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PubMed2006

Rotator cuff repair using an acellular dermal matrix graft: an in vivo study in a canine model.

PURPOSE: Large rotator cuff tears present a challenge to orthopaedic surgeons. Because tissue may be insufficient or of inadequate quality to undergo repair, a variety of materials have been used as adjuncts. Human dermal tissue may be processed to render it acellular, and thus less immunogenic, but with the extracellular matrix left intact, creating a collagen scaffold with favorable characteristics. Because of these traits, use in rotator cuff repair was proposed. METHODS: A canine model for a full-thickness infraspinatus tendon tear was used. Tendon was excised from the bony interface to the myotendinous junction, and a human acellular dermal matrix graft (experimental) or the autologous excised tendon (control) was used to bridge the defect. Animals were sacrificed, and shoulders were evaluated histologically and biomechanically. RESULTS: At time 0, strength of control and experimental repairs was similar. At 6 weeks, the strength of the experimental repair was half that of the control side. Strength of control specimens remained the same at 6 and 12 weeks, but by 12 weeks, the strength of the experimental repair was equal to that of the control. Histologically, cells infiltrated the control and experimental specimens by 6 weeks; chronic inflammation was consistent with surgery and repair. At 6 months, control and experimental specimens mimicked normal tendon structure grossly and histologically. CONCLUSIONS: Use of human acellular dermal matrix as a patch is a viable option in this model of large rotator cuff defects. Within 6 weeks, histologic evidence of native cell infiltration and neotendon development was observed. Within 12 weeks, the strength of the dermal matrix graft repair was equivalent to that of autologous tendon. At 6 months, control and graft specimens mimicked normal tendon structure grossly and histologically. CLINICAL RELEVANCE: This study provides in vivo animal data to support the use of this acellular dermal matrix graft for repair of full-thickness rotator cuff defects. Additional studies are indicated to determine the role of this material in the treatment of humans with rotator cuff tears.

Animals↗
PubMed2004

Effectiveness of tendon transfers for massive rotator cuff tears: a simulation study.

UNLABELLED: OBJECTIVE To determine what the most effective tendon transfer is in the case of a dysfunctional rotator cuff. DESIGN: A tendon transfer procedure of latissimus dorsi, teres major or a combination of these two to the insertions of either teres minor, infraspinatus, supraspinatus, or subscapularis is simulated using a biomechanical musculoskeletal model of the upper extremity. BACKGROUND: Massive rotator cuff tears are not easily repaired. To compensate for this loss of rotator cuff function other techniques like muscle transfers are developed. METHODS: Three range of motion tasks and six activities of daily living of 24 subjects were measured. Kinematics from these tasks were used as input to the Delft Shoulder and Elbow Model. The muscle parameters of the Delft Shoulder and Elbow Model were modified to simulate a rotator cuff tear and the ability to perform the measured tasks with and without simulated transfer procedures was checked. RESULTS: The highest improvements (28-30%, P = 0.00 ) in the ability to perform tasks were observed after a simulated tendon transfer of either both muscles or teres major alone attached to the supraspinatus or infraspinatus insertion. Although all transfer procedures produce significant improvements (P = 0.00 ), there is a significant difference between the procedures (Chi square=58.8, P = 0.00 ) dependent on attachment site. CONCLUSIONS: According to the simulation procedure used in the current study, a tendon transfer of teres major and latissimus dorsi or teres major alone to the supraspinatus insertion appears to be the most effective procedure in the case of a dysfunctional rotator cuff. Practical factors, like subacromial space, volume of the muscles and tendons, tensile properties and the ability to split the muscles, will finally determine which is the preferred transfer option.

Analysis of Variance↗
PubMedDate not supplied

Passive tension and gap formation of rotator cuff repairs.

The objectives of this study were to quantify the relationship between passive tension of rotator cuff repairs and arm position and to examine the effect of this tension on repair gap formation. Five patients undergoing open surgical rotator cuff repair of the supraspinatus tendon were recruited. Tendon tension was recorded as the supraspinatus was advanced into a bone trough and secured. The relationship between arm position and repair tension was then measured. Standardized rotator cuff tears were created in 3 cadaveric shoulders and repaired by use of the intraoperative technique. The difference in tension measured between 0 degrees and 30 degrees abduction was statically applied for 24 hours and the gap formation measured. Repair tension increased with advancement of the supraspinatus tendon into the bone trough. Abduction reduced the repair load. The mean reduction in load by 30 degrees abduction was 34 N. Twenty-four hours of 34-N loading caused gap formation of 9 mm in cadaveric rotator cuff repairs. Passive tension in surgically repaired rotator cuffs may contribute to repair failure and can be modified by arm positioning.

Adult↗
PubMedDate not supplied

Combined pectoralis major and latissimus dorsi tendon transfer for massive rotator cuff deficiency.

This report is a retrospective review of 11 consecutive patients treated with a combined transfer of the latissimus dorsi and pectoralis major tendons for massive rotator cuff deficiency. Each patient's chief complaint was diminished shoulder function and motion with little or no accompanying pain. The primary operative objective was to increase active shoulder motion. All 11 patients were followed up for at least 2 years (range, 24 to 42 months). The mean active elevation improved from 42 degrees preoperatively to 86 degrees postoperatively. The mean active external rotation improved from 0 degrees to 13 degrees. On the basis of the Medical Research Council scale, the mean abduction strength improved from 2.3 to 3.1 and the mean external rotation strength improved from 2.1 to 2.7. Overall, 4 patients made no improvement, 2 improved slightly, and 5 improved significantly. We conclude that a combined transfer of the latissimus dorsi and pectoralis major is a reasonable and safe procedure that may restore active elevation and external rotation in some patients' shoulders with a massive rotator cuff deficiency that have not responded favorably to traditional nonoperative and operative techniques. However, it is difficult to conclude, based on our experience, for which patients this surgery can be predictably successful.

Adult↗
PubMedDate not supplied

Acromial spur: relationship to aging and morphologic changes in the rotator cuff.

This study's objective is to elucidate the relationship between acromial spur formation and rotator cuff pathology or aging. The subjects comprised 1029 shoulders in control, cadaveric, and operative groups. A radiograph in the supraspinatus outlet view was taken in all subjects. The lengths of the incident spurs were measured and classified into 3 sizes (small, <5 mm; medium, <10 mm; and large, > or =10 mm). The rotator cuff was macroscopically classified as normal or as having bursal-side fraying, joint-side tear, intratendinous tear, bursal-side tear, complete tear limited to the supraspinatus tendon, or massive tear. In the control group, the overall incidence of spurs and spur size increased with advancing age (P < .001), but the majority of spurs were small (<5 mm). In the cadaveric group, the overall incidence did not correlate with advancing age (P > .05). However, spur size increased with age in subjects aged 50 years or older (P < .001). The incidence of spurs in rotator cuffs with bursal-side tears was highest and was significantly higher than that in normal cuffs and cuffs with bursal-side fraying and intratendinous tears. We observed 40% of medium spurs and 69% of large spurs in cases with bursal-side tears, complete tears limited to the supraspinatus tendon, and massive tears. In the operative group, the overall incidence correlated to advancing age (P < .001), reaching 80% or more in subjects aged 30 years or older. In addition, the size of spurs was larger than that in the other 2 groups in all age groups with few exceptions (P < .05). Small spurs were associated with advancing age. Morphologic change to the bursal side of the rotator cuff may enhance spur growth. The presence of a small spur has no diagnostic value for rotator cuff tears. Spurs measuring 5 mm or more, however, are of diagnostic value because of their high rate of association with bursal-side tear, complete tears limited to the supraspinatus tendon, or massive tears.

Acromioclavicular Joint↗
PubMed2001

Biochemical markers in the synovial fluid of glenohumeral joints from patients with rotator cuff tear.

It is known that rotator cuff tears are sometimes accompanied by joint destruction. Our purpose was to elucidate the pathology with this condition. Thirty-two synovial fluid (SF) samples aspirated from the glenohumeral joints of patients with rotator cuff tears, including 7 with partial-thickness and 25 with full-thickness tears of the rotator cuff (10 massive and 15 isolated supraspinatus tendon (SSp) tears), were examined. Collagenase (MMP-1), stromelysin 1 (MMP-3), tissue inhibitor of metalloproteinases-1 (TIMP-1) and carboxy-terminal type II procollagen peptide (pCOL Il-C) were measured in the SF using the respective sandwich enzyme immunoassays. Glycosaminoglycan (GAG) was also quantified with a cationic dye binding method using 1,9-dimethylmethylene blue. Levels of any molecules except pCOL II-C in the SF appeared to be higher in full-thickness tears than those in partial-thickness tears. Moreover, levels of MMP-1, MMP-3 and GAG in the SF were significantly higher in massive tears of the rotator cuff in comparison with those in isolated SSp tears. Such significance was not observed in the levels of TIMP-1 or pCOL II C in the SF. We examined the relation of those levels with operative findings or clinical parameters from full-thickness tears, and observed significant correlations of the tear size with the levels of MMP-1, MMP-3 and GAG in the SF. Although these marker molecules in SF do not always originate from cartilage, our results may indicate the potential for accelerated cartilage-degrading activity in the glenohumeral joint in massive tears of the rotator cuff.

Adult↗
PubMed1997

Cyclic loading of transosseous rotator cuff repairs: tension overload as a possible cause of failure.

Previous experimental studies of failure of rotator cuff repair have involved a single pull to ultimate load. Such an experimental design does not represent the cyclic loading conditions experienced in vivo. We created 1 cm x 2 cm rotator cuff defects in 16 cadaver shoulders, repaired each defect with transosseous simple sutures, and cyclically loaded the repairs by a servohydraulic materials test system actuator at physiologic rates and loads (rate of 33 mm/sec to a load of 180 N.). A progressive gap was noted in each specimen, for a 100% rate of failure of the repairs. A 5 mm gap developed at an average of 25 cycles, and a 10 mm gap developed at an average of 188 cycles. The central suture always failed first and by the largest magnitude. This study suggests that rotator cuff tears that are repaired with a "tension overload" of a portion of the muscle-tendon units will undergo gradual failure with physiologic cyclic loading until the normal resting lengths of the muscle-tendon units are restored. This "controlled failure" of the repairs may explain residual defects that have been demonstrated by ultrasonography and by arthrography in patients with "successful" rotator cuff repairs. Clinical implications are that: 1) rotator cuff tears should be repaired without tension if possible; and 2) transosseous bone tunnels should ideally extend distal to the weak metaphysical bone so that purchase is obtained into cortical bone for greater fixation strength.

Adolescent↗
PubMed1997

Acromion-splitting approach through an os acromiale for repair of a massive rotator cuff tear.

Os acromiale, failure of fusion of the secondary centers of ossification of the acromion process, has been noted as a contributing factor in shoulder impingement syndrome and rotator cuff tears. Treatments for symptomatic os acromiale with or without rotator cuff tears have been reported in the literature and range from excision of small fragments to fusion of larger, fragments with internal fixation and bone grafting. Generally, rotator cuff repairs have been performed when possible. We report an acromion splitting approach through an existing os acromiale to gain exposure for the repair of a massive rotator cuff tear. Subsequent to this repair, the acromion was repaired with internal fixation. Good functional use of the patient's upper extremity was obtained and the patient expressed satisfaction with the surgical outcome. The acromion splitting approach is a viable approach in patients with an os acromiale and a coexistent rotator cuff tear.

Acromion↗
PubMedDate not supplied

Rotator cuff repair in spinal cord injury patients.

Previous studies on the treatment of rotator cuff tears in wheelchair-bound patients have concentrated on nonsurgical management. We conducted a retrospective review to determine the effectiveness of surgical repair of rotator cuff tears in spinal cord-injured patients. Five male patients with rotator cuff tears confirmed by physical examination and magnetic resonance imaging underwent rotator cuff repair. Two of eight shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved in 6 of 8 shoulders. Strength was increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other spinal cord injury patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Surgery for spinal cord injury patients with rotator cuff tears can improve their functional capability and autonomy while reducing their pain. Compliance with the demanding postoperative rehabilitation is essential; therefore proper patient selection is crucial for optimal results.

Adult↗
PubMedDate not supplied

Lag signs in the diagnosis of rotator cuff rupture.

We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.

Adolescent↗
PubMedDate not supplied

Age-related prevalence of rotator cuff tears in asymptomatic shoulders.

To determine the prevalence of rotator cuff tears in asymptomatic shoulders we conducted a prospective clinical and ultrasonographic study of 411 volunteers. We anticipated an age-dependent outcome and divided the patients into 4 age-groups. Overall, we found evidence of a rotator cuff tear in 23% of the patients. In group 1 (aged 50 to 59 years), 13% (22 of 167) of the patients had tears; in group 2 (aged 60 to 69 years), 20% (22 of 108) of the patients had tears; in group 3 (aged 70 to 79 years), 31% (27 of 87) of the patients had tears; and in group 4 (age > 80 years), 51% (25 of 49) of the patients had tears. An astonishingly high rate of rotator cuff tears in patients with asymptomatic shoulders was thus demonstrated with increasing patient age. At this stage it remains unclear, however, which parameters convert an asymptomatic rotator cuff tear into a symptomatic tear. As a result, rotator cuff tears must to a certain extent be regarded as "normal" degenerative attrition, not necessarily causing pain and functional impairment.

Aged↗
PubMed2006

Movement patterns of the upper extremity and trunk before and after corrective surgery of impaired forearm rotation in patients with cerebral palsy.

The effect of surgical correction of impaired forearm rotation on associated body movement patterns was studied prospectively by comparison of preoperative and postoperative three-dimensional video analysis of the upper extremity and trunk in eight male and two female patients with hemiplegic cerebral palsy (CP; mean age 16y 2mo [SD 4y 11mo]; range 11-27y). A customized parameter, 'extrinsic forearm rotation', was used to quantify associated movements supplementing forearm rotation. After surgical correction of the pronation deformity, active forearm supination during a functional reaching task had improved by a mean of 37 degrees in combination with significantly decreased extrinsic forearm rotation by a mean of 13 degrees . In addition, an average loss of 16 degrees of active pronation in combination with increased extrinsic forearm rotation (mean 8 degrees ) was observed. On the basis of these results we conclude that successful surgical correction of a pronation deformity in patients with CP directly affects related movement patterns of the upper extremity and trunk.

Adolescent↗
PubMed2001

Repair of rotator cuff tears in golfers.

PURPOSE: Golfers continue to play through the years that rotator cuff disease becomes more common. We sought to establish the results of acromioplasty and rotator cuff repair in golfers, including their ability to return to the sport. STUDY TYPE: Case series. METHODS: Of 30 golfers who underwent 32 rotator cuff repairs, 29 were interviewed, completed a detailed questionnaire, and returned for a physical examination. All of the patients were recreational or regional tournament golfers. Fifteen had open acromioplasty and rotator cuff repair and 16 had arthroscopic acromioplasty and mini-open repair. The average age at surgery was 60 years (range, 39 to 76 years). At surgery, most were moderate size tears (2 to 6 cm(2)). RESULTS: At average follow-up of 37 months (range, 24 to 60 months), all but 3 patients are currently golfing. For patients who are currently golfing, there was no significant difference in handicaps or drive distances at most recent follow-up compared with presymptomatic handicaps and drive distances (P >.05). Twenty-three patients report that they are playing at their presymptomatic competitive level without pain. Three patients report playing at a lower competitive level than before. CONCLUSION: In our experience, acromioplasty and rotator cuff repair predictably allow for eventual return to pain-free golfing at a similar competitive level for most recreational-level athletes.

Adult↗
PubMed2002

Arthroscopically assisted mini-open rotator cuff repair.

PURPOSE: To review the results of arthroscopically assisted mini-open rotator cuff repair. TYPE OF STUDY: Retrospective clinical review. METHODS: From 1990 to 1994, 67 patients (69 shoulders) had a rotator cuff repair for a full-thickness tear; 63 of these patients had an arthroscopically assisted mini-open rotator cuff repair. Of these, 22 were lost to follow-up; thus, 41 patients were retrospectively reviewed for this study. The average patient age was 51 years and the average follow-up was 36 months. UCLA scores incorporating preoperative and postoperative pain, function, strength, and range of motion data were used to analyze the results. RESULTS: At follow-up, 38 patients (93%) were rated as excellent or good, 3 patients (7%) were rated as fair, and none was rated as poor. All patients showed improvement in pain and function after surgery and all of the patients were satisfied with the procedure. The average UCLA score was 32.3. There was a small but significant (P <.0001) difference between UCLA scores of Workers' Compensation patients (UCLA score, 29; n = 11) versus noncompensation patients (UCLA score, 33; n = 30). In addition, the return-to-work interval was prolonged in the Workers' Compensation cases. There were no significant differences in UCLA scores on the basis of tear size (P <.4286) or patient age (P <.1131). CONCLUSIONS: Our data suggest that the arthroscopically assisted mini-open technique for rotator cuff repair is an excellent approach for repair of a torn rotator cuff.

Adult↗
PubMed2002

LactoSorb plates for rotator cuff repair.

PURPOSE: We present our preliminary studies using LactoSorb plates (Lorenz/Biomet, Warsaw, IN) for rotator cuff repair in humans. The use and application of this plate are described as an adjunct to prevent hole migration in trough-tunnel repairs of rotator cuff tears. METHODS: Fifty patients with rotator cuff tears documented by magnetic resonance imaging underwent arthroscopic subacromial decompression followed by a mini-open repair of the rotator cuff. Tears were repaired using a trough and tunnel technique, horizontal mattress sutures, and a standard LactoSorb plate. Follow-up was obtained on 45 patients, 26 male and 19 female, with an average age of 61.6 years. The patients were followed-up and evaluated at 5 days, 1 month, 3 months, 6 months, and a minimum of 1 year postoperatively. All surgeries were performed by the same surgeon and followed a similar rehabilitation protocol. RESULTS: There were 89% excellent results, 9% good results, and 2% fair results. There were no poor results. No significant swelling, tenderness, or erythema was noted at the operative site, and there were no infections. Postoperative radiographs at 3, 6, and 12 months did not show any bone erosion. No repeat surgical procedures were necessary. CONCLUSION: The results of our study support the use of LactoSorb bioabsorbable plates in the repair of rotator cuff tears to prevent hole migration and potentially poor results or failures of repairs. The LactoSorb plate appears to maintain its strength during the healing period of the repair and does not elicit any clinically noticeable inflammatory process.

Absorbable Implants↗
PubMedDate not supplied

[Traumatic rupture of the rotator cuff in an adolescent--case report].

A traumatic rotator cuff tear is a very rare condition, especially in the adolescent. We report about a 14-year-old boy who fell onto the right arm while riding his bicycle. Immediately after the accident he described some kind of click in his right shoulder. he was referred to our institution 3 days after the trauma. The MRI showed a huge defect of the labrumligament complex including the rotator interval. Intraoperatively, we found a complete disruption of the subscapularis and supraspinatus tendons as well as of the anterior stabilizers. We performed a modified Bankart repair and a reconstruction of the ruptured rotator cuff. The patient returned to his former sports as cyclist 3 months after surgery. This case is of clinical relevance because of the traumatic disruption of an intact rotator cuff in a young patient. Not the bone but rather the tendons and ligaments were the weakest link in this situation. In cases of primary traumatic shoulder dislocation, we have to look for bony and soft-tissue damage including the rotator cuff. With the present high standards in ultrasound and MR imaging we have to keep these techniques in mind in order not to overlook this type of accompanying injury.

Adolescent↗
PubMedDate not supplied

Two 6-year follow-up studies of large and massive rotator cuff tears: comparison of outcome measures.

The purposes of this report are (1) to describe the development of a quality-of-life outcome measure for rotator cuff disease (RC-QOL) and a new simple test of rotator cuff function, the Functional Shoulder Elevation Test (FSET), and (2) to compare these with the SF-36 and the American Shoulder and Elbow Surgeons Assessment (ASESA) in a cohort of 86 patients with surgically treated large and massive rotator cuff tears. The RC-QOL is a 34-item self-administered questionnaire that has demonstrated excellent reliability, face validity, and ability to discriminate between large and massive cuff tears; it has also confirmed the construct of higher correlations with the other shoulder outcome measures than with the SF-36. The FSET is a simple test of rotator cuff function that uses 5% body weight and measurement of pain and discomfort on a 100-point visual analog scale. It was highly correlated with the RC-QOL and ASESA and discriminated between large and massive cuff tears. The study achieved an 82% follow-up at an average of 3.5 years. Large cuff tears had statistically significantly improved outcome scores in comparison with massive cuff tears on these 3 outcome measures. The SF-36, however, was not able to discriminate between tear sizes. The RC-QOL and the FSET are recommended outcome measures for rotator cuff disease.

Adult↗
PubMedDate not supplied

Correlation of radiographic and arthroscopic findings with rotator cuff tears and degenerative joint disease.

The purpose of this study was to identify early signs of rotator cuff tear and glenohumeral articular cartilage degeneration by using conventional radiography. A non-weighted anteroposterior oblique and a weighted active abduction view were evaluated for superior humeral migration and matching degenerative changes at the inferolateral acromion and superior aspect of the greater tuberosity in 40 patients who underwent shoulder arthroscopy. Measurements of the glenohumeral distance were performed. Surgical reports were reviewed to determine rotator cuff and glenohumeral articular cartilage status. Matching degenerative changes correlate with complete rotator cuff tear (P =.04); superior migration does not. Severe glenohumeral cartilage loss correlates with narrowing of the superior joint space on the anteroposterior oblique radiograph (P =.02) and with narrowing of the mid joint space on the active abduction view (P =.05). Both glenohumeral articular cartilage degenerative change and rotator cuff injury, before formation of typical sequelae of chronic rotator cuff tear, can be detected with the use of conventional radiography.

Adult↗