Leesa M. Galatz

The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears

BACKGROUND The impact of a recurrent defect on the outcome after rotator cuff repair has been controversial. The purpose of this study was to evaluate the functional and anatomic results after arthroscopic repair of large and massive rotator cuff tears with use of ultrasound as an imaging modality to determine the postoperative integrity of the repair. METHODS Eighteen patients who had complete arthroscopic repair of a tear measuring >2 cm in the transverse dimension were evaluated at a minimum of twelve months after surgery and again at two years after surgery. The evaluation consisted of a standardized history and physical examination as well as calculation of the preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons. The strength of both shoulders was quantitated postoperatively with use of a portable dynamometer. Ultrasound studies were performed with use of an established and validated protocol at a minimum of twelve months after surgery. RESULTS Recurrent tears were seen in seventeen of the eighteen patients. Despite the absence of healing at twelve months after surgery, thirteen patients had an American Shoulder and Elbow Surgeons score of >/=90 points. Sixteen patients had an improvement in the functional outcome score, which increased from an average of 48.3 to 84.6 points. Sixteen patients had a decrease in pain, and twelve had no pain. Although eight patients had preoperative forward elevation to <95 degrees, all eighteen regained motion above shoulder level and had an average of 152 degrees of elevation. At the second evaluation, a minimum of twenty-four months after surgery, the average score, according to the system of the American Shoulder and Elbow Surgeons, had decreased to 79.9 points; only nine patients had a score of >/=90 points, and six patients had a score of </=79 points. The average forward elevation decreased to 142 degrees. CONCLUSIONS Arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects; however, at a minimum follow-up of two years, the results deteriorated with only twelve patients who had an American Shoulder and Elbow Surgeons score of >/=80.

The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders.

BACKGROUND Very little comparative information is available regarding the demographic and morphological characteristics of asymptomatic and symptomatic rotator cuff tears. This information is important to provide insight into the natural history of rotator cuff disease and to identify which factors may be important in the development of pain. The purpose of the present study was to compare the morphological characteristics and prevalences of asymptomatic and symptomatic rotator cuff disease in patients who presented with unilateral shoulder pain. METHODS Five hundred and eighty-eight consecutive patients in whom a standardized ultrasonographic study had been performed by an experienced radiologist for the assessment of unilateral shoulder pain were evaluated with regard to the presence and size of rotator cuff tears in each shoulder. The demographic factors that were analyzed included age, gender, side, and cuff thickness. All of these factors were evaluated with regard to their correlation with the presence of pain. RESULTS Of the 588 consecutive patients who met the inclusion criteria, 212 had an intact rotator cuff bilaterally, 199 had a unilateral rotator cuff tear (either partial or full thickness), and 177 had a bilateral tear (either partial or full thickness). The presence of rotator cuff disease was highly correlated with age. The average age was 48.7 years for patients with no rotator cuff tear, 58.7 years for those with a unilateral tear, and 67.8 years for those with a bilateral tear. Logistic regression analysis indicated a 50% likelihood of a bilateral tear after the age of sixty-six years (p < 0.01). In patients with a bilateral rotator cuff tear in whom one tear was symptomatic and the other tear was asymptomatic, the symptomatic tear was significantly larger (p < 0.01). The average size of a symptomatic tear was 30% greater than that of an asymptomatic tear. Overall, patients who presented with a full-thickness symptomatic tear had a 35.5% prevalence of a full-thickness tear on the contralateral side. CONCLUSIONS There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms, we recommend surveillance at yearly intervals for patients with known rotator cuff tears that are treated nonoperatively.

Prospective longitudinal analysis of postoperative shoulder function : a ten-year follow-up study of full-thickness rotator cuff tears.

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Factors Affecting Healing Rates After Arthroscopic Double-Row Rotator Cuff Repair

Background Double-row arthroscopic rotator cuff repairs were developed to improve initial biomechanical strength of repairs to improve healing rates. Despite biomechanical improvements, failure of healing remains a clinical problem. Purpose To evaluate the anatomical results after double-row arthroscopic rotator cuff repair with ultrasound to determine postoperative repair integrity and the effect of various factors on tendon healing. Study Design Case series; Level of evidence, 4. Methods Forty-eight patients (49 shoulders) who had a complete arthroscopic rotator cuff repair (double-row technique) were evaluated with ultrasound at a minimum of 6 months after surgery. Outcome was evaluated at a minimum of 1-year follow-up with standardized history and physical examination, visual analog scale for pain, active forward elevation, and preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons and the Simple Shoulder Test. Quantitative strength was measured postoperatively. Results Ultrasound and physical examinations were performed at a minimum of 6 months after surgery (mean, 16 months; range, 6 to 36 months) and outcome questionnaire evaluations at a minimum of 12 months after surgery (mean, 29 months; range, 12 to 55 months). Of 49 repairs, 25 (51%) were healed. Healing rates were 67% in single-tendon tears (16 of 24 shoulders) and 36% in multitendon tears (9 of 25 shoulders). Older age and longer duration of follow-up were correlated with poorer tendon healing (P < .03). Visual analog scale for pain, active forward elevation, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores all had significant improvement from baseline after repair (P < .0001). Conclusion Increased age and longer duration of follow-up were associated with lower healing rates after double-row rotator cuff repair. The biological limitation at the repair site, as reflected by the effects of age on healing, appears to be the most important factor influencing tendon healing, even after maximizing repair biomechanical strength with a double-row construct.

Nicotine delays tendon-to-bone healing in a rat shoulder model

BACKGROUND Many studies have shown that nicotine negatively impacts fracture healing and bone fusion processes. However, very little is known about its effect on tendon and ligament healing. The goal of the present study was to evaluate the effect of nicotine on tendon-to-bone healing. METHODS Supraspinatus tendons in both shoulders of seventy-two rats were transected and repaired to the humeral head. Osmotic pumps were implanted subcutaneously, and nicotine or saline solution was delivered for ten, twenty-eight, or fifty-six days. Cell morphology was evaluated with use of histologic sections. Cells were counted, and proliferating cell nuclear antigen (PCNA) immunohistochemistry was performed to assess cellular proliferation. In situ hybridization was performed to measure type-I collagen mRNA expression. Biomechanical and geometric properties were assessed. RESULTS Inflammation persisted longer in the nicotine group than in the saline solution group. Cellular proliferation was higher in the saline solution group than in the nicotine group at the early time-points. Type-I collagen expression was higher in the saline solution group at twenty-eight days. Mechanical properties increased over time in both groups. Maximum stress was significantly lower in the nicotine group than in the saline solution group at ten days. Maximum force was significantly lower in the nicotine group than in the saline solution group at twenty-eight days. Maximum force was significantly higher in the nicotine group than in the saline solution group at fifty-six days. Stiffness was not different between the groups at any time-point. CONCLUSIONS Nicotine caused a delay in tendon-to-bone healing in a rat rotator cuff animal model. Mechanical properties increased over time in both groups, but the properties in the nicotine group lagged behind those in the saline solution group. Chronic inflammation and decreased cell proliferation may partly explain the inferior biomechanical properties in the nicotine group as compared with the saline solution group. CLINICAL RELEVANCE Failure of rotator cuff repair is a major clinical problem. The adverse effect of nicotine on rotator cuff healing noted in this clinically appropriate animal model may be an important clinical consideration.

Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears

BACKGROUND Partial-thickness rotator cuff tears are a common cause of shoulder pain, yet the appropriate surgical treatment is controversial. In particular, very little information is available regarding rotator cuff integrity after operative repair. The purpose of this study was to evaluate the functional outcome and anatomic healing rate after arthroscopic repair of high-grade partial (>50%) thickness tears of the supraspinatus tendon. METHODS Forty-one consecutive patients (forty-two shoulders) who had undergone arthroscopic conversion of a partial-thickness rotator cuff tear to a full-thickness tear and subsequent repair were evaluated with ultrasound for evidence of rotator cuff healing. Clinical outcomes were assessed with use of validated outcomes measures, and all patients were reexamined by an independent observer. RESULTS The average patient age was fifty-three years. Thirty-seven (88%) of the forty-two shoulders had an intact rotator cuff repair seen on ultrasound at an average of eleven months postoperatively. The remaining five patients had a full-thickness defect in the tendon. The mean American Shoulder and Elbow Surgeons (ASES) score improved from 46.1 points preoperatively to 82.1 points at the time of follow-up. The overall rate of patient satisfaction was 93%. The average age of the patients with an intact rotator cuff was 51.8 years compared with 62.6 years for those with a persistent defect (p = 0.02). CONCLUSIONS Arthroscopic repair of high-grade partial-thickness rotator cuff tears results in a high rate of tendon healing. Patient age is an important factor in tendon healing.

Transitioning to arthroscopic rotator cuff repair: the pros and cons.

There has been much recent enthusiasm regarding complete arthroscopic rotator cuff repair, and it is becoming apparent that, for many, this newer technique may be a preferable alternative to the more traditional mini-open rotator cuff repair. Several short-term studies have demonstrated that complete arthroscopic repair has excellent results comparable with those of mini-open repair, which is also an excellent technique. The choice of which procedure may be better for an individual patient or surgeon can be based on a variety of considerations, including the patients expectations, the pathoanatomy of the cuff, and the surgical experience of the surgeon. The relative merits and disadvantages of arthroscopic rotator cuff repair are discussed on the basis of those considerations. When a surgeon is deciding which procedure to perform, it is important that the basic principles of rotator cuff repair not be compromised and that he or she perform the procedure that is most reproducible given his or her level of experience; however, for those who are now utilizing miniopen repair, arthroscopic repair may have important advantages and may be worth pursuing in the future. If a surgeon chooses to obtain the skills necessary to perform a complete arthroscopic repair, performance of the mini-open procedure offers an excellent opportunity to make an orderly transition.

Sustained delivery of transforming growth factor beta three enhances tendon-to-bone healing in a rat model

Despite advances in surgical technique, rotator cuff repairs are plagued by a high rate of failure. This failure rate is in part due to poor tendon‐to‐bone healing; rather than regeneration of a fibrocartilaginous attachment, the repair is filled with disorganized fibrovascular (scar) tissue. Transforming growth factor beta 3 (TGF‐β3) has been implicated in fetal development and scarless fetal healing and, thus, exogenous addition of TGF‐β3 may enhance tendon‐to‐bone healing. We hypothesized that: TGF‐β3 could be released in a controlled manner using a heparin/fibrin‐based delivery system (HBDS); and delivery of TGF‐β3 at the healing tendon‐to‐bone insertion would lead to improvements in biomechanical properties compared to untreated controls. After demonstrating that the release kinetics of TGF‐β3 could be controlled using a HBDS in vitro, matrices were incorporated at the repaired supraspinatus tendon‐to‐bone insertions of rats. Animals were sacrificed at 14–56 days. Repaired insertions were assessed using histology (for inflammation, vascularity, and cell proliferation) and biomechanics (for structural and mechanical properties). TGF‐β3 treatment in vivo accelerated the healing process, with increases in inflammation, cellularity, vascularity, and cell proliferation at the early timepoints. Moreover, sustained delivery of TGF‐β3 to the healing tendon‐to‐bone insertion led to significant improvements in structural properties at 28 days and in material properties at 56 days compared to controls. We concluded that TGF‐β3 delivered at a sustained rate using a HBDS enhanced tendon‐to‐bone healing in a rat model.

Cigarette Smoking Increases the Risk for Rotator Cuff Tears

There is little available evidence regarding risk factors for rotator cuff tears. Cigarette smoking may be an important risk factor for rotator cuff disease. The purpose of this study was to determine if cigarette smoking correlates with an increased risk for rotator cuff tears in patients who present with shoulder pain. A questionnaire was administered to 586 consecutive patients 18 years of age or older who had a diagnostic shoulder ultrasound for unilateral, atraumatic shoulder pain with no history of shoulder surgery. Three hundred seventy-five patients had a rotator cuff tear and 211 patients did not. Data regarding cigarette smoking were obtained for 584 of 586 patients. A history of smoking (61.9% versus 48.3%), smoking within the last 10 years (35.2% versus 30.1%), mean duration of smoking (23.4 versus 20.2 years), mean packs per day of smoking (1.25 versus 1.10 packs per day), and mean pack-years of smoking (30.1 versus 22.0) correlated with an increased risk for rotator cuff tear. We observed a dose-dependent and time-dependent relationship between smoking and rotator cuff tears. We observed a strong association between smoking and rotator cuff disease. This may indicate smoking is an important risk factor for the development of rotator cuff tears.Level of Evidence: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

The role of mechanobiology in tendon healing.

Mechanical cues affect tendon healing, homeostasis, and development in a variety of settings. Alterations in the mechanical environment are known to result in changes in the expression of extracellular matrix proteins, growth factors, transcription factors, and cytokines that can alter tendon structure and cell viability. Loss of muscle force in utero or in the immediate postnatal period delays tendon and enthesis development. The response of healing tendons to mechanical load varies depending on anatomic location. Flexor tendons require motion to prevent adhesion formation, yet excessive force results in gap formation and subsequent weakening of the repair. Excessive motion in the setting of anterior cruciate ligament reconstruction causes accumulation of macrophages, which are detrimental to tendon graft healing. Complete removal of load is detrimental to rotator cuff healing; yet, large forces are also harmful. Controlled loading can enhance healing in most settings; however, a fine balance must be reached between loads that are too low (leading to a catabolic state) and too high (leading to microdamage). This review will summarize existing knowledge of the mechanobiology of tendon development, homeostasis, and healing.