Arthroscopic repair of rotator cuff tears. using absorbable anchors with a single-row technique

Transcription

1 Journal of Orthopaedic Surgery 2010;18(3):332-7 Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique Raffele Russo, 1 Fabio Cautiero, 1 Gerardo Giudice, 1 Michele Ciccarelli, 1 Valeria Visconti 2 1 Orthopaedic and trauma surgery, Pellegrini Hospital, Napoli, Italy 2 Orthopaedic and trauma surgery, San Leonardo Hospital, Castellamare di Stabia, Italy ABSTRACT Purpose. To review outcomes of arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique. Methods. 66 patients underwent arthroscopic repair for rotator cuff tears using absorbable anchors with a single-row technique. 51 of them aged 37 to 73 (mean, 57) years had been followed up for a mean of 29 (range, 20 37) months. The extent of the tear was classified as large, medium or small. Functional outcome was assessed using the Constant score. Constant scores and re-tear rates in 3 patient groups (classified by patient age and tear size) were compared. Results. Among the 66 patients, there were 24 large, 29 medium and 13 small cuff tears, and a total of 48, 37, and 18 anchors were used, respectively. Among the 51 patients, the median Constant score improved significantly after arthroscopy (30 vs. 73, p<0.0001). Six shoulders had complete re-tears; their median Constant score was 48 and their adjusted Constant score was 65%. Complete re-tears occurred more often in patients aged >60 years than in those aged 50 to 59 years and <50 years (4/15 vs. 1/22 vs. 1/14), and more often in patients with large tears than in those with medium and small tears (4/24 vs. 2/29 vs. 0/13). Conclusion. Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique is reliable in patients aged <60 years with small or medium tears. Key words: absorbable implants; arthroscopy; rotator cuff; suture anchors; ultrasonography INTRODUCTION Shoulder arthroscopy enables more accurate diagnosis of rotator cuff diseases and study of such structures. 1 Arthroscopic repair of cuff tendons consists of simple debridement for partial tears to side-to-side sutures with absorbable or non-absorbable materials, and reattachment of tendons to bone at the footprint with Address correspondence and reprint requests to: Dr Fabio Cautiero, Salita Arenella n 43, 80129, Napoli, Italy. fabiocau@inwind.it

2 Vol. 18 No. 3, December 2010 Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique 333 titanium or absorbable anchors or screws with or without a knot. Its outcomes are similar to those in open or mini-open repairs. 2 7 Use of metal anchors and a double-row technique in repair of rotator cuff tears have achieved good outcomes; high failure rates have been reported for absorbable anchors. We reviewed outcomes of arthroscopic repair of rotator cuff tears using absorbable anchors and a single-row technique. MATERIALS AND METHODS Between June 2004 and June 2006, 66 patients underwent arthroscopic repair for full-thickness rotator cuff tears by a single surgeon, using absorbable screw anchors (Spiralok 5.0 mm; Mitek Worldwide, Westwood [MA], USA) with a singlerow technique. 51 of them aged 37 to 73 (mean, 57) years had been followed up for a mean of 29 (range, 20 37) months. All patients had a history of chronic shoulder pain and functional disability refractory to conservative therapy for a minimum of 6 weeks. Patients with degenerative acromioclavicular disease or fatty degeneration (according to the Goutallier classification 8,9 ) were included. Patients having only capsulotomy, capsulolyses, long head of the biceps tenotomy or acromioclavicular arthroplasty were excluded, as were patients with grade II or III glenohumeral degenerative changes 10 or with shoulder rigidity. The extent of the rotator cuff tear was classified as large (>5 cm), medium (3 5 cm), or small (<3 cm), and according to the sagittal plane as segments A to F (the lateral and medial bands of the coracohumeral ligament were considered separate structures). Massive tears involved all segments; anterior-toposterior tears were considered large. Functional outcome was assessed using the Constant score. Tendon healing was assessed using ultrasonography (Fig. 1). Pre- and post-operative Constant scores of the 51 patients were not normally distributed, based on the Shapiro-Wilk test (p=0.011 and p=0.004, respectively). Thus, outcomes were compared using the non-parametric Wilcoxon test, with a significance level set at shoulder suspension device, with 45º abduction and 20º forward flexion using 4 to 5 kg of arm traction. After examination of the glenohumeral joint, the arthroscope was inserted into the subacromial space to remove the subacromial deltoideal bursa. This revealed the bursal surface of the rotator cuff and enabled medial retraction for assessment of the tendon. The lower portion of the acromion and the acromioclavicular joint were examined to confirm the impingement or reduced subacromial space. In large cuff tears with tendon retraction, a juxtaglenoideal capsulotomy was performed and interval slides taken, 11 using a 4-mm shaver or a radiofrequency instrument just above the superior labrum between capsular tissue and glenoideal bone. For L- and U- shaped tears, side-to-side sutures (absorbable or not) were used to facilitate fixation to the bone with anchors. The tendon was fixed to the footprint on the greater tuberosity with bioabsorbable anchors (Fig. 2). Each anchor was loaded with double suture number 2; mattress knots were used to close the tears; the number of anchors used depended on the lesion size (Fig. 3). If the long head of the biceps was unstable with a pulley system lesion, tenotomy was performed. In patients younger than 50 years, tenotomy was stabilised with a tenodesis by one of the anchors sutures. If the subacromial space was restricted, after temporary removal of arm traction, acromioplasty was performed. If the acromioclavicular deep ligament was destroyed leaving the joint unstable, a mini-mumford procedure was carried out. If the acromioclavicular joint was stable but degenerative osteophytes were present, the co-planing procedure was performed. Surgical technique To improve viewing, controlled hypotension with a systolic blood pressure ranging from 85 to 95 mm Hg was induced during arthroscopy. Patients were placed in the lateral decubitus position, with the body angled 30º posteriorly. The affected arm was positioned in a Figure 1 Ultrasound image showing a repaired tendon at 14-month follow-up.

3 334 R Russo et al. Journal of Orthopaedic Surgery RESULTS Among the 66 patients, there were 24 large, 29 medium and 13 small rotator cuff tears, and a total of 48, 37, and 18 anchors were used, respectively. According to the sagittal plane classification, there were 26 supraspinatus tendon tears, 14 infraspinatus and supraspinatus tendon tears, 6 subscapularis tears, one isolated infraspinatus tendon rupture, and 19 massive tears. Two patients had undergone open repair at other hospitals. The long head of the biceps tendon was unstable and degenerative in 34 patients, whereas the tear was complete in 6. The aetiologies included acromioclavicular joint degenerative disease (n=8), cartilage damage to the humeral head (n=8), supraspinatus tendon calcification (n=2), acromial calcification (n=1), degenerative changes on the humeral articular surface (n=5), and acromioclavicular arthritis (n=3). The various procedures performed are shown in Table 1. Among the 51 patients, the median Constant (a) (b) (c) Figure 2 Arthroscopic view of full-thickness cuff tear: (a) supraspinatus tendon tear, (b) introduction of anchor-screw with double sutures, and (c) the repaired cuff. (a) (b) (c) (d) (e) Figure 3 The anterior view of single-row fixation of supraspinatus tear: (a) the site for reattachment to the bone, cleared of soft tissue, is prepared with special tools; (b) the anchor is placed to the foot-print; (c) the sutures are passed through the tendon and (d) closed in a mattress knot fashion; and (e) the superior view of single-row repair.

4 Vol. 18 No. 3, December 2010 Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique 335 score improved significantly after arthroscopy (30 vs. 73, p<0.0001, Table 2). Based on ultrasonography, 26 patients healed completely. 16 had a thin tendon without a lesion, 6 had a complete re-tear, 3 had a partial re-tear, 2 had loss of biceps tenodesis, and 13 had calcification in the repaired site. The 6 patients with complete re-tears had a median Constant score of 48 and an adjusted Constant score of 65%. Only 2 of them developed pain and loss of motion. Complete re-tears occurred more often in patients aged >60 years than in those aged 50 to 59 years and <50 years (4/15 vs. 1/22 vs. 1/14), and more often in patients with large tears than in those with medium and small tears (4/21 vs. 2/17 vs. 0/13) [Table 2]. DISCUSSION Rotator cuff repair should aim to achieve high fixation strength, minimal gap formation, and mechanical stability 12 so as to improve pain and function. 9,13,14 83 to 92% of arthroscopic cuff repairs achieve satisfactory results Techniques using staples or suture anchors in single or double rows have been Table 1 Surgical procedures performed for 51 patients during arthroscopy Procedure No. of patients Repair with anchors 51 Biceps tenotomy 11 Biceps tenodesis 23 Acromioplasty 16 Side-to-side sutures 16 Co-planing 2 Mini-Mumford 1 described, 5,7,20 24 but few reported on tendon-cuff integrity after arthroscopic repair. 25 Metal implants can lead to complications, especially in patients with chronic rotator cuff tears, poor-quality bone in the greater tuberosity, and articular damage caused by a loose or intra-articular metal anchor. 26,27 Metal implants can cause distortion and artefacts on magnetic resonance imaging. 28 Fixation with absorbable tacks is similar to fixation with metal anchors and transosseus sutures, 29,30 but absorbable sutureless screw anchors in poly-l-lactide acid may not perform adequately under cyclic loading conditions during rehabilitation. 31 Poor outcomes have been reported in patients having absorbable screws, compared to metal suture anchors. 16 Arthroscopic repairs of massive rotator cuff tears have a failure rate of up to 94%. 4,25,32 Different fixation methods including the Mason-Allen stitch, the massive cuff stitch, and the double-row technique have been reported. 19,23,25,31,33 Double-row fixation has a significantly higher ultimate tensile load than single-row types; the massive cuff stitch technique has similar cyclic and load-to-failure characteristics as double-row techniques. 32 Anterior repairs of the supraspinatus tendon are significantly stronger than posterior repairs. 32 In a series of 105 shoulders treated with arthroscopic double-row cuff repair, 33 the failure rate at the 2-year follow-up was 11%. 17 out of 18 patients with large tears treated with the arthroscopic single-row technique had recurrent tears. 25 Assessed by computed tomographic arthrography, 71% of 65 patients had complete healing after arthroscopic repair of full thickness supraspinatus tears using a tension band suture technique. 34 A recurrence rate of 7% for supraspinatus tendon tears was detected using ultrasonography, but the rate was 25% when the rotator interval was also torn. 35 Magnetic resonance Parameter Table 2 The Constant score and re-tear rate according to patient age and tear size No. of patients Median±SD (range) Constant score Preop Postop Adjusted (%) p Value No. of complete re-tears Overall 51 30±8 ( ) 73±13.5 (30 95) 90.5 (43 113) - 6 Patient age (years) < ±10 77± ±10 74± > ±6 67± Tear size Small 13 34±11 80± Medium 17 29±7 74± < Large 21 27±7 68±12 86 <

5 336 R Russo et al. Journal of Orthopaedic Surgery imaging may have a tendency to overestimate the re-rupture rate Ultrasonography enables better evaluation of tendon thinning with greater accuracy in the assessment of the rotator cuff. 39,40 It is a dynamic evaluation and low-cost procedure. This study has several limitations. The singlerow technique was not compared with the doublerow technique. The absorbable anchors were not compared with metal devices. The number of patients was small, and the follow-up was short. REFERENCES 1. Andren L, Lundberg BJ. Treatment of rigid shoulders by joint distension during arthrography. Acta Orthop Scand 1965;36: Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): A prospective study with 2- to 4-year follow-up. Arthroscopy 2003;19: Bennett WF. Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19: Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg 2006;15: Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 1998;80: Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 2002;11: Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 1998;14: Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304: Goutallier D, Postel JM, Lavau L, Bernageau J. Impact of fatty degeneration of the supraspinatus and infraspinatus muscles on the prognosis of surgical repair of the rotator cuff [in French]. Rev Chir Orthop Reparatrice Appar Mot 1999;85: Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am 1983;65: Lo IK, Burkhart SS. The interval slides in continuity: a method of mobilizing the anterosuperior rotator cuff without disrupting the tear margins. Arthroscopy 2004;20: Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br 1994;76: Cofield RH. Rotator cuff disease of the shoulder. J Bone Joint Surg Am 1985;67: Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR. Postoperative assessment of shoulder function: a prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5: Johnson L. Diagnostic and surgical arthroscopy of the shoulder. St Louis: C Mosby; Cummins CA, Appleyard RC, Strickland S, Haen PS, Chen S, Murrell GA. Rotator cuff repair: an ex vivo analysis of suture anchor repair techniques on initial load to failure. Arthroscopy 2005;21: Gartsman GM, Brinker MR, Khan M. Early effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff: an outcome analysis. J Bone Joint Surg Am 1998;80: Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med 2008;36: 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: De Beer JF, Boezaart AP, Van Rooyen K. Arthroscopic rotator cuff repair: a review of 96 cases. J Bone Joint Surg Br 2001;83(Suppl I): Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy 2003;19: Snyder SJ. Technique of arthroscopic rotator cuff repair using implantable 4-mm Revo suture anchors, suture Shuttle Relays, and no. 2 nonabsorbable mattress sutures. Orthop Clin North Am 1997;28: Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fixation. Arthroscopy 2005;21: 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: Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86: Flatow EL, Bigliani LU. Complications of rotator cuff repair. Complication Orthop 1992;8: Kaar TK, Schenck RC Jr, Wirth MA, Rockwood CA Jr. Complications of metallic suture anchors in shoulder surgery: A report of 8 cases. Arthroscopy 2001;17: Ozbaydar M, Elhassan B, Warner JJ. The use of anchors in shoulder surgery: a shift from metallic to bioabsorbable anchors. Arthroscopy 2007;23: Goradia VK, Mullen DJ, Boucher HR, Parks BG, O Donnell JB. Cyclic loading of rotator cuff repairs: A comparison of bioabsorbable tacks with metal suture anchors and transosseous sutures. Arthroscopy 2001;17:360 4.

6 Vol. 18 No. 3, December 2010 Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique Klinger HM, Steckel H, Spahn G, Buchhorn GH, Baums MH. Biomechanical comparison of double-loaded suture anchors using arthroscopic Mason-Allen stitches versus traditional transosseous suture technique and modified Mason-Allen stitches for rotator cuff repair. Clin Biomech (Bristol, Avon) 2007;22: Lee S, Mahar A, Bynum K, Pedowitz R. Biomechanical comparison of bioabsorbable sutureless screw anchor versus suture anchor fixation for rotator cuff repair. Arthroscopy 2005;21: Ma CB, Comerford L, Wilson J, Puttlitz CM. Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared with single-row fixation. J Bone Joint Surg Am 2006;88: Lafosse L, Brozska R, Toussaint B, Gobezie R. The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique. J Bone Joint Surg Am 2007;89: 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: Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res 1994;304: Motamedi AR, Urrea LH, Hancock RE, Hawkins RJ, Ho C. Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears. J Shoulder Elbow Surg 2002;11: Owen RS, Iannotti JP, Kneeland JB, Dalinka MK, Deren JA, Oleaga L. Shoulder after surgery: MR imaging with surgical validation. Radiology 1993;186: Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals initial experience. Radiology 1999;213: Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am 2004;86: Ziegler DW. The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders. J Shoulder Elbow Surg 2004;13:291 7.