Shoulder

A systematic review of the clinical outcomes of single row versus double row rotator cuff repairs

Multiple factors including muscle atrophy, fatty infiltration, smoking, advanced patient age, and increasing tear size have been identified as risk factors for retear after rotator cuff repair. However, little is known about what effect the length of the residual rotator cuff tendon has on the success of repair and patient outcomes.

This study included 64 patients. Patients were stratified based on a residual tendon length of greater than 15 mm (group 1, residual tendon) or 15 mm or less (group 2, no residual tendon). Rotator cuff tendon integrity was then evaluated using ultrasound imaging at 6 months. Outcome measures included the Single Assessment Numeric Evaluation score, visual analog scale score, EQ5D Index score, Global Rating of Change score, and Penn Shoulder Score.

No differences were found between groups regarding demographic data or repair configuration. Assessment of tendon healing demonstrated an increased rate of tendons that had “not healed” in group 2 (19.3% [n = 5] vs. 13.2% [n = 5]), but this difference was not statistically significant (P = .55). Functional outcome scores improved significantly from preoperatively to final follow-up in both groups and displayed no differences at 6-month follow-up.

A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. Although there was a trend toward a decreased rate of healing in patients with smaller residual tendons, this was not significant.

The purpose of this study was to evaluate the biomechanical and histologic properties of rotator cuff repairs using a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA (poly(l-lactide-co-glycoside)) microfibers in an animal model compared to standard anchors in an ovine model.

Fifty-six (n = 56) skeletally mature sheep were randomly assigned to a repair of an acute infraspinatus tendon detachment using a innovative anchor-PLGA scaffold device (Treatment) or a similar anchor without the scaffold (Control). Animals were humanely euthanized at 7 and 12 weeks post repair. Histologic and biomechanical properties of the repairs were evaluated and compared.

The Treatment group had a significantly higher fibroblast count at 7 weeks compared to the Control group. The tendon bone repair distance, percentage perpendicular fibers, new bone formation at the tendon-bone interface, and collagen type III deposition was significantly greater for the Treatment group compared with the Control group at 12 weeks (P ≤ .05). A positive correlation was identified in the Treatment group between increased failure loads at 12 weeks and the following parameters: tendon-bone integration, new bone formation, and collagen type III. No statistically significant differences in biomechanical properties were identified between Treatment and Control Groups (P > .05).

Use of a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA microfibers improves the histologic properties of rotator cuff repairs in a sheep model. Improved histology was correlated with improved final construct strength at the 12-week time point.

Although numerous risk factors have been described, the effects of temperament, which is defined as a risk factor for certain disorders, on the outcome of patients undergoing rotator cuff surgery have not been investigated.

We investigated whether a relationship exists between affective temperament and the outcome of patients undergoing rotator cuff surgery.

The outcomes of 176 patients undergoing rotator cuff surgery were examined using the Oxford and Constant questionnaires as well as visual analog scale values preoperatively and postoperatively. Inclusion criteria were defined as 1) dissatisfaction with pain despite 6 months of nonoperative treatment; 2) rotator cuff defects with full-thickness, small- to large-sized defects; 3) presence of a single dominant temperament or nondominant temperament; 4) no history of a diagnosed psychiatric disorder; and 5) a minimum of greater than 1 year of follow-up after surgery. Exclusion criteria were 1) other comorbid shoulder pathology; 2) irreparable or partial rotator cuff rupture; 3) grade 3 retractions; 4) grade 3-4 fatty infiltration; 5) other comorbid diseases such as diabetes, thyroid disorders, or inflammatory diseases; 6) history of shoulder surgery; 7) infection of the shoulder joint; 8) neurologic deficit in muscles around the shoulder; 9) two or more dominant temperaments; and 10) history of acromioclavicular joint resection and/or biceps tenodesis with cuff repair. All patient temperaments were evaluated according to the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto questionnaire version.

The mean follow-up time was 45.5 months. The outcomes of patients with depressive temperament were worse than of patients with a nondominant temperament. This situation was observed both preoperatively and postoperatively. However, a similar relationship between nondominant and anxious temperament groups was observed only postoperatively.

We noticed that depressive and anxious temperaments had a negative effect on patient outcomes after rotator cuff surgery; however, nondominant temperaments had a positive effect on patient outcomes.

Level III; Retrospective Comparative Study.

Contact pressure and contact area are among the most important mechanical factors studied to predict the effectiveness of a rotator cuff repair. The suture configurations can strongly affect these factors but are rarely correlated with each other. For example, there is a significant difference between the single-row technique and the transosseous or transosseous-like approaches in terms of footprint contact area coverage. A finite element model–based approach is presented and applied to account for various parameters (eg, suture pretension, geometry of the repair, effect of the sutures, geometry of the lesion) and to compare the efficacy of different repair techniques in covering the original footprint.

The model allows us to evaluate the effect of parameters such as suture configuration and position and suture pretension. The validity of such an approach was assessed in comparing 3 different repair techniques: single row, transosseous equivalent, and double row.

Results from the application of the models show that the double-row and transosseous-equivalent techniques lead to progressive increase of the contact area compared with the single-row approach, supporting the conclusion that transosseous-equivalent fixation leads to an increase of the contact area and a better distribution of the pressure coverage.

The 3-dimensional finite element model approach allows multiple variables to be assessed singularly, weighing the specific influence. Moreover, the approach presented in this study could be a valid tool to predict and to reproduce different configurations, identifying how to reduce the stress over the tendon and when a repair could be effective or not.

Every year approximately 18 million Americans report shoulder pain, a large percentage of which are a result of rotator cuff disease. Rotator cuff tear progression can be difficult to predict. Factors associated with tear enlargement include increasing symptoms, advanced age, involvement of 2 or more tendons, and rotator cable lesion. Nonsurgical treatment can be effective for patients with full-thickness tears. When conservative treatment fails, surgical repair provides a reliable treatment alternative. Recurrent tears after surgery can compromise outcomes, particularly for younger patients with physically demanding occupations. Revision surgery provides satisfactory results for those with symptomatic re-tears. If the tear is deemed irreparable, addressing concomitant biceps pathology or performing partial repairs can reliably improve pain and potentially reverse pseudoparalysis. The reverse shoulder arthroplasty has limited indications in the setting of rotator cuff tears and should be reserved for patients with painful pseudoparalysis and associated arthropathy.