Lisa Briggs

Intraoperative Determinants of Rotator Cuff Repair Integrity: An Analysis of 500 Consecutive Repairs

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.

Arthroscopic Undersurface Rotator Cuff Repair

Our standard method to repair a torn rotator cuff usually involved an arthroscopic evaluation of the glenohumeral joint, then placing the arthroscope in the subacromial space, debridement of the torn edges of the tendon, and the landing site and reattachment of the torn tendon to the bone with suture anchors. We modified our technique so that these steps were performed while the arthroscope remained in the glenohumeral joint. Thus the repair was visualized from the undersurface rather than the bursal side of the rotator cuff. The aim of this study is to describe the “undersurface” technique and evaluate its effect on operative time, postoperative pain and function, and cuff integrity. The operative time, patient-determined outcomes, and ultrasound determined cuff integrity of 2 cohorts of consecutive patients who had a rotator cuff tear repaired arthroscopically with a knotless system (Opus Magnum, ArthroCare Corporation, Sydney, Australia) either through the standard bursal side approach (bursal repair; n=60) or undersurface repair; (n=50), were compared. The groups were matched for age (mean 60 y for both groups) and tear size (2.8 cm2 vs. 2.9 cm2; P=0.81). Those patients who had a combined undersurface and bursal repair, those who had other significant shoulder pathologies or surgeries, or were unable to complete 6 months follow-up were excluded. The average operative time for the bursal repair group was 48 minutes and for the undersurface repair was 16 minutes (P<0.001). Patients in the undersurface group showed earlier reduction in the frequency of pain during activity and less difficulty with reaching behind the back at 6 months (30% less difficult, P=0.011). Ultrasonographic retear rate at 6 months (bursal 15%; undersurface 20%) was similar (P=0.7). The undersurface approach to arthroscopic rotator cuff repair was on average more than three times faster than the conventional bursal side approach, and resulted in similar retear rate but more superior clinical outcomes in the first 6 months after repair.

A Comparison of Outcomes After Arthroscopic Repair of Partial Versus Small or Medium-Sized Full-Thickness Rotator Cuff Tears

BACKGROUND Little is known about the outcomes after repair of partial-thickness rotator cuff tears. The aim of this study was to assess the outcome after repair of partial-thickness rotator cuff tears compared with full-thickness tears. Our hypothesis was that repair of partial-thickness tears leads to more shoulder stiffness but fewer retears compared with repair of full-thickness tears. METHODS A group of 105 consecutive patients who had a full-thickness tear measuring <3 cm2 was compared with a group of sixty-four patients who had a partial-thickness tear. All tears were repaired with use of a knotless single-row arthroscopic repair. The American Shoulder and Elbow Surgeons (ASES) score and standardized patient and examiner-determined outcomes were obtained preoperatively and at six, twelve, and twenty-four weeks and at two years after surgery. Rotator cuff integrity was determined by ultrasound examination at six months and two years after surgery. RESULTS Examiner-determined postoperative stiffness at six weeks was common in both groups (50% of those with a partial-thickness tear and 47% of those with a full-thickness tear) but was decreased compared with preoperative findings in both groups to 21% and 19%, respectively, at three months and to 15% and 14% at six months. The ultrasound-determined retear rate was small (5% in the partial-thickness group and 10% in the full-thickness group) at six months, but increased to 10% and 20%, respectively, at twenty-four months. The ASES score, patient-determined overall shoulder function, and all pain scores were superior to preoperative scores at six months (p < 0.001) and at twenty-four months (p < 0.001) in both groups. CONCLUSIONS Arthroscopic repair of partial-thickness and small and medium-sized full-thickness rotator cuff tears was associated with excellent medium-term clinical outcomes with low retear rates. The data did not support our hypothesis: the differences in retear rate and postoperative shoulder stiffness rate found between the two groups did not reach significance.

Diagnostic Ultrasound: Examination of the Shoulder

This paper is designed to outline a routine shoulder examination, identify bony landmarks, discuss patient position, and outline the requirements for an ultrasound imaging room. Real-time high-resolution ultrasound is our preferred choice of imaging to evaluate rotator cuff pathology. Structures imaged routinely in real-time ultrasound are the biceps brachii long head, the subscapularis, the supraspinatus tendon and muscle belly, the infraspinatus, the subacromial bursa, subdeltoid bursa, and the posterior labrum and capsule. The structures that are not well demonstrated with ultrasound are the deep bones and labra of the shoulder joint. High-resolution, real-time ultrasound shows in considerable detail the intratendinous changes that commonly occur in rotator cuff pathology. Tendon tears are easily visualized, as are changes within the echo texture of the tendon.

Ultrasound changes after rotator cuff repair: is supraspinatus tendon thickness related to pain?

BACKGROUND Little is known about the morphology of healing rotator cuffs after surgical repair. This investigation aimed to determine whether there are changes in tendon thickness, subacromial bursa, anatomical footprint, tendon vascularity, and capsular thickness after rotator cuff repair, and whether supraspinatus tendon thickness correlates with pain. METHODS Fifty-seven patients completed a validated pain questionnaire. Using a standardized protocol, their shoulders were scanned by the same ultrasonographer at 1 week, 6 weeks, 3 months, and 6 months postarthroscopic repair by a single surgeon. The contralateral shoulders, if uninjured, were also scanned. RESULTS Of 57 patients, 4 re-tore their tendons at 6 weeks and 4 retore at 3 months. Sixteen of the remaining 49 patients had intact contralateral supraspinatus tendons. The repaired supraspinatus tendon thickness remained unchanged throughout the 6 months. Compared to week 1, at 6 months, bursal thickness decreased from 1.9 (0.7) mm to 0.7 (0.5) mm (P < .001); anatomical footprint increased from 7.0 (2.0) mm to 9.3 (1.5) mm; tendon vascularity decreased from mild to none (P < .001); posterior capsule thickness decreased from 2.3 (0.8) mm to 1.3 (0.6) mm (P < .001). Frequency and severity of pain and shoulder stiffness decreased (P < .001). There was no correlation between tendon thickness and pain. CONCLUSION After rotator cuff repair, there was an immediate increase in subacromial bursa thickness, tendon vascularity, and posterior glenohumeral capsular thickness. These normalized after 6 months. Tendon thickness was unchanged while footprint contact was comparable with the contralateral tendons. There was no correlation between tendon thickness and pain.

Morphologic Changes of Synthetic (ePTFE) Interpositional Patch Repair for Massive Irreparable Rotator Cuff Tear: A Short-Term Prospective Clinical Study

Background: Massive, irreparable rotator cuff tears are difficult to manage. One option is to replace the lost tissue with a synthetic patch, for example, expanded polytetrafluoroethylene (ePTFE). There is, however, no information regarding ePTFE patch healing in humans. The aim of this study, therefore, was to evaluate healing of an irreparable rotator cuff tear treated with an interpositional ePTFE patch. Methods: The shoulders of consecutive patients undergoing interpositional ePTFE (Gore-Tex) patch repair for reconstruction of an irreparable rotator cuff tear by a single surgeon were evaluated by an experienced ultrasonographer using a standardized protocol, and by validated patient and examiner outcome measures preoperatively, and at 1, 6, 12 weeks, and 6 months postarthroscopic rotator cuff reconstruction. Results: Ten patients with an average age of 64 years (range, 42 to 85 y) and mean±SEM rotator cuff defects of 20±3.3 cm2 repaired with an ePTFE interpositional graft completed the study. Signs of healing on ultrasound were present at the patch to bone interface in 60% (6/10) of shoulders in a week, whereas 30% (3/10) showed signs of healing at the patch to tendon interface at 12 weeks after surgery. ePTFE patch to tendon thickness was 3.1±0.3 mm a week after surgery, decreasing to 1.9±0.2 mm at 6 months (P=0.05). The patch landing site dimensions (7.3±0.9 mm), thickness at the patch to bone interface (3.7±0.3 mm), and vascularity at the patch to bone and patch to tendon interfaces were unchanged over 6 months. The subacromial bursa was thickened at 1 week postoperatively (2.1±0.2 mm), thinned at 6 weeks (1.7±0.2 mm, P=0.04), thicker at 12 weeks (2.2±0.6 mm), and was within normal thickness after 6 months at 1.2±0.1 mm (P<0.0003). Healing at the patch to bone interface was noted in 10/10 patients, and 9/10 patients at the patch to tendon interface, 6 months after surgery. There were no retears. Frequency and level of pain improved (P<0.05), whereas the shoulders were less stiff (P=0.002). The overall rating of patients on their shoulders improved from very bad to poor before surgery to fair to good 6 months after surgery (P=0.002). Internal rotation, external rotation, and adduction strengths improved 1.6-fold (P<0.05), whereas the supraspinatus strength doubled (P=0.0006). Impingement signs were less at 6 months (P=0.001). Conclusions: This study showed excellent healing of massive, irreparable rotator cuff tears after reconstruction using ePTFE interpositional patch. Signs of healing on ultrasound were present at the patch to bone and patch to tendon interfaces at 1 and 12 weeks, respectively. Patch to tendon interface thickness increased after surgery and gradually decreased in thickness after 6 months, whereas the thickening of the subacromial bursa at 1 week after surgery normalized over 6 months. There were no retears. These morphologic changes were accompanied by improvements in pain, strength, and impingement signs.