Laura Ruzzini

Equivalent Clinical Results of Arthroscopic Single-Row and Double-Row Suture Anchor Repair for Rotator Cuff Tears A Randomized Controlled Trial

Background Restoring the anatomical footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomical configuration of the rotator cuff footprint. Hypothesis There is no difference in clinical and imaging outcome between single-row and double-row suture anchor technique repairs of rotator cuff tears. Study Design Randomized controlled trial; Level of evidence, 1. Methods The authors recruited 60 patients. In 30 patients, rotator cuff repair was performed with a single-row suture anchor technique (group 1). In the other 30 patients, rotator cuff repair was performed with a double-row suture anchor technique (group 2). Results Eight patients (4 in the single-row anchor repair group and 4 in the double-row anchor repair group) did not return at the final follow-up. At the 2-year follow-up, no statistically significant differences were seen with respect to the University of California, Los Angeles score and range of motion values. At 2-year follow-up, postoperative magnetic resonance arthrography in group 1 showed intact tendons in 14 patients, partial-thickness defects in 10 patients, and full-thickness defects in 2 patients. In group 2, magnetic resonance arthrography showed an intact rotator cuff in 18 patients, partial-thickness defects in 7 patients, and full-thickness defects in 1 patient. Conclusion Single- and double-row techniques provide comparable clinical outcome at 2 years. A double-row technique produces a mechanically superior construct compared with the single-row method in restoring the anatomical footprint of the rotator cuff, but these mechanical advantages do not translate into superior clinical performance.

Histopathology of the Supraspinatus Tendon in Rotator Cuff Tears

Background Causes of rotator cuff pathology are poorly understood. Hypothesis Macroscopically intact supraspinatus tendon may show profound light microscopy changes. These changes may be the pathogenic precursor to a subsequent rotator cuff tear. Study Design Comparative laboratory study. Methods Tendon samples were harvested from 88 individuals (49 men, 39 women; mean age, 58.2 years) who had sustained a rotator cuff tear and underwent arthroscopic repair of the lesion, and from 5 male patients who died of cardiovascular events (mean age, 69. 6 years). A full-thickness supraspinatus tendon biopsy specimen was harvested en bloc within the arthroscopically intact middle portion of the tendon between the lateral edge of the tendon tear and the muscle-tendon junction. Slides stained with hematoxylin and eosin were interpreted twice by the same observer using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased colagen stainability, and hyalinization. Intraobserver reliability of the subscore readings was calculated. Results The mean pathologic sum-score of ruptured tendons was significantly greater than the mean pathologic score of control tendons (15.66 ± 1.82 vs 3.7 ± 2.31, P = .001). Within each specific category of tendon abnormalities, the control and ruptured tendons were significantly different <χ2 test); all variables were significantly different (Mann-Whitney U test <0.05; P = .001). The agreement between the 2 readings ranged from 0.56 to 0.86 (kappa statistics). Conclusion Nonruptured supraspinatus tendons, even at an advanced age, and ruptured supraspinatus tendons are clearly part of 2 distinct populations. Clinical Relevance During cuff repair, it is not necessary to excessively freshen the torn tendon to bleeding tissue: the macroscopically intact supraspinatus tendon is degenerated as well, and the failed healing response is not limited to the ends of the torn tendon.

No Advantages in Repairing a Type II Superior Labrum Anterior and Posterior (SLAP) Lesion When Associated With Rotator Cuff Repair in Patients Over Age 50 A Randomized Controlled Trial

Background Arthroscopic management has been recommended for some superior labrum anterior and posterior (SLAP) lesions, but no studies have focused on patients over 50 years of age with rotator cuff tear and a type II SLAP lesion. Hypothesis In patients over 50 years of age with an arthroscopically confirmed lesion of the rotator cuff and a type II SLAP lesion, there is no difference between (1) repair of both lesions and (2) repair of the rotator cuff tear without repair of the SLAP II lesion but with a tenotomy of the long head of the biceps. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the type II SLAP lesion (group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (group 2). Seven patients (2 in group 1 and 5 in group 2) were lost to final follow-up. Results At a minimum 2.9 years’ follow-up, statistically significant differences were seen with respect to the University of California, Los Angeles (UCLA) score and range of motion values. In group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a preoperative average rating of 10.4 (range, 6–14) to an average of 27.9 (range, 24–35) postoperatively (P < .001). In group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a preoperative average rating of 10.1 (range, 5–14) to an average of 32.1 (range, 30–35) postoperatively (P < .001) There was a statistically significant difference in total postoperative UCLA scores and range of motion when comparing the 2 groups postoperatively (P < .05). Conclusions There are no advantages in repairing a type II SLAP lesion when associated with a rotator cuff tear in patients over 50 years of age. The association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of the type II SLAP lesion and the rotator cuff.

Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon

Objective: To examine the relative prevalence of histological changes that have been found to be associated with the process of tendinopathy in lesions of the tendon of the long head of the biceps brachii and to evaluate the reliability of histopathological evaluation of tendon tissue in lesions of the tendon of the long head of the biceps. Design: Tendon samples were taken from 51 patients (31 men, 20 women; mean age 63.2 years) who underwent arthroscopic release of the long head of the biceps tendon because of refractory biceps tendinopathy and from 5 male patients who died of cardiovascular events (mean age 69.6 years). Histological examination was performed using haematoxylin and eosin staining of sections, which were interpreted using a semiquantitative grading scale assessing fibre structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen staining and hyalinisation. Results: The mean (SD) pathological sum score of ruptured tendons was greater than that of control tendons (15.76 (3.11) vs 3.4 (1.9), p<0.001). Within each specific category of tendon abnormalities, the χ2 test showed significant differences between the control and ruptured tendons; all the variables were significantly different (Mann–Whitney U test 0.05, p<0.001). Using the κ statistic, the agreement between the two readings ranged from 0.53 to 0.85. Conclusions: Unruptured tendons of the long head of the biceps, even at an advanced age and ruptured tendons of the long head of the biceps are clearly part of two distinct populations.

Arthroscopic Salvage of Failed Arthroscopic Bankart Repair: A Prospective Study with a Minimum Follow-up of 4 Years

Background Data on arthroscopic salvage of failed arthroscopic Bankart repair are lacking. Purpose To prospectively evaluate the surgical outcome of arthroscopic salvage of failed arthroscopic Bankart repair. Study Design Case series; Level of evidence, 4. Methods Operations were performed on 10 patients (8 male and 2 female; mean age at revision, 25.6 years; range, 18-41 years). The mean interval from the time of the revision surgery to the final follow-up was 68 months (range, 46-83 months). Objective testing included preoperative and postoperative range of motion. Outcome measures included the rating system of the University of California at Los Angeles. The surgical procedure was performed in a consistent manner: capsular plications, suture anchor repair of the displaced labrum, and, when indicated, rotator interval closure. Results The University of California at Los Angeles rating system showed a statistically significant improvement from a preoperative mean rating of 11.7 (range, 6-14) to a mean of 31.7 (range, 29-35) postoperatively (P < .05). All patients had a full and equal postoperative range of motion compared with the preoperative range of motion. One patient experienced recurrent dislocations after the salvage procedure. None of the other 9 patients experienced a recurrent dislocation, with all returning to their previous sports levels. Conclusion Arthroscopic Bankart revision surgery is a reliable procedure with respect to recurrence rate, range of motion, and shoulder function in carefully selected patients.

Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears

Objective: To determine the plasma glucose levels in non-diabetic patients with rotator cuff tear. Design: Frequency-matched case–control study. Setting: University Teaching Hospital. Participants: The study included 194 subjects who were operated on at our institution. Group 1 included 97 consecutive patients (36 men and 61 women; mean age: 62.9 years, range 37 to 82) who underwent arthroscopic repair of a rotator cuff tear in 2007 and 2008. Group 2 (control group) included 97 patients (36 men and 61 women; mean age: 61.6 years, range 36 to 80) who underwent arthroscopic meniscectomy for a meniscal tear in the same period, and had no evidence of shoulder pathology. These patients were frequency-matched by age (within 3 years) and gender with patients of Group 1. Main outcome measure: Measurement of fasting plasma glucose levels. Results: Patients with rotator cuff tears (Group 1) showed statistically significantly higher fasting plasma glucose levels within the normoglycaemic range (p = 0.007) than patients with meniscal tear (Group 2). Conclusions: The present study suggests that normal, but in the high range of normal, increasing plasma glucose levels may be a risk factor for rotator cuff tear. An enhanced understanding of these factors holds the promise of new approaches to the prevention and management of rotator cuff tears.

Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman Bridge repair

BackgroundRotator cuff tears are frequently associated with pathologies of the long head of the biceps tendon (LHBT). Tenotomy and tenodesis of the LHBT are commonly used to manage disorders of the LHBT.MethodsWe present an arthroscopic soft tissue LHBT tenodesis associated with a Roman Bridge (double pulley – suture bridges) repairResultsTwo medial row 5.5-mm Bio-Corkscrew suture anchors (Arthrex, Naples, FL), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL), are placed in the medial aspect of the footprint. A shuttle is passed through an anterior point of the rotator cuff and through the LHBT by means of a Penetrator or a BirdBeak suture passer (Arthrex, Naples, FL). A tenotomy of the LHBT is performed. All the sutures from the anteromedial anchor are passed through a single anterior point in the rotator cuff using a shuttle technique. All the sutures from the posteromedial anchor are passed through a single posterior point in the rotator cuff. The sutures in the medial row are tied using the double pulley technique. A suture limb is retrieved from each of the medial anchors and manually tied as a six-throw surgeons knot over a metal rod. The two free suture limbs are pulled to transport the knot over the top of the tendon bridge. The two free suture limbs are then used to produce suture bridges over the tendon, using a Pushlock (Arthrex, Naples, FL), placed 1 cm distal to the lateral edge of the footprint. The same double pulley – suture bridges technique is repeated for the other two suture limbs from the two medial anchors.ConclusionThis technique allows to perform a double pulley – suture bridges repair for a rotator cuff tear, associated with a soft tissue tenodesis for the management of LHBT pathology. The tenodesis of the LHBT is performed just with the passage of a shuttle inside the LHBT, after passing it through the anterior portion of the rotator cuff, with successive detachment of the LHBT from the glenoid. It is a technically easy procedure which can be performed relatively quickly, and does not require additional fixation.

Arthroscopic management of calcific tendinitis of the subscapularis tendon

Calcific tendinitis is a common disorder of the rotator cuff. Conservative treatment is frequently successful. For the patients remaining symptomatic after conservative treatment, excision of the calcium deposits offers a generally reliable pain relief. While calcific tendinitis is seen commonly affecting the supraspinatus tendon, it has been rarely reported involving the subscapularis tendon. We report on the clinical features, radiographic findings, arthroscopic treatment and results of one patient who presented a calcific tendonitis involving the subscapularis tendon of the left shoulder unresponsive to conservative treatment and associated subcoracoid stenosis and coracoid impingement.

The Roman Bridge: a "double pulley - suture bridges" technique for rotator cuff repair

BackgroundWith advances in arthroscopic surgery, many techniques have been developed to increase the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing.MethodsWe present an arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon-footprint contact area and mean pressure.ResultsTwo medial row 5.5-mm Bio-Corkscrew suture anchors (Arthrex, Naples, FL), which are double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL), are placed in the medial aspect of the footprint. Two suture limbs from a single suture are both passed through a single point in the rotator cuff. This is performed for both anchors. The medial row sutures are tied using the double pulley technique. A suture limb is retrieved from each of the medial anchors through the lateral portal, and manually tied as a six-throw surgeons knot over a metal rod. The two free suture limbs are pulled to transport the knot over the top of the tendon bridge. Then the two free suture limbs that were used to pull the knot down are tied. The end of the sutures are cut. The same double pulley technique is repeated for the other two suture limbs from the two medial anchors, but the two free suture limbs are used to produce suture bridges over the tendon, by means of a Pushlock (Arthrex, Naples, FL), placed 1 cm distal to the lateral edge of the footprint.ConclusionThis technique maximizes the advantages of two techniques. On the one hand, the double pulley technique provides an extremely secure fixation in the medial aspect of the footprint. On the other hand, the suture bridges allow to improve pressurized contact area and mean footprint pressure. In this way, the bony footprint in not compromised by the distal-lateral fixation, and it is thus possible to share the load between fixation points. This maximizes the strength of the repair and provides a barrier preventing penetration of synovial fluid into the healing area of tendon and bone.

Simultaneous arthroscopic implantation of autologous chondrocytes and high tibial osteotomy for tibial chondral defects in the varus knee

There is no consensus on the ideal management of patients with chondral defects of the medial tibial plateau and varus malalignment of the knee. We performed a cohort study to evaluate the outcome of patients affected by these conditions, who underwent arthroscopic implantation of autologous chondrocytes and a medial opening wedge high tibial osteotomy. Eight patients (four men and four women; mean age, 50 years, range: 42 to 58) with chondral defects of the medial tibial plateau in a varus knee underwent arthroscopic implantations of autologous chondrocytes in conjunction with a medial opening wedge osteotomy. At final post-operative follow up of 28 months following the index procedure, the post-operative scores were improved for the IKDC score (four patients abnormal and four patients severely abnormal to four patients normal, three patients nearly normal and one patient abnormal), Lysholm score (65.7 range 49-88 to 94.6 range 89-100), Tegner score (3.7 range 3-5 to 7 range 5-8) and VAS score (7.2 to 2.0). In conclusion, the association of arthroscopic implantation of autologous chondrocytes with a medial opening wedge osteotomy of the proximal tibia is a viable option for the management of chondral defects in varus knees.