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Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes.

We performed a prospective, randomized study to determine whether arthroscopic subacromial decompression changes the outcome of rotator cuff repair. We performed a power analysis to ensure statistical validity. Patients scheduled for arthroscopic rotator cuff repair were randomized to cuff repair with arthroscopic subacromial decompression (group 1) or without it (group 2). All other aspects of the surgical and postsurgical treatment were identical. We included patients with full-thickness tears limited to the supraspinatus tendon and a type 2 acromion. We excluded patients with prior surgery, those with larger tears involving two or more tendons, those with a type 1 or 3 acromion, those with workers' compensation claims, and those who had concomitant procedures (labral repair, acromioclavicular joint resection) There were 47 patients in group 1 and 46 in group 2. Minimum follow-up was 1 year (mean, 15.6 +/- 3.3 months). We recorded the American Shoulder and Elbow Surgeons (ASES) shoulder scores preoperatively and postoperatively. There was no statistical difference in postoperative ASES scores between group 1 (91.5 +/- 10.3) and group 2 (89.2 +/- 15.1) (P =.392). The change in ASES score over time did not differ between the two groups (61.1 vs 60.2, P =.363). In conclusion, within the parameters described above, arthroscopic subacromial decompression does not appear to change the functional outcome after arthroscopic repair of the rotator cuff.

Adult↗
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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↗
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Six-month magnetic resonance imaging follow-up of large and massive rotator cuff repairs reinforced with porcine small intestinal submucosa.

Small intestinal submucosa (SIS) has been used for reinforcement of other tissues in the body with success and has been shown to act as a bioabsorbable tissue scaffold that promotes and assists healing. The effectiveness of using porcine SIS as a tissue scaffold for reinforcement of rotator cuff repair is unclear. This study evaluates both clinical and magnetic resonance imaging (MRI) follow-up at 6 months in patients with large and massive rotator cuff tears treated with open repair and SIS reinforcement or interpositional grafting. Eleven consecutive patients who underwent open rotator cuff repair with SIS augmentation for large or massive tears were selected retrospectively, and their charts were reviewed. Magnetic resonance images were then obtained at least 6 months after the index procedure. Patients were evaluated clinically and with a questionnaire, and an American Shoulder and Elbow Surgeons shoulder score was calculated. Results showed retear on MRI in 10 of 11 patients with recurrence of large, retracted tears. One repair remained intact by MRI evaluation at 10 months. Clinically, there was no statistically significant difference between preoperative and postoperative shoulder scores by use of a paired t test analysis (P =.70). Five patients had worse scores postoperatively. We concluded that, though SIS xenografting may be effective in other areas of the body for tendon healing, its use in reinforcement of large and massive rotator cuff repairs seems to be ineffective and does not improve clinical outcome.

Aged↗
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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↗
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Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results.

Shoulder surgery is often associated with severe postoperative pain. Previous results in which single or continuous subacromial infiltration of local anesthetics was used as a method of postoperative pain relief have been contradictory. This study was initiated to evaluate the postoperative analgesic effect of a subacromial continuous 0.25% bupivacaine infusion at a rate of 6 mL/h after elective open shoulder surgery. We hypothesized that this procedure would improve postoperative analgesia while reducing morphine requirements. By use of a prospective, double-blind, randomized study design, 50 consecutive patients undergoing acromioplasty and rotator cuff repair surgery received a multiorifice catheter placed in the subacromial space. Twenty patients received 0.25% bupivacaine (group 1), and twenty-two patients received saline solution (group 2). The primary endpoints in the two groups were total morphine consumption administered by patient-controlled analgesia and the patient's subjective pain level evaluated by a visual analog scale during the first 48 postoperative hours. No major technical or pharmacologic side effects were noticed, and the indwelling pain catheter was well tolerated by all patients. There was no statistically significant difference (P < .05) either in total cumulative morphine consumption microg/48 h (73.2 +/- 43.1 vs 60.9 +/- 35.9) or in subjective pain perception 10-point visual analog scale (3.2 +/- 1.4 vs 3.1 +/- 1.5) between the two study groups. The continuous subacromial infiltration of 0.25% bupivacaine at a rate of 6 mL/h is concluded to be ineffective in providing pain relief supplementary to patient-controlled analgesia after open rotator cuff repair and acromioplasty surgery.

Adult↗
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Heterotopic ossification after primary shoulder arthroplasty.

We have assessed the incidence of heterotopic ossification (HO) after primary shoulder joint replacement in 126 shoulders; 58 patients had hemiarthroplasty, and 68 had total shoulder joint replacement. HO developed to a minor extent in 15% of patients (19/126). There was no statistical difference between hemiarthroplasty or total shoulder replacement or between male and female patients. Patients with cuff tear arthropathy were the only group with an increased risk (36.4% [4/11]) of having HO develop. In patients with osteoarthritis, fractures, or rheumatoid arthritis, HO occurred in less than 14.5% (15/115). Nonsteroidal anti-inflammatory drugs (NSAIDs) did not appear to have any effect on HO as in hip replacement, as HO developed in 15.15% of patients having NSAIDs postoperatively and in 15.05% of patients without NSAIDs. Prophylaxis of HO with NSAIDs seems only to be indicated in patients with cuff tear arthropathy.

Adult↗
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Management of early deep infection after rotator cuff repair surgery.

Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (<6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection.

Adult↗
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Differential patterns of muscle activation in patients with symptomatic and asymptomatic rotator cuff tears.

Patients with rotator cuff tears have varying degrees of symptom expression. Our purpose was to evaluate the differential firing patterns of the rotator cuff, deltoid, and scapular stabilizer muscle groups in normal control subjects and in patients with symptomatic and asymptomatic 2-tendon rotator cuff tears. Eighteen subjects were evaluated: six normal subjects and twelve with 2-tendon cuff tears (six asymptomatic and six symptomatic). All cuff tear patients had magnetic resonance imaging (MRI) scans documenting superoposterior tear configurations involving the supraspinatus and infraspinatus tendons; all normal subjects had an ultrasound examination confirming the absence of cuff pathology. Subjects were grouped based on shoulder examination and outcomes questionnaires. Asymptomatic patients had minimal pain (<3 on the visual analog scale and no loss of active range of motion compared with the contralateral side); symptomatic patients had pain greater than 3 on the visual analog scale and decreased range of motion compared with the contralateral side (>10 degrees of motion loss). Electromyographic activity from 12 muscles and kinematic data were collected simultaneously during 10 functional tasks. Both symptomatic and asymptomatic cuff subjects demonstrated a trend toward increased muscle activation during all tasks compared with normal subjects. During the internal rotation tasks, asymptomatic patients had significantly greater (P<.05) subscapularis activity than symptomatic patients (65% maximal voluntary contraction [MVC] vs 42% MVC). During the carrying task, asymptomatic patients demonstrated significantly less (P<.03) upper trapezius muscle activation than symptomatic patients (16% MVC vs 50% MVC). During shoulder elevation tasks, symptomatic patients had significantly greater supraspinatus (52% MVC vs 28% MVC, P<.03), infraspinatus (32% MVC vs 16% MVC, P<.05), and upper trapezius (39% MVC vs 20% MVC, P<.04) muscle activation compared with asymptomatic patients. During heavy elevation (8 lb), asymptomatic patients showed a trend toward increased activation (P<.06) of the subscapularis compared with symptomatic patients (34% MVC vs 21% MVC). Differential shoulder muscle firing patterns in patients with rotator cuff pathology may play a role in the presence or absence of symptoms. Asymptomatic subjects demonstrated increased firing of the intact subscapularis, whereas symptomatic subjects continued to rely on torn rotator cuff tendons and periscapular muscle substitution, resulting in compromised function.

Adult↗
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Massive rotator cuff tears: the result of partial rotator cuff repair.

Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P<.001). Active elevation improved from 114 degrees to 154 degrees , and no patient lost strength after surgery. The ability to raise the arm to at least 135 degrees improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears.

Adult↗
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Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases.

The purpose of this study is to evaluate the objective, subjective, and radiographic results of arthroscopic biceps tenotomy in selected patients with rotator cuff tears. Three hundred seven arthroscopic biceps tenotomies were performed in patients with full- thickness rotator cuff tears. Patients were selected for arthroscopic tenotomy if the tear was thought to be irreparable or if the patient was older and not willing to participate in the rehabilitation required after rotator cuff repair. Patients were evaluated clinically and radiographically at a mean of 57 months' follow-up (range, 24-168 months). The mean Constant score increased from 48.4 points preoperatively to 67.6 points postoperatively ( P < .0001). Eighty-seven percent of patients were satisfied or very satisfied with the result. The acromiohumeral interval decreased by a mean of 1.3 mm during the follow-up period and was associated with a longer duration of follow-up ( P < .0001). Preoperatively, 38% of patients had glenohumeral arthritis; postoperatively, 67% of patients had glenohumeral arthritis. Concomitant acromioplasty was statistically associated with better subjective and objective results only in patients with an acromiohumeral distance greater than 6 mm. Fatty infiltration of the rotator cuff musculature had a negative influence on both the functional and radiographic results ( P < .0001). Arthroscopic biceps tenotomy in the treatment of rotator cuff tears in selected patients yields good objective improvement and a high degree of patient satisfaction. Despite these improvements, arthroscopic tenotomy does not appear to alter the progressive radiographic changes that occur with long-standing rotator cuff tears.

Acromion↗
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Biceps tenodesis associated with arthroscopic repair of rotator cuff tears.

Associated lesions of the biceps tendon are commonly found during arthroscopic repair of rotator cuff tears. These lesions are treated with tenodesis, classically performed through an open approach. However, it seems reasonable to seek a single approach to correct both lesions; therefore, we have proposed a new arthroscopic technique that allows an exclusive arthroscopic tenodesis by including the biceps tendon in the rotator cuff suture, a surgical technique with a single suture of the rotator cuff that includes the biceps tendon. We treated 97 shoulders in 96 patients arthroscopically for complete rotator cuff tears. Of these shoulders, 15 required tenodesis for treatment of biceps tendon lesions. Through an arthroscopic approach, a subacromial decompression followed by a rotator cuff repair was carried out in association with a biceps tenodesis. In this technique, one limb of the suture was passed through the biceps tendon, and the other was passed through the rotator cuff tear, bringing both tissues together in the final suture. Of the patients, 9 were men and 5 were women. Their mean age was 71 years (range, 41-80 years). The dominant arm was affected in all patients. Postoperative evaluation, by use of the UCLA score, after a mean follow-up period of 32.4 months showed satisfactory results in 93.4% of patients: 11 had excellent results, 3 had good results, and only 1 had an unsatisfactory result. In this case a postoperative magnetic resonance imaging scan showed an intact rotator cuff and biceps tenodesis. The suture involving the rotator cuff and the biceps tendon proved effective to correct both lesions, with the main advantage being that an additional approach was not required.

Aged↗
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Influence of provider volume on length of stay, operating room time, and discharge status for rotator cuff repair.

Length of hospital stay, operating room time, and disposition of patient on discharge are important determinants of health care resource utilization. We examined the relationship between these determinants and hospital/surgeon volume for rotator cuff repair. A total of 9,973 patients undergoing rotator cuff repair were extracted from the New York State Ambulatory Surgery Databases for the years 1997 through 2000. Surgeon volume and hospital volume were divided into low-, intermediate-, and high-volume categories. Multivariate regression models were used to estimate the risk-adjusted association between provider volume and outcomes. Patients operated on by low-volume surgeons had significantly higher likelihood for an extended length of stay when compared with those operated on by high-volume surgeons (adjusted odds ratio for extended length of stay, 2.3; 95% confidence interval, 1.2-4.4). There was a linear trend for a higher proportion of routine patient discharge with increasing surgeon volume. The mean operating room times for low- and intermediate-volume surgeons were significantly higher than that for high-volume surgeons (P < .001). We conclude that high-volume providers use health care resources more efficiently.

Adult↗
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Effect of rotator cuff pathology on shoulder rhythm.

The purpose of this study was to test the hypothesis that shoulder rhythm is affected by rotator cuff pathology during arm elevation. We divided 42 subjects into 3 groups: those with full-thickness rotator cuff tears (RCTs) (n = 14), those with tendinopathy (n = 13), and control subjects (n = 15). Shoulder kinematics was recorded while subjects performed elevation in the sagittal and scapular planes. Euler angles were computed for scapular and humeral elevation. Data were divided into 3 equal phases. Lines were fit and the slope determined for each phase. Significant differences in slopes ( P < .05) were found between experimental groups for both motions. The RCT group had higher slopes in the initial and middle phases for sagittal elevation and in the middle phase for scapular abduction. The scapula was elevated more in the RCT group in the initial two thirds of movement. This motion may change the length of remaining muscles so that they operate on a more effective part of their length-tension curve.

Adult↗
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Biomechanical effects of supraspinatus repair on the glenohumeral joint.

We repaired full-thickness rotator cuff tears in human cadaveric shoulder specimens. The purpose of this study was to determine whether a repaired supraspinatus will result in a change in joint forces, contact pressures and area, and position of the humerus relative to the glenoid compared with the pathologic and simulated complete-tear specimens. Force couples exist in the coronal plane between the deltoid and the inferior portion of the rotator cuff and in the transverse plane between the anterior cuff (subscapularis) and posterior cuff (infraspinatus and teres minor). This has served as a model for shoulder and rotator cuff research. Our model differs from previous studies in that the pectoralis major and latissimus dorsi/teres major were included because they are important contributors to shoulder function. Muscle force simulation was performed through a clamp, cable, and pneumatic system for the tendons of the rotator cuff, pectoralis major, and teres major/latissimus dorsi. Each specimen was tested in its native state of a full-thickness supraspinatus tear in 10 degrees and 60 degrees of abduction with neutral humeral rotation. In each position there were 2 loading conditions: (1) all muscles loaded with 60 N and (2) deltoid loaded with 90 N and 60 N for all others (3:2 ratio between the deltoid and supraspinatus). Pathologic tear, repaired, and simulated complete-tear conditions were subjected to the same testing sequence. After repair, there was an increase in percent inferior force in the 10 degrees abduction, 60-N loaded condition ( P = .02). The increase in percent inferior force may represent greater concavity-compression and spacer effect, which are both important functions of the supraspinatus. Contact pressure decreased in both the pathologic and simulated complete-tear conditions at 10 degrees abduction with 90-N deltoid loading ( P = .01). A corresponding increase in area was observed at this position for the pathologic tear condition only ( P = .01). This could represent greater concavity-compression, indicating that strengthening may provide a biomechanical benefit.

Aged↗
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The relationship among strength and mobility measures and self-report outcome scores in persons after rotator cuff repair surgery: impairment measures are not enough.

In the past, measures of active range of motion and strength testing were deemed sufficient to "prove" the efficacy of treatment interventions. In the current outcomes milieu, however, the focus has shifted to patient-centered assessment (ie, patients' ability to perform activities that are personally relevant). We report results from a study with patients in the private practice of a shoulder surgeon. In this study we evaluated the relationship between impairment measures and scores from several shoulder outcome scales. In addition, we examined transcripts of interviews with shoulder patients regarding the impact of shoulder problems on their lives. One hundred eight persons participated in a randomized trial of home exercise instruction after arthroscopic repair of rotator cuff tears. Two impairment measures were used-strength estimates obtained by use of a Nicholas electronic dynamometer and range of motion in the standing position. Self- reported outcomes were measured by use of the Shoulder Pain and Disability Index (SPADI) and the University of Pennsylvania (UPenn) Shoulder Scale. Pearson correlation coefficients were calculated to estimate the associations between scores on impairment measures and self-report measures. R 2 values were calculated to estimate the proportion of variance shared by impairment and self-report scores. We found that the linear relationship between impairment scores and patient-reported outcomes was quite low, explaining as little as 8% of the total variance. Qualitative analysis of patient interviews suggests that patients distinguish between their impairment and their status on personally relevant outcomes. Future research should evaluate the nature of patient judgments of shoulder health outcomes.

Exercise Therapy↗
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Superior excursion of the humeral head: a diagnostic tool in rotator cuff tear surgery.

Superior excursion of the humeral head on the face of the glenoid was investigated to determine whether a relationship exists between the degree of humeral head excursion and the identity of the injured tendon in a shoulder with a torn rotator cuff. Twenty-seven patients with unilateral full-thickness rotator cuff tears diagnosed by either positive arthrogram or magnetic resonance imaging were included in this study. Three groups were formed based on intraoperative findings: 10 patients had isolated supraspinatus tendon tears (group 1), 11 patients had supraspinatus and infraspinatus tears (group 2), and 6 patients had supraspinatus, infraspinatus, and subscapularis tendon tears (group 3). There was no statistically significant difference between the degree of humeral head excursion in groups 1 and 2. However, patients in group 3 had a statistically significantly higher degree of excursion of the humeral head (P < .05) when compared with groups 1 and 2. In addition, an inverse relationship between the degree of humeral head excursion and preoperative Constant scores was found. Superior excursion of the humeral head on the glenoid had a significantly higher incidence in patients with subscapularis tears, and a larger amount of excursion was present in patients who had lower preoperative Constant scores.

Adult↗
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Lag signs.

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Humans↗