COA 2014 Arthroscopic Rotator Cuff Repair Techniques What should we really be doing? C. Benjamin Ma, MD Chief, Sports Medicine and Shoulder Surgery University of California, San Francisco Department of Orthopaedic Surgery
Disclosures Research Support AOSSM Arthritis Foundation NIH Zimmer Clinical Trial Moximed Histogenics Zimmer
Arthroscopic Rotator Cuff Repair How to fix? Single vs Double Row Who to fix? What is too fat? What to fix? The undetected injury What to add? PRP?
How to fix?
Arthroscopic RCR Retrospective study 18pts Arthroscopic RCR of >2cm transverse tears Min 1 yr f/u, mean 2yrs Recurrent tears 17/18 pts. Functional result did not correlate with cuff integrity. ASES (48 85) with 88% pain relief. Results deteriorated over time. Galatz and Yamaguchi, JBJS 2004
Biomechanical Results- DR vs SR Authors Biomechanics Footprint Smith and Wallace Kim Less gap formation Less gap formation JBJS Nov 2006 AJSM 2006 Ma Stronger JBJS 2006 Meier Stronger Arthroscopy 2006 Lorbach Stronger AJSM 2008 Baums Stronger KSSTA 2008 Meier Better JSES 2006 Mazzocca +/- Better AJSM 2005 Nelson +/- Better Arthroscopy 2008
Randomized Clinical Trials 40 patients randomized to single vs double row RCT Mean tear size 1.8cm Mean # of anchors 2.25 single row 3.2 double row 2 retears in each group No differences in clinical outcomes In general, Failure Rate of Small tears are Low Burks et al, AJSM 2009
Prospective Cohort 78 patients with full-thickness rotator cuff repairs 40 Single-row fixation 38 double-row fixation prospective cohort At 2 years after surgery ASES scores were 91.6 vs and 93.0 Constant score was 76.7 vs 80.0 No differences in small to medium (<3 cm) tears. Large to massive tears (>3 cm) ASES and Constant scores and Shoulder Strength Index, DR > SR Park et al, AJSM 2008
Prospective Clinical Trials 31 patients with double row vs 35 patients with single row non randomized Improvement in Constant score Anatomic Repairs 19/31 for double row 14/35 for single row (P<0.05) No difference in clinical results Better healing rate for double-row Charouseet et al, AJSM 2007
LaFosse 2007 Sugaya 2007 Charousset 2007 Park 2008 Grasso 2009 Franceschi 2007 Burks 2009 Prospective 105 12/105 failures Better than historic Retrospective Prospective cohort 41 DR 31 SR 31 DR 35 SR Better MRI healing for DR Failures 12/31 21/35 No sig clinical diff Better MRI appearance No sig clinical diff Diff healing rate Prospective cohort 78 Significantly better for large tears Prospective Randomized Prospective Randomized Prospective Randomized 80 No difference 60 Post-op MRI 14/10/2 18/7/1 40 MRI 2 retears per gp No difference No diff Small tears 1.8cm
Single vs double row Meta analysis all level I randomized controlled trials 7 studies No significant differences in preop to postop ichanges in ASES, UCLA Overall retear rate 25.9% for SR, 14.2% for DR Main differences with partial-thickness retears Millet et al, ASES 2014
Is DR always better than SR? Look at remnant tendon length 30 patients with remnant tendons <10 mm in length (group 1) 48 with remnant tendons 10 mm in length (group 2). In group 1, there was 1 retear (6%) with the SR repair and 6 (46%) with the DR-SB repair. In group 2, there were 3 retears (19%) with the SR repair and 2 (6%) with the DR-SB repair. Kim et al, AJSM 2013
Remnant Length Retear rate was significantly higher in patients with the DR-SB repair in group 1 (P =.025), while there was no significant difference between the 2 techniques in group 2 (P =.316). Remnant tendon length should be considered to improve repair integrity. The SR technique may provide superior rotator cuff integrity when remnant tendons are <10 mm in length.
Who to fix?
Fatty Infiltration Rotator cuff injury can lead to changes in muscle architecture Fatty infiltration atrophy Repair of the rotator cuff tear Higher failure associated with preoperative amount of fatty infiltration and atrophy Even if successful no reversal of fat infiltration Mixed improvement of atrophy at best Fuchs JBJS 2006, Liem Arthroscopy 2006, Gladstone AJSM 2007 Gerber JSES 2007, Shen JSES 2008, Goutallier et al CORR 1994
How to we quantify fat? Goutallier Classification Initial description CT study Stage 0 - Normal muscle Stage 1 - Some fatty streaks Stage 2 - Less than 50% fat vs muscle Stage 3-50% fat vs muscle Stage 4 - Greater than 50% fat vs muscle
Modified Goutallier Classification First described for CT and modified for MRI 1,2 Qualitative assessment Moderate inter-observer reliability (Κ = 0.53) 3 Grade 0 Normal Grade 1 Streaks of fat Grade 2 More muscle than fat Grade 3 Equal muscle and fat Grade 4 More fat than muscle
Is there a better way? IDEAL sequence Fat Fraction Values Correlate to Goutallier Classification Goutallier Grade Mean Fat Fraction Value Range 0 2.1% (1.3%) 0 5.59% 1 5.6% (2.3%) 1.1-9.70% 2 8.5% (2.7%) 6.4 14.86% 3 16.2% (1.1%) 15.25 17.77% 4 24.7% (3.4%) 19.85 29.63% Pearson s correlation coefficient r = 0.93 Nardo and Ma et al, JMRI 2014
IDEAL Values Correlate with Clinical Parameters Muscles Spearman Rank Spearman Spearman Rank Spearman Correlation- p-values Correlation-GC p-values GC IDEAL IDEAL Supraspinatus Pain VAS 0.128 0.012 0.3557 0.9318 FF Strength 0.206 0.032 0.1382 0.8215 Ab Strength 0.448 0.223 0.0011* 0.1201 Infraspinatus Pain VAS 0.119 0.087 0.3910 0.5336 ER Strength 0.368 0.370 0.0067* 0.0064* Subscapularis Pain VAS 0.313 0.193 0.0214* 0.1625 IR Strength 0.39 0.30 0.0051* 0.0357* Nardo and Ma et al, JMRI 2014
What to fix?
Missed rotator cuff tears Most common rotator cuff tear Supraspinatus tendon tear Most commonly missed rotator cuff tear Subscapularis tendon tear Difficult diagnosis
Subscapularis tear
Subscapularis tear
Bear hug sign Good to test subscapularis tendon strength Good for superior tears Barth et al, Arthroscopy 2006
Look for the tear
What to add?
Platelet Rich Plasma Prospective randomized double- blinded study on the use of PRP for RCR Arthroscopic rotator cuff repair No difference in VAS scores, narcotic use No difference in ROM, SST, ASES, UCLA Retear rate the same on MRI 43% PRP vs 29% control Weber et al, AJSM 2013
Large to massive rotator cuff tears? Use of L-PRP for large or massive rotator cuff repairs Double-row cross-suture cuff repair 2 years followup Charousset et al, Arthroscopy 2014
Large or Massive Cuff Repair No difference in cuff healing No difference in recurrent tear rate No difference in patient reported outcomes Conclusion L-PRP did not improve outcomes Charousset et al, Arthroscopy 2014
Results of PRP 23 randomized and 10 prospective cohort studies Treatment for impingement, rotator cuff, lateral epicondilitis, ACL, patella, tibia and spine Sheth and Bhandari et al, JBJS 2012
Results of PRP Lack of standardization of protocols, platelet separation techniques and outcome measures No obvious evidence to support usage Sheth and Bhandari et al, JBJS 2012
Arthroscopic Rotator Cuff Repair How to fix? Single for small? Double Row for larger tears remnant tendon Who to fix? Check for fat What to fix? Look for subscapularis tendon tear What to add? NOT PRP!
On the other hand.