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PubMed1996

[A study of the neurologic risk in tendino-muscular advancement of supra-spinatus and infra-spinatus in the repair of large rotator cuff rupture].

PURPOSE OF THE STUDY: An anatomical study by Warner et al. (1992) showed that an advancement of supra and infra-spinatus of more than 3 cm could be deleterious for the suprascapular nerve or its branches. In pathological conditions, the limit of possible advancement could even be less than 3 cm. The authors wanted to know whether this technique, which they use for the repair of large rotator cuff tears, could have neurological effects in surgical practice. MATERIAL: 24 shoulders among 24 patients having had a rotator cuff repair using a musclar advancement have been studied. In 13 cases only the supraspinatus had been advanced, and in 11 cases both supra and infraspinatus have been advanced. METHODS: The suprascapular nerve status has been studied postoperatively by EMG. EMG was performed at a mean 8.5 months follow-up. Motor unit potentials were studied at rest and after maximal contraction. Electro-stimulation at Erb's point was used to evaluate muscular latency. All repairs have been controlled by opaque arthrography, and a CT scan grading of muscular fatty degeneration was performed. In 19 cases EMG had also been performed preoperatively. RESULTS: At revision, 17 EMG were considered normal. In one case there was an impairment of the first primary trunk, already noticed preoperatively. Only 6 EMG anomalies probably related to surgery have been noticed, although the width of the tear in the coronal plane was nearly always of more than 3 cm. 4 of these 6 shoulders had been explored preoperatively by EMG, and were recorded as normal before surgery. Electric impairment was limited to the supraspinatus in 3 cases (increase of muscular latency after single advancement in two cases, polyphasic motor unit potential after double advancement in one case), to the infraspinatus in one case (polyphasic motor unit potentials recorded in the infraspinatus after single advancement of the supraspinatus), and concerned both muscles in 2 cases (increase of muscular latencies after double advancement). DISCUSSION: Muscular advancement was usually performed for tears of more than 2.5 cm wide, and so should be deleterious for suprascapular nerve, according to Warner et al. studies. But in most cases no neurological impairment could be observed in surgical practice. This could be due to the fact that the gap to repair is due not only to a loss of substance in the tendons but also to muscular retraction. In a first step, the muscular release allows to correct this muscular retraction ("muscular" advancement). The advancement remaining then to be performed is about 2 cm wide ("tendino-muscular" advancement). CONCLUSION: It appears that in surgical practice supra and infraspinatus advancement threatens only moderatly the suprascapular nerve or its branches, even if the width of the tear is greater than 3 cm. Postoperative immobilization in slight lateral elevation further reduces the importance of this advancement.

Arthrography↗
PubMed1996

Site and size of rotator-cuff tear. Findings at ultrasound, double-contrast arthrography, and computed tomography arthrography with surgical correlation.

RATIONALE AND OBJECTIVES: The authors discuss findings of ultrasound (US), double-contrast arthrography (AG), and contrast computed tomography arthrography (CTA) in assessing precise site and size of rotator-cuff tears. METHODS: Eighty-six patients were compared prospectively in a masked fashion; the results of surgery were studied in 25 patients and the results of arthroscopy were studied in 61 patients. RESULTS: Ultrasound detected 80% (8 of 10) of the partial-thickness tears and 90% (18 of 20) of the full-thickness tears. Arthrography and CTA had identical results with 70% sensitivity (7 of 10) in partial-thickness tears; AG showed 90% (18 of 20) and CTA 95% (19 of 20) of the full-thickness tears. Arthrography had two false-positive findings, and US and CTA had one each. The size of a tear could be evaluated correctly with AG in 30% (9 of 30), with US in 70% (21 of 30) and with CTA in 76% (23 of 30). More extensive tears were encountered at US than had been found at surgery in 2% (2 of 86) and less extensive tears in 9% (8 of 86); CTA depicted more extensive tears in 2% (2 of 86) and less extensive tears in 6% (6 of 86), respectively. The site of a tear could be evaluated with AG in 30% (9 of 30); US and CTA showed the site correctly in every patient in which the tear could be diagnosed. CONCLUSION: Ultrasound and CTA were equally accurate in diagnosing and evaluating the size and site of rotator-cuff tears. Double-contrast AG was less accurate in the diagnosis of tears and the size and site of tears clearly could be assessed worse.

Adult↗
PubMed2001

Results of open repair of the rotator cuff--a long-term review of 79 shoulders.

In 72 patients with 79 tears of the rotator cuff that had been completely repaired by open surgery, the outcome was evaluated on the basis of history, Constant functional score and radiography. At a mean follow-up period of 6.75 years, the Constant score was 71.5 points on average, showing a high correlation with the patients' subjective satisfaction, but the score was not a reliable indicator of recurrence. The larger the cuff tear, the poorer the result was. However, deterioration was not related to the duration of follow-up or the patient's age. The presence of acromioclavicular arthrosis also had no influence on the overall result. A comparison of follow-up radiographs with those obtained immediately after surgery revealed (despite postoperative flat subacromial resection) evidence of heterotopic bone formations or ossifications in nearly half of the patients. However, except for individual cases, this had no significant influence on the clinical result or the Constant score.

Adult↗
PubMedDate not supplied

Open repair of massive rotator cuff tears in patients aged sixty-five years or over: is it worthwhile?

The purpose of the study was to evaluate the functional outcome and identify possible preoperative prognostic factors in patients aged 65 years or over undergoing open repair for a massive (>5 cm) full-thickness rotator cuff tear. Patients were assessed after a mean of 48 months by an independent observer by use of the Constant score and the Oxford Shoulder Questionnaire. The outcome was excellent or good in 44% and poor in 23%. The patient satisfaction rate was 84%. Pain relief was obtained in 93%. We found three preoperative variables to be significantly associated with a poor outcome: female sex, duration of symptoms greater than 34 months before surgery, and American Society of Anesthesiologists grade. The results of our study suggest that appropriately selected patients who are aged 65 years or over with a massive full-thickness rotator cuff tear can be expected to have a good functional outcome and pain relief after repair.

Age Factors↗
PubMed2006

The effect of arthroscopic suture passing instruments on rotator cuff damage and repair strength.

There are a variety of arthroscopic devices used to pass sutures through the rotator cuff for its repair. Because they vary in size and shape, it is possible that they could damage the cuff and affect the integrity of the repair. We chose four devices for assessment--SutureLasso (Arthrex, Naples, FL), straight BirdBeak (Arthrex, Naples, FL), Viper (Arthrex, Naples, FL), and a #7 tapered Mayo needle--and performed cuff reattachments in four paired shoulders using suture anchors. These repairs were cycled and tested to failure. The SutureLasso and Mayo needle repairs failed at approximately 285 N whereas the BirdBeak and Viper failed during cycling at 150 N. It appears that the devices, which made the bigger holes in the cuff, can compromise the integrity of the repair.

Arthroscopy↗
PubMed1987

MR imaging of the shoulder: diagnosis of rotator cuff tears.

Twenty-five patients with known or suspected tears of the rotator cuff in 26 shoulders underwent MR imaging. All patients also underwent arthrography or surgery. MR visualized abnormalities consistent with a tear in 20 of the 22 tears diagnosed by arthrography or surgery. In most cases, tears were seen as regions of increased signal intensity within the cuff on long-TR pulse sequences, although two cases simply showed an almost complete absence of normal cuff. The MR appearance of the two cases with partial tears was similar to that of full-thickness tears. Of the four cases with normal arthrograms, one case had MR findings consistent with a tear. We conclude that MR has good potential for the noninvasive diagnosis of rotator cuff tears. Its ultimate role in this diagnosis must await prospective studies comparing its accuracy with that of sonography, CT, and arthrography.

Adult↗
PubMedDate not supplied

Sterile synovio-cutaneous fistula: a potential complication of repair of large and massive rotator cuff tears.

We present 4 patients who underwent mobilization and repair of large or massive rotator cuff tears (maximum dimension, >/=3.0 cm). In all 4 patients, sterile synovio-cutaneous fistulas developed within several weeks of the index procedure. All required further debridement surgery, multiply in 3 cases, with 1 case requiring a rotational flap for wound closure. Tissue at surgery appeared necrotic and avascular, with extensive inflammatory response, and we postulate that this was possibly related to the extensive mobilization needed to achieve cuff closure. Despite the complications, all fistulas eventually were closed, and all 4 patients were eventually satisfied with the functional status of their shoulders. We conclude that a sterile synovio-cutaneous fistula is a possible complication of mobilization and repair of large or massive rotator cuff tears.

Aged↗
PubMed1994

The joint side tear of the rotator cuff. A followup study by arthrography.

A clinical followup study was performed of joint side tears of the rotator cuff to define the pathogenic mechanisms and factors that affect their evolution. From 1982 to 1992, the authors treated 61 joint side tears, diagnosed by arthrography. Among them, 40 tears were follow-up during conservative treatment. Arthrographies were repeated at a mean of 412 days. There were 16 male and 20 female patients, with a mean age of 61 years. Two male and two female patients had bilateral tears. The average shoulder assessment score according to the Japanese Orthopaedic Association rating at the initial visit to the hospital was 68 points, and 80 points at followup time. Followup arthrographies revealed disappearance of the torn portion in four instances, reduction of the tear size in four, enlargement of the tear size in 21, and progress to full thickness cuff tear in 11 patients. Prognosis of the joint side tear appears to be worse with increasing age, larger tear size, and absence of history of trauma.

Adolescent↗
PubMedDate not supplied

Acromial spur formation in patients with rotator cuff tears.

In this study we analyzed the acromial spurs of 15 patients with impingement syndrome undergoing open rotator cuff repair. Mineral apposition analysis and quantitative cytochemical techniques for glucose-6-phosphate dehydrogenase (G6PD) activity (pentose phosphate pathway), alkaline phosphatase (ALP) activity (osteoblast activity), and tartrate-resistant acid phosphatase (TRAP) activity (osteoclast phenotype) were used to examine the distribution and level of activity of selected marker enzymes within the acromial spur insertion into the coracoacromial ligament in order to establish whether local behavior of bone cells is consistent with the proposed secondary development of the acromial spur. Our results indicate that G6PD and ALP activity was higher in osteoblasts on the inferior surface compared with the superior surface of the acromial spur in all patients (P <.001). This area correlated to the most intense area of mineral apposition shown by dual tetracycline labeling. TRAP activity revealed a heterogeneous distribution within the samples. A greater G6PD activity per cell (mean increase of 87%) was seen at the tip compared with that in post- and pre-tip zones within the coronal plane (P <.0002). The qualitative and quantitative enzyme analyses show that the acromial insertion of the coracoacromial ligament is actively involved in bone turnover. The spatial distribution patterns of metabolically active bone-forming osteoblastic cells compared with a heterogeneous distribution of TRAP-positive osteoclasts provide evidence of bone remodeling consistent with the morphologic contours of the acromial enthesis. The sites of oxytetracycline labeling appear to correlate with the sites of high ALP and G6PD activity, which supports the concept of spur formation being a secondary phenomenon in the presence of established rotator cuff tears.

Acid Phosphatase↗
PubMed1988

Sonographic evaluation of the rotator cuff.

This article emphasizes the utility of ultrasound examination in the diagnosis of rotator cuff disease. A complete description is given of the way in which ultrasound examination of the shoulder is performed, the illustrations demonstrating normal anatomy as well as staging of the disease. The use of ultrasound in this setting can help to prevent a great deal of the pain associated with shoulder injury by establishing the nature and stage of injury before rotator cuff tear occurs.

Humans↗
PubMed1997

MR arthrography of the rotator cuff and labral-ligamentous complex.

In MR imaging of the shoulder, diagnostic success requires the delineation of complex anatomic structures and the demonstration of subtle abnormalities. Magnetic resonance (MR) arthrography extends the capabilities of conventional MR imaging because contrast solution separates intra-articular structures and outlines abnormalities. There are several major contributions of MR arthrography. In assessment of the rotator cuff, arthrographic MR images enable the accurate differentiation of full-thickness tears from other cuff abnormalities, as well as the determination of tendon quality. In shoulders with suspected glenohumeral instability, arthrographic MR images show the locations of labral tears relative to the origins of glenohumeral ligaments. This article illustrates normal arthrographic MR features of the shoulder as well as common pathological disorders of the rotator cuff and labral-ligamentous complex.

Adult↗
PubMed1994

Surgical procedure and results of repair of massive tears of the rotator cuff.

One hundred eighty-seven patients (189 shoulders) were treated surgically between 1970 and 1992 for massive rotator cuff tears using either a tendon-to-tendon repair or the McLaughlin procedure. The age of the patients ranged from 20 to 86 years; 95% of them were 45 years or older. The average followup was 6 years 9 months. Excellent or good functional results were attained in 93% of patients. Thirty-three percent of those who underwent tendon to tendon repair complained of pain after overuse compared with only 18% who had the McLaughlin Procedure.

Adult↗
PubMed2006

Biomechanical evaluation of the relation between number of suture anchors and strength of the bone-tendon interface in a goat rotator cuff model.

PURPOSE: The effect of contact area between tendon and bone on ultimate pullout strength of a repaired tendon is not known. The purpose of this study was to test whether the strength of a healed bone-tendon interface is related to the amount of tendon that is in contact with bone at the time of repair. METHODS: A total of 20 mature goats underwent bilateral open rotator cuff repair of the infraspinatus tendon. The tendon edge was repaired to bleeding cancellous bone in each case with the use of suture anchors. The tendon was repaired with 2 anchors (contact area A; n = 20) on 1 shoulder and 4 anchors (contact area B; n = 20) on the contralateral shoulder. Ten goats were euthanized at 4 weeks (group 1) and 10 goats at 8 weeks (group 2) postoperatively. Twelve specimens were evaluated with ultrasound in the sagittal and coronal planes in a saline bath before mechanical testing was conducted. Ultimate load to failure was reported for each shoulder. Data were analyzed by means of a paired t test and Wilcoxon signed-rank test. RESULTS: Ultrasound evaluation revealed several instances in groups 1/2 and contact areas A/B in which clear gap formation occurred without scar (collagen) interdigitation at the bone-tendon interface. Failures occurred at the bone-tendon repair site in all specimens during biomechanical testing. The mean load to failure for all specimens in group 1 was 350.7 N; it was 619.4 N for specimens in group 2 (P = .0002). In group 1, specimens with contact area A had a mean load to failure of 317.3 N; specimens with contact area B had a mean load to failure of 375.5 N (P = .15). In group 2, specimens repaired with contact area A had a mean ultimate load to failure of 635.8 N, whereas contact area B specimens had an ultimate failure strength of 688.5 N (P = .45; Wilcoxon signed-rank). CONCLUSIONS: Increasing the number of suture anchors and the surface area of the tendon that is in contact with bone at the repair site increased the ultimate load to failure of the repaired tendon at both 4 and 8 weeks postoperatively by less than 10% at both intervals. This was not a statistically significant increase in failure strength in this model. CLINICAL RELEVANCE: This animal model shows no statistically significant differences in strength at the repair site between a 2-anchor and a 4-anchor rotator cuff repair. This information may have direct clinical applications for the surgical technique employed in the repair of rotator cuffs.

Animals↗
PubMed1996

MR evaluation of rotator cuff pathology using T2-weighted fast spin-echo technique with and without fat suppression.

OBJECTIVE: This study was designed to compare MR imaging findings from T2-weighted fast spin-echo images with and without fat suppression and then to compare surgical results with those MR imaging interpretations in the evaluation of rotator cuff disease. SUBJECTS AND METHODS: T2-weighted fast spin-echo images--with and without fat suppression--of 177 shoulder MR imaging studies were reviewed separately in a retrospective, randomized, and blinded fashion. Both sets of images were read in conjunction with the corresponding proton density-weighted images. The diagnosis of normal tendon, tendinosis, degeneration, and partial- and full-thickness tears was made using established criteria. RESULTS: T2-weighted fast spin-echo techniques with and without fat suppression showed excellent agreement in the diagnosis of normal tendon (kappa=.90) amd full-thickness tears (kappa=.98), good agreement for partial tears (kappa=.70) and moderate agreement for the combined group of tendinosis and degeneration (kappa=.53). MR imaging and surgical correlation in 43 patients showed 86% specificity (95% confidence interval, 65-96%) for intact tendons, and 100% sensitivity (95% confidence interval, 82-100%) for full-thickness tears on T2-weighted fast spin-echo imaging--both without and with fat suppression. For partial tears, MR imaging showed a sensitivity of 92% (95% confidence interval, 65-99%) with fat suppression and 67% (95% confidence interval, 39-86%) without fat suppression. CONCLUSION: T2-weighted fast spin-echo imaging--with or without fat suppression--is a highly sensitive technique in the diagnosis of normal tendons and complete tears of the rotator cuff. Because of increased lesion conspicuity, fat suppression tends to perform better in the diagnosis of partial tears.

Confidence Intervals↗
PubMedDate not supplied

Full-thickness rotator cuff tears. A biomechanical comparison of suture versus bone anchor techniques.

We performed a biomechanical comparison of two rotator cuff repair techniques using fresh-frozen human cadavers. Nine pairs of cadaveric shoulders had standardized full-thickness tears made at the supraspinatus tendon insertion. One of each pair of the cadaveric shoulders was repaired by pulling the tendon into a bone trough in the humeral head using standard sutures. The remaining half of the pairs was repaired using anchor sutures. The repairs were tested using a servohydraulically operated material testing system. The anchor suture repair was significantly stronger than the standard suture technique irrespective of bone quality. Failure occurred predominantly through bone in the suture repairs and as a result of suture breakage in the anchor repairs. The anchors should be placed into the edge of the subchondral bone adjacent to the articular surface. The surgeon should direct the anchor so that the direction of the pull is approximately 90 degrees to the anchor, with the humerus at 30 degrees of abduction.

Aged↗
PubMed1995

US depiction of partial-thickness tear of the rotator cuff.

PURPOSE: To test previously defined ultrasound (US) criteria for identification of partial-thickness tears of the rotator cuff. MATERIALS AND METHODS: Before shoulder arthroscopy, 52 patients with shoulder pain for more than 3 months were examined with a 7.5-MHz commercially available linear-array transducer and a standardized study protocol. The criteria used to detect partial-thickness tears were (a) a mixed hyper- and hypoechoic focus in the crucial zone of the supraspinatus tendon and (b) a hypoechoic lesion visualized in two orthogonal imaging planes with either articular or bursal extension. RESULTS: The US findings were reported as partial-thickness tears in 17 shoulders, of which three were false-positive findings. There was one false-negative finding. The sensitivity of US in depiction of partial-thickness tears was 93%, and specificity was 94%. The positive predictive value was 82%, and the negative predictive value was 98%. CONCLUSION: US can depict most partial-thickness tears with use of the criteria described.

Acromion↗
PubMed2004

Long-term MRI findings in operated rotator cuff tear.

PURPOSE: To describe magnetic resonance imaging (MRI) findings at long-term follow-up after rotator cuff (RC) tear using standard MRI sequences without fat saturation. MATERIAL AND METHODS: Twenty-eight patients aged 55.8+/-7.6 underwent MRI examination 4.6+/-2.1 years after surgery for RC tear. Standard sequences in oblique coronal, oblique sagittal, and axial planes were obtained. The RC, including re-tears and tendon degeneration, was independently evaluated by two observers. Thickness of the supraspinatus tendon and narrowing of the subacromial space were measured. The clinical outcome was evaluated with the Constant score and compared with the MRI findings. RESULTS: The RC tear was traumatic in 18 (64%) patients and degenerative in 10 (36%). At follow-up, 11 (39%) had normal RC tendons with good clinical outcome. Four (14%) patients had painful tendinosis without RC tear. A full-thickness RC tear was found in 7 (25%) patients and a partial tear in 6 (21%). In one patient with a full-thickness tear, and in two with partial tear, tendinosis was found in another of the RC tendons. The subacromial space was narrowed in 13 (46%) of the patients. A narrowing of the subacromial space correlated with re-tear (P<0.05). CONCLUSIONS: The RC may be evaluated with standard MRI sequences without fat saturation at long-term follow-up. A normal appearance of the RC is correlated with good clinical outcome, while re-tear and tendinosis are associated with pain.

Adult↗
PubMed2005

Use of preoperative magnetic resonance imaging to predict rotator cuff tear pattern and method of repair.

PURPOSE: To determine the magnetic resonance imaging (MRI) criteria for predicting rotator cuff tear pattern and method of repair. TYPE OF STUDY: Retrospective MRI/arthroscopy correlation. METHODS: Sixty-six preoperative MRI scans were evaluated. The maximum medial to lateral length (L) of the tear was measured on T2-weighted coronal cuts. The maximum anterior to posterior width (W) was measured on T2-weighted sagittal cuts. The cases were divided into 3 groups: group 1, short-wide tears, L < or = W, L < 2 cm; group 2, long-narrow tears, L > W, W < 2 cm; and group 3, long-wide tears, L > or = 2 cm, W > or = 2 cm. RESULTS: Of the 66 MRI scans, 55 were adequate for standardized measurement. Group 1, 16 cases: 15 were found at arthroscopy to be crescent-shaped tears repaired end-to-bone; 1 was repaired with interval slides. Group 2, 22 cases: all 22 were repaired side-to-side/margin convergence. Group 3, 17 cases: 12 required interval slides, 1 partial repair was performed, and 4 were repaired side-to-side/margin convergence. CONCLUSIONS: Tear pattern and method of repair can be predicted on high-quality MRI scan. Group 1, L < or = W and L < 2 cm, predicts a crescent-shaped tear and end-to-bone repair (positive predictive value, 93.8%). Group 2, L > W and W < 2 cm, predicts a longitudinal tear and side-to-side/margin convergence repair (positive predictive value 100%). Group 3, L > or = 2 cm and W > or = 2 cm, predicts a massive contracted tear and that primary end-to-bone or side-to-side repairs are usually not possible and that interval slides or partial repair may be necessary (positive predictive value, 76.5%). The overall diagnostic model based on usable MRI scans significantly predicted arthroscopic findings (P < .001 for chi-square test). LEVEL OF EVIDENCE: Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

Adult↗