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PubMed2007

Biomechanical fixation in arthroscopic rotator cuff repair.

Rotator cuff repair remains a challenging and rapidly evolving field. Several recent studies have shown that arthroscopic repair yields functional results similar to those of mini-open and open procedures, with all of the benefits of minimally invasive surgery. However, the "best" repair construct remains relatively unknown, with wide variations in surgeon preference and conflicting evidence in the literature. The most recent developments in basic science, suture and suture anchor technology, and innovative prospects for arthroscopic rotator cuff repair are reviewed.

Arthroscopy↗
PubMed2007

Arthroscopic rotator cuff repair with and without subacromial decompression: a prospective randomized study.

PURPOSE: Our purpose was to evaluate the role of subacromial decompression in the arthroscopic repair of full-thickness rotator cuff tears in a prospective randomized clinical study. METHODS: Arthroscopic cuff repair was performed in 80 patients with a full-thickness rotator cuff tear. They were divided into 2 groups comprising 40 patients each. In group 1 arthroscopic rotator cuff repair was performed with subacromial decompression. In group 2 the repair was performed without decompression. Rotator cuff tears were repaired via metal suture anchors for tendon-to-bone repair, side-to-side repair, or a combination of the 2 techniques. Results were evaluated by use of the Constant score normalized for age and gender, as well as the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires. On analyzing the results at 2 years' follow-up, we considered the following independent variables: age; gender; dominance; location, shape, area, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis tendon; treatment of biceps tendon; rotator cuff repair technique; and type of acromion. A univariate and multivariate statistical analysis was performed to determine which variables were independently associated with the outcome. RESULTS: Comparison between the groups did not show significant differences for each variable considered. The overall results for the Constant score were 103.6 points in group 1 and 96.1 points in group 2; those for the DASH score were 18.2 points and 23.1 points, respectively; and those for the Work-DASH score were 23.7 points and 26.2 points, respectively. Univariate and multivariate analysis showed that the following variables significantly and independently influenced the outcome: age; shape, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis; and repair technique. Subacromial decompression did not influence the outcome significantly for each scoring system considered. CONCLUSIONS: At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. Longer follow-up studies will be necessary to confirm the clinical relevance of these observations. LEVEL OF EVIDENCE: Level I, randomized controlled trial with no significant difference but narrow confidence intervals.

Aged↗
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↗
PubMed2004

Biomechanical analysis of tendon transfers for massive rotator cuff tears.

OBJECTIVE: To determine why certain tendon transfers are mechanically more effective than other tendon transfers for the treatment of a massive rotator cuff tear. 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 the loss of rotator cuff function, techniques such as muscle transfers are developed. METHODS: Three range of motion 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. A biomechanical analysis of the transferred muscles was performed, taking outcome variables such as moment arms, muscle length and muscle force into account. RESULTS: Due to the massive rotator cuff tear, an elevation and external rotation moment is lost. When the tendon was transferred to the insertions of infraspinatus or supraspinatus, the humerus was capable of elevating and externally rotating. CONCLUSIONS: On the basis of mechanical parameters such as moment arms, muscle length and force it can be concluded that a tendon transfer of the teres major to the supraspinatus insertion will produce the best functional outcome in the treatment of massive rotator cuff tears. RELEVANCE: To find biomechanical evidence for an optimal tendon transfer that will lead to improved treatment of patients with a massive rotator cuff tear.

Biomechanical Phenomena↗
PubMed2005

Pathological Teres Major activation in patients with massive rotator cuff tears alters with pain relief and/or salvage surgery transfer.

BACKGROUND: Massive rotator cuff tears impose restraints on overhand arm functionality and are often accompanied by pain. After musculotendinous Teres Major transfer, overhand arm function is generally restored and pain is reduced. The assumed mechanical abduction insufficiency and Teres Major muscle function adaptation will be experimentally verified. METHODS: Principal Teres Major muscle activation (surface IEMG averaged over 3s) is recorded for 12-24 isometric and isotonic force directions perpendicular to the 60 degrees forward flexed humerus in three conditions: prior to surgery (n = 6 patients), prior to surgery and after subacromial anaesthetic (n = 6) and post-surgery (n = 3). Principal direction and on-, offset directions were estimated. FINDINGS: Teres Major activation adapts both to pathological and post surgery conditions: the normal activation during adduction changes into activation during forward flexion or abduction. Glenohumeral stabilisation, not abduction torque, seems to be the explanation for post surgery Teres Major transfer success. INTERPRETATIONS: The pathological absence of Supraspinatus and Infraspinatus forces during forward flexion result in increased upward glenohumeral instability. The superior translations are compensated for by Teres Major activity during forward flexion. This translation-'force' function conflicts with the adduction-generating rotation-'torque' function. This may explain the pain-induced reduction of arm elevation in these patients. Musculotendinous transfer solves the force-torque conflict by changing the moment arm of the Teres Major from adduction to abduction. Teres Major can now both compensate for the loss of Supraspinatus and Infraspinatus forces needed for glenohumeral stabilisation and contribute to forward flexion of the arm.

Biomechanical Phenomena↗
PubMed2006

Suprascapular nerve block disrupts the normal pattern of scapular kinematics.

BACKGROUND: Patients with full thickness rotator cuff tears typically demonstrate an increase in scapular motion, both in the clinic and under controlled laboratory conditions. To better understand the mechanisms behind this pattern of motion, we propose a suprascapular nerve block as an appropriate model of dysfunction of the supraspinatus and infraspinatus, which are the two tendons most commonly affected in cuff tear patients. METHODS: Healthy subjects underwent testing for 3D scapular kinematics with a Polhemus magnetic tracking device and isometric force measurements during external rotation. A suprascapular nerve block was then performed with the injection of lidocaine into the suprascapular notch of each subject. Scapular kinematics and isometric force measurements were repeated after confirmation of the block. FINDINGS: The nerve block resulted in no significant changes in clavicular rotations and scapular posterior tilting. However, there was a significant increase in scapular external rotation and upward rotation. While kinematic changes returned to baseline within 25 min of the block, force measurements did not return to baseline until 75 min post-block. Interpretation. The results of this study, especially those for upward rotation, are in general agreement with what has been found for patients with rotator cuff tears. While the supraspinatus and infraspinatus do not directly control the movement of the scapula, they appear to result in a compensatory change in scapular motion. Although more work needs to be done, it appears that abnormal scapular motion patterns observed in patients with cuff tears may therefore be compensatory in nature.

Adult↗
PubMed2006

Comparative study of different tendon grasping techniques for arthroscopic repair of the rotator cuff.

BACKGROUND: One cause of early failure of rotator cuff repairs is the pull out of the suture through the tendon. The aims of this study were to investigate the initial strength and failure mode of different tendon grasping techniques and to evaluate an alternative stitch proposed for arthroscopic repair of rotator cuff tendons. METHODS: Four different stitches were investigated: simple stitch, Mattress, modified Mason-Allen and simple stitch closed over a horizontal loop. The last stitch was proposed as an alternative to the modified Mason-Allen stitch since the former is simpler to sew arthroscopically than the latter. The experimental procedure was designed to assess the mechanical behaviour of the stitches. Tests were performed using sheep infraspinatus tendons. Two different non-absorbable sutures were used. Each specimen was preloaded with about 30 N and then loaded to failure. RESULTS: No significant difference was found in compliance among the four investigated stitches. Conversely, the tensile strength of the simple stitch and Mattress was lower than the tensile strength of the other two stitches, while no significant difference was observed between the modified Mason-Allen and the simple stitch closed over a horizontal loop. The maximum grasping power of these two 'reinforced' stitches was achieved only with the high-strength suture. INTERPRETATION: The simple stitch closed over a horizontal loop seems to be an attractive alternative to the modified Mason-Allen for arthroscopic repair of the rotator cuff and it seems recommendable instead of simple or Mattress stitches. The use of a high-strength suture would increase the tensile strength of the grasping in the case of good quality tendon tissue.

Animals↗
PubMed2006

Decreasing glenoid inclination improves function in shoulders with simulated massive rotator cuff tears.

BACKGROUND: A massive rotator cuff tear leads to poor shoulder function as evidenced by diminished glenohumeral abduction and superior translation of the humeral head compared to its normal position. The inclination angle of the glenoid has been associated with rotator cuff tears. The objective of this study was to quantify the effect of a decreased glenoid inclination angle on glenohumeral kinematics during active abduction in shoulders with a simulated, massive rotator cuff tear. METHODS: Eight fresh-frozen full upper extremities were tested using a dynamic shoulder testing apparatus. After recording the kinematics of the intact shoulder, a massive rotator cuff tear was surgically simulated. An osteotomy of the glenoid was then performed and the inclination angle was decreased by 30 degrees . The translation of the humeral head during abduction and the maximum abduction angle were recorded. FINDINGS: With an intact rotator cuff minimal humeral head translation on the glenoid occurred and the maximum abduction angle was mean 85.5 degrees (SD 7.4 degrees ). A massive rotator cuff tear resulted in superior translation of the humeral head with impingement on the acromion. The maximum abduction angle was mean 15.5 degrees (SD 9.4 degrees ). Decreasing the inclination angle of the glenoid resulted in a significant reduction of superior humeral head translation during abduction and there was no impingement on the acromion. The maximum abduction achieved was mean 28.5 degrees (SD 17.0 degrees ). INTERPRETATION: From a clinical perspective the reduced superior translation may decrease shoulder pain since the humeral head no longer impinges on the acromion. Further investigations are necessary to assess if the improvement in abduction is clinically significant.

Cadaver↗
PubMed2006

Shoulder magnetic resonance imaging.

MRI provides excellent soft tissue contrast and allows for multiplanar imaging in anatomic planes. Because of these advantages MRI has become the study of choice for imaging of shoulder pathology. Some structures, such as the rotator cuff, humeral head contour, and glenoid shape, are evaluated well with conventional MRI. When more sensitive evaluation of the labrum, capsule, articular cartilage, and glenohumeral ligaments is required or when a partial-thickness rotator cuff tear is suspected,magnetic resonance arthrography with intra-articular contrast can be performed. For MR arthrography contrast is injected directly into the glenohumeral joint. This article reviews the appearances of normal anatomic structures in MRI of the shoulder and disorders involving the rotator cuff and glenoid labrum.

Humans↗
PubMed2006

MRI of the postoperative shoulder.

Pain in the postoperative shoulder is difficult for all individuals involved. The patient has already undergone a surgical procedure and is presenting now with pain possibly relating to a complication of the procedure or reinjury. In addition, the patient typically has undergone a series of maneuvers, from physical therapy to cortisone injection, without relief of the symptoms. For the orthopaedic surgeon the possibility of a complication of the procedure is disheartening. Finally, for the radiologist the postoperative shoulder usually is more difficult to interpret because of a change in the normal anatomy, not knowing exactly what was accomplished at surgery or what techniques or types of equipment were used, and, more typically, the presence of artifact.

Arthrography↗
PubMed2006

Using support vector machines to optimally classify rotator cuff strength data and quantify post-operative strength in rotator cuff tear patients.

Shoulder strength data are important for post-operative assessment of shoulder function and have been used in diagnosis of rotator cuff pathology. Support vector machines (SVM) employ complex analysis techniques to solve classification and regression problems. A SVM, a machine learning technique, can be used for analysis and classification of shoulder strength data. The goals of this study were to determine the diagnostic competency of SVM based on shoulder strength data and to apply SVM analysis in efforts to derive a single representative shoulder strength score. Data were taken from fourteen isometric shoulder strength measurements of each shoulder (involved and uninvolved) in 45 rotator cuff tear patients. SVM diagnostic proficiency was found to be comparable to reported ultrasound values. Improvement of shoulder function was accurately represented by a single score in pairwise comparison of the pre-operative and the 12 month post-operative group (P < 0.004). Thus, the SVM-based score may be a promising metric for summarizing rotator cuff strength data.

Artificial Intelligence↗
PubMed2003

Shoulder surgery: from cuff repair to joint replacement. An update.

REPAIRING FULL THICKNESS CUFF TEARS.--Despite the sound rationale for repairing full-thickness rotator cuff tears, the procedure may fail to restore cuff integrity, which is indispensable to optimal cuff function. The functional role of each cuff muscle and the factors associated with anatomic failure (particularly those related to the muscles and tendons) provide a basis for rational patient selection and for determination of the best surgical strategy on a case-by-case basis. SHOULDER ARTHROPLASTY IN PATIENTS WITH GLENOHUMERAL JOINT DISEASE.--Total shoulder arthroplasty in patients with glenohumeral joint disease provides better outcomes than humeral hemiarthroplasty. The choice between a semi-constrained total prosthesis and a reverse constrained total prosthesis should be based on the nature of the joint disease (either centered humeral head or normal cuff function or migrated humeral head and abnormal cuff function). At present, only the semi-constrained total prosthesis has been proved effective in the long-term when used in a patient with a centered humeral head and active cuff. This provides additional support for repairing cuff tears whenever possible in patients who are still young.

Arthroplasty, Replacement↗
PubMedDate not supplied

The impact of preoperative smoking habits on the results of rotator cuff repair.

We examined the outcomes of patients who underwent surgical treatment for rotator cuff tears to test the hypothesis that patients who did not smoke would have better postoperative scores than smokers. Medical charts were reviewed for patients who underwent rotator cuff repair between 1990 and 1993. We examined age, smoking status, workers' compensation status, and the size of the rotator cuff tear to determine the effect of scores on the UCLA questionnaire and a subjective pain assessment. There were 95 smokers and 129 nonsmokers. Mean preoperative UCLA scores for smokers and nonsmokers were 15.9 and 17.6, respectively; mean postoperative scores were 25.0 and 32.0, respectively. Nonsmokers had a significantly greater increase in total UCLA scores than smokers (P <.0001) and significantly higher improvement in pain scores, and more nonsmokers were classified as having good or excellent results based on the UCLA rating. On the basis of our data, nonsmokers undergoing rotator cuff repair have greater improvement of pain and better results postoperatively than smokers.

Adult↗
PubMedDate not supplied

Fibrous cartilage in the rotator cuff: A pathogenetic mechanism of tendon tear?

There is no consensus on the pathogenesis of rotator cuff tears. Fibrous cartilage has been hypothesized to develop in some tendons as a result of shear or compressive forces, resulting in a tissue less capable of resisting normal tensile load and more prone to tearing. To test the hypothesis that metaplastic fibrocartilage in the rotator cuff could be involved in the pathogenic mechanism of its tear, samples from 34 acute and chronic torn rotator cuffs were subjected to histologic and immunohistologic study for the presence and type of cartilage (hyaline, fibrous, or elastic) in the area of the lesion and surrounding tissues. Detection of type I and II collagen, S-100 protein, and chondroitin sulfate allowed areas of fibrous cartilage to be seen in all samples, suggesting that the characteristic of rotator cuff tendons to work both in tension and in compression may stimulate fibrocartilaginous metaplasia and lead to a complete tear.

Adult↗
PubMedDate not supplied

Association of osteopenia of the humeral head with full-thickness rotator cuff tears.

Rotator cuff tendon repair may fail for various reasons. Although the role of repair techniques and of the musculotendinous unit has been studied, there is little information on the quality of the bone to which the tendon is to be repaired. Therefore, 14 cadaveric humeral heads, 7 specimens without and 7 with a full-thickness rotator cuff tendon tear, were quantitatively assessed by use of high-resolution micro-computed tomography. Bone density is higher below the articular surface than in the greater tuberosity (40% vs 10%-20%), and tendon tears are associated with a reduction in cancellous bone density of greater than 50%, leading to a virtually hollow greater tuberosity, with intact cortical bone. The results found suggest that in long-standing rotator cuff tears, creating a deep trough should be avoided to achieve reliable tendon-to-bone contact. For optimal suture fixation to bone, sutures or anchors should be positioned subcortically or medially under the articular surface.

Aged↗
PubMedDate not supplied

The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders.

This study presents the use of in-office ultrasound, performed by an attending orthopaedic surgeon, as a means of evaluating the integrity of the rotator cuff. The results of 282 shoulder sonograms in patients ultimately treated surgically were included. Findings at surgery were recorded and compared with those documented during the ultrasound examination. Ultrasound findings included 118 full-thickness and 143 partial-thickness rotator cuff tears and 6 intact cuffs confirmed at surgery. One patient with a partial supraspinatus tear on ultrasound was intact at surgery, nine with complete supraspinatus tears had partial-thickness tears at surgery, one with an intact supraspinatus had a full-thickness tear at surgery, and four with partial-thickness supraspinatus tears had full-thickness tears at surgery. The sensitivity, specificity, positive predictive value, and negative predictive value were 94.1%, 96.1%, 96.6%, and 93.2%, respectively, for partial-thickness tears; 95.9%, 94.3%, 92.9%, and 96.8%, respectively, for full-thickness tears; and 99.6%, 85.7%, 99.6%, and 85.7%, respectively, when the rotator cuff was evaluated for damage (either partial- or full-thickness tears). This series documents the ability of an orthopaedic surgeon to image the rotator cuff effectively using portable ultrasound in the clinic setting, allowing for a more efficient implementation of the management plan.

Adolescent↗