Rotator Cuff Defects Research Articles

In vitro analysis of rotator cuff repairs: A comparison of arthroscopically inserted tacks or anchors with open transosseous repairs

The purpose of this study was to employ a cyclic loading protocol to compare rotator cuff repair strengths of arthroscopically inserted cuff tacks and suture anchors with the traditional open transosseous suture repair. In vitro cadaveric analysis. Full-thickness 1 x 3-cm rotator cuff defects were created in 25 fresh-frozen cadaveric shoulders, and were randomized to 1 of 4 repair groups: (1) open repair with transosseous sutures, (2) arthroscopic repair with 2 singly loaded suture anchors, (3) arthroscopic repair with 2 doubly loaded suture anchors, and (4) arthroscopic repair with cuff tacks. All repairs were cyclically loaded from 10 to 180 N, and the numbers of cycles to 50% (5-mm gap) and 100% (10-mm gap) failure were recorded. The number of cycles to 100% failure was significantly higher for the arthroscopic doubly loaded suture anchor repairs when compared with the (1) open transosseous suture repair (P = .009), (2) arthroscopic cuff tack repair (P = .003), and (3) arthroscopic singly loaded suture anchor repair (P = .02). Additionally, the number of cycles to 50% failure was significantly higher for all anchors versus open or tack repair (P = .03 for both). Immediate postoperative fixation of rotator cuff repairs with doubly loaded suture anchors was more stable than that provided by the open transosseous suture repairs, arthroscopic singly loaded suture anchors, or cuff tacks. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process. These in vitro results indicate that superior immediate postoperative fixation of rotator cuff repairs may be achieved with the doubly loaded suture anchors. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.

Effektivität der Physiotherapie in Eigenregie bei Rotatorenmanschettendefekten

Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. A series of 30 patients (38 shoulders) with rotator cuff tears seen by ultrasonography were included in this prospective study. Rotator cuff tears were divided into partial defects (group A), full thickness tears of the supraspinatus tendon (group B), and massive rotator cuff defects (group C). Treatment consisted of a home program of stretching and strengthening exercises that were performed by the patients daily for a period of 12 weeks and controlled by a physician every 2 weeks. Range of motion, a modified constant score, and impingement signs at initial examination and after 12 weeks were compared. All groups experienced improvement in range of motion. The Constant scores improved significantly (p < 0.05) in all groups (A: 13.0 [+/- 7.9 SD], B: 13.2 [+/- 11.4 SD], and C: 17.5 [+/- 6.6 SD]). Impingement signs showed a downward trend in all groups. The results of this study show that patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect.

Margin convergence of the posterior rotator cuff to the biceps tendon.

Massive rotator cuff tears can often be repaired arthroscopically with satisfactory results. Tear pattern recognition, knot security, and loop security are essential in the repair of large and massive rotator cuff tears. In the case of a massive U-shaped tear, with a contracted immobile supraspinatus and a deficient rotator interval, a type of margin convergence technique can be used. This technique allows for the partial closure of the rotator cuff defect along with the proximal advancement of the posterior cuff by securing the posterior leaf of the cuff tendon to the tendon of the long head of the biceps brachii. Because of the mechanical effect of strain reduction in margin convergence, this procedure decreases the strain at the margin of the posterior cuff, thereby protecting its repair to bone. Our goal with this procedure is not to obtain healing of the cuff to the biceps, but to optimize the conditions for healing of the rotator cuff to bone.

Margin convergence of the posterior rotator cuff to the biceps tendon

Massive rotator cuff tears can often be repaired arthroscopically with satisfactory results. Tear pattern recognition, knot security, and loop security are essential in the repair of large and massive rotator cuff tears. In the case of a massive U-shaped tear, with a contracted immobile supraspinatus and a deficient rotator interval, a type of margin convergence technique can be used. This technique allows for the partial closure of the rotator cuff defect along with the proximal advancement of the posterior cuff by securing the posterior leaf of the cuff tendon to the tendon of the long head of the biceps brachii. Because of the mechanical effect of strain reduction in margin convergence, this procedure decreases the strain at the margin of the posterior cuff, thereby protecting its repair to bone. Our goal with this procedure is not to obtain healing of the cuff to the biceps, but to optimize the conditions for healing of the rotator cuff to bone.

Ultrasonographic evaluation of the rotator cuff after shoulder arthroplasty

Ultrasonography of the rotator cuff tendons is a standard imaging technique. Although increasing numbers of shoulder arthroplasty are performed, there is no available data concerning the use of ultrasound after shoulder replacement. Our experimental study was performed to analyse the value of ultrasonography after shoulder arthroplasty a) in an ex-vivo-setting and b) in a retrospective analysis of our patients after shoulder hemiprothesis. After defrosting, anatomic modular humeral head replacement was performed in four fresh-frozen specimens with intact rotator cuffs. The supraspinatus and subscapularis tendons of each specimen were either detached to simulate a cuff defect or reattached anatomically (four times per specimen). Two experienced examiners then performed ultrasonography to evaluate the two tendons to be either intact or deficient. In a retrospective study, 22 patients with 25 hemiprotheses of the shoulder underwent clinical and sonographic examination. For documentation of the clinical findings, the Constant score was used. In the cadaver study, the reliability of the method was slightly higher for the subscapularis tendon (13 correct, 3 false results) than for the supraspinatus tendon (12 correct, 4 false results). In our patients, rotator cuff defects and effusions around the biceps tendon and in the subdeltoid bursa could be detected. Normal sonograms correlated with good clinical results. In the cadaver study, we found a good reproducibility of in-vivo conditions. We believe that ultrasonography is beneficial in follow-up evaluation after shoulder arthroplasty.

Biomechanical effect of patch graft for large rotator cuff tears: a cadaver study.

It is not possible for some rotator cuff tears to be repaired because of a large defect associated with muscle retraction. The purpose of the current study was to investigate the use of a synthetic patch graft to restore abduction force transmission in the glenohumeral joint with a rotator cuff defect. Shoulders from cadavers (n = 10) were fixed in the hanging arm and in neutral rotation, and loading was applied to the rotator cuff tendons and middle deltoid. After a simulated supraspinatus tendon defect and retraction, a patch graft was inserted into the defect and the effects of reattachment to the greater tuberosity, narrowing of the defect by using a smaller graft, and anterior graft attachment (rotator interval tissue versus subscapularis) were investigated. Abduction torque generation was measured and normalized to the intact condition. Compared with torque generation after creation of a supraspinatus defect (61% of normal torque), abduction torque increased with a graft between the infraspinatus and either the rotator interval (68% of normal) or subscapularis (80% of normal). The optimum grafting technique for abduction torque restoration occurred with a reduced size patch connected anteriorly to the subscapularis and sutured to the greater tuberosity (107% of normal). The patch graft acts to redirect force transmission, thereby providing a potential treatment option for otherwise irreparable defects. These same principles can be applied when tendon transfers are used to reconstruct large or massive cuff tears.

Shoulder arthroplasty without a rotator cuff.

Patients with glenohumeral arthritis and absent or irreparable lesions of the rotator cuff represent a therapeutic challenge for orthopedic surgeons. In the June issue of Orthopedics, Dr Gilles Walch discussed the Delta reverse design shoulder prosthesis as a method of managing this problem. Although the Delta prosthesis is currently successful in Europe, it is not yet available in the United States. One technique for managing this problem in North America as well as Europe is a new system that uses the standard Global Advantage humeral component with the special Cuff Tear Arthropathy head. In this issue of Orthopedics, codeveloper and inventor of the Global™ Total Shoulder Prosthesis System, Dr Charles A. Rockwood, Jr discusses treatment options, which are currently available in the United States, for patients with glenohumeral arthritis and irreparable rotator cuff defects.

Milwaukee shoulder: correlating possible etiologic variables.

The current study evaluated the relative correlation of apatite crystal-induced inflammation and rotator cuff deficiency in the development of cuff tear arthropathy. Thirty-seven patients with full thickness rotator cuff tears were evaluated by history, physical examination, and plain radiographs. Thirty patients had surgical intervention for their rotator cuff defects, and calipers were used intraoperatively to quantify the size of the tear in its largest diameter. The remaining seven patients were treated nonoperatively and the size of the tear was quantified using magnetic resonance imaging. Synovial fluid was obtained from all patients and analyzed for crystal content using an alizarin red stain. Synovial fluid also was analyzed for leukocyte count and differential, prostaglandin E, and matrix metalloproteinase. An unpaired Student's t test revealed that significantly higher levels of prostaglandin E were found in the synovial fluid of patients with apatite crystals, shown by alizarin red stain. Chi squared analysis showed that patients with elevated crystal levels were significantly more likely to have large rotator cuff tears or glenohumeral arthritis. Establishing such relations potentially can elucidate the etiology and treatment of this complex disorder.(2) (2)

Deterioration of the PTFE Felt Graft for Rotator Cuff Defect

Deterioration of the PTFE Felt Graft for Rotator Cuff Defect

The biomechanics of total shoulder arthroplasty

Total shoulder arthroplasty requires release of contracted tissues, repair of rotator cuff defects, reconstruction of normal skeletal anatomy with proper sizing, and positioning of components.' Arthroplasty of the shoulder is unlike arthroplasty of the hinge joints when the collateral ligaments afford a high degree of stability and is even distinct from the hip when bony conformity is large and range of motion is less. Normal shoulder kinematics can only be achieved when normal articular anatomy is reestablished, and the passive and active stabilizers are balanced. This article presents the mechanics and pathomechanics of the glenohumeral joint for total shoulder arthroplasty.

Prospective Longitudinal Analysis of Postoperative Shoulder Function

Rotator cuff repair is associated with good short or mid-term results, but to date there have been no long-term functional outcome studies demonstrating durability of results over time. In most long-term studies, the results have been compared with those of historical controls or with those of other, short-term follow-up studies. The purpose of the present prospective study was to evaluate short and long-term shoulder function after surgical repair in a single population of patients in order to follow changes over time. Thirty-three patients underwent surgery, performed by one surgeon, for the treatment of a chronic, symptomatic, full-thickness rotator cuff defect. Data were obtained from questionnaires and physical examinations preoperatively, at two years, and at ten years. Identical standardized pain and function questionnaires were used and clinical evaluation was performed in a consistent fashion at all time-periods. The activity level, Constant score, level of disability, shoulder function score, and patient's subjective rating of the outcome were determined at the time of the final follow-up and compared with the same parameters at the two-year follow-up examination in order to determine if early results change with time. At the ten-year follow-up examination, there was no change in the raw Constant score determined at the two-year examination. When the Constant score was normalized for expected age-related changes, the percentage of patients who had a satisfactory result at ten years was even greater than the percentage at two years. Activity level decreased significantly over the time-period (p = 0.005). At the final follow-up examination, twelve patients worked at the same occupation as they had when the two-year examination was performed, two worked at a less strenuous occupation, and the remaining patients were retired. Only two patients retired because of problems related to the shoulder. The level of disability decreased over the study period, and there was a small improvement in the patients' self-assessment shoulder function score. The patients' subjective assessment of the outcome remained unchanged. The results of open rotator cuff repair for chronic tears do not deteriorate with time (ten years). The level of disability decreases, presumably because of a concurrent decrease in the activity level and in the demand on the shoulder as the patient ages. It is important to consider age-related changes when assessing the final outcome.

Rotator cuff repair in a district hospital setting: Outcomes and analysis of prognostic factors

In a prospective study of 58 complete rotator cuff tears, 54 patients underwent surgery by a single surgeon for chronic, symptomatic, full-thickness rotator cuff defects. An independent observer performed the evaluation. Fifty-two of 58 patients reported marked relief of pain and rated themselves as having mild or no deficit in their ability to perform daily activities. The study evaluated preoperative and intraoperative factors that influenced postoperative outcome. Eighty-three percent of patients had good or excellent results according to the modified Constant scoring system and 76% with the UCLA system. There was no pain or minimal pain in 90%, and 92% reported overall improvement after the surgery. It is concluded that in a patient with a full-thickness rotator cuff tear, pain and shoulder function can be improved by acromioplasty and cuff repair, but a slight decrease in the range of motion and muscle strength will probably remain. (J Shoulder Elbow Surg 2001;10:236-41.)

Cyclic loading of rotator cuff repairs: A comparison of bioabsorbable tacks with metal suture anchors and transosseous sutures

Purpose: The purposes of the study were (1) to compare rotator cuff repair strengths after cyclic loading of 2 bioabsorbable nonsuture-based tack-type anchors, transosseous sutures, and a metal suture-based anchor, and (2) to correlate bone mineral density with mode of failure and cycles to failure. We hypothesized that specimens with a lower bone density would fail through bone at a lower number of cycles independent of the method of cuff fixation. Type of Study: Ex vivo biomechanical study. Methods: Standardized full-thickness rotator cuff defects were created in 30 fresh-frozen cadaveric shoulders that were randomized to 1 of 4 repair groups: transosseous sutures; Mitek Super suture anchors (Mitek Surgical Products, Westwood, MA); smooth bioabsorbable 8-mm Suretacs (Acufex, Smith & Nephew Endoscopy, Mansfield, MA); or spiked bioabsorbable 8-mm Suretacs (Acufex). All repairs were cyclically loaded from 10 to 180 N; the numbers of cycles to 50% (gap, 5 mm) and 100% (gap, 10 mm) failure were recorded. Results: In comparing the repair groups, we found only 1 significant difference: the number of cycles to 100% failure was significantly higher (P <.05) for the smooth bioabsorbable tack than for the transosseous suture group. There were no statistically significant (P ≤.05) differences in bone mineral densities with regard to each specimen’s mode of failure. Conclusions: Our results suggested that immediate postoperative fixation provided by bioabsorbable tacks was similar to that provided by Mitek anchors and more stable than that provided by transosseous sutures. Therefore, the immediate postoperative biomechanical strength of bioabsorbable tacks seems comparatively adequate for fixation of selected small rotator cuff tears. However, additional evaluation in an animal model to examine degradation characteristics and sustained strength of repair is recommended before clinical use.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 360–364

Muscle efficiency in total shoulder prosthesis implantation: dependence on position of the humeral head and rotator cuff function

Modern shoulder prostheses permit an anatomic reconstruction of the joint, although the biomechanical advantages are not proven. The goal of this study was to investigate the relationship between position of the humeral head and function of the shoulder prosthesis (muscle efficiency). Shoulder elevation-motion and rotator cuff defects were simulated in vitro in a robot-assisted shoulder simulator. The EPOCA Custom Offset shoulder prosthesis (Argomedical AG, Cham, CH) was implanted in seven normal shoulders (77 +/- 20 kg, 55 +/- 14 years). Active elevation was simulated by hydraulic cylinders, and scapulothoratic motion by a specially programmed industrial robot. Muscle efficiency (elevation-angle/muscle-force of the deltoid muscle) was measured in anatomic (ANA), medialised (MED) and lateralised (LAT) positions of the humeral head, with or without rotator cuff muscle deficiency. Medialisation increased efficiency by 0.03 +/- 0.04 deg/N (p = 0.022), lateralisation decreased it by 0.04 +/- 0.06 deg/N (p = 0.009). Supraspinatus muscle deficiency increased the deltoid force required to elevate the arm, and thus decreased efficiency (ANA p = 0.091, MED p = 0.018, LAT p = 0.028). The data confirm that the position of the humeral head affects the mechanics of total shoulder arthroplasty. Medialisation increases efficiency of the deltoid muscle and may prove useful in compensating isolated supraspinatus muscle deficiency. Lateralisation, in contrast, leads to an unfavorable situation.

Prevalence of rotator cuff defects in dislocated fractures of the humerus head in elderly patients

Humeral head fractures are commonly found in elderly patients. A high rate of spontaneous rotator cuff tears in this patient group may endanger good results following surgical treatment. 70 patients > 65 years with dislocated humeral head fractures were prospectively studied and treated surgically following a standardised treatment protocol. In all cases the rotator cuff was examined intraoperatively. A tear of the rotator cuff was documented in 4 cases (5%). The prevalence of rotator cuff tears in elderly patients with dislocated humeral head fractures is significantly smaller than expected referring to magnetic resonance-, sonographic and cadaveric studies of same-age patients without fracture. Therefore the rotator cuff may serve as retention anchor for the surgical treatment of dislocated humeral head fractures in elderly patients.

Extensibility of the supraspinatus muscle with a rotator cuff tear evaluated by magnetic resonance imaging

An estimate of the extensibility of the supraspinatus muscle after a rotator cuff tear is useful in selecting the most appropriate operative procedure and the prognosis after surgery. We studied the relationship between the morphological findings of the supraspinatus muscle on magnetic resonance imaging and its elongation length. Twenty-one shoulders of 20 patients with massive rotator cuff tears were scanned parallel to the long axis of the supraspinatus muscle. The ratio of the largest width of the supraspinatus muscle belly to the distance from the greater tuberosity to the proximal end of the supraspinatus muscle was termed the supraspinatus muscle belly ratio. The appearance of linear bands and the degree of retraction of the tendon of the supraspinatus muscle were analyzed. The extensibility of the supraspinatus muscle decreased when the degree of retracted tendon was high, while no correlation was found with the length of the rotator cuff defect, the supraspinatus muscle belly ratio, or the appearance of linear bands.

Juxta-articular myxoma of the shoulder presenting as a cyst of the acromioclavicular joint: A case report

Treatment of patients with subcutaneous cystic lesions of the acromioclavicular joint has yielded unpredictable results unless the underlying pathologic process producing the cyst is addressed.4,9 Three causes of this lesion have been reported in the literature: true ganglion,9,2 mechanical irritation of a degenerated acromioclavicular joint by direct contact with the humeral head through a rotator cuff defect,8 and up-welling of glenohumeral joint fluid through a rotator cuff defect (“geyser” sign).3,4 We report a case of juxta-articular myxoma of the shoulder involving both the acromioclavicular joint and the glenohumeral joint in the presence of a large rotator cuff tear as an additional cause of acromioclavicular cyst. The aggressive behavior of this lesion compared with other known causes warrants the attention of surgeons who evaluate and treat this condition. CASE REPORT A 68-year-old right-hand-dominant man had a soft tissue mass over the superior surface of his right acromioclavicular joint compatible with subcutaneous acromioclavicular cyst. The lesion was excised by a general surgeon in the patient’s home district but recurred 5 weeks later. The cyst was reexcised, and a pathologic diagnosis of juxta-articular myxoma was confirmed by the Armed Forces Institute of Pathology. Two months later recurrence in the same location prompted referral to our facility for evaluation and further treatment. Physical examination showed a 2.5-cm marble-sized soft tissue mass superior to the right acromioclavicular joint with marked erythema, shiny skin edges at the previous scar, and dense induration and firm attachment to the underlying acromion. Glenohumeral range of motion was unrestricted; no pain was elicited on motion examination. After routine radiography was performed, computed tomography scan indicated erosion of the acromioclavicular joint and apparent cystic change in the humeral head. Magnetic resonance imaging evaluation of the shoulder with the 1.5-Tesla Siemens Magnetom System suggested a chronic rotator cuff tear, subdeltoid fluid, a synovial or gan

Histological Healing of PTFE Felt Graft for Rotator Cuff Defect: A Study of Canines

Histological Healing of PTFE Felt Graft for Rotator Cuff Defect: A Study of Canines

Rotator cuff defect healing: A biomechanical and histologic analysis in an animal model

Rotator cuff tears are one of the most common causes of pain and disability in the upper extremity. With the use of an animal model, we studied the healing response of a controlled defect in the normal supraspinatus tendon and in a tendon with a reduced intrinsic healing capacity. In 36 Sprague-Dawley rats, defects (2 mm × 2 mm) were created in the supraspinatus tendons bilaterally. To model a tendon with an intrinsically reduced capacity to heal, the tissue adjacent to the defect area in the left shoulder was treated with in situ freezing. The contralateral tendon was not frozen. After 3 (n = 12), 6(n = 12), and 12(n = 12) weeks, animals were killed and underwent histologic (n = 4 from each group) and biomechanical (n = 8 from each group) evaluation. An additional group of untreated animals served as a normal control group. On histologic evaluation 78% of tendons had persistent defects (defined as incomplete closure of the defect site). Over time, the tissue from both groups demonstrated an improved histologic grade but did not reach normal levels, even at 12 weeks. No histologic differences were found between defect healing in normal tendons and in those treated with in situ freezing. On biomechanical evaluation there were also no significant differences between treatment groups. Over time, an improvement occurred in tissue properties, indicating that some healing of the defects had occurred. However, these tissue properties remained an order of magnitude lower than those of normal control tendons. These findings indicate that there is an active but inadequate repair response to the defect in the rat supraspinatus tendon, which is not significantly worsened by in situ freezing of the tissue around the defect. This model has applications

Spontaneous detachment of the deltoid muscle origin

Three patients with four affected shoulders with spontaneous detachment of the deltoid origin are reported. In this group spontaneous detachment of the deltoid origin was associated with chronic massive rotator cuff defects. Detachment of the deltoid origin was associated with an acute, sudden onset of shoulder weakness. Pain was not a prominent complaint, and shoulder function was poor because of weakness. Spontaneous detachment of the deltoid origin can occur with chronic massive rotator cuff tears and can be responsible for an acute onset of shoulder weakness.