Abstract
Background: The treatment of rotator cuff tears has evolved from
open surgical repairs to complete arthroscopic repairs over the past two
decades. In this study, we reviewed the results of arthroscopic rotator cuff
repairs with the so-called double-row, or footprint, reconstruction
technique.
Methods: Between 1998 and 2002, 264 patients underwent an
arthroscopic rotator cuff repair with double-row fixation. The average age at
the time of the operation was fifty-nine years. Two hundred and thirty-eight
patients (242 shoulders) were available for follow-up; 210 were evaluated with
a full clinical examination and thirty-two, with a questionnaire only.
Preoperative and postoperative examinations consisted of determination of a
Constant score and a visual analogue score for pain as well as a full physical
examination of the shoulder. Ultrasonography was done at a minimum of twelve
months postoperatively to assess the integrity of the cuff.
Results: The average score for pain improved from 7.4 points (range,
3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points)
postoperatively. The subjective outcome was excellent or good in 220 (90.9%)
of the 242 shoulders. The average increase in the Constant score after the
operation was 25.4 points (range, 0 to 57 points). Ultrasonography
demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47%
(fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two)
of the forty-one with a repair of a large tear, 93% (113) of the 121 with a
repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a
small tear. Strength and active elevation increased significantly more in the
group with an intact repair at the time of follow-up than in the group with a
failed repair; however, there was no difference in the pain scores.
Conclusions: Arthroscopic rotator cuff repair with double-row
fixation can achieve a high percentage of excellent subjective and objective
results. Integrity of the repair can be expected in the majority of shoulders
treated for a large, medium, or small tear, and the strength and range of
motion provided by an intact repair are significantly better than those
following a failed repair.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Arthroscopic repairs of rotator cuff tears have become more popular than
open or mini-open
repairs1. Less
soft-tissue damage, faster rehabilitation, and scars with a better cosmetic
appearance are mentioned as advantages of these arthroscopic
repairs2-4.
Less postoperative pain and a shorter hospital stay could also be
advantages5. Reports
published in the literature have described high percentages of good or
excellent results even for large or massive
tears6-9,
and the results of these repairs have been comparable with those of open or
mini-open rotator cuff
repairs3.
Performance of an acromioplasty and the duration of the tear or symptoms have
been reported to not influence the outcome of rotator cuff
repair9,10.
Different techniques for performing arthroscopic rotator cuff repair have
been
described4,11-13.
The surgical technique is demanding, with a steep learning curve. In our
institution, so-called double-row
fixation12 is the
standard technique for arthroscopic repair of the rotator cuff. With this
method, the anatomy of the footprint insertion of the supraspinatus tendon is
restored by the placement of medial and lateral rows of suture anchors. This
provides a large tendon-to-bone contact area and therefore, in theory,
enhances healing.
Although good results of arthroscopic rotator cuff repair have been
reported, only a few studies have included an objective investigation of the
integrity of the repair with imaging modalities such as
ultrasound8,14-19.
The purpose of our study was to evaluate the outcome of the double-row
technique for arthroscopic rotator cuff repair and to correlate the integrity
of the repair with the clinical outcome.
Between 1998 and 2002, 264 patients underwent an arthroscopic repair of a
complete rotator cuff tear. A tear was diagnosed on the basis of the findings
of clinical evaluation, strength testing, and ultrasound examination.
Conservative treatment, which consisted of a combination of subacromial
injections with steroids and physiotherapy, had failed for all of the chronic
rotator cuff tears included in this study. Patients younger than sixty years
of age who had had a full-thickness tear for less than three months following
a traumatic event were advised to have a rotator cuff repair. Patients with an
identifiable tear of the subscapularis tendon were excluded from this
study.
The average duration of symptoms at the time of surgery was fourteen months
(range, one to 130 months). Preoperatively, all patients underwent a
sonographic examination of the shoulder, performed by the senior author (J.F.
de B.). Magnetic resonance arthrography was performed to judge the
repairability of massive tears. The tangent
sign20,21,
more than the tear size or the amount of tendon retraction, was used as the
main indicator of repairability. The tangent sign is present (positive) when
the muscle belly of the supraspinatus does not cross a drawn line from the
superior border of the scapular spine to the superior border of the coracoid
process on a sagittal magnetic resonance imaging scan; this represents
supraspinatus atrophy and indicates an irreparable tear. The tear was also
considered irreparable if, during arthroscopy, no reduction of the tendon over
the footprint area could be achieved (as tested by pulling the tendon with a
grasper over the footprint area). Constant
scores22 and visual
analogue pain scores were recorded preoperatively. Strength-testing was done
with an Isobex device (Cursor, Bern, Switzerland).
All patients underwent a standard ultrasound examination and physical
examination at three, six, and twelve weeks postoperatively. The final
follow-up evaluation consisted of determination of the Constant score and a
visual analogue pain score as well as a physical examination that included
Isobex strength-testing. In addition, the patients completed a subjective
questionnaire to rate the outcome as excellent, good, moderate, or poor. An
ultrasound examination was also done at the final follow-up visit to assess
the integrity of the rotator cuff repair
(Fig. 1). An independent
examiner with extensive experience with ultrasonography performed all of the
examinations.
At the time of follow-up, twelve patients (twelve shoulders) had died and
another fourteen patients (fourteen shoulders) could not be contacted. All of
the patients who died had been older than seventy-five years of age, and none
of the deaths were related to the shoulder surgery. This left 238 patients
(242 shoulders) available for follow-up. All were contacted, and 207 (210
shoulders) returned for full clinical examination, including ultrasound
imaging. A subjective outcome questionnaire and a visual analogue score for
pain were used to evaluate the remainder of the patients.
The average duration of follow-up was twenty-two months (range, twelve to
forty-nine months). The patients seen at the time of follow-up (131 men and
107 women) had been an average of fifty-nine years of age (range, nineteen to
eighty-three years of age) at the time of the operation. One hundred and
fifty-one (62%) of the operatively treated shoulders were on the side of the
dominant extremity. One hundred and nine tears (45%) were associated with some
form of trauma, according to the patients.
Tears were classified as small (<1 cm), medium (1 to 3 cm), large (>3
to 5 cm), or massive (>5 cm) at the time of surgery. There were thirty-two
massive, forty-one large, 121 medium, and sixteen small tears. During the
operation, the surgeon subjectively classified the tendon quality as good in
151 shoulders, moderate in forty-seven, and very poor in twelve.
Because of pathological changes in the biceps (degeneration, damage, and/or
subluxation), thirteen shoulders underwent biceps tenotomy, eleven underwent
tenodesis, and four had an absent biceps tendon at the time of surgery.
Preoperative radiographs were available for 136 shoulders. These demonstrated
a type-I acromion in forty-one shoulders (30%), a type-II acromion in
sixty-seven (49%), and a type-III acromion in twenty-eight
(21%)23.
Forty-three acromioclavicular joints (32%) showed signs of osteoarthritis, but
only three were clearly symptomatic. Those three shoulders were treated with
an arthroscopic excision of the distal part of the clavicle. In another
thirteen shoulders, large osteophytes of the acromioclavicular joint were seen
during arthroscopy, and those shoulders also underwent a distal clavicular
excision.
Description of Technique
All operations were performed with the patient under general anesthesia,
with a supplemental interscalene block for postoperative pain control. The
patients were placed in the beach-chair position, with the arm draped free.
Normal saline solution at 0°C was used for irrigation with an arthroscopy
pump. In a previous internal research project, use of this cold arthroscopy
fluid was associated with a decrease in postoperative pain. In the absence of
a heart or brain condition, relative hypotension was provided, with a systolic
pressure of approximately 100 mm Hg. Normal pump pressure was set between 60
and 90 mm Hg. If bleeding compromised visibility, the pump pressure was
increased. After a standard posterior portal was established, arthroscopy was
performed to address intra-articular pathology and to assess the personality
of the tear. In the case of a partially torn or severely degenerated biceps
tendon, a biceps tenotomy or tenodesis was performed. The surgeon decided
between these two options on the basis of the age of the patient and the
cosmetic requirements. In general, we prefer to do a biceps tenodesis in
patients younger than sixty years of age. Through the same skin incision in
the posterior "soft spot," the arthroscope was redirected into the
subacromial space, without violation of the infraspinatus muscle. All
additional portals were established as needed with use of a spinal needle
under direct vision.
Through a lateral subacromial portal, as much bursal tissue was removed as
needed to obtain a good view of the rotator cuff and the tear. After
completion of the bursectomy, the supraspinatus and infraspinatus muscles and
the base of the scapular spine became clearly visible. This is important for
the assessment of the rotator cuff tear, and specifically for the evaluation
of the muscle quality, as well as for later suture management. The arthroscope
was then placed in the lateral subacromial portal to improve visualization of
the tear. With a shaver inserted through the posterior portal, the posterior
part of the subacromial bursa could be cleared for optimum visibility. An
anterolateral portal was then made, with use of a spinal needle to optimize
placement. This portal was also used for anchor placement. Through this
portal, a grasper was used to assess the reducibility of the tear: during this
maneuver, excellent visibility of the direction of the muscle fibers is of
utmost importance since approximation of the tendons to the tuberosity is not
necessarily accomplished with a medial-to-lateral pull; often, a combined
posteroanterior reduction maneuver is used instead. If excessive traction was
necessary for reduction (of a large or massive tear), a perilabral capsulotomy
was performed with an arthroscopic elevator inserted through the anterolateral
portal. Further release consisted of an interval
slide24, including
a release of the coracohumeral ligament. Once adequate reduction was
established and found to be satisfactory, a modified Neviaser
portal25 was
created. If the torn tendon(s) could not be reduced over the footprint area,
the tear was considered irreparable. An acromioplasty was then performed to
increase the working space. With an arthroscopic burr inserted through the
lateral portal, the anterior part of the acromion was removed along a line
from the lateral portal to the anterior part of the acromioclavicular joint.
With use of the posterior portal, the anteroinferior aspect of the acromion
was resected, connecting the inferior cut with the anterior cut. If present,
infraclavicular spurs were resected through the lateral portal, and if
clinical signs of acromioclavicular pathology (local joint pain, pain with
horizontal adduction, and pain relief after an injection of the
acromioclavicular joint with local anesthetics) were present preoperatively,
an arthroscopic resection of the distal part of the clavicle was performed in
addition.
The degenerated cuff end was then débrided with a basket punch to
remove the frayed part of the tendon and to obtain a good tendon edge for
reattachment to the bone. The footprint was thoroughly cleared of soft tissue.
The bone was only minimally abraded with a burr, enough to produce a roughened
surface to allow soft tissue ingrowth. U-shaped tears were repaired with
side-to-side sutures before anchorage to the footprint. Anchors were then
placed medially and laterally on the footprint. The number of anchors depends
on the tear size. A medium-size tear usually requires one medial and two
lateral anchors. For a small tear, two anchors are normally sufficient to
establish a strong repair. If two medial anchors were necessary, they were
placed at the edge of the articular cartilage, approximately 1 cm apart. An
anchor (Twinfix 5.0; Smith and Nephew, Memphis, Tennessee), preloaded with two
Ethibond number-2 sutures (Ethicon, Somerville, New Jersey), was inserted at
the junction of the articular cartilage and the footprint for medial fixation.
The anterolateral portal was used for this step, with the free movement of the
shoulder allowing insertion of the anchor at an angle with the tip pointing in
the medial-inferior direction to increase the pull-out strength. The sutures
were passed through the tendon at the muscle-tendon junction in a mattress
fashion, with use of a retrograde suture passer (Ideal Suture Grasper; DePuy
Mitek, Raynham, Massachusetts) through a modified
Neviaser25 or
posterior portal, depending on which provides the best access. The decision of
which portal to use was made by trial insertion of a knot-pusher. Special
attention was given to addressing lamination in the supraspinatus tendon.
So-called deep lamination is located on the articular side of the tendon and
represents the original attachment of the tendon to the medial edge of the
footprint. When the medial sutures were passed, the laminated deep part of the
tendon was pulled laterally to its original insertion. Later in the procedure,
the superficial part of the tendon was pulled more laterally to cover the
footprint.
After both suture ends were retrieved and delivered outside through the
anterolateral portal, the gliding capacity of the sutures in their anchors was
assessed and the sutures were tied with a sliding knot with loop security
(Nicky's knot26)
with use of the knot-pusher. The knots were secured with three
alternating-post half-hitches. If the suture failed to glide, the tuberosity
was redirected, by rotation of the arm, under the portal to align the
direction of pull on the suture with the portal. After the medial mattress
sutures were tied, the rotator cuff usually covered the footprint, with the
lateral end in line with the lateral tip of the tuberosity. A lateral anchor
was then inserted, just lateral to the highest tip of the greater tuberosity.
The anchor was loaded with two Ethibond number-2 sutures. The retrograde
suture passer was used to pass the sutures through either the Neviaser or the
posterior portal. The suture end coming through the tendon became the post for
the sliding knot, enabling a shift of the tissue laterally to the anchor. Two
single-loop sutures produced a firm attachment of the lateral aspect of the
tendon to the footprint (Figs. 2-A, 2-B,
and 2-C). When two lateral anchors were needed, they were placed
approximately 1 cm apart. At the end of the procedure, the arthroscope was
placed back in the glenohumeral joint to confirm the stability of the repair
and the reattachment of the tendon to its original place of medial
insertion.
Postoperatively, a sling was applied. Rehabilitation consisted of passive
range-of-motion exercises starting on the first postoperative day. Active
range-of-motion exercises were initiated at six weeks postoperatively and
strengthening exercises, at ten weeks.
Statistical Methods
Data analysis was done with statistical software (Statistica 6.0; StatSoft,
Tulsa, Oklahoma). Analysis of variance was used to compare averages for
different groups. Repeated-measures analysis of variance was used to compare
average preoperative with postoperative measurements. In one instance,
analysis of covariance was used to control for specified covariables. To
determine dependencies between categorical variables, the chi-square test was
employed. A significant difference was defined as p < 0.05.
Analysis of the subjective questionnaires and visual analogue scores of
both the patients evaluated with a clinical examination and those assessed
with a questionnaire only revealed an improvement in the average visual
analogue pain score from 7.4 points (range, 3 to 10 points) preoperatively to
0.7 point (range, 0 to 3 points) postoperatively, with 166 patients (69.7%)
reporting complete resolution of symptoms following the surgery. The
subjective outcome was rated as excellent or good for 220 (90.9%) of the 242
operatively treated shoulders, moderate for eighteen (7.4%), and poor for four
(1.7%). At three weeks postoperatively, ultrasound evaluation showed an intact
repair in 190 (90.5%) of the 210 clinically assessed shoulders. The repair was
not intact in thirteen shoulders (6.2%), and no ultrasonography was done or
the result was not recorded in the medical record for seven shoulders (3.3%).
At the time of final follow-up, ultrasonography showed an intact repair in 174
shoulders (82.9%) and a retorn, degenerated, or absent tendon in thirty-two
(15.2%). The result was unknown for four shoulders (1.9%). Of the 190
shoulders in which ultrasonography had shown an intact repair at three weeks
postoperatively, 92% had an intact repair at the time of final follow-up.
Use of the chi-square test demonstrated no further deterioration of the
results with longer follow-up. In an analysis of the 190 shoulders with an
intact repair at three weeks postoperatively, we compared a group of 122
shoulders that had been followed for twelve to twenty-four months with a group
of sixty-eight that had been followed for more than twenty-four months. In the
first group, nine shoulders (7%) with an intact repair at three weeks
postoperatively had a failure of the repair at the time of the final
follow-up. In the second group, six shoulders (9%) with an intact repair at
three weeks had a failure at the time of follow-up. This difference was not
significant (p = 0.74).
Forty-seven percent (fifteen) of the thirty-two repairs of massive tears,
78% (thirty-two) of the forty-one repairs of large tears, 93% (113) of the 121
repairs of medium tears, and 88% (fourteen) of the sixteen repairs of small
tears were intact. These differences in the success of the repair according to
the tear size were highly significant (p < 0.0001).
Table I shows the outcomes of
the ultrasound findings at three weeks postoperatively and at the time of
final follow-up for the different tear sizes.
Poor quality of the tendon, as assessed by the surgeon at the time of
surgery, was also related to the ultrasound findings, with more failed repairs
of tears of poor-quality tendons (p < 0.0001).
Although, on the average, the patients with an intact repair were younger
than those with a failed repair as documented with ultrasound (fifty-seven
compared with sixty-four years old), analysis of covariance with the size of
the tear taken into account showed no significant difference in age between
those with and those without a failed repair. The percentage of the patients
with an intact repair did not differ between the group with a traumatic tear
and the group with a nontraumatic tear or with regard to the duration of
symptoms.
The average preoperative Constant score in the group that returned for
clinical examination was 54.9 points (range, 25 to 75 points), and this score
improved by an average 25.4 points (range, 0 to 57 points), to a mean of 80
points, at the time of follow-up. This change was significant (p < 0.001).
The Constant score improved significantly more in the group with an intact
repair (26.3 points of improvement) than in the group with a failed repair
(21.1 points) (p = 0.02).
The integrity of the repair, as found on the ultrasound examination, did
not influence the pain outcome, as shown in
Figure 3. The postoperative
increase in the strength component of the Constant score, which was
objectively measured with an Isobex device, was significantly higher in the
group with an intact repair (4.2 points) than for the patients with a failed
repair (2.4 points) (p = 0.0014) (Fig.
4). The range of motion of the shoulder improved postoperatively
in most of the patients, but active elevation was significantly better in the
patients with an intact repair (average, 170°) than in those with a failed
repair (average, 160°) (p = 0.02) (Fig.
5).
We found no relationship between the subjective outcomes and the ultrasound
results. This meant that patients with an excellent subjective outcome could
have failure of the repair as shown by ultrasound imaging.
Four of the repair failures were treated with revision surgery. At the time
of that surgery, two patients were found to have an irreparable tear, with one
of them having an absent subscapularis tendon. The remaining two patients had
a repeat arthroscopic repair, which subsequently failed.
Excluding the retears, the complications included five superficial
infections, thirteen cases of transient neuritis following interscalene nerve
blocks, four cases of so-called bursitis requiring débridement and
suture removal, and two episodes of anchor pull-out. The overall reoperation
rate was 4% (ten of 242). There was a substantial rate of postoperative
painful stiffness (a limited active and passive range of motion), which was
found in forty-four of the 242 shoulders and which resolved at an average of
three months.
Arthroscopic repairs of the rotator cuff have been performed for more than
twenty years15 and
have been shown to provide good clinical
results3,5-7,9,15,27-29.
Only a few investigators have assessed the integrity of the rotator cuff after
arthroscopic rotator cuff
repairs8,15,29.
Of the first thirty-five arthroscopic repairs done by Wilson et
al.15, thirty-three
were followed by repeat arthroscopy to remove the staple. During this
second-look arthroscopy, the authors noted the repair to be intact in
twenty-four (73%) of the thirty-three cases. Two patients refused to have an
arthroscopy for removal of the staples. The clinical results in this group
were superior to those in the group in which the rotator cuff had not healed.
In a recent article, Galatz et
al.8 reported
failure of seventeen of eighteen arthroscopic repairs of tears longer than 2
cm, with deterioration of the clinical results after one year. In our study,
we used ultrasound imaging to assess the integrity of rotator cuff repairs.
This imaging modality is known for its high accuracy in the assessment of the
condition of the rotator
cuff30-32,
even in the postoperative
situation33-35,
and ultrasound performed by an orthopaedic surgeon in an office setting has
been shown to have high sensitivity and
specificity31. Our
overall rate of successful repairs, as demonstrated by ultrasound imaging, was
83% (174 of 210), with a success rate of 88% (fourteen of sixteen) for small
tears and 93% (113 of 121 repairs) for medium tears.
Although the majority of our patients had improvement following the
surgery, we found a significant difference between the group with an intact
repair and the group with a failed repair. The patients with an intact repair
at the time of follow-up had significantly more movement and strength compared
with the group with an unsuccessful repair. The pain scores improved
significantly after the repairs in both groups, however. Although some studies
have not shown a relationship between repair integrity (after either an open
or an arthroscopic procedure) and functional
results14,16,
our results correlate with the findings of studies in which significantly
better results were seen in patients with an intact
repair15,17-19.
The most significant difference that we found was in improvement in strength.
Strength, or the lack thereof, is known to influence patient satisfaction
after rotator cuff
repair36,37.
We therefore think that achieving healing of the rotator cuff is paramount and
that optimal conditions for cuff healing must thus be created during surgery.
According to Gerber et
al.38, these
conditions must include a high initial strength to failure, minimal gap
formation, and the maintenance of mechanical stability until solid healing has
occurred. Fealy et
al.39 found good
clinical results with double-row mini-open arthroscopically assisted
rotator-cuff repair. In 2003, Lo and
Burkhart12
described an arthroscopic technique that was similar to ours to restore the
anatomical insertion of the supraspinatus tendon with double-row fixation. To
enhance the chances of good tendon-to-bone healing, there must be a large
tendon-bone contact area. Placement of the suture anchors in a double-row
configuration, medially and laterally over the original insertion of the
tendon on the tuberosity, can provide optimal attachment of the repaired
tendon and adequate coverage of its original footprint.
A second condition for a successful repair is good initial strength of the
repair. In a biomechanical cadaveric study performed with
others40, we found
superior initial strength and less gap formation with double-row fixation than
with the single-row fixation method. Other biomechanical studies have
confirmed these
findings41-46.
Mazzocca et al.47
did not find a significant difference in initial fixation strength or gap
formation but observed better restoration of the footprint of the
supraspinatus with the double-row rotator cuff repair. Sugaya et
al.29 found better
healing after rotator cuff repair when a double-row technique had been used
than when a single-row technique had been employed. Two additional
observations have convinced us of the superiority of double-row fixation over
single-row fixation. When examining the glenohumeral joint arthroscopically
following a rotator cuff repair with a single lateral anchor, we observed that
the tendon was lifted off of the medial part of the footprint by the
arthroscopic water pressure. Presumably, this could compromise the conditions
for tendon-to-bone healing. The second observation that we made while viewing
the rotator cuff repaired with a single lateral suture anchor, from the
glenohumeral joint side, was a phenomenon that we refer to as the
windshield-wiper phenomenon. When rotational movements of the arm
were made, the repaired tendon was lifted off of the footprint and the medial
aspect of the footprint freely rotated under the tendon, simulating a
windshield wiper. Again this has the potential to compromise the healing of
the repair. This observation is especially important because most
postoperative protocols allow passive motion in the early postoperative
phase2-4,7,8,15,27,48.
The windshield-wiper phenomenon is eliminated by double-row fixation.
Therefore, safe and early postoperative passive motion can be permitted after
double-row fixation of the rotator cuff.
The disadvantages of this double-row technique are the costs of suture
anchors and the increased operating time. In our experience, the majority of
the cases require no more than two or three suture anchors for a standard
double-row repair of a small or medium-sized tear. Our average operating time
for a standard double-row rotator-cuff repair has been between forty-five and
sixty minutes. We therefore think that the number of suture anchors used and
the length of the operating time are only minimally increased.
The strengths of this study include the large number of patients, the
objective assessment of the repair integrity with ultrasound imaging, and the
objective clinical assessment of the functional results with use of an Isobex
device for strength measurement. A relative weakness is the fact that the
operative technique (double-row fixation) was not compared directly with the
single-row technique. Finally, many of our patients were followed for only one
year; however, we did not find more deterioration of the results in the
subgroup of patients followed for two years.
In conclusion, our study showed good subjective and clinical results after
arthroscopic double-row fixation for the treatment of rotator cuff tears. Cuff
integrity was confirmed after the majority of the repairs of large, medium,
and small tears, and cuff integrity resulted in a significantly better range
of motion and strength in comparison with those parameters in patients who had
a failure of the repair. ?
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