The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 5

Scientific Articles | May 01, 2007

Repair Integrity and Functional Outcome After Arthroscopic Double-Row Rotator Cuff Repair: A Prospective Outcome Study

Hiroyuki Sugaya, MD¹; Kazuhiko Maeda, MD¹; Keisuke Matsuki, MD¹; Joji Moriishi, MD¹

¹ Funabashi Orthopaedic Sports Medicine Center, 1-833 Hazama, Funabashi, Chiba 2740822, Japan. E-mail address for H. Sugaya: hsugaya@nifty.com

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at Funabashi Orthopaedic Sports Medicine Center, Funabashi, Chiba, and the Department of Orthopaedic Surgery, Kawatetsu Chiba Hospital, Chiba, Japan

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 May 01;89(5):953-960. doi: 10.2106/JBJS.F.00512

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Abstract

Background: The retear rate following rotator cuff repair is variable. Recent biomechanical studies have demonstrated that double-row tendon-to-bone fixation excels in initial fixation strength and footprint coverage compared with the single-row or transosseous fixation methods. This study was designed to report the repair integrity and clinical outcome following arthroscopic double-row rotator cuff repair.

Methods: A consecutive series of 106 patients with full-thickness rotator cuff tears underwent arthroscopic double-row rotator cuff repair with use of suture anchors and were followed prospectively. Twenty patients lacked complete follow-up data or were lost to follow-up. The eighty-six study subjects included fifty-two men and thirty-four women, with an average age of 60.5 years. There were twenty-six small, thirty medium, twenty-two large, and eight massive tears. Clinical outcomes were evaluated at an average of thirty-one months. Repair integrity was estimated with use of magnetic resonance imaging, which was performed, on the average, fourteen months postoperatively, and was classified into five categories, with type I indicating sufficient thickness with homogeneously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity; and type V, the presence of a major discontinuity.

Results: The average clinical outcome scores all improved significantly at the time of the final follow-up (p < 0.01). At a mean of fourteen months postoperatively, magnetic resonance imaging revealed that thirty-seven shoulders had a type-I repair; twenty-one, a type-II repair; thirteen, a type-III repair; eight, a type-IV repair; and seven, a type-V repair. The overall rate of retears (types IV and V) was 17%. The retear rate was 5% for small-to-medium tears, while it was 40% for large and massive tears. The shoulders with a type-V repair demonstrated significantly inferior functional outcome in terms of overall scores and strength compared with the other types of repairs (p < 0.01).

Conclusions: Arthroscopic double-row repair can result in improved repair integrity compared with open or miniopen repair methods. However, the retear rate for shoulders with large and massive tears remains higher than that for smaller tears, and shoulders with large repair defects (type V) demonstrate significantly inferior functional outcomes.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Although recent studies have revealed that functional outcomes after arthroscopic rotator cuff repair are comparable with those after open or mini-open repair^1-8, only a few studies have described structural outcomes after arthroscopic repair^9-12. According to the literature, the reported retear rate after open or mini-open rotator cuff repair has ranged from 24% (twenty-four of 100 shoulders) to 94% (sixteen of seventeen shoulders)^13-21, as demonstrated by arthrography^13,16,19, ultrasonography^10,14,15, and magnetic resonance imaging^{9,17,18,20,21}. Further, the repair integrity is influenced by the preoperative size of the rotator cuff tear and the tissue quality^{10-12,15,17,21}, and a better functional outcome may be achieved in a repair with better postoperative cuff integrity^{11,14,15,17,21}. Because of the insufficient number of outcome studies, as well as one that described surprisingly poor structural outcome after arthroscopic single-row repair¹⁰, arthroscopic rotator cuff repair is generally believed to be inferior to open or mini-open repair with regard to fixation strength and repair integrity. A double-row fixation for rotator cuff repairs has been developed to strengthen the anchoring of the tendon to bone with satisfactory functional results^22-24. Furthermore, recent biomechanical studies have demonstrated that the double-row tendon-to-bone fixation is better in initial fixation strength and footprint coverage than single-row or transosseous fixation techniques^23,25. In addition, in a clinical study, Sugaya et al. reported the superiority of the arthroscopic double-row technique to the single-row technique in a retrospective comparative study¹². However, clinical evidence supporting the superiority of arthroscopic double-row fixation over conventional methods is still insufficient. The purpose of this study was to report the repair integrity and clinical outcome following arthroscopic double-row rotator cuff repair in a prospective fashion.

Materials and Methods

Materials and Methods | Results | Discussion | References

Patient Selection

From April 2001 to May 2003, 157 consecutive patients who failed conservative treatment underwent arthroscopic rotator cuff repair by a single surgeon (H.S.). Seven patients who had been scheduled for revision surgery or who had a major associated abnormality, such as an anterior glenoid fracture, were not included in this study. Therefore, 150 patients were selected as candidates for this prospective study and gave informed consent prior to surgery. The criteria for inclusion in this study were a full-thickness rotator cuff tear confirmed during surgery, arthroscopic double-row rotator cuff repair, magnetic resonance imaging for evaluation of the integrity of the rotator cuff between one and two years postoperatively along with a preoperative magnetic resonance imaging scan, and a final functional evaluation at a minimum of two years postoperatively. Thirty-seven patients had partial-thickness tears, which were confirmed during surgery, and seven patients underwent alternative methods other than the arthroscopic double-row repair because they had massive retracted irreparable tears with fatty degeneration and severe atrophy of the affected muscles. Therefore, these forty-four patients were excluded, and 106 patients were enrolled in this study. Of those patients, twenty were lost to follow-up before two years postoperatively or were unable to have a postoperative magnetic resonance imaging scan. Consequently, this study includes eighty-six shoulders in eighty-six patients. The fifty-two men and thirty-four women had an average age of 60.5 years (range, forty-one to seventy-seven years) at the time of surgery. The follow-up rate was 81% (eighty-six of 106 patients). The final functional evaluation was performed at an average of thirty-one months (range, twenty-four to forty-nine months) postoperatively, and the magnetic resonance imaging scan was acquired at a mean of fourteen months (range, twelve to twenty-four months) postoperatively. The surgery was performed in the dominant extremity in sixty-three patients and in the nondominant extremity in twenty-three patients. The preoperative tear size was assessed during arthroscopic surgery. Twenty-six tears were small (<1 cm in length), thirty were medium (1 to 3 cm), twenty-two were large (3 to 5 cm), and eight were massive (>5 cm)²⁶.

Patient Assessment

The patients underwent a standard history and physical examination as well as imaging studies, including bilateral anteroposterior radiographs of the shoulder in both internal and external rotation and supraspinatus outlet radiographs. All patients had a magnetic resonance imaging scan on the affected side, which confirmed a defect at the tendinous portion of the rotator cuff. However, the tear size and pattern were determined during diagnostic arthroscopy. All patients were assessed with use of the scoring system of the Japanese Orthopaedic Association (JOA)²⁷, the rating scale of the University of California at Los Angeles (UCLA)²⁸, and the shoulder index of the American Shoulder and Elbow Surgeons (ASES)²⁹ preoperatively and at the time of the final follow-up at an average of thirty-one months (range, twenty-four to forty-nine months). The JOA score is a 100-point scoring system, with 30 points for pain, 20 points for function, 30 points for range of motion, and 20 points for radiographic findings and stability. The UCLA rating scale is a 35-point scale, with 10 points for pain, 10 points for function, and 5 points each for strength, motion, and patient satisfaction. The ASES shoulder index consists of a pain score and a section including ten self-assessed activities of daily living. Subjective pain was rated from 0 to 10 on a visual analog scale, which was calculated as a maximum total of 50 points. Ten activities of daily living were rated on a numeric scale, according to the patient's ability to perform them, which was calculated as a maximum total of 50 points. Therefore, the total possible score for the entire ASES index was 100 points.

Magnetic Resonance Imaging

Magnetic resonance imaging was performed with a 1.5-T closed-type scanner (Gyroscan PowerTrak 3000; Philips, Best, The Netherlands) or a 0.3-T open-type scanner (ARIS II; Hitachi, Tokyo, Japan). Oblique coronal, oblique sagittal, and axial T2-weighted spin-echo magnetic resonance images (repetition time and echo time of 3200 msec and 85 msec, respectively, for the Philips scanner and 2180 msec and 96 msec for the Hitachi scanner) were acquired for structural and qualitative assessment of the rotator cuff, and repair integrity was determined. The slice thickness for the Philips and Hitachi scanners was 4 and 3 mm, respectively, with an interslice gap of 0.5 mm. The field of view was 18 and 16 cm, and the image matrix was 256 by 512 and 288 by 200, respectively. All patients underwent a postoperative magnetic resonance imaging scan at one to two years (average, fourteen months). Repair integrity was classified into five categories with use of oblique coronal, oblique sagittal, and transverse views of T2-weighted images. Type I indicated a repaired cuff that had sufficient thickness with homogeneously low intensity on each image; type II, sufficient thickness associated with a partial high-intensity area; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity in more than one slice of each image, suggesting a small tear; and type V, the presence of a major discontinuity on each image, suggesting a medium or large tear^9,12.

Surgical Procedure

All procedures were performed with the patient under general anesthesia in the beach-chair position. A posterior portal was established for the initial assessment of the glenohumeral joint. An anterior portal through the rotator interval was established as the working portal for the treatment of intraarticular lesions. The tear size and presence of delamination^30,31 were carefully determined.

The arthroscope was then removed from the glenohumeral joint and redirected into the subacromial space. A lateral portal and a posterolateral portal were also established. Any pathological bursal tissue that impeded clearance of the space was removed, and arthroscopic subacromial decompression was performed to create a flat acromial undersurface in all patients. The amount of bone removed varied, depending on the extent of proliferation of acromial osteophytes in each patient. Osteophytes in the inferior part of the acromioclavicular joint and the distal end of the clavicle were also removed if necessary. The posterolateral portal was mainly used as the viewing portal in these procedures. The tear size and pattern were again evaluated, and the mobility and reparability of the torn cuff were estimated. If the mobility of the tendon was insufficient in larger tears, a tendon mobilization procedure, including a partial or entire capsulotomy and coracohumeral ligament release, was performed prior to the repair. The footprint of the greater tuberosity was débrided to expose cortical bone, avoiding excessive removal of bone tissue. A bone trough was not created.

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Fig. 1: Schematic drawings showing double-row fixation in shoulders with delamination. The superficial bursal side layer and the deep articular side layer were repaired separately with use of simple sutures.

The tendon-to-bone fixation technique varied according to the presence of delamination. With a delaminated lesion (Fig. 1), the medial row of metal suture anchors loaded with number-2 permanent sutures (Fastin RC 5.0; DePuy Mitek, Norwood, Massachusetts) was inserted through the superolateral portal first and located just lateral to the articular surface of the humeral head, and then the number-2 permanent sutures were placed through the margin of the inferior (and usually more medial) layer of the rotator cuff with use of a Caspari punch (CONMED Linvatec, Largo, Florida) loaded with looped 2-0 nylon suture. An intra-articular suture relay was performed³¹. After all medial-row simple sutures were placed, knot-tying was performed with use of a self-locking sliding knot. To accomplish secure knot-tying, the arm was abducted at an optimal degree of rotation to reduce tensile forces on the suture during the knot-tying. Next, a lateral row of anchors was inserted at the lateral ridge of the greater tuberosity. Then, sutures were placed through the superior layer of the rotator cuff with use of an Ideal Suture Grasper (DePuy Mitek) or other tissue-penetrating instruments and the Caspari punch. After placement of all simple sutures, knot-tying was performed in the same fashion (Figs. 2-A and 2-B, 2-C and 2-D). In the shoulders without delamination of the rotator cuff (Figs. 3 and 4), the medial portion of the cuff was penetrated with use of the tissue-penetrating instruments and the sutures were grasped and passed in a mattress fashion. Before knot-tying for the medial row was done, a lateral row of anchors was inserted at the lateral margin of the greater tuberosity. Then, the sutures for the lateral row were placed through the lateral margin of the cuff. Knot-tying for the lateral row was performed first, and then the repair was completed with knot-tying for the medial row. Longitudinal tears or u-shaped tears were repaired with side-to-side number-2 Ethibond stitches (Ethicon, Somerville, New Jersey) prior to tendon-to-bone fixation. The number of suture anchors varied with the size of the tear. We used an average of 1.4 anchors (range, one to three anchors) for the medial row, 1.8 anchors (range, one to three anchors) for the lateral row, and 3.3 anchors (range, two to six anchors) overall.

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Fig. 2-A and Fig. 2-B: Figs. 2-A through 2-D Arthroscopic images of a right shoulder with delamination of the rotator cuff. Fig. 2-A Intra-articular view from the posterior portal shows a rotator cuff tear with delamination. Fig. 2-B The subacromial bursal view from the posterolateral portal shows completed fixation of the medial row.

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Fig. 2-C and Fig. 2-D: Fig. 2-C The subacromial bursal view shows completed fixation of the lateral row. Fig. 2-D An intra-articular view of the same shoulder shows complete reduction of the articular layer of the delamination.

Postoperative Protocol

The shoulders were immobilized for three to four weeks with use of a sling immobilizer with an abduction pillow (DeRoyal, Powell, Tennessee). Isometric rotator-cuff exercises and relaxation of the muscles around the shoulder girdle were initiated on the day after surgery. After the immobilization period, passive and active-assisted exercises were initiated for forward flexion and external rotation, avoiding the provocation of pain. After six weeks, patients began strengthening exercises of the rotator cuff and the scapular stabilizers. Rehabilitation was consistently performed with the assistance of a physical therapist. Three months after the operation, patients were permitted to practice light sports activities. Full return to sports and heavy labor was allowed after six months according to the individual's functional recovery.

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Fig. 3: Schematic drawings showing double-row fixation of a torn rotator cuff without delamination. Sutures for the medial row are placed first in a mattress fashion. Then, simple sutures for the lateral row are placed through the lateral margin of the cuff. Knot-tying for the lateral row is performed first, and then the repair is completed with the knot-tying for the medial row.

Statistical Analysis

The Student t test was used to compare the difference between the preoperative and postoperative scores of the JOA scoring system, the UCLA rating scale, and the shoulder index of the ASES. One-factor analysis of variance was used to compare the repair integrity and the functional scores. The significance level was set at p = 0.05.

Results

Materials and Methods | Results | Discussion | References

Functional Outcome

All three rating systems reflected a significant improvement in the status of the shoulders when the preoperative scores were compared with the scores at the time of the final follow-up (p < 0.01). The average total score had increased from 65.8 points (range, 33 to 88 points) preoperatively to 95.0 points (range, 74 to 100 points) with use of the JOA score, from 14.5 points (range, 5 to 24 points) to 32.9 points (range, 18 to 35 points) with use of the UCLA rating scale, and from 42.3 points (range, 10 to 80 points) to 94.3 points (range, 60 to 100 points) with use of the ASES shoulder index (Table I).

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TABLE I Preoperative and Postoperative Shoulder Scores

Shoulder Scoring System*	Score†
	Preop.	Postop.	P Value
JOA score
Total	65.8 (11.4)	95.0 (6.1)	<0.01
Pain	10.1 (4.7)	28.2 (3.2)	<0.01
Function	13.3 (4.5)	19.3 (1.7)	<0.01
Range of motion	22.8 (5.7)	27.7 (2.3)	<0.01
UCLA rating scale
Total	14.5 (4.3)	32.9 (3.7)	<0.01
Pain	2.4 (1.5)	9.3 (1.2)	<0.01
Function	4.6 (2.0)	9.1 (1.3)	<0.01
Range of motion	4.1 (1.1)	5.0 (0)	<0.01
Strength	3.3 (1.3)	4.8 (0.5)	<0.01
ASES shoulder index
Total	42.3 (12.9)	94.3 (9.7)	<0.01
Pain	15.7 (8.0)	47.4 (5.4)	<0.01
Function	26.3 (9.7)	47.0 (5.0)	<0.01

JOA = Japanese Orthopaedic Society²⁷, UCLA = University of California at Los Angeles²⁸, and ASES = American Shoulder and Elbow Surgeons²⁹. †The values are given as the mean with the standard deviation in parentheses.

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TABLE I Preoperative and Postoperative Shoulder Scores

Shoulder Scoring System*	Score†
	Preop.	Postop.	P Value
JOA score
Total	65.8 (11.4)	95.0 (6.1)	<0.01
Pain	10.1 (4.7)	28.2 (3.2)	<0.01
Function	13.3 (4.5)	19.3 (1.7)	<0.01
Range of motion	22.8 (5.7)	27.7 (2.3)	<0.01
UCLA rating scale
Total	14.5 (4.3)	32.9 (3.7)	<0.01
Pain	2.4 (1.5)	9.3 (1.2)	<0.01
Function	4.6 (2.0)	9.1 (1.3)	<0.01
Range of motion	4.1 (1.1)	5.0 (0)	<0.01
Strength	3.3 (1.3)	4.8 (0.5)	<0.01
ASES shoulder index
Total	42.3 (12.9)	94.3 (9.7)	<0.01
Pain	15.7 (8.0)	47.4 (5.4)	<0.01
Function	26.3 (9.7)	47.0 (5.0)	<0.01

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Fig. 4: Arthroscopic image of the right shoulder from the posterior portal showing a rotator cuff tear without delamination.

Repair Integrity

With regard to repair integrity at a mean of fourteen months postoperatively, magnetic resonance imaging scans revealed thirty-seven shoulders (43%) with a type-I repair, twenty-one (24%) with a type-II repair, thirteen (15%) with a type-III repair, eight (9%) with a type-IV repair, and seven (8%) with a type-V repair. The overall rate of retears (types IV and V) was 17% (fifteen of eighty-six shoulders). To put it differently, fifty-eight shoulders (67%) had a continuous cuff with sufficient thickness, thirteen (15%) had a continuous cuff with insufficient thickness, and fifteen (17%) had a retorn cuff overall. The retear rate was 5% (three of fifty-six shoulders) for small-to-medium tears, whereas it was 40% (twelve of thirty shoulders) for large and massive tears (Table II).

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TABLE II Repair Integrity

Preoperative Tear Size	Type I	Type II	Type III	Type IV	Type V
Overall (n = 86)	37 (43)	21 (24)	13 (15)	8 (9.3)	7 (8)
Small (n = 26)	16 (62)	7 (27)	3 (12)
Medium (n = 30)	15 (50)	9 (30)	3 (10)	2 (<1)	1 (<1)
Large (n = 22)	6 (27)	3 (14)	5 (23)	5 (23)	3 (14)
Massive (n = 8)		2	2	1	3

The values are given as the number of patients with the percentage in parentheses.

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TABLE II Repair Integrity

Preoperative Tear Size	Type I	Type II	Type III	Type IV	Type V
Overall (n = 86)	37 (43)	21 (24)	13 (15)	8 (9.3)	7 (8)
Small (n = 26)	16 (62)	7 (27)	3 (12)
Medium (n = 30)	15 (50)	9 (30)	3 (10)	2 (<1)	1 (<1)
Large (n = 22)	6 (27)	3 (14)	5 (23)	5 (23)	3 (14)
Massive (n = 8)		2	2	1	3

The values are given as the number of patients with the percentage in parentheses.

Repair Integrity Compared with Functional Outcomes

The JOA score for type-V rotator cuffs demonstrated significantly lower results in terms of overall function and strength compared with other types of repaired rotator cuffs (p < 0.01). However, with the numbers studied, type-IV cuffs did not demonstrate any significant functional inferiority compared with other types of shoulders without discontinuity. Similar results were obtained with the UCLA and ASES scoring systems (Table III).

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TABLE III Repair Integrity Compared with Functional Outcomes

		Scoring System*
Classification of Repair Integrity	No. of Shoulders	JOA			UCLA			ASES
		Score	P Value	Score	P Value	Score	P Value
Type I	37	96.5 (4.2)	0.04†	33.8 (1.9)	0.06	96.9 (5.2)	0.03†
Type II	21	96.4 (4.1)	0.22	33.9 (1.9)	0.17	96.7 (5.8)	0.2
Type III	13	94.3 (5.3)	0.66	32.6 (4.6)	0.75	93.8 (9.4)	0.85
Type IV	8	94.8 (7.0)	0.91	32.1 (4.5)	0.53	91.3 (12.7)	0.35
Type V	7	84.1 (9.1)	<0.01‡	27.0 (6.2)	<0.01‡	78.1 (17.2)	<0.01‡

The values are given as the mean with the standard deviation in parentheses. JOA = Japanese Orthopaedic Society²⁷, UCLA = University of California at Los Angeles²⁸, and ASES = American Shoulder and Elbow Surgeons²⁹. †Compared with the other types, the outcome was significantly better (p < 0.05). ‡Compared with the other types, the outcome was significantly inferior (p < 0.01).

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TABLE III Repair Integrity Compared with Functional Outcomes

		Scoring System*
Classification of Repair Integrity	No. of Shoulders	JOA			UCLA			ASES
		Score	P Value	Score	P Value	Score	P Value
Type I	37	96.5 (4.2)	0.04†	33.8 (1.9)	0.06	96.9 (5.2)	0.03†
Type II	21	96.4 (4.1)	0.22	33.9 (1.9)	0.17	96.7 (5.8)	0.2
Type III	13	94.3 (5.3)	0.66	32.6 (4.6)	0.75	93.8 (9.4)	0.85
Type IV	8	94.8 (7.0)	0.91	32.1 (4.5)	0.53	91.3 (12.7)	0.35
Type V	7	84.1 (9.1)	<0.01‡	27.0 (6.2)	<0.01‡	78.1 (17.2)	<0.01‡

Complications

There were no intraoperative or perioperative complications. No patient had a neural injury, wound infection, or a suture anchor problem.

Discussion

Materials and Methods | Results | Discussion | References

It is clear that the ideal rotator cuff repair should have high initial fixation strength, minimal gap formation, and mechanical stability that is sufficient until tendon-to-bone healing is established³². The use of a double row of suture anchors is generally believed to provide a more anatomic repair by creating a large area of contact of the repaired tendon to the footprint of the greater tuberosity with a better opportunity for biological healing^22,24. In fact, Waltrip et al.²³ compared the initial fixation strength of their double-row repair, in which suture anchors were used for the medial row and transosseous fixation for the lateral row, with the isolated single-row suture anchor repair and traditional isolated transosseous techniques. Their cadaver study demonstrated that the initial fixation strength of the double-row technique exceeded that of the other methods. Tuoheti et al.³³ and Meier and Meier²⁵ demonstrated that the specific double-row suture anchor fixation provided superior repair contact area compared with the single row of suture anchors or the transosseous suture technique in cadaveric studies. Further, Meier and Meier also demonstrated superior stability of the repair site with the double row compared with other repair methods³⁴. These biomechanical studies provide a rationale for the use of the double-row technique.

The repair integrity in this study compared quite favorably with that reported for open or mini-open^13-21 and arthroscopic single-row repair^9-11, with a retear rate of 5% (three of fifty-six shoulders) for small-to-medium tears and 17% (fifteen of eighty-six shoulders) overall. However, in large and massive tears, although the retear rate was considerably better compared with that of other reports, a retear rate of 40% (twelve of thirty shoulders) is still not acceptable. On the other hand, with regard to functional outcomes in relation to the repair integrity, shoulders with a type-V repair demonstrated inferior outcomes while those with a type-IV repair did not. These results suggest that a small defect remaining after surgery does not have an adverse effect on the postoperative function; in other words, we probably do not have to be overly concerned about postoperative small rotator cuff defects detected by magnetic resonance imaging or ultrasonography. We believe that the function of the rotator cuff in maintaining the centralization of the humeral head against the glenoid fossa is well preserved in shoulders even with a small defect.

Consequently, to obtain an excellent functional outcome, surgeons have to ensure that the postoperative development of a large type-V rotator cuff defect is avoided. Patient selection is one of the most important factors in avoiding postoperative structural failures. Preoperative magnetic resonance imaging for the evaluation of atrophy and fatty degeneration of muscle is a key factor in patient selection^17,18. It has been our experience that in shoulders with severe residual muscle degeneration, which is compatible with stage-3 and 4 muscles according to the classification system of Goutallier et al.³⁵, it is relatively difficult to bring the torn tendon end back to the original footprint; therefore, we do not consider these shoulders to be suitable for primary repair. On the other hand, evaluation of the rotator cuff during surgery is also important. Besides the evaluation of tendon quality and mobility, the evaluation and management of delamination is an important factor in obtaining a satisfactory structural outcome. Matsuki et al.³⁶ reported that the prevalence of delamination exceeded 82% (103 of 126 shoulders) in their series and that the articular layer, which seems to originate from the posterior oblique fibers of the infraspinatus, was thicker and more retracted compared with the superficial bursal layer, which seems to be a combination of transverse fibers of the infraspinatus and supraspinatus. Therefore, we believe that these two layers should be repaired separately as we described. Matsuki et al. also suggested that secure repair of the articular layer to the medial portion of the footprint was a key to success³⁶. In fact, we believe that, in the present study, our special attention to the delamination and its careful management, with repair of the articular layer to the medial side of the footprint separately from the superficial layer, helped us to achieve better structural outcomes. Further, because the articular side of the rotator cuff insertion is reported to be under the most stress during shoulder motion^37,38, strong sutures are recommended for the medial-row repair to minimize postoperative structural failures.

Higher costs and prolonged surgery time are among the possible concerns with arthroscopic double-row rotator cuff repair. We believe, however, that the benefit of arthroscopic repair for patients more than overcomes the cost issue, if we can provide better structural and functional outcomes with higher patient satisfaction.

In conclusion, arthroscopic double-row repair of a rotator cuff tear has demonstrated improved repair integrity compared with traditional open or mini-open techniques. However, the retear rate in shoulders with large and massive tears was still high. Although the functional outcomes in shoulders with small (type-IV) defects were similar to the outcomes in shoulders without a defect, shoulders with large (type-V) defects had significantly inferior functional outcomes. ?

References

Materials and Methods | Results | Discussion | References

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Topics

rotator cuff ; tendon ; shoulder region ; vibration ; rotator cuff repair

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Hiroyuki Sugaya, Kazuhiko Maeda, Keisuke Matsuki, Joji Moriishi; Repair Integrity and Functional Outcome After Arthroscopic Double-Row Rotator Cuff RepairA Prospective Outcome Study. The Journal of Bone & Joint Surgery. 2007 May;89(5):953-960.

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