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PubMed2001

The effect of immobilization on rotator cuff healing using modified Mason-Allen stitches: a biomechanical study in sheep.

Long-term biomechanical integrity of the surgical site is crucial to the outcome of rotator cuff repair. Usually after rotator-cuff surgery, the arm is immobilized for 6-12 weeks to minimize disruption at the healing site. Unfortunately, currently there is very little clinical data on the effects of immobilization after rotator cuff surgery. This study analyzed the effect of immobilization on rotator cuff healing by comparing the healing strength of the tendon in a bone trough using a sheep model. In sixteen (16) female adult sheep, the right infraspinatus tendons were reattached into a bone trough using a modified Mason-Allen suture pattern. After surgery, each sheep was randomly assigned into either an immobilized or non-immobilized treatment group. The immobilized group was fitted with a softball taped under the foot to restrict limb movement for 6 weeks. The non-immobilized treatment group was allowed to fully bear weight on the treated shoulder. At 26 weeks, the animals were sacrificed and the surgical shoulders were harvested and stored in a -30 degrees C freezer. Biomechanical testing was performed using a MTS 809 Axial/Torsional Servohydraulic System. Special cryo-grips were used to test the infraspinatus tendon-bone interface in anatomical alignment. All samples were preloaded with 10 +/- 5 N, and then force was measured during a crosshead displacement of 500 mm/min until failure. Force and displacement were acquired at 100 Hz and used to calculate load-to-failure and stiffness of the bone-tendon interface. The load-to-failure (N) and stiffness (N/cm) were determined for both treatment groups. For the non-immobilized group, the loads to failure and stiffness means were 2571.95 +/- 329.9 N and 2319.09 +/- 457.72 N/cm. The immobilized group means were 2954.42 +/- 473.52 N (load-to-failure) and 2579.13 +/- 383.51 N/cm (stiffness). A two-tailed two-samples unequal variance student t-test with significance set at 0.05, found no significant difference between the treatment groups for load-to-failure (p = 0.2174) and stiffness (p = 0.8286).

Animals↗

PubMed2006

Stiffness and rotator cuff tears: incidence, arthroscopic findings, and treatment results.

PURPOSE: Although stiffness of the shoulder has been evaluated after rotator cuff repair, it has not been studied in patients with cuff tears that occurred before repair. The primary purpose of this study was to determine whether preoperative stiffness persists after cuff repair. We also evaluated the incidence and possible causes of stiffness in patients who underwent arthroscopic rotator cuff repair. METHODS: This was a retrospective evaluation of 72 arthroscopic patients who underwent rotator cuff repair. Preoperative range-of-motion (ROM) deficits in abduction, forward flexion, external rotation, and internal rotation were recorded and were added together to determine the total ROM deficit (TROMD). Patients were then divided into 3 groups on the basis of TROMD. Group 1 comprised 42 patients with 0 degrees to 20 degrees TROMD. Group 2 consisted of 24 patients with 25 degrees to 70 degrees TROMD, and group 3 included 6 patients with a TROMD greater than 70 degrees. Preoperative medical history, intraoperative condition of the capsule and bursa, and cuff tear size were recorded. RESULTS: Capsular and bursal abnormalities were more common in stiffer patients, but arthroscopic evidence of adhesive capsulitis was found only in group 3 (3 of 6 patients). Postoperatively, average TROMD deficit decreased from 10 degrees to 4 degrees in group 1, from 36 degrees to 12 degrees in group 2, and from 89 degrees to 31 degrees in group 3. No reoperations or postoperative manipulations were reported in group 1 or 2. In group 3, 3 patients (the only 3 with adhesive capsulitis) showed no or minimal improvement in postoperative ROM. These 3 patients required a secondary arthroscopic capsular release. After all 3 repairs had completely healed, the TROMD averaged 35 degrees in this subgroup. CONCLUSIONS: Preoperative stiffness is common in patients who undergo rotator cuff repair. Mild and moderate stiffness generally resolve after surgery followed by routine therapy. Patients with a TROMD of 70 degrees or more may have adhesive capsulitis as well as a cuff tear and may not do well with cuff repair alone. LEVEL OF EVIDENCE: Level IV, case series.

Adult↗

PubMedDate not supplied

Pull-out strength of suture anchors for rotator cuff and Bankart lesion repairs.

Surgical reconstructions of anterior-inferior shoulder instabilities and rotator cuff injuries require secure fixation of soft tissue to bone. Sutures are inserted directly through transosseous tunnels in current techniques, which are surgically complex and not always adequate for fixation strength. Using fresh-frozen cadaveric human specimens, our objectives were 1) to compare immediate pull-out strength of two versions of polyacetal suture anchors (wedge and rod) with conventional suture-only attachment techniques in Bankart lesion and rotator cuff repairs, and 2) to compare pull-out strength of the two polyacetal suture anchors with a metallic suture anchor. Our results indicate no significant differences in fixation strength of Bankart lesions or rotator cuff repairs using sutures only, or using wedge or rod polyacetal suture anchors (P = 0.70). Pull-out force did not differ significantly (P = 0.37) between the two polyacetal anchors. Polyacetal anchors exhibited higher pull-out forces than metallic anchors when inserted into metaphyseal regions of the tibia and significantly higher pull-out forces (P < 0.001) when inserted into metaphyseal regions with thicker cortical walls. Our results indicate that both polyacetal suture anchors provide adequate immediate fixation for soft tissue repairs in the human shoulder.

Acetals↗

PubMed2003

Pathologic evidence of degeneration as a primary cause of rotator cuff tear.

Histopathologic, histochemical, and morphometric studies were done on 80 medial stumps of torn rotator cuff tendons to clarify the cause of tears. A high prevalence and diffuse distribution of degenerative changes were observed in the rotator cuff tendons including thinning and disorientation of collagen fibers, myxoid degeneration, hyaline degeneration, chondroid metaplasia, calcification, vascularproliferation, and fatty infiltration. No distinct inflammatory reaction was observed. Thinning and disorientation of collagen fibers, myxoid degeneration, and hyaline degeneration were seen in all cases. All changes except vascular proliferation and fatty infiltration were more pronounced in the middle to deep layers of the tendons than in the superficial layer. The collagen fibers were disoriented in the deep layer of the tendons, shown by microscopic image analysis. The frequency and distribution of thinning and disorientation of collagen fibers, myxoid degeneration, and hyaline degeneration suggest that these are early degenerative processes. Chondroid metaplasia and calcification may be chronic pathologic changes that occur after tearing regardless of the type of tear. Preexisting degenerative change in the middle and deep layers of the tendon in association with microtrauma seems to be the main cause of rotator cuff tears.

Adipose Tissue↗

PubMedDate not supplied

The association of suprascapular neuropathy with massive rotator cuff tears: a preliminary report.

We studied a prospective, consecutive series of 8 patients presenting with massive rotator cuff tears (>5 cm. in maximum dimension), all associated with severe retraction and fatty infiltration of the supraspinatus muscle on magnetic resonance imaging studies. All 8 patients had suprascapular neuropathy shown by electromyography (EMG) findings of denervation in the supraspinatus and/or infraspinatus muscles. Clinically, all patients had severe limitation of active motion, with no patient able to elevate their affected arm actively >40 degrees . Four patients elected débridement and partial surgical repair using margin convergence principles via a mini-open approach. Follow-up of these patients averaged 24 months. All 4 patients regained the ability to elevate their affected arm to >90 degrees , and to place their hand actively behind their head without assistance. Two of the 4 surgical patients consented to follow-up EMG studies that demonstrated, in both cases, that the suprascapular nerve had significant renervation potentials, with almost complete recovery of the nerve in 1 case. We conclude that suprascapular neuropathy may be associated with massive rotator cuff tears, and that partial rotator cuff repair may allow recovery of the nerve and improvement of function.

Aged↗

PubMedDate not supplied

Supplementation of rotator cuff repair with a bioresorbable scaffold.

BACKGROUND: Repair of a torn rotator cuff should have sufficient initial strength of the fixation to permit appropriate rehabilitation. HYPOTHESIS: Augmentation with a woven polylactic acid scaffold strengthens repairs of the rotator cuff. STUDY DESIGN: Controlled laboratory study. METHODS: In the suture-anchor model, 10 pairs of sheep infraspinatus tendons were detached and repaired to suture anchors. In half of the matched specimens, the repair was reinforced with a woven poly-lactic acid scaffold repaired with the tendon to bone. In the bone-bridge model, sutures were passed through a trough and over a bone bridge distal to the greater tuberosity; half were reinforced by the scaffold. The repairs were tested to failure with a hydraulic testing machine. RESULTS: The mean ultimate strength of suture-anchor repairs augmented with the scaffold (167.3 +/- 53.9 N) was significantly greater than that of nonaugmented fixation (133.2 +/- 38.2 N). Failure occurred when the tendon pulled through the sutures; the scaffold remained intact. Scaffold reinforcement of the bone bridge significantly increased the ultimate strength from 374.6 +/- 117.6 N to 480.9 +/- 89.2 N, and the scaffold remained intact in 8 of 10 specimens. CONCLUSIONS: The scaffold significantly increased the initial strength of rotator cuff repair by approximately 25%.

Absorbable Implants↗

PubMed2004

Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study.

OBJECTIVE: To determine the prevalence and clinical impact of rotator cuff tears in asymptomatic volunteers. MATERIALS AND METHODS: Sonographic examinations of the shoulder of 212 asymptomatic individuals between 18 and 85 years old were performed by a single experienced operator. The prevalence and location of complete rotator cuff tears were evaluated. The clinical assessment was based on the Constant Score. Magnetic resonance imaging (MRI) of the shoulder was obtained in those patients where US showed rotator cuff pathology. RESULTS: Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (P < 0.01). CONCLUSION: There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living.

Activities of Daily Living↗

PubMed1997

Partial repair of massive rotator cuff tears: the evolution of a concept.

Partial repair of massive rotator cuff tears has eliminated the need for tendon transfers to close large defects. Side-to-side repair is usually done as a first step, with the margins of the tear then repaired to bone. Side-to-side repair causes a "margin convenience" toward the greater tuberosity, enhancing the mechanics of the construct by decreasing the strain at the free margin of the rotator cuff tear. By combining tendon-to-tendon repair with the tendon-to-bone repair, the surgeon can create a functional rotator cuff in most patients with massive tears.

Arthroscopy↗

PubMed1996

Ultrasonography for diagnosis of rotator cuff tear.

In this study the clinical usefulness of ultrasonography in the diagnosis of rotator cuff tears was assessed. One hundred twenty-two patients undergoing preoperative ultrasonography were evaluated surgically. Three different ultrasonographic machines were applied with a 7.5-MHz linear-array transducer. Surgery confirmed a sensitivity of 79% for full-thickness tears and 50% for partial thickness tears. In 73 patients with negative ultrasonographic findings, the specificity was 100% for full-thickness tears and 90% for partial-thickness tears. The diagnostic sensitivity for full-thickness tears of the Hitachi EUB-340 system was significantly lower than those of Hitachi EUB-415 and EUB-515, and thus the former cannot be recommended for detection of rotator cuff tears. The sensitivity with regard to partial-thickness tears was also significantly lower with the Hitachi EUB-340 system as compared to the Hitachi EUB-515. There were no significant differences in false-positive rate among the three machines used. In conclusion, accurate ultrasonographic diagnosis of rotator cuff tear requires a high-resolution machine, as well as considerable experience in interpretation.

Adult↗

PubMed1996

Rotator cuff disorders.

The supraspinatus, infraspinatus, teres minor and subscapuĺaris muscles form a musculotendinous rotator cuff that provides dynamic stability to the shoulder joint. Symptoms of rotator cuff injury include limitation of motion, weakness and pain that often radiates down the upper arm and is present at night. Examination may reveal deltoid and rotator cuff atrophy, tenderness, limited passive range of motion and weakness on abduction and external rotation. Radiographs may show degenerative changes of the acromion or acromioclavicular joint, cysts, sclerosis and spurs of the greater tuberosity, and calcific deposits within the supraspinatus tendon. In most patients with subacromial impingement, conservative management, including physical therapy, nonsteroidal anti-inflammatory drugs and subacromial injections, is successful. Failure of conservative therapy after six to 12 weeks merits further evaluation with magnetic resonance imaging or arthrography, and consideration of surgery.

Humans↗

PubMed2001

Immunolocalization of cytokines and growth factors in subacromial bursa of rotator cuff tear patients.

Inflammation in the subacromial bursa causes pain in patients suffering from rotator cuff tear, with this long-lasting inflammation leading to fibrosis and thickening of the subacromial bursa. Both inflammatory cytokines and mechanical stress, and impingement in the subacromial space, might induce and worsen this inflammation. However, little is known of the mechanism of this inflammation. In this study, we used immunohistological staining to demonstrate the expression of Interleukin-1 beta (IL-1 beta), Tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta), and basic fibroblast growth factor (bFGF) in subacromial bursa derived from the patients suffering from rotator cuff tear. On the other hand the expression of these inflammatory cytokines and growth factors were little detected only to a small degree in patients with anterior shoulder instability who did not have severe shoulder pain and impingement in the subacromial space. Our findings suggest that those inflammatory cytokines and growth factors may play an important role in inflammation of the subacromial bursa. Controlling the expression of these cytokines and growth factors might be important for treating patients suffering from shoulder pain due to rotator cuff tear.

Acromion↗

PubMed1988

Current concepts in the radiographic evaluation of the rotator cuff.

This review discusses the disease of the rotator cuff and evaluates our current tools for imaging it. The rotator cuff consists of the cojoined tendons of the short rotator muscles of the shoulder. Derangements of the cuff, which can result from degeneration, trauma, or overuse, are frequent causes of shoulder pain. Until the present decade, imaging of the cuff depended on injection of contrast into either the underlying joint (arthrogram) or overlying bursa (bursogram). Computed tomography (CT) has added additional dimensions to arthrography but has not played a major role in the diagnosis of cuff pathology. Ultrasonography (US) has been shown to be of diagnostic value in imaging cuff tears and has shown promise in defining pathology in the intact cuff. Magnetic resonance imaging (MRI) has the potential for imaging the cuff; its roles here are not yet defined.

Humans↗

PubMed2002

The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study.

BACKGROUND: Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis. Consequently, the prognostic implications of rotator cuff disease in patients undergoing prosthetic replacement for the treatment of primary glenohumeral osteoarthritis are uncertain. The purpose of this study was to report the effects of the condition of the supraspinatus tendon and the rotator cuff musculature on the results of shoulder arthroplasty in the treatment of primary osteoarthritis. METHODS: Five hundred and fifty-five shoulders in 514 patients who had an arthroplasty for the treatment of primary glenohumeral osteoarthritis as part of a multicenter study were evaluated. Forty-one shoulders had a partial-thickness tear of the supraspinatus, and forty-two had a full-thickness tear. Ninety shoulders had moderate (stage-2) fatty degeneration of the infraspinatus, and nineteen had severe (stage-3 or 4) degeneration. Eighty-four shoulders had moderate fatty degeneration of the subscapularis, and fifteen had severe degeneration. The influence of the condition of the supraspinatus tendon and the infraspinatus and subscapularis musculature on the postoperative outcome was evaluated with respect to the scores according to the system of Constant and Murley, active mobility, subjective satisfaction, radiographic result, and rate of complications. RESULTS: The shoulders were evaluated at a mean of 43.1 months postoperatively. With the numbers available, supraspinatus tears were not found to influence the postoperative outcome with respect to the total Constant score, active mobility, subjective satisfaction, radiographic result, or rate of complications. Additionally, the treatment of these tears did not markedly influence the outcome parameters. Conversely, both shoulders with moderate fatty degeneration and those with severe degeneration of the infraspinatus were associated with poorer results than those with no degeneration with respect to the total Constant score (p < 0.0005), active external rotation (p < 0.0005), active forward flexion (p = 0.001), and subjective satisfaction (p = 0.031). Similar although less dramatic results were seen with fatty degeneration of the subscapularis. CONCLUSIONS: This study demonstrates that minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.

Adult↗

PubMed1996

Arthroscopic assessment of rotator cuff tear reparability.

To evaluate the efficacy of arthroscopic techniques in determining the potential reparability of complete rotator cuff tears, a clinical investigation was performed. The parameters of tear size measurement, tendon quality, tendon mobility, and suture anchor placement were evaluated. These parameters were determined using both arthroscopic and open surgical technique. No statistically significant differences were noted when the arthroscopic findings were compared with the findings at open rotator cuff repair. Arthroscopic techniques can reliably assess rotator cuff tear size, tendon quality, tendon mobility, and suture anchor placement.

Arm Injuries↗

PubMed2004

Arthroscopic repair of large rotator cuff tears using the interval slide technique.

PURPOSE: In some cases of larger and chronic rotator cuff tears, the supraspinatus tendon may be held in a retracted position by the contracted tissue of the rotator interval and the attached coracohumeral ligament. This study was performed to evaluate the utility and clinical effectiveness of an arthroscopic release of the rotator interval from the supraspinatus tendon combined with repair of the rotator cuff. TYPE OF STUDY: Prospective clinical follow-up study. METHODS: Forty-three arthroscopic rotator cuff repairs were performed and followed up for an average of 32 months. All of these patients had large, contracted tears that could not be adequately mobilized without a rotator interval release. In each case, an arthroscopic rotator interval release and superior capsular release were performed to improve cuff mobility. End-to-bone and side-to-side repair was performed depending on the configuration of the tear. Postoperatively, the patients were evaluated using a modified University of California Los Angeles (UCLA) rating system. RESULTS: Forty-two repairs were available for at least 2-year follow-up. No cases of deltoid morbidity or progressive superior migration of the humeral head were seen. The average overall preoperative score was 17.4 (range, 9-26). The average postoperative score was 36.4 (range, 20-45). We saw 21 excellent, 6 good, 11 fair, and 4 poor results based on prior criteria established for smaller tears. All of the average postoperative scoring categories were improved from preoperative scores. Only 3 patients were not satisfied with their results. CONCLUSIONS: The use of the interval slide technique greatly improves supraspinatus mobility in the case of large retracted tears. Although average improvements were less than in our previous study of smaller tears, complete or partial repair of these tears yields good results and high patient satisfaction.

Aged↗

PubMed2005

Comparison of fat-suppressed T2-weighted fast spin-echo sequence and modified STIR sequence in the evaluation of the rotator cuff tendon.

OBJECTIVE: This study was performed to determine whether a modified version of the classic STIR sequence provides similar information about the integrity of the rotator cuff tendon as the commonly used fat-suppressed T2-weighted fast spin-echo sequence. SUBJECTS AND METHODS: Sixty-one consecutive MRI examinations of the shoulder in 57 patients were performed using a coronal oblique T1-weighted spin-echo sequence, a modified version of the STIR sequence, and a fat-suppressed T2-weighted fast spin-echo sequence. Three reviewers independently assessed the rotator cuff tendon using the coronal oblique modified inversion recovery sequence and T1-weighted spin-echo sequence. After a minimum of 4 weeks, reviewers assessed the rotator cuff tendon using the fat-suppressed T2-weighted fast spin-echo sequence and T1-weighted spin-echo sequence. The kappa statistic was used to measure the degree of concordance between interpretations when each sequence was used independently. The conditional probability that a full- and a partial-thickness tear would be diagnosed on both sequences was calculated. Image quality was assessed in a side-by-side comparison. RESULTS: The overall weighted kappa score was 0.82, which indicates excellent concordance between the two sequences. If a full-thickness tear of the rotator cuff tendon was found on the fat-suppressed T2-weighted fast spin-echo sequence, there was a 94.1% probability that the same conclusion would be reached using the modified inversion recovery sequence. If a partial-thickness tear was found on the fat-suppressed T2-weighted fast spin-echo sequence, there was an 80.3% probability that the same conclusion would be reached with the modified inversion recovery sequence. Fat suppression in the modified inversion recovery sequence was superior to that in the T2-weighted fast spin-echo sequence in 26-39% of the examinations. CONCLUSION: The modified inversion recovery sequence and fat-suppressed T2-weighted fast spin-echo sequence provide similar information about the integrity of the rotator cuff tendon.

Adult↗

PubMed1990

The microangiographic pattern of the rotator cuff of the dog.

The spontaneous degeneration of the human rotator cuff seems to have mechanical and nutritive causes. Until now it was not known whether other species without an acromion had a vascularization of the rotator tendons which is similar to that of man. We therefore investigated the rotator cuff of dogs microangiographically. The results show a characteristic vascular pattern in each of the rotator tendons which is similar to that of man. Most important is the fact that the supraspinatus tendon shows an area of hypovascularity close to its insertion. Thus, the dog may be used for experimental purposes relating to the rotator cuff.

Animals↗

PubMed1997

The rotator cuff. Full-thickness tears. Mini-open repair.

Arthroscopically assisted rotator cuff repair, through a mini-open, deltoid-splitting approach, is an effective treatment for small- to medium-sized full-thickness tears of the rotator cuff. Advantages over traditional open repair include relative deltoid preservation, the ability to assess and treat coexisting intra-articular pathology, shorter hospitalization, reduced early morbidity, easier and quicker rehabilitation, and a smaller scar. Standard open repair is preferred for larger tears with a greater degree of tendon retraction or when the subscapularis tendon is involved in the tear.

Arthroscopy↗