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Arthroscopic Rotator Cuff Repair With and Without Arthroscopic Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears (SS-35)
ABSTRACTS age. We hypothesize that there is no difference in the expected value of surgical versus non-surgical treatment. Methods: Our methods are expected values decision analysis with sensitivity analysis which is a systematic tool for quantitating clinical decisions. We evaluated 100 random individuals over 40 for the following variables: age, gender, activity level (IKDC), and visual analog scale regarding potential outcome preferences. Patients with prior knee injury or surgery were excluded. A decision tree was constructed (operative versus nonoperative potential outcomes). Literature review determined probabilities of outcomes. Statistical fold-back analysis calculated optimum treatment. Sensitivity analysis determined effect of changing outcome probabilities on the decision. Results: Sixty-nine patients were included; (31 with prior knee injury or surgery were excluded). Mean age was 53 (range 40-80), 48 % were male, activity level was normally distributed (with a slight lower activity skew as anticipated for an older population). Expected-value for operative treatment was 7.99 versus 1.86 for non-operative treatment. Increasing the probability of surgical complications (sensitivity analysis) decreased the expected value of operative treatment but not below the expected value of non-operative treatment. Conclusions: In contrast to the null hypothesis, decision analysis demonstrates that surgery is the optimal treatment of ACL rupture in patients over 40 years of age. A limitation is that by convention, decision analysis does not investigate actual patients with the condition. It is clinically relevant that individuals over 40 are extremely averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite risk of surgical complications. Arthroscopic Rotator Cuff Repair With and Without Arthroscopic Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears (SS-35). Randy Mascarenhas, M.D., Peter MacDonald, M.D., F.R.C.S.C., Peter Lapner, M.D., F.R.C.S.C., Sheila McRae, M.Sc., and Jeff Leiter, M.Sc. Summary: Regardless of the surgical procedure employed for rotator cuff repair, controversy exists regarding the value of performing an acromioplasty in addition to the rotator cuff repair. This randomized controlled trial examines the hypothesis that the results of arthroscopic rotator cuff repair are not improved by the addition of an acromioplasty. Early results support this hypothesis, but the only revision surgeries performed have occurred in the no acromioplasty group in patients with type II and III acromions. This may indicate a specific subgroup of
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patients that may benefit from acromioplasty in addition to rotator cuff repair. Purpose: Arthroscopic rotator cuff repair without acromioplasty in the treatment of full-thickness rotator cuff tears may offer the same degree of improvement as repair that includes acromioplasty without threatening the shoulder stability provided by the acromion and coracoacromial ligament. This study examines the hypothesis that the results of arthroscopic cuff repair are not improved by the addition of an acromioplasty. Methods: Patients included those referred for assessment after six months of failed conservative management and that were diagnosed with a full-thickness tear up to 4 cm in size of one or more tendons of the rotator cuff. Patients were randomly assigned to the arthroscopic rotator cuff repair with acromioplasty group (ACR) or the repair only group (No ACR). The procedures were identical with the exception of there being no division of the coracoacromial ligament or resection of the acromion for those in the No ACR group. Both groups experienced the same post-operative rehabilitation protocol. The surgeon and patient were not blinded to the type of procedure; however, the research assistant who performed follow-up appointments was blinded to the surgical protocol. Primary outcomes were the Western Ontario Rotator Cuff Index (WORC) and the American Shoulder and Elbow Surgeons standardized form for the assessment of the shoulder (ASES). Time of both measures was pre-op, and post-op at 3, 6, 12, 18, and 24 months. Sample size estimation was 43 patients per group based on results from a related pilot study with alpha⫽0.05, beta⫽0.20 and a clinically significant difference of 25% between groups with expected loss to follow-up of 15%. Comparison between the two surgical groups across time points was done using a mixed model repeated measures analysis of variance (p⬍0.05; power 80%). Results are reported for outcomes at 3- and 6-month post-surgery. Results: Enrollment in the study is completed and 45 patients have completed at least 6 months of follow-up (see table 1). WORC and ASES scores for both the ACR and No ACR groups were significantly higher at 3- and 6-months post-surgery compared to pre-operative scores (See figures 1 and 2). No statistically significant difference were identified between the groups at 3 months or 6 months post-surgery (see figures 1 and 2). However, patients in the ACR group reported improved quality of life scores on both measures compared to the No ACR group (see figures 1 and 2). To date, three patients have required revision surgery and all have come from the no ACR group. One patient had a type II acromion and two exhibited type III acromions.
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ABSTRACTS
Conclusions: This study provides evidence that while there may be minimum added benefit to performing acromioplasty in the arthroscopic treatment of full-thickness rotator cuff tears, a particular subgroup of patients may benefit from the addition of an acromioplasty. Specifically, this refers to patients with type II and type III acromions. Two-year follow-up is being conducted as part of this study to clarify if this conclusion is supported in the longer term. Vascularity of the Rotator Cuff After Arthroscopic Repair: Characterization Using Contrast-Enhanced Ultrasound (SS-36). Seth C. Gamradt, M.D., Stephen Fealy, M.D., Russell Warren, M.D., David W. Altchek, M.D., Ronald S. Adler, M.D., Ph.D., and Alex Maderazo, M.D. Summary: Robust vascularity is present at the anchor site in the greater tuberosity three months after arthroscopic rotator cuff repair. Blood supply for the tendon-bone interface comes from the tuberosity. Purpose: Persistent defects are common after rotator cuff repair; this suggests that the biology of tendon-bone healing in rotator cuff repair is suboptimal. To date, there has been limited in-vivo assessment of vascularity of the shoulder after rotator cuff repair. This study aims to characterize the vascularity of the rotator cuff tendon/ bone interface after arthroscopic repair using contrast enhanced ultrasound. Methods: After obtaining Institutional Review Board approval, 13 patients (mean age:58.5) were enrolled in the study. Patients underwent arthroscopic single row rotator cuff repair with suture anchors (average 2 anchors doubly loaded with #2 nonabsorbable suture) of supraspinatus tears that averaged 2 cm x 1.25 cm in size. The patients then underwent lipid microsphere (Definity, 10L/kg, Bristol Myers Squibb) contrast-enhanced shoulder ultrasound examinations three months after rotator cuff repair with images obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to optimally visualize the blood flow to the shoulder. Qualitative and quantitative analysis of blood flow was performed using ultrasound imaging quantification and analysis software (QLAB; Philips, Andover, MA). Results: Table 1 summarizes the vascularity data in the three regions of interest in intact repairs. A robust vascular response was seen at the anchor site in the greater tuberosity three months after rotator cuff repair. Comparatively little blood flow was observed in the rotator cuff tendon. Exercise recruited blood flow to all three regions of interest. 10 of 13 repairs were com-
pletely intact on ultrasound examination. Blood flow was diminished at the anchor site in repairs with a persistent defect. Conclusions: This study quantifies in vivo vascularity of the rotator cuff three months after arthroscopic repair. Three conclusions can be drawn from these data. 1) The rotator cuff is relatively avascular after repair at three months. 2) A robust vascular response occurs at the suture anchor site in the greater tuberosity. This suggests that the blood supply for healing of the tendon-bone interface after rotator cuff repair comes from the bony side. An intact repair may be necessary to foster angiogenesis at the repair site. 3) Exercise recruits blood flow to both the greater tuberosity and rotator cuff. This study is limited in that only one time point was considered. However, these data suggest that the repaired rotator cuff tendon is relatively avascular and that the blood supply to the tendon bone interface comes from the tuberosity. Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: Is There a Tendon Healing in Patients Older Than 65 Years? (SS-37). Christophe Charousset, M.D., Kunal Kalra, M.D., Jean Grimberg, M.D., and Louis D. Duranthon, M.D. Summary: Our study was to assess clinical results and tendon healing of rotator cuff tears (RCT) repaired arthroscopically in 88 patients older than 65 years Simple Shoulder Test score was 2.4 (1-6) preoperatively and 9.7(3-4) at the last follow-up. (p Purpose: Surgical repair of rotator cuff tears (RCT) in older patients is usually limited to debridement without real tendon repair. To our knowledge there is no study in the literature which evaluated the healing of repaired RCT in older patients. The aim of our study was to assess clinical results and tendon healing of RCT repaired arthroscopically in patients older than 65 years. Methods: It was a non randomized prospective study including patients over 65 with a complete RCT arthroscopically repaired. Patients were pre and postoperatively clinically assessed with the Constant score and the Simple Shoulder Test (SST). A CT arthrogram was systematically realized before surgery and 6 months postoperatively for tendon healing assessment. Results: Between January 2001 and December 2004, 88 patients with a mean age of 70 years (65-85) were included in the study and reviewed with a mean follow-up of three years (2-5). RCT included more than two tendons in 45 cases, frontal retraction was distal in 58 cases, mean fatty degenerative index was 0.6 (0-3). 13 patients had minimal chondral lesions. SST score was 2.4 (1-6) preoperatively and 9.7(3-4) at
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patients that may benefit from acromioplasty in addition to rotator cuff repair. Purpose: Arthroscopic rotator cuff repair without acromioplasty in the treatment of full-thickness rotator cuff tears may offer the same degree of improvement as repair that includes acromioplasty without threatening the shoulder stability provided by the acromion and coracoacromial ligament. This study examines the hypothesis that the results of arthroscopic cuff repair are not improved by the addition of an acromioplasty. Methods: Patients included those referred for assessment after six months of failed conservative management and that were diagnosed with a full-thickness tear up to 4 cm in size of one or more tendons of the rotator cuff. Patients were randomly assigned to the arthroscopic rotator cuff repair with acromioplasty group (ACR) or the repair only group (No ACR). The procedures were identical with the exception of there being no division of the coracoacromial ligament or resection of the acromion for those in the No ACR group. Both groups experienced the same post-operative rehabilitation protocol. The surgeon and patient were not blinded to the type of procedure; however, the research assistant who performed follow-up appointments was blinded to the surgical protocol. Primary outcomes were the Western Ontario Rotator Cuff Index (WORC) and the American Shoulder and Elbow Surgeons standardized form for the assessment of the shoulder (ASES). Time of both measures was pre-op, and post-op at 3, 6, 12, 18, and 24 months. Sample size estimation was 43 patients per group based on results from a related pilot study with alpha⫽0.05, beta⫽0.20 and a clinically significant difference of 25% between groups with expected loss to follow-up of 15%. Comparison between the two surgical groups across time points was done using a mixed model repeated measures analysis of variance (p⬍0.05; power 80%). Results are reported for outcomes at 3- and 6-month post-surgery. Results: Enrollment in the study is completed and 45 patients have completed at least 6 months of follow-up (see table 1). WORC and ASES scores for both the ACR and No ACR groups were significantly higher at 3- and 6-months post-surgery compared to pre-operative scores (See figures 1 and 2). No statistically significant difference were identified between the groups at 3 months or 6 months post-surgery (see figures 1 and 2). However, patients in the ACR group reported improved quality of life scores on both measures compared to the No ACR group (see figures 1 and 2). To date, three patients have required revision surgery and all have come from the no ACR group. One patient had a type II acromion and two exhibited type III acromions.
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ABSTRACTS
Conclusions: This study provides evidence that while there may be minimum added benefit to performing acromioplasty in the arthroscopic treatment of full-thickness rotator cuff tears, a particular subgroup of patients may benefit from the addition of an acromioplasty. Specifically, this refers to patients with type II and type III acromions. Two-year follow-up is being conducted as part of this study to clarify if this conclusion is supported in the longer term. Vascularity of the Rotator Cuff After Arthroscopic Repair: Characterization Using Contrast-Enhanced Ultrasound (SS-36). Seth C. Gamradt, M.D., Stephen Fealy, M.D., Russell Warren, M.D., David W. Altchek, M.D., Ronald S. Adler, M.D., Ph.D., and Alex Maderazo, M.D. Summary: Robust vascularity is present at the anchor site in the greater tuberosity three months after arthroscopic rotator cuff repair. Blood supply for the tendon-bone interface comes from the tuberosity. Purpose: Persistent defects are common after rotator cuff repair; this suggests that the biology of tendon-bone healing in rotator cuff repair is suboptimal. To date, there has been limited in-vivo assessment of vascularity of the shoulder after rotator cuff repair. This study aims to characterize the vascularity of the rotator cuff tendon/ bone interface after arthroscopic repair using contrast enhanced ultrasound. Methods: After obtaining Institutional Review Board approval, 13 patients (mean age:58.5) were enrolled in the study. Patients underwent arthroscopic single row rotator cuff repair with suture anchors (average 2 anchors doubly loaded with #2 nonabsorbable suture) of supraspinatus tears that averaged 2 cm x 1.25 cm in size. The patients then underwent lipid microsphere (Definity, 10L/kg, Bristol Myers Squibb) contrast-enhanced shoulder ultrasound examinations three months after rotator cuff repair with images obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to optimally visualize the blood flow to the shoulder. Qualitative and quantitative analysis of blood flow was performed using ultrasound imaging quantification and analysis software (QLAB; Philips, Andover, MA). Results: Table 1 summarizes the vascularity data in the three regions of interest in intact repairs. A robust vascular response was seen at the anchor site in the greater tuberosity three months after rotator cuff repair. Comparatively little blood flow was observed in the rotator cuff tendon. Exercise recruited blood flow to all three regions of interest. 10 of 13 repairs were com-
pletely intact on ultrasound examination. Blood flow was diminished at the anchor site in repairs with a persistent defect. Conclusions: This study quantifies in vivo vascularity of the rotator cuff three months after arthroscopic repair. Three conclusions can be drawn from these data. 1) The rotator cuff is relatively avascular after repair at three months. 2) A robust vascular response occurs at the suture anchor site in the greater tuberosity. This suggests that the blood supply for healing of the tendon-bone interface after rotator cuff repair comes from the bony side. An intact repair may be necessary to foster angiogenesis at the repair site. 3) Exercise recruits blood flow to both the greater tuberosity and rotator cuff. This study is limited in that only one time point was considered. However, these data suggest that the repaired rotator cuff tendon is relatively avascular and that the blood supply to the tendon bone interface comes from the tuberosity. Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: Is There a Tendon Healing in Patients Older Than 65 Years? (SS-37). Christophe Charousset, M.D., Kunal Kalra, M.D., Jean Grimberg, M.D., and Louis D. Duranthon, M.D. Summary: Our study was to assess clinical results and tendon healing of rotator cuff tears (RCT) repaired arthroscopically in 88 patients older than 65 years Simple Shoulder Test score was 2.4 (1-6) preoperatively and 9.7(3-4) at the last follow-up. (p Purpose: Surgical repair of rotator cuff tears (RCT) in older patients is usually limited to debridement without real tendon repair. To our knowledge there is no study in the literature which evaluated the healing of repaired RCT in older patients. The aim of our study was to assess clinical results and tendon healing of RCT repaired arthroscopically in patients older than 65 years. Methods: It was a non randomized prospective study including patients over 65 with a complete RCT arthroscopically repaired. Patients were pre and postoperatively clinically assessed with the Constant score and the Simple Shoulder Test (SST). A CT arthrogram was systematically realized before surgery and 6 months postoperatively for tendon healing assessment. Results: Between January 2001 and December 2004, 88 patients with a mean age of 70 years (65-85) were included in the study and reviewed with a mean follow-up of three years (2-5). RCT included more than two tendons in 45 cases, frontal retraction was distal in 58 cases, mean fatty degenerative index was 0.6 (0-3). 13 patients had minimal chondral lesions. SST score was 2.4 (1-6) preoperatively and 9.7(3-4) at