- Email: [email protected]
Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears
J Shoulder Elbow Surg (2014) 23, 1675-1681
www.elsevier.com/locate/ymse
Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears Sungwook Choi, MDa, Myung Ku Kim, MDb, Gyeong Min Kim, MDa, Young-Ho Roh, MDa, Im Kyung Hwang, MDc, Hyunseong Kang, MDa,* a
Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, South Korea Department of Orthopaedic Surgery, Inha University School of Medicine, Incheon, South Korea c Department of Radiologic Medicine, Jeju National University Hospital, Jeju, South Korea b
Background: This study was conducted to evaluate clinical outcomes, maintenance of repair integrity, and retear rate after arthroscopic rotator cuff repair by a suture bridge technique among patients with medium, large, and massive rotator cuff tears. Methods: We evaluated 147 patients who had undergone arthroscopic rotator cuff repair. Clinical and functional evaluations were performed with the Constant and University of California–Los Angeles scores. All patients were confirmed to have magnetic resonance imaging evidence of tendon healing at least 12 months postoperatively. Results: The average postoperative time to follow-up magnetic resonance imaging was 23.4 months (range, 12-48 months). A total of 25 (17.0%) retears were observed. All clinical outcome scores were improved significantly at follow-up. Larger intraoperative tear sizes were correlated with higher retear rates. The incidence of retear was also higher in cases in which the preoperative fatty degeneration grade was higher. The incidence of retear increased with age and in the heavy worker group (e.g., farmers, carriers, car mechanics) but was not statistically significant. Conclusions: Arthroscopic rotator cuff repair by a suture bridge technique yields improvements in clinical outcome measures and a relatively high degree of patient satisfaction despite the fact that repair integrity is not maintained in many cases. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff tear; arthroscopic repair; suture bridge technique; fatty degeneration; tear size; retear
This work was supported by a research grant from Jeju National University Hospital. This study was approved by the Institutional Review Board of Jeju National University Hospital (2010-27).
*Reprint requests: Hyunseong Kang, MD, Department of Orthopaedic Surgery, Jeju National University Hospital, Ara-1-dong, Jeju city, Jeju, South Korea. E-mail address: [email protected] (H. Kang).
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.02.021
1676 In arthroscopic repair of rotator cuff tears, patient-related factors are likely to exert a strong influence on rotator cuff healing. The factors that influence repair integrity include patient age, tear size, and quality of bone and tendon (retraction, muscle atrophy, and fatty infiltration).2,6,12 Furthermore, social history, especially occupation and smoking, may influence tear size, tendon quality, and repair integrity.5 The primary goal of rotator cuff repair is to maximize tendon healing. The suture bridge technique was introduced to maximize the utility of the repair construct and to compress the repaired tendon to the bone.3,11,17 On the basis of biomechanical studies, the suture bridge repair technique resulted in better clinical and structural outcomes compared with other arthroscopic repair techniques.3 The aim of this study was to evaluate clinical outcomes, maintenance of repair integrity, and recurrence rate after use of the suture bridge technique in patients with medium, large, and massive rotator cuff tears. Furthermore, we evaluated the retear patterns in cases with structural failure after arthroscopic suture bridge repair with follow-up magnetic resonance imaging (MRI). Finally, we compared the clinical and radiologic outcomes between heavy and light workers.
Materials and methods Patient selection Between May 2008 and September 2010, 258 patients with fullthickness rotator cuff tears underwent arthroscopic double-row rotator cuff repair at Jeju National University Hospital (Jeju, Korea). The inclusion criteria were patients who had a fullthickness rotator cuff tear confirmed by preoperative MRI with failed initial nonoperative treatment and who consequently underwent a complete arthroscopic rotator cuff repair by a suture bridge technique. Patients were excluded if they had labral tears, glenohumeral arthritis, or inflammatory diseases. Patients undergoing revision procedures were also excluded, as were 49 patients with small tears and 19 patients with massive irreparable tears. Patients with small tears were excluded because, in most cases, the functional outcome was acceptable and the possibility of retear was low, making these inappropriate for the objectives of this research. A total of 12 patients were clinically lost to follow-up. An additional 31 patients were excluded because of lack of follow-up MRI after surgery. Subsequently, a retrospective review was performed for the remaining 147 patients (77.4%). The average patient age at the time of surgery was 62.8 years (range, 46-79 years). The average postoperative follow-up duration was 31.2 months (range, 24-48 months). The sample included 65 men and 82 women, with the repairs being performed on 103 right and 44 left shoulders. The cuff tear was in the dominant arm in 137 cases and in the nondominant arm in 10 cases. A single tendon (supraspinatus) was involved in 109 cases (74.1%), with multiple tendon involvement (supraspinatus, subscapularis, or infraspinatus) in 38 cases (25.9%). All rotator cuff repairs were performed by an arthroscopic suture bridge technique. Patients reported a history of trauma in 46 cases (31.3%). The patients were divided into 2 occupational groups. The heavy worker group included patients whose occupation required
S. Choi et al. handling and moving objects or physically demanding work (e.g., farmers, carriers, car mechanics). The light worker group included patients whose occupation required relatively lower physical demands (e.g., housewives, office workers).
Tear evaluation During surgery, the rotator cuff tear was measured. We evaluated the repair integrity of cuff muscles with the classification proposed by Sugaya et al19 through follow-up MRI: type I, sufficient thickness with homogeneous low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, presence of a minor discontinuity; type V, presence of a major discontinuity (Fig. 1). We defined types IV and V as retears. We assessed the retear patterns on the basis of the description used by Cho et al10: type 1, no repaired cuff tissue remaining on insertion site; type 2, remnant cuff tissue remaining on the greater tuberosity. We also evaluated individual fatty degeneration and global fatty degeneration (global fatty degeneration index) by the classification of Goutallier et al: grade 0, no fatty deposits; grade 1, some fatty streaks; grade 2, more muscle than fat; grade 3, as much muscle as fat; and grade 4, less muscle than fat.14 Fatty degeneration of the cuff muscles was evaluated in soft tissue windows on sagittal MRI sections. For each injured shoulder, we evaluated fatty degeneration for individual cuff muscles and for all cuff muscles combined by calculating the global fatty degeneration index as the mean value of the grades for the supraspinatus, infraspinatus, and subscapularis. Tear size and fatty degeneration were examined by preoperative MRI (Achieva 3.0T; Philips, Amsterdam, The Netherlands). The tear sizes were confirmed intraoperatively under arthroscopy with a probe. The size of the rotator cuff tear was based on the greatest dimension of tendon tear as follows: small, <1 cm; medium, 1 to 3 cm; large, 3 to 5 cm; or massive, >5 cm. Repair integrity was evaluated by follow-up MRI studies, which were performed an average of 23.4 months (range, 12-48 months) after the respective rotator cuff repair.
Clinical evaluation Clinical evaluations were performed preoperatively and an average of 31.2 months (range, 24-48 months) postoperatively with the Constant score and the Shoulder Rating Scale of the University of California at Los Angeles (UCLA).12 The Constant score includes the following four categories: pain, 15 points; activities of daily living, 20 points; range of motion, 40 points; and power, 25 points.11
Surgical technique All surgical procedures were performed by the same surgeon. Each operation was performed under general anesthesia, in a semilateral position. Subacromial decompression was performed with a burr in all patients. Diagnostic glenohumeral arthroscopy was performed, and accompanying intra-articular lesions were identified. After insertion of an arthroscope into the subacromial space, subacromial decompression was performed. Tear size, tendon quality, and presence of delamination were identified at the time of surgery.
Factors associated after rotator cuff repair
1677
Figure 1 (A) Preoperative coronal T2-weighted image showing a full-thickness tear. (B) Postoperative coronal T2-weighted image showing a completely healed state of a repaired rotator cuff (type I by Sugaya classification) at 24 months after surgery.
Figure 2 (A) Arthroscopic view showing a medium-size full-thickness tear (2 2 cm) and (B) a repair configuration after arthroscopic rotator cuff repair by a suture bridge technique. (C) Arthroscopic view showing a large full-thickness tear (3 3 cm) and (D) a repair configuration after arthroscopic rotator cuff repair by a suture bridge technique. For tendon mobilization, any retracted tendon was released from adhesion, and the footprint of the greater tuberosity was debrided. Medial row anchors (3.7 mm and 4.5 mm Bio-Corkscrew suture anchor; Arthrex, Naples, FL, USA) were inserted at the medial edge of the footprint. The selection of anchor size depended on the bone quality of the footprint and anchor stability. Either Scorpion (Arthrex, Naples, FL, USA) or suture hook (Linvatec, Largo, FL, USA) was used to pass the suture through the supraspinatus tendon, near the musculotendinous junction. The knots were tied on the medial row, and the tendon was reduced into the bone. Lateral row anchors (3.5 mm and 4.5 mm Bio-PushLock anchor
and SwiveLock; Arthrex) were inserted 5 to 10 mm below the greater tuberosity, after preparing the bone sockets. The number of anchors depended on the tear size (Fig. 2).
Postoperative rehabilitation An abduction brace was used for 4 to 6 weeks postoperatively. The rehabilitation regimen differed on the basis of the extent of the tear and tendon quality. Pendulum exercises began on the day after surgery. Patients with medium or large tears started rehabilitation on the third postoperative day, and patients with
1678 Table I
S. Choi et al. Correlation between intraoperative tear size and clinical outcome
Intraoperative tear size Medium (n ¼ 94) Large (n ¼ 38) Massive (n ¼ 15) Overall (n ¼ 147)
UCLA score
Constant score
Preoperative
Postoperative
P value
Preoperative
Postoperative
P value
14.3 13.8 12.2 14.0
30.4 31.4 28.8 30.4
<.001 <.001 <.001 <.001
54.1 52.9 50.0 53.3
84.2 87.9 77.2 84.3
<.001 <.001 <.001 <.001
(5-27) (9-29) (3-20) (3-29)
(15-35) (13-35) (4-35) (4-35)
(26-85) (32-83) (20-66) (20-85)
(61-98) (50-100) (11-92) (11-100)
UCLA, University of California–Los Angeles.
Figure 3
Correlation between preoperative tear size and repair integrity.
massive tears began rehabilitation 1 week postoperatively. Initially, passive forward flexion exercises were performed with a continuous passive movement machine (ORMED GmbH, Freiburg, Germany). Active exercises were not allowed until 6 weeks postoperatively. The patients were educated in the use of the abduction brace for 6 weeks during ambulation except while doing the rehabilitation. For the ensuing 6 weeks, active motion of the shoulder was slightly increased.
Statistical analysis All statistics were analyzed with the SPSS software package (version 18.0; SPSS Inc, Chicago, IL, USA). The paired t test was performed to assess functional scores between the preoperative and postoperative results. Pearson c2 test was performed to assess the correlation between repair integrity and other factors. A P value < .05 was considered to indicate statistical significance. Comparisons of factors that influence retear rate, such as relative risk and multiple logistic regression analysis, were performed.
Results Arthroscopic findings demonstrated medium tears in 94 cases (63.9%), large tears in 38 cases (25.9%), and massive tears in 15 cases (10.2%). The mean UCLA score increased from a preoperative mean of 14.0 points (range, 5-24) to 30.4
points (range, 9-35) at last follow-up (P < .001). Furthermore, the Constant score improved from a preoperative mean of 53.3 points (range, 26-67) to 84.3 points (range, 4698) at last follow-up (P < .001). The 18 patients (72%) who experienced retears were satisfied with their outcome on the basis of the UCLA score (Table I). By the Sugaya classification to assess repair integrity with MRI, type I healing was observed in 33 cases (22.4%), type II in 76 cases (51.7%), type III in 13 cases (8.8%), type IV in 9 cases (6.1%), and type V in 16 cases (10.9%). The overall number of retears (types IV and V) was 25 cases (17.0%). The retear rate was 10.6% (10 of 94) in medium tears, 18.4% (7 of 38) in large tears, and 53.3% (8 of 15) in massive tears. A larger intraoperative tear size was associated with higher rate of retear (P < .001), which was statistically significant (Fig. 3). We also found 5 type I retears (20.0%) and 20 type II retears (80.0%). Regarding preoperative fatty degeneration, there was no retear observed among the 29 grade 1 cases, with 7 retears (10.4%) among the 67 grade 2 cases. A retear was found in 18 (35.3%) of 51 grade 3 and grade 4 cases. Higher preoperative fatty degeneration grades were associated with increased incidence of retear (P < .001) (Fig. 4). The patients were subdivided into 2 age groups for assessment of tendon healing. A retear was observed in 11 (13.6%) of 81 patients younger than 65 years. Among the
Factors associated after rotator cuff repair
Figure 4
1679
Correlation between global fatty degeneration index (GFDI) and repair integrity.
66 patients older than 65 years, 14 (21.2%) experienced a retear. The incidence of retear tended to be higher for patients older than 65 years, but this difference was not statistically significant (P ¼ .229). Retear rates were also evaluated according to workload. A retear was observed in 14 (18.7%) of the 75 patients in the heavy worker group, whereas 11 (15.3%) patients had a retear in the light worker group. Although the heavy worker group experienced a higher rate of retear, this difference did not reach statistical significance (P ¼ .341) (Table II). The heavy workers returned to work at an average of 3.2 months (range, 2-6 months), and their retear rate was 18.7% (14 cases). There were 2 factors that significantly influenced retear rate, as analyzed by multiple logistic regression analysis (Table III). We analyzed several factors for potential association with retear rates and found tear size and fatty degeneration grade to be associated with retear rate.
Table II
Retear rate increase by age and workload Retear
Age < 65 years (n ¼ 81) Age 65 years (n ¼ 66) Light worker (n ¼ 72) Heavy worker (n ¼ 75)
Odds ratio
95% Confidence interval
.229
1.713
0.720-4.079
.341
1.273
0.535-3.025
11 (13.6%) 14 (21.2%) 11 (15.3%) 14 (18.7%)
Odds ratio by age and extent of work.
Table III Factors that influence retear rate by multiple logistic regression analysis P value
Odds ratio
95% Confidence interval
6.236 0.653
.058
1.921
0.978-3.773
1.412
.001
4.103
2.062-8.165
Coefficient
Discussion Arthroscopic rotator cuff repair is associated with significant improvements in shoulder pain, function, and motion.1,2,18 Advances have been made in arthroscopic rotator cuff repair, and many recent studies demonstrate good clinical results.1,2,4,19 In this study, we confirmed that retear rates are higher in cases of larger intraoperative tear size and higher preoperative fatty degeneration grade. Our study, using a double-row construct, showed healing rates comparable to those reported by Harryman et al,16 and we would recommend its use for treating rotator cuff tears.15,20,21 The integrity of rotator cuff repair correlates with clinical improvement. Therefore, it is important to maintain this integrity until complete healing is achieved. However, previous studies of the single-row repair technique have shown an anatomic failure rate ranging from
P value
Constant score Intraoperative size Global fatty degeneration index
22% to 25%.6 The causes of retears are variable and included poor-quality tendon tissue, pullout of suture anchor, suture breakage, and inappropriate rehabilitation.10 Recent studies have shown structural healing after double-row rotator cuff repair to have biomechanical characteristics and reconstruction of the rotator cuff footprint superior to those of a single-row repair, with higher rates of intact tendon healing.8
1680 Preoperative fatty degeneration is known to be an important factor affecting the integrity of a repaired rotator cuff. According to Goutallier et al, severe fatty degeneration was correlated with unsatisfactory surgical outcomes and a high retear rate.14 Similarly, retear rates and preoperative fatty degeneration were also significantly correlated in our study. Furthermore, a retear was found in 18 (35.3%) of the 51 cases of grade 3 and grade 4 fatty degeneration. Boileau et al2 found that patients older than 65 years had only a 43% chance of tendon healing and suggested that age is a negative factor associated with poor healing. However, Charousset et al7 have suggested that age itself is not associated with poor repair rates. Our results show that an older age (P ¼ .229) is not significantly correlated with a poor healing rate. In our study, a large proportion of the patients had either a large or massive tear resulting in an overall retear rate of 17.0% (25 cases). Among the 38 large tear cases, there were 7 (18.4%) retears; among the 15 massive tear cases, 8 (53.3%) experienced a retear. Cho et al9 reported a retear rate of 33.3% with the suture bridge technique; the proportion of patients with large to massive tears in that study was 43.1%. Recently, Cho et al9 found a frequent retear pattern of ‘‘medial cuff failure’’ in patients who had undergone arthroscopic repair with the suture bridge technique. This may be associated with the possibility of strangulation and relatively quick necrosis of the repaired tendon at the medial row. Similarly, we also found that 20 cases (80%) of the 25 retears occurred at the musculotendinous junction. In the 25 retear cases, we found that the Constant score improved from 55.4 to 79.5 and that the UCLA score improved from 13.1 to 28.3, both of which were statistically significant. In terms of the UCLA score, 18 patients (72%) were satisfied with the outcome of surgery. All patients were asked to avoid the overuse of their shoulders in their daily life with no limitation of lifting. However, the heavy workers returned to work at an average of 3.2 months (range, 26 months) postoperatively with a retear rate of 18.7% (14 cases). As mentioned before, clinical symptoms improved regardless of structural status, which is similar to the findings of other studies.13,16 A retear does not always represent a surgical failure, as long as there are improvements in functional outcomes such as pain and range of motion. One limitation of this study is the small number of cases. In addition, the surgery was performed by a single orthopedic surgeon, and the experimental design was not a randomized controlled blind trial. Experimental groups were selected retrospectively, and the control variable was not appropriate.
Conclusions Rotator cuff repair by an arthroscopic suture bridge technique resulted in improvement in clinical outcome
S. Choi et al. measures at an average follow-up of 1 year. The majority of retears were at the musculotendinous junction, and the retear rate was statistically correlated with preoperative fatty degeneration and tear size only. Interestingly, most of the patients who experienced retears were satisfied with the results of surgery, even though repair integrity was not maintained. This suggests that structural healing and clinical outcome do not always correlate.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tear (small to medium): a prospective study with 2- to 4-year follow up. Arthroscopy 2003;19:249-56. http://dx.doi.org/10.1053/jars.2003. 50083 2. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-40. http://dx.doi.org/10.2106/JBJS.D.02035 3. Burkhart SS, Adams CR, Schoolfield JD. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: the SwiveLock-FiberChain construct versus standard double-row repair. Arthroscopy 2009;25:274-81. http://dx.doi.org/10.1016/j. arthro.2008.09.024 4. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: analysis of results by tear size and by repair techniquedmargin convergence versus direct tendon-to-bone repair. Arthroscopy 2001; 17:905-12. 5. Carbone S, Gumina S, Arceri V, Campagna V, Fagnani C, Postacchini F. The impact of preoperative smoking habit on rotator cuff tear: cigarette smoking influences rotator cuff tear sizes. J Shoulder Elbow Surg 2012;21:56-60. http://dx.doi.org/10.1016/j.jse. 2011.01.039 6. Carbonel I, Martinez AA, Calvo A, Ripalda J, Herrera A. Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: a prospective randomized clinical study. Int Orthop 2012;36: 1877-83. http://dx.doi.org/10.1007/s00264-012-1559-9 7. Charousset C, Bellaiche L, Kalra K, Petrover D. Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older? Arthroscopy 2010;26:302-9. http://dx.doi.org/ 10.1016/j.arthro.2009.08.027 8. Chen M, Xu W, Donq Q, Huanq Q, Xie Z, Mao Y. Outcomes of singlerow versus double-row arthroscopic rotator cuff repair: a systematic review and meta-analysis of current evidence. Arthroscopy 2013;29: 1437-49. http://dx.doi.org/10.1016/j.arthro.2013.03.076 9. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011;39:2108-16. http://dx.doi.org/10.1177/ 0363546510397171
Factors associated after rotator cuff repair 10. Cho NS, Yi JW, Lee BG, Rhee YG. Re-tear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med 2010;38:664-71. http://dx.doi.org/10.1177/ 0363546509350081 11. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;(214):160-4. 12. Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing ? A systematic review. Am J Sports Med 2010;38:835-41. http://dx.doi.org/10. 1177/0363546509359679 13. El-Azab H, Buchmann S, Beitzel K, Waldt S, Imhoff AB. Clinical and structural evaluation of arthroscopic double-row suture-bridge rotator cuff repair: early results of a novel technique. Knee Surg Sports Traumatol Arthrosc 2010;18:1730-7. http://dx.doi.org/10.1007/ s00167-010-1257-3 14. Goutallier D, Postel JM, Lequilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J shoulder Elbow Surg 2003; 12:550-4. 15. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired
1681
16.
17.
18.
19.
20. 21.
large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86: 219-24. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982-9. Koh KH, Laddha MS, Lim TK, Park JH, Yoo JC. Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively? J Shoulder Elbow Surg 2012;21:859-66. http://dx.doi.org/10.1016/j.jse.2011.05.027 Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6year follow-up. J Shoulder Elbow Surg 2002;11:19-24. http://dx.doi. org/10.1067/mse.2002.120142 Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am 2007;89:953-60. http://dx.doi.org/10.2106/JBJS.F.00512 Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow up. Arthroscopy 1998;14:45-51. Wilson F, Hinov V, Adams G. Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up. Arthroscopy 2002;18:136-44.
www.elsevier.com/locate/ymse
Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears Sungwook Choi, MDa, Myung Ku Kim, MDb, Gyeong Min Kim, MDa, Young-Ho Roh, MDa, Im Kyung Hwang, MDc, Hyunseong Kang, MDa,* a
Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, South Korea Department of Orthopaedic Surgery, Inha University School of Medicine, Incheon, South Korea c Department of Radiologic Medicine, Jeju National University Hospital, Jeju, South Korea b
Background: This study was conducted to evaluate clinical outcomes, maintenance of repair integrity, and retear rate after arthroscopic rotator cuff repair by a suture bridge technique among patients with medium, large, and massive rotator cuff tears. Methods: We evaluated 147 patients who had undergone arthroscopic rotator cuff repair. Clinical and functional evaluations were performed with the Constant and University of California–Los Angeles scores. All patients were confirmed to have magnetic resonance imaging evidence of tendon healing at least 12 months postoperatively. Results: The average postoperative time to follow-up magnetic resonance imaging was 23.4 months (range, 12-48 months). A total of 25 (17.0%) retears were observed. All clinical outcome scores were improved significantly at follow-up. Larger intraoperative tear sizes were correlated with higher retear rates. The incidence of retear was also higher in cases in which the preoperative fatty degeneration grade was higher. The incidence of retear increased with age and in the heavy worker group (e.g., farmers, carriers, car mechanics) but was not statistically significant. Conclusions: Arthroscopic rotator cuff repair by a suture bridge technique yields improvements in clinical outcome measures and a relatively high degree of patient satisfaction despite the fact that repair integrity is not maintained in many cases. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff tear; arthroscopic repair; suture bridge technique; fatty degeneration; tear size; retear
This work was supported by a research grant from Jeju National University Hospital. This study was approved by the Institutional Review Board of Jeju National University Hospital (2010-27).
*Reprint requests: Hyunseong Kang, MD, Department of Orthopaedic Surgery, Jeju National University Hospital, Ara-1-dong, Jeju city, Jeju, South Korea. E-mail address: [email protected] (H. Kang).
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.02.021
1676 In arthroscopic repair of rotator cuff tears, patient-related factors are likely to exert a strong influence on rotator cuff healing. The factors that influence repair integrity include patient age, tear size, and quality of bone and tendon (retraction, muscle atrophy, and fatty infiltration).2,6,12 Furthermore, social history, especially occupation and smoking, may influence tear size, tendon quality, and repair integrity.5 The primary goal of rotator cuff repair is to maximize tendon healing. The suture bridge technique was introduced to maximize the utility of the repair construct and to compress the repaired tendon to the bone.3,11,17 On the basis of biomechanical studies, the suture bridge repair technique resulted in better clinical and structural outcomes compared with other arthroscopic repair techniques.3 The aim of this study was to evaluate clinical outcomes, maintenance of repair integrity, and recurrence rate after use of the suture bridge technique in patients with medium, large, and massive rotator cuff tears. Furthermore, we evaluated the retear patterns in cases with structural failure after arthroscopic suture bridge repair with follow-up magnetic resonance imaging (MRI). Finally, we compared the clinical and radiologic outcomes between heavy and light workers.
Materials and methods Patient selection Between May 2008 and September 2010, 258 patients with fullthickness rotator cuff tears underwent arthroscopic double-row rotator cuff repair at Jeju National University Hospital (Jeju, Korea). The inclusion criteria were patients who had a fullthickness rotator cuff tear confirmed by preoperative MRI with failed initial nonoperative treatment and who consequently underwent a complete arthroscopic rotator cuff repair by a suture bridge technique. Patients were excluded if they had labral tears, glenohumeral arthritis, or inflammatory diseases. Patients undergoing revision procedures were also excluded, as were 49 patients with small tears and 19 patients with massive irreparable tears. Patients with small tears were excluded because, in most cases, the functional outcome was acceptable and the possibility of retear was low, making these inappropriate for the objectives of this research. A total of 12 patients were clinically lost to follow-up. An additional 31 patients were excluded because of lack of follow-up MRI after surgery. Subsequently, a retrospective review was performed for the remaining 147 patients (77.4%). The average patient age at the time of surgery was 62.8 years (range, 46-79 years). The average postoperative follow-up duration was 31.2 months (range, 24-48 months). The sample included 65 men and 82 women, with the repairs being performed on 103 right and 44 left shoulders. The cuff tear was in the dominant arm in 137 cases and in the nondominant arm in 10 cases. A single tendon (supraspinatus) was involved in 109 cases (74.1%), with multiple tendon involvement (supraspinatus, subscapularis, or infraspinatus) in 38 cases (25.9%). All rotator cuff repairs were performed by an arthroscopic suture bridge technique. Patients reported a history of trauma in 46 cases (31.3%). The patients were divided into 2 occupational groups. The heavy worker group included patients whose occupation required
S. Choi et al. handling and moving objects or physically demanding work (e.g., farmers, carriers, car mechanics). The light worker group included patients whose occupation required relatively lower physical demands (e.g., housewives, office workers).
Tear evaluation During surgery, the rotator cuff tear was measured. We evaluated the repair integrity of cuff muscles with the classification proposed by Sugaya et al19 through follow-up MRI: type I, sufficient thickness with homogeneous low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, presence of a minor discontinuity; type V, presence of a major discontinuity (Fig. 1). We defined types IV and V as retears. We assessed the retear patterns on the basis of the description used by Cho et al10: type 1, no repaired cuff tissue remaining on insertion site; type 2, remnant cuff tissue remaining on the greater tuberosity. We also evaluated individual fatty degeneration and global fatty degeneration (global fatty degeneration index) by the classification of Goutallier et al: grade 0, no fatty deposits; grade 1, some fatty streaks; grade 2, more muscle than fat; grade 3, as much muscle as fat; and grade 4, less muscle than fat.14 Fatty degeneration of the cuff muscles was evaluated in soft tissue windows on sagittal MRI sections. For each injured shoulder, we evaluated fatty degeneration for individual cuff muscles and for all cuff muscles combined by calculating the global fatty degeneration index as the mean value of the grades for the supraspinatus, infraspinatus, and subscapularis. Tear size and fatty degeneration were examined by preoperative MRI (Achieva 3.0T; Philips, Amsterdam, The Netherlands). The tear sizes were confirmed intraoperatively under arthroscopy with a probe. The size of the rotator cuff tear was based on the greatest dimension of tendon tear as follows: small, <1 cm; medium, 1 to 3 cm; large, 3 to 5 cm; or massive, >5 cm. Repair integrity was evaluated by follow-up MRI studies, which were performed an average of 23.4 months (range, 12-48 months) after the respective rotator cuff repair.
Clinical evaluation Clinical evaluations were performed preoperatively and an average of 31.2 months (range, 24-48 months) postoperatively with the Constant score and the Shoulder Rating Scale of the University of California at Los Angeles (UCLA).12 The Constant score includes the following four categories: pain, 15 points; activities of daily living, 20 points; range of motion, 40 points; and power, 25 points.11
Surgical technique All surgical procedures were performed by the same surgeon. Each operation was performed under general anesthesia, in a semilateral position. Subacromial decompression was performed with a burr in all patients. Diagnostic glenohumeral arthroscopy was performed, and accompanying intra-articular lesions were identified. After insertion of an arthroscope into the subacromial space, subacromial decompression was performed. Tear size, tendon quality, and presence of delamination were identified at the time of surgery.
Factors associated after rotator cuff repair
1677
Figure 1 (A) Preoperative coronal T2-weighted image showing a full-thickness tear. (B) Postoperative coronal T2-weighted image showing a completely healed state of a repaired rotator cuff (type I by Sugaya classification) at 24 months after surgery.
Figure 2 (A) Arthroscopic view showing a medium-size full-thickness tear (2 2 cm) and (B) a repair configuration after arthroscopic rotator cuff repair by a suture bridge technique. (C) Arthroscopic view showing a large full-thickness tear (3 3 cm) and (D) a repair configuration after arthroscopic rotator cuff repair by a suture bridge technique. For tendon mobilization, any retracted tendon was released from adhesion, and the footprint of the greater tuberosity was debrided. Medial row anchors (3.7 mm and 4.5 mm Bio-Corkscrew suture anchor; Arthrex, Naples, FL, USA) were inserted at the medial edge of the footprint. The selection of anchor size depended on the bone quality of the footprint and anchor stability. Either Scorpion (Arthrex, Naples, FL, USA) or suture hook (Linvatec, Largo, FL, USA) was used to pass the suture through the supraspinatus tendon, near the musculotendinous junction. The knots were tied on the medial row, and the tendon was reduced into the bone. Lateral row anchors (3.5 mm and 4.5 mm Bio-PushLock anchor
and SwiveLock; Arthrex) were inserted 5 to 10 mm below the greater tuberosity, after preparing the bone sockets. The number of anchors depended on the tear size (Fig. 2).
Postoperative rehabilitation An abduction brace was used for 4 to 6 weeks postoperatively. The rehabilitation regimen differed on the basis of the extent of the tear and tendon quality. Pendulum exercises began on the day after surgery. Patients with medium or large tears started rehabilitation on the third postoperative day, and patients with
1678 Table I
S. Choi et al. Correlation between intraoperative tear size and clinical outcome
Intraoperative tear size Medium (n ¼ 94) Large (n ¼ 38) Massive (n ¼ 15) Overall (n ¼ 147)
UCLA score
Constant score
Preoperative
Postoperative
P value
Preoperative
Postoperative
P value
14.3 13.8 12.2 14.0
30.4 31.4 28.8 30.4
<.001 <.001 <.001 <.001
54.1 52.9 50.0 53.3
84.2 87.9 77.2 84.3
<.001 <.001 <.001 <.001
(5-27) (9-29) (3-20) (3-29)
(15-35) (13-35) (4-35) (4-35)
(26-85) (32-83) (20-66) (20-85)
(61-98) (50-100) (11-92) (11-100)
UCLA, University of California–Los Angeles.
Figure 3
Correlation between preoperative tear size and repair integrity.
massive tears began rehabilitation 1 week postoperatively. Initially, passive forward flexion exercises were performed with a continuous passive movement machine (ORMED GmbH, Freiburg, Germany). Active exercises were not allowed until 6 weeks postoperatively. The patients were educated in the use of the abduction brace for 6 weeks during ambulation except while doing the rehabilitation. For the ensuing 6 weeks, active motion of the shoulder was slightly increased.
Statistical analysis All statistics were analyzed with the SPSS software package (version 18.0; SPSS Inc, Chicago, IL, USA). The paired t test was performed to assess functional scores between the preoperative and postoperative results. Pearson c2 test was performed to assess the correlation between repair integrity and other factors. A P value < .05 was considered to indicate statistical significance. Comparisons of factors that influence retear rate, such as relative risk and multiple logistic regression analysis, were performed.
Results Arthroscopic findings demonstrated medium tears in 94 cases (63.9%), large tears in 38 cases (25.9%), and massive tears in 15 cases (10.2%). The mean UCLA score increased from a preoperative mean of 14.0 points (range, 5-24) to 30.4
points (range, 9-35) at last follow-up (P < .001). Furthermore, the Constant score improved from a preoperative mean of 53.3 points (range, 26-67) to 84.3 points (range, 4698) at last follow-up (P < .001). The 18 patients (72%) who experienced retears were satisfied with their outcome on the basis of the UCLA score (Table I). By the Sugaya classification to assess repair integrity with MRI, type I healing was observed in 33 cases (22.4%), type II in 76 cases (51.7%), type III in 13 cases (8.8%), type IV in 9 cases (6.1%), and type V in 16 cases (10.9%). The overall number of retears (types IV and V) was 25 cases (17.0%). The retear rate was 10.6% (10 of 94) in medium tears, 18.4% (7 of 38) in large tears, and 53.3% (8 of 15) in massive tears. A larger intraoperative tear size was associated with higher rate of retear (P < .001), which was statistically significant (Fig. 3). We also found 5 type I retears (20.0%) and 20 type II retears (80.0%). Regarding preoperative fatty degeneration, there was no retear observed among the 29 grade 1 cases, with 7 retears (10.4%) among the 67 grade 2 cases. A retear was found in 18 (35.3%) of 51 grade 3 and grade 4 cases. Higher preoperative fatty degeneration grades were associated with increased incidence of retear (P < .001) (Fig. 4). The patients were subdivided into 2 age groups for assessment of tendon healing. A retear was observed in 11 (13.6%) of 81 patients younger than 65 years. Among the
Factors associated after rotator cuff repair
Figure 4
1679
Correlation between global fatty degeneration index (GFDI) and repair integrity.
66 patients older than 65 years, 14 (21.2%) experienced a retear. The incidence of retear tended to be higher for patients older than 65 years, but this difference was not statistically significant (P ¼ .229). Retear rates were also evaluated according to workload. A retear was observed in 14 (18.7%) of the 75 patients in the heavy worker group, whereas 11 (15.3%) patients had a retear in the light worker group. Although the heavy worker group experienced a higher rate of retear, this difference did not reach statistical significance (P ¼ .341) (Table II). The heavy workers returned to work at an average of 3.2 months (range, 2-6 months), and their retear rate was 18.7% (14 cases). There were 2 factors that significantly influenced retear rate, as analyzed by multiple logistic regression analysis (Table III). We analyzed several factors for potential association with retear rates and found tear size and fatty degeneration grade to be associated with retear rate.
Table II
Retear rate increase by age and workload Retear
Age < 65 years (n ¼ 81) Age 65 years (n ¼ 66) Light worker (n ¼ 72) Heavy worker (n ¼ 75)
Odds ratio
95% Confidence interval
.229
1.713
0.720-4.079
.341
1.273
0.535-3.025
11 (13.6%) 14 (21.2%) 11 (15.3%) 14 (18.7%)
Odds ratio by age and extent of work.
Table III Factors that influence retear rate by multiple logistic regression analysis P value
Odds ratio
95% Confidence interval
6.236 0.653
.058
1.921
0.978-3.773
1.412
.001
4.103
2.062-8.165
Coefficient
Discussion Arthroscopic rotator cuff repair is associated with significant improvements in shoulder pain, function, and motion.1,2,18 Advances have been made in arthroscopic rotator cuff repair, and many recent studies demonstrate good clinical results.1,2,4,19 In this study, we confirmed that retear rates are higher in cases of larger intraoperative tear size and higher preoperative fatty degeneration grade. Our study, using a double-row construct, showed healing rates comparable to those reported by Harryman et al,16 and we would recommend its use for treating rotator cuff tears.15,20,21 The integrity of rotator cuff repair correlates with clinical improvement. Therefore, it is important to maintain this integrity until complete healing is achieved. However, previous studies of the single-row repair technique have shown an anatomic failure rate ranging from
P value
Constant score Intraoperative size Global fatty degeneration index
22% to 25%.6 The causes of retears are variable and included poor-quality tendon tissue, pullout of suture anchor, suture breakage, and inappropriate rehabilitation.10 Recent studies have shown structural healing after double-row rotator cuff repair to have biomechanical characteristics and reconstruction of the rotator cuff footprint superior to those of a single-row repair, with higher rates of intact tendon healing.8
1680 Preoperative fatty degeneration is known to be an important factor affecting the integrity of a repaired rotator cuff. According to Goutallier et al, severe fatty degeneration was correlated with unsatisfactory surgical outcomes and a high retear rate.14 Similarly, retear rates and preoperative fatty degeneration were also significantly correlated in our study. Furthermore, a retear was found in 18 (35.3%) of the 51 cases of grade 3 and grade 4 fatty degeneration. Boileau et al2 found that patients older than 65 years had only a 43% chance of tendon healing and suggested that age is a negative factor associated with poor healing. However, Charousset et al7 have suggested that age itself is not associated with poor repair rates. Our results show that an older age (P ¼ .229) is not significantly correlated with a poor healing rate. In our study, a large proportion of the patients had either a large or massive tear resulting in an overall retear rate of 17.0% (25 cases). Among the 38 large tear cases, there were 7 (18.4%) retears; among the 15 massive tear cases, 8 (53.3%) experienced a retear. Cho et al9 reported a retear rate of 33.3% with the suture bridge technique; the proportion of patients with large to massive tears in that study was 43.1%. Recently, Cho et al9 found a frequent retear pattern of ‘‘medial cuff failure’’ in patients who had undergone arthroscopic repair with the suture bridge technique. This may be associated with the possibility of strangulation and relatively quick necrosis of the repaired tendon at the medial row. Similarly, we also found that 20 cases (80%) of the 25 retears occurred at the musculotendinous junction. In the 25 retear cases, we found that the Constant score improved from 55.4 to 79.5 and that the UCLA score improved from 13.1 to 28.3, both of which were statistically significant. In terms of the UCLA score, 18 patients (72%) were satisfied with the outcome of surgery. All patients were asked to avoid the overuse of their shoulders in their daily life with no limitation of lifting. However, the heavy workers returned to work at an average of 3.2 months (range, 26 months) postoperatively with a retear rate of 18.7% (14 cases). As mentioned before, clinical symptoms improved regardless of structural status, which is similar to the findings of other studies.13,16 A retear does not always represent a surgical failure, as long as there are improvements in functional outcomes such as pain and range of motion. One limitation of this study is the small number of cases. In addition, the surgery was performed by a single orthopedic surgeon, and the experimental design was not a randomized controlled blind trial. Experimental groups were selected retrospectively, and the control variable was not appropriate.
Conclusions Rotator cuff repair by an arthroscopic suture bridge technique resulted in improvement in clinical outcome
S. Choi et al. measures at an average follow-up of 1 year. The majority of retears were at the musculotendinous junction, and the retear rate was statistically correlated with preoperative fatty degeneration and tear size only. Interestingly, most of the patients who experienced retears were satisfied with the results of surgery, even though repair integrity was not maintained. This suggests that structural healing and clinical outcome do not always correlate.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tear (small to medium): a prospective study with 2- to 4-year follow up. Arthroscopy 2003;19:249-56. http://dx.doi.org/10.1053/jars.2003. 50083 2. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-40. http://dx.doi.org/10.2106/JBJS.D.02035 3. Burkhart SS, Adams CR, Schoolfield JD. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: the SwiveLock-FiberChain construct versus standard double-row repair. Arthroscopy 2009;25:274-81. http://dx.doi.org/10.1016/j. arthro.2008.09.024 4. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: analysis of results by tear size and by repair techniquedmargin convergence versus direct tendon-to-bone repair. Arthroscopy 2001; 17:905-12. 5. Carbone S, Gumina S, Arceri V, Campagna V, Fagnani C, Postacchini F. The impact of preoperative smoking habit on rotator cuff tear: cigarette smoking influences rotator cuff tear sizes. J Shoulder Elbow Surg 2012;21:56-60. http://dx.doi.org/10.1016/j.jse. 2011.01.039 6. Carbonel I, Martinez AA, Calvo A, Ripalda J, Herrera A. Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: a prospective randomized clinical study. Int Orthop 2012;36: 1877-83. http://dx.doi.org/10.1007/s00264-012-1559-9 7. Charousset C, Bellaiche L, Kalra K, Petrover D. Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older? Arthroscopy 2010;26:302-9. http://dx.doi.org/ 10.1016/j.arthro.2009.08.027 8. Chen M, Xu W, Donq Q, Huanq Q, Xie Z, Mao Y. Outcomes of singlerow versus double-row arthroscopic rotator cuff repair: a systematic review and meta-analysis of current evidence. Arthroscopy 2013;29: 1437-49. http://dx.doi.org/10.1016/j.arthro.2013.03.076 9. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011;39:2108-16. http://dx.doi.org/10.1177/ 0363546510397171
Factors associated after rotator cuff repair 10. Cho NS, Yi JW, Lee BG, Rhee YG. Re-tear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med 2010;38:664-71. http://dx.doi.org/10.1177/ 0363546509350081 11. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;(214):160-4. 12. Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing ? A systematic review. Am J Sports Med 2010;38:835-41. http://dx.doi.org/10. 1177/0363546509359679 13. El-Azab H, Buchmann S, Beitzel K, Waldt S, Imhoff AB. Clinical and structural evaluation of arthroscopic double-row suture-bridge rotator cuff repair: early results of a novel technique. Knee Surg Sports Traumatol Arthrosc 2010;18:1730-7. http://dx.doi.org/10.1007/ s00167-010-1257-3 14. Goutallier D, Postel JM, Lequilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J shoulder Elbow Surg 2003; 12:550-4. 15. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired
1681
16.
17.
18.
19.
20. 21.
large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86: 219-24. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982-9. Koh KH, Laddha MS, Lim TK, Park JH, Yoo JC. Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively? J Shoulder Elbow Surg 2012;21:859-66. http://dx.doi.org/10.1016/j.jse.2011.05.027 Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6year follow-up. J Shoulder Elbow Surg 2002;11:19-24. http://dx.doi. org/10.1067/mse.2002.120142 Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am 2007;89:953-60. http://dx.doi.org/10.2106/JBJS.F.00512 Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow up. Arthroscopy 1998;14:45-51. Wilson F, Hinov V, Adams G. Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up. Arthroscopy 2002;18:136-44.