Sharlene A. Teefey

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.

Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases.

BACKGROUND Although many investigators have evaluated the accuracy of ultrasonography and magnetic resonance imaging for the detection of full and partial-thickness rotator cuff tears, few have directly compared the two tests. The purpose of our study was to compare the accuracy of the two tests for detection and measurement of the size of rotator cuff tears, with arthroscopic findings used as the standard. METHODS One hundred and twenty-four consecutive patients with shoulder pain were prospectively studied with ultrasonography and magnetic resonance imaging. Seventy-one had subsequent arthroscopy, and they formed the study group. The arthroscopic diagnosis was a full-thickness tear in forty-six patients, a partial-thickness tear in nineteen, and no tear in six. The presence or absence of a full or partial-thickness tear and the tear size as demonstrated by each imaging test and at the time of arthroscopy were recorded. The findings of the imaging tests and arthroscopy were then compared for each parameter. RESULTS Ultrasonography correctly identified forty-five of the forty-six full-thickness tears and magnetic resonance imaging, all forty-six. Ultrasonography correctly identified thirteen of the nineteen partial-thickness rotator cuff tears and magnetic resonance imaging, twelve of the nineteen. The overall accuracy for both imaging tests was 87%. Ultrasonography correctly predicted the degree of retraction of 73% of the full-thickness tears and the length of 85% of the partial-thickness tears, and magnetic resonance imaging correctly predicted the retraction and length of 63% and 75%, respectively. Ultrasonography correctly predicted the width of 87% of the full-thickness tears and 54% of the partial-thickness tears, and magnetic resonance imaging correctly predicted the width of 80% and 75%, respectively. No significant differences between ultrasonography and magnetic resonance imaging were demonstrated (p > 0.05). CONCLUSIONS Ultrasonography and magnetic resonance imaging had comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. When an investigator has comparable experience with both imaging tests, the decision regarding which test to perform for rotator cuff assessment does not need to be based on accuracy concerns. The choice can be based on other factors, such as the importance of ancillary clinical information (regarding lesions of the glenoid labrum, joint capsule, or surrounding muscle or bone), the presence of an implanted device, patient tolerance, and cost.

Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases.

Background: There has been limited acceptance of shoulder ultrasonography by orthopaedic surgeons in the United States. The purpose of this retrospective study was to determine the diagnostic performance of high-resolution ultrasonography compared with arthroscopic examination for the detection and characterization of rotator cuff tears. Methods: One hundred consecutive shoulders in ninety-eight patients with shoulder pain who had undergone preoperative ultrasonography and subsequent arthroscopy were identified. The arthroscopic diagnosis was a full-thickness rotator cuff tear in sixty-five shoulders, a partial-thickness tear in fifteen, rotator cuff tendinitis in twelve, frozen shoulder in four, arthrosis of the acromioclavicular joint in two, and a superior labral tear and calcific bursitis in one shoulder each. All ultrasonographic reports were reviewed for the presence or absence of a rotator cuff tear and a biceps tendon rupture or dislocation. All arthroscopic examinations were performed according to a standardized operative procedure. The size and extent of the tear and the status of the biceps tendon were recorded for all shoulders. The findings on ultrasonography and arthroscopy then were compared for each parameter. Results: Ultrasonography correctly identified all sixty-five full-thickness rotator cuff tears (a sensitivity of 100 percent). There were seventeen true-negative and three false-positive ultrasonograms (a specificity of 85 percent). The overall accuracy was 96 percent. The size of the tear on transverse measurement was correctly predicted in 86 percent of the shoulders with a full-thickness tear. Ultrasonography detected a tear in ten of fifteen shoulders with a partial-thickness tear that was diagnosed on arthroscopy. Five of six dislocations and seven of eleven ruptures of the biceps tendon were identified correctly. Conclusions: Ultrasonography was highly accurate for detecting full-thickness rotator cuff tears, characterizing their extent, and visualizing dislocations of the biceps tendon. It was less sensitive for detecting partial-thickness rotator cuff tears and ruptures of the biceps tendon.

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.

Symptomatic progression of asymptomatic rotator cuff tears a prospective study of clinical and sonographic variables

BACKGROUND The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic. METHODS A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period. RESULTS With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment. CONCLUSIONS Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function.

Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies.

ObjectiveTo determine the relative benefit of staging laparoscopy in peripancreatic and biliary malignancies. Summary Background DataStaging laparoscopy has been used in a variety of peripancreatic and biliary malignancies. The utility of the technique in subsets of these types of cancer has not been systematically compared. MethodsOne hundred fifty-seven patients underwent laparoscopy after conventional tumor staging; 89 were also staged with laparoscopic ultrasonography. Diagnostic categories were cancer of the pancreatic head and uncinate process, cancer of the body and tail of pancreas, cancer of the extrahepatic bile duct, cancer of the gallbladder, and cancer of the ampulla of Vater/duodenum. ResultsIn patients with cancer of the head of the pancreas, metastatic disease or vascular invasion was discovered frequently by laparoscopy (31%), whereas in ampullary/duodenal cancer it was never found. The laparoscopic findings in cancer of the head of the pancreas had an important influence on treatment decisions, whereas in cancer of the ampulla/duodenum, laparoscopy had no effect on clinical decisions. Laparoscopy also substantially influenced the treatment of gallbladder cancer; in other tumor types, results were intermediate. Laparoscopic ultrasonography was valuable in cancer of the head of the pancreas. ConclusionsThe utility of staging laparoscopy depends on diagnosis. It is recommended for continued use in pancreatic head and gallbladder cancers but not in ampullary malignancies.

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.

Location and initiation of degenerative rotator cuff tears: An analysis of three hundred and sixty shoulders

BACKGROUND It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes. METHODS Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups. RESULTS The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate. CONCLUSIONS Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon.

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.