Comparison of two arthroscopic repair techniques for small-medium supraspinatus tendon tear: 1 triple-loaded vs 2 double-loaded metallic sutures anchors

doi:10.1016/j.jcot.2022.101950

Journal of Clinical Orthopaedics and Trauma

Volume 31, August 2022, 101950

https://doi.org/10.1016/j.jcot.2022.101950 Get rights and content

Abstract

Introduction

Surgical repair of the rotator cuff is based on the use of anchors whose ideal numbers and configurations continue to be controversial. We compared the clinical-functional results arising from the arthroscopic repair of shoulders, with small-medium lesions of the supraspinatus tendon, among patients using one anchor with three sutures, or two anchors with two sutures.

Methods

In this retrospective study patient were resolved into 2 groups. Clinical and functional results were assessed based on Constant Score and instrumental isometric examination.

Results

Patients in Group 1 experienced shoulder repair using a single anchor with three sutures (n = 21, mean age = 56 years, range = 51–65). In Group 2, patients received two anchors with two sutures each (n = 24, mean age = 59 years, range = 24–75). The mean follow-up time was 15 months. The mean values of the operated shoulders’ Constant Score were 88.05 and 88.25 respectively. Examination of isometric test results in operated shoulders, healthy shoulders and the two different rotator cuff repair techniques did not reveal any statistically significant differences.

Conclusion

In the arthroscopic repair of small-medium supraspinatus tendon tears, the short to mid-term clinical and functional outcomes arising from use of 1 triple-loaded or 2 double-loaded metallic sutures anchors are comparable.

Introduction

A rotator cuff (RC) tear is debilitating and is manifested by significant pain and shoulder dysfunction. RC tears are the most common cause of shoulder pain and its prevalence increases with age, with an increased frequency in patients over 50 years old.¹^,² The prevalence of acute RC tears is 2.5 per 10 000 patients aged from 40 to 75 years.³ RC tears can be successfully treated with surgery after a period of conservative treatment. Surgical repairs of RC tears have become increasingly commonplace.⁴ RC tear repair is based on the use of anchors, which can be screwed into or impacted into bone. Despite its increasing prevalence, the ideal device and anchor configuration for an RC tear repair remains unresolved and still open for clinical-biomechanical investigation. There are two main arthroscopic repair techniques currently employed including the single row (SR) and double row (DR). The more common technique is the SR, even though the DR repair is more robust. Although the DR produces a greater strain on the repaired tendon and is a more involved and expensive procedure to undertake, the greater footprint reconstruction of the DR technique increases the contact pressure of the RC tendon to the bone; to illustrate, in vitro biomechanical studies show a significantly higher primary stability in comparison to the SR technique.4, 5, 6, 7 The enhanced strength of the DR is likely due to the greater number of sutures compared with the SR.⁸ By contrast, some biomechanical studies found no difference in load-to-failure, or gap-formation between SR and DR repairs.⁹^,¹⁰ The SR technique is currently recommended for tendon tears less than 3 cm in size accompanied by good quality tendon tissue; in comparison, the DR repair is recommended in cases of gaps larger than 3 cm and accompanied by poor quality of tendon tissue. In large lesions, chronic and retracted, even a DR repair has a high risk of failure.⁴ The price of anchors varies considerably according to the brand and generation, but typically, a three sutures loaded metallic anchor has a price similar to a two sutures one. Anchor costs vary widely by country, and institution; although pricing contracts are confidential, anchors prices run between $200 and $350 ($US) in the United States.⁶^,¹¹ Consequently, the number of anchors used in an RC tear repair is a significant component of the total cost.⁵ The additional cost incurred by each suture anchor used is two-fold: the cost of the implant as well as a longer operative time (implant, pass, and tie suture).¹²^,¹³ At the follow up post-surgical examination, it is feasible to derive an accurate clinical evaluation of the operated shoulder by the use of tools to test muscle strength by isokinetic and isometric paradigms and thereby gain a clear indication of the comparative effectiveness of the SR and DR protocols.¹⁴^,¹⁵

Our study is retrospective, we follow up shoulders with small and medium lesions of the supraspinatus tendon which were arthroscopically repaired. The aim of this study is to compare the clinical and functional results between lesions repaired using 1 anchor with 3 sutures or 2 anchors with 2 sutures; the authors’ hypothesis is that there is no difference between the two groups.

Section snippets

Methods

From September 2011 to July 2013, 85 patients underwent arthroscopic RC repair in our department. Prior to surgical intervention, these patients had failed to respond to conservative treatment, which consisted of 6 months of physical and pharmacologic therapy. All patients were informed about risks and benefits of the surgical technique as normal practice and all provided written informed consent conforming to Ethical Standards of the 1964 Declaration of Helsinki as revised in 2000. The

Surgical procedure and postoperative program

Surgery was performed in lateral decubitus, with brachial plexus block and general anesthesia. The affected shoulder was in traction with 5 Kg at 30° of abduction on the scapular plane. A standard three portal arthroscopy was performed (anterior, posterior, lateral) and a fourth portal was used for the anchor's implantation. A diagnostic arthroscopy of both glenohumeral articular and sub-acromial sides was performed in order to confirm a supraspinatus tendon tear and associated lesions (we did

Clinical and strength evaluation

We evaluated the patients with a shoulder physical examination and a test of their abduction strength. The Constant score was used to evaluate pain and shoulder function.²² Joint movements were measured with a goniometer and strength in abduction was measured with a handheld dynamometer (model 01163, Lafayette Instrument Company, Lafayette, Indiana). Constant score, and abduction strength-values were collected at the last follow up visit, or, after recall.

Isometric testing

We measured force and work in internal and external rotations of operated and healthy shoulders in two different positions (15° of internal rotation and 25° of external rotation). The isometric test was performed using a Technogym Rev 7000 VX machine (Technogym, Bologna, Italy) with a standardized protocol (Fig. 1).¹⁴ The isometric test allowed the evaluation of strength and muscular work levels in a shoulder after a RC repair, and calculated the difference in strength levels between operated

Ultrasonographical examination

Both groups of patients were subject to US evaluation of the repaired supraspinatus at follow up. Ultrasonographical findings were evaluated using the Sugaya classification which, although originally proposed for MRI, has been validated for US evaluation of tendon healing.²³ Tendon thickness and echo structure were assessed; patients were then classified in 5 groups (Type I, II patients were considered as healed; Type III, IV and V were considered as a retear).

Statistical analysis

All analyses were performed using Statistical Stata 9.3 software (StataCorp, College Station, TX). The Shapiro-Wilk test was used to determine normality of data. We used nine parameters to compare the two different RC repair techniques with 1 or 2 metallic anchors in small to medium supraspinatus tears. They included: the Constant score of the operated shoulder, the cuff rotator force and work of operated and healthy shoulders at 15° of internal rotation and in 25° of external rotation.¹⁴^,²² We

Results

The 45 patients who reached a minimum follow up of 6 months (18 women and 27 men), had a mean of age 57 (24–75) years at the time of surgery and were resolved into two groups; patients in Group 1 underwent tendon-bone repair with a three sutures anchor, while patients in Group 2 had a tendon-bone fixation with 2 anchors each with 2 sutures. The mean values of the operated shoulders’ Constant Score of 88.05 (66–100) in Group 1 and 88.25 (75–99) in Group 2 were not significantly different. Mean

Discussion

Our patients presented good functional and clinical results after their arthroscopic RC repair. The mean value of Constant Scores in Group 1 (88.05/100) was comparable with group 2 (88.25/100); the difference within the two groups was not statistically significant and were both consistent with expected and well established Constant Score values.⁴ Furthermore, there were no significant differences between the two groups in the rest of the parameters measured (pain, range of motion, strength …).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

All procedures complied with standards defined by the local ethics committee (Comitato etico Brianza, asst-Monza, Protocol number 0014041, 04/30/2020).

The manuscript submitted to the Journal has not been published elsewhere or are not being considered for publication elsewhere and that the research reported will not be submitted for publication elsewhere until a final

Declaration of competing interest

None.

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Comparison of all-suture anchors with metallic anchors in arthroscopic cuff repair: Structural and functional properties and clinical suitability
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This study examined and compared all-suture anchors with metallic anchors in the arthroscopic repair of small to medium supraspinatus tears; a multi-dimensional evaluation protocol assessed (i) clinical, (ii) ultrasonographical, and (iii) functional criteria at mid-term.
A sample of 40 patients, prescreened from a larger group who had undergone arthroscopic rotator cuff repair, were resolved into two groups of 20, based on the type of anchor used in their surgery (all-suture or metallic) and were evaluated postoperatively (mean = 44.3 months, SEM = 22.4 months, minimum period = 10.3 months). Clinical assessments included (i) objective and subjective scores (Constant, DASH, SPADI, SST), (ii) ultrasonographical examination, as well as (iii) isometric and isokinetic strength testing. Raw data from the operated side was compared with those from the contralateral side within each group. Raw data for the PROMs and for the US evaluation were compared between groups. Strength data, as well as the Constant score values, were further analyzed based on (i) the difference between operated and intact sides, as well as (ii) the strength ratio between operated and intact sides; the transformed data were then compared between the two groups.
We found no statistically significant differences in any of the parameters considered between shoulders operated using ASAs or MAs, nor between operated and non-operated sides in each group.
Our findings indicate that the reliability and performance characteristics of all-suture anchors and metallic anchors are practically indistinguishable for arthroscopic treatment of small to medium lesions of the supraspinatus tendon.
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Technical considerations of the rotator cuff repair remain of great importance as retear rates remain high. The double-row (DR) rotator cuff repair was designed to better restore the native enthesis footprint to maximize healing. The DR repair features a medial and lateral row of suture anchors. Anatomical and cadaveric studies have demonstrated improved footprint restoration with DR repair. Biomechanically, the DR repair has a superior load to failure, decreased gap formation under cyclic loading, and greater contact areas and pressures. It is unclear whether the number of sutures per anchor may be more important than the number of rows and the row configuration. Medial row knots and suture tape constructs may improve the biomechanics of the repair, but the impact on clinical outcomes is unknown. High-quality clinical studies have shown that the DR repair in small to medium tears does not yield better clinical outcomes than the single-row (SR) and is not cost-effective. Healing rates seem to improve with the DR repair, and retear rates may be slightly reduced. However, in larger tears, the DR repair demonstrates favorable clinical outcomes with significant increases in functional scores, healing rates, and retear rates compared to SR repair. Although the DR repair has biomechanical advantages to SR constructs, clinical evidence suggests that the double-row repair should be reserved for large to massive tear patterns.
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Comparison of two arthroscopic repair techniques for small-medium supraspinatus tendon tear: 1 triple-loaded vs 2 double-loaded metallic sutures anchors

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Surgical procedure and postoperative program

Clinical and strength evaluation

Isometric testing

Ultrasonographical examination

Statistical analysis

Results

Discussion

Funding

Declaration of competing interest

Clin Sports Med

Arthrosc J Arthrosc Relat Surg

J shoulder Elb Surg

Arthroscopy

Arthrosc J Arthrosc Relat Surg

Arthrosc J Arthrosc Relat Surg

Arthrosc J Arthrosc Relat Surg

An epidemiological study of rotator cuff pathology using the Health Improvement Network database

Bone Jt J

High incidence of acute full-thickness rotator cuff tears

Acta Orthop

I.S.Mu.L.T. – rotator cuff tears guidelines

Muscles Ligaments Tendons J

Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery

J Shoulder Elbow Surg

Rotator cuff disease of the shoulder

J Bone Joint Surg Am

Suture number determines strength of rotator cuff repair

J Bone Jt Surgery-American

The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears

J Bone Jt Surg

Biomechanical evaluation of arthroscopic rotator cuff repairs

J Bone Jt Surg

Price transparency for medical devices

Health Aff