to 4.3%). The incidence in rotator cuff tears less than or equal to 3 cm was 0.5%, and the incidence in tears greater than 3 cm was 11%. Patients undergoing arthroscopic rotator cuff repair of a tear greater than 3 cm in size were at a significantly higher risk of having early metallic suture anchor pullout than patients undergoing repair of a smaller tear (relative risk, 22; P = .001). Among the 61 patients undergoing arthroscopic subscapularis repair, no suture anchor failures were observed at the lesser tuberosity. Of the 9 anchors that failed, 8 (89%) pulled out of the posterior aspect of the greater tuberosity. There is a minimal risk of suture anchor pullout in small- to medium-sized tears; however, this risk increases with larger tear sizes. We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout. Level III, prognostic case series.

Arthroscopic Treatment for Pigmented Villonodular Synovitis of the Shoulder Associated With Massive Rotator Cuff Tear

Our purpose was to investigate arthroscopic treatment of patients diagnosed with pigmented villonodular synovitis (PVNS) of the shoulder and massive rotator cuff tear with the initial presentation of large, recurrent joint effusion. From December 2005 to June 2007, 5 patients (3 males and 2 females) diagnosed with PVNS of the shoulder and massive rotator cuff tear were treated with arthroscopic synovectomy, partial cuff repair, or debridement if the cuff was irreparable. All 5 patients were followed-up for a mean of 22.4 months (range, 12 to 33 months). Outcomes were measured with use of the American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scoring systems. Two patients received partial rotator cuff repair by suture anchors and another 2 received suture repairs only. All of the patients had residual tear with variable sizes. With a mean follow-up of 22.4 months (range, 12 to 33 months), the mean ASES and UCLA scores improved from preoperative values of 48.2 and 7.8 to 80.0 and 29.6 points, respectively (P < .05). All patients were satisfied with the procedure, and no signs of recurrence were noted during the follow-up period. Five cases of PVNS of the shoulder and massive rotator cuff tears with the initial symptoms of shoulder effusion and function limitation were reported. After arthroscopic synovectomy and partial rotator cuff repair or debridement, all patients gained symptomatic and limited functional improvement at an average follow-up of 22 months. Level IV, therapeutic case series.

Predictive Factors of Subtle Residual Shoulder Symptoms after Transtendinous Arthroscopic Cuff Repair

Background Transtendinous repair is a well-known technique for the arthroscopic management of partial rotator cuff tear. However, there are not a lot of clinical follow-up studies in the literature reporting data on this approach, and, moreover, potential factors responsible to influence the outcomes have not been investigated. Purpose To evaluate clinical outcomes after arthroscopic transtendinous repair and to identify predictive factors of residual shoulder symptoms. Study Design Case series; Level of evidence, 4. Methods Fifty-four patients with a mean age of 56.7 ± 8.8 years (range, 31-71 years) who had undergone an arthroscopic transtendon repair for a painful articular-sided rotator cuff tear with a minimum of 2 years of follow-up were contacted. Clinical outcomes using a patient-based questionnaire, the Constant score, University of California at Los Angeles score, Simple Shoulder Test, and visual analog scale were evaluated. The influence of patient age, presence or absence of a trauma responsible for the cuff tear, presence of associated shoulder lesions, millimeters of exposed footprint, and millimeters of torn tendon retraction on the outcomes were assessed. Results The mean cuff tear exposure footprint was 5.2 mm, and the mean retraction of the torn part of the tendon was 8 mm. Only one patient reported dissatisfaction with surgery because of persistence of pain during overhead activities. After arthroscopic repair, University of California at Los Angeles, Constant, and Simple Shoulder Test scores were significantly improved from 14.1, 45.3, and 9.8 to 32.9, 90.6, and 0.8, respectively (P < .001). Twenty-two patients (41%) reported occasional shoulder discomfort at the extremes of range of motion (particularly at extremes of abduction and internal rotation) occurring during some daily living and sports activities. The best multivariate model showed that residual shoulder discomfort is strongly linked with a partial thickness supraspinatus tendon avulsion-type articular-sided rotator cuff lesion consisting of a large tendon retraction and/or a relatively small exposure footprint area in an older patient in the absence of a specific trauma (P < .001). Conclusion Arthroscopic transtendon partial articular supraspinatus tendon avulsion-type rotator cuff repair was a reliable procedure that resulted in a good outcome in terms of pain relief and shoulder scores in 98% of the 54 patients. Better results could be expected in patients with less tendon retraction, a larger footprint exposure, of younger age, and with a clinical history of trauma.

Management of Internal Impingement and Partial Rotator Cuff Tears in the Throwing Athlete

Internal impingement is a condition that can cause significant disability to the elite throwing athlete. Unlike classical impingement, internal impingement is thought to occur when the undersurface of the rotator cuff and greater tuberosity come in contact with the posterosuperior glenoid and labrum during the late cocking and early acceleration phase of throwing, when the arm is in the abducted and maximally externally rotated position. Although several theories have been proposed as to the exact mechanism of this condition, all theories lead to similar pathology. This includes rotator cuff pathology, typically partial undersuface tears, and posterosuperior labral pathology. Ultimately, the thrower’s mechanics and core body fitness are of utmost importance. Treatment of internal impingement is initially nonoperative, with special emphasis on core strength, stability, and flexibility, in addition to optimization of throwing mechanics. If surgical intervention is indicated, we prefer to eliminate pain generators within the shoulder, repair structural damage if necessary, and minimize the potential for postoperative motion loss. Techniques for superior labral repair, intratendinous rotator cuff repair, and partial articular-sided rotator cuff repair are reviewed.

The association of suprascapular neuropathy with massive rotator cuff tears: A preliminary report

We studied a prospective, consecutive series of 8 patients presenting with massive rotator cuff tears (>5 cm. in maximum dimension), all associated with severe retraction and fatty infiltration of the supraspinatus muscle on magnetic resonance imaging studies. All 8 patients had suprascapular neuropathy shown by electromyography (EMG) findings of denervation in the supraspinatus and/or infraspinatus muscles. Clinically, all patients had severe limitation of active motion, with no patient able to elevate their affected arm actively >40 degrees . Four patients elected débridement and partial surgical repair using margin convergence principles via a mini-open approach. Follow-up of these patients averaged 24 months. All 4 patients regained the ability to elevate their affected arm to >90 degrees , and to place their hand actively behind their head without assistance. Two of the 4 surgical patients consented to follow-up EMG studies that demonstrated, in both cases, that the suprascapular nerve had significant renervation potentials, with almost complete recovery of the nerve in 1 case. We conclude that suprascapular neuropathy may be associated with massive rotator cuff tears, and that partial rotator cuff repair may allow recovery of the nerve and improvement of function.