Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Joseph P. Iannotti MD, PhD*,
Cleveland Clinic and Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
Posted November 2007
The paper by Ide et al. describes the clinical and anatomic
outcome after arthroscopic repair of anterosuperior rotator cuff tears in a
prospective clinical series of patients. The arthroscopic procedure was
performed by a single surgeon who used a standard surgical procedure and postoperative
protocol. Twenty patients had a minimum of two years of follow-up with magnetic
resonance imaging. All patients had a full-thickness tear of a portion of the superior
two-thirds of the subscapularis tendon. Thirteen patients had a supraspinatus
tear in addition to the subscapularis tear (a total of two tendon tears), and seven
patients had a supraspinatus tear and an infraspinatus tear in addition to the
subscapularis tear (a total of three tendon tears). All tears were repairable
and were associated with a traumatic event, thereby defining a time that the
tear occurred. In all instances, the tear was repaired within six months of the
injury, with an average time until repair of 2.7 months. Patients with stage-3
or 4 atrophy of the muscle were excluded from this study. These anatomic and
patient parameters are ideal criteria for repair of large and massive tears of
the rotator cuff involving the subscapularis tendon. The arthroscopic surgical
techniques were performed by an experienced surgeon. Postoperatively, the arm
was supported in a sling with an abduction pillow, and only passive or active-assisted
range-of-motion exercises were permitted for six weeks after surgery. Despite
these favorable conditions, one third of the tears failed to heal.
This study, like others, correlates healing of the repaired
rotator cuff tendons to better clinical outcome1-4, size of the tear2,5,
the degree of muscle atrophy1,6,7, tendon retraction1, and age of the patients8,9. The study was comprised of a well-defined
group of patients who underwent a uniformly applied surgical technique and postoperative
rehabilitation protocol in which clinical as well as anatomic parameters were defined
at follow-up. This paper establishes a standard by which other series can be
compared.
Approximately one-third of the tears had a persistent full-thickness
defect, noted on magnetic resonance imaging, at the time of follow-up. The
anatomical and clinical results reported in this paper are equal to the best
results reported in the literature for patients with two or three tendon tears1,10.
Tendon failure after repair relates to many biomechanical factors, such as the
initial strength of the repair, the tension on the repair, and the quality of
the tendon and bone. None of the repairs in this series demonstrated failure of
the anchors from bone. This suggests that the structural defects were related
to failure at the tendon-suture interface. In this series, larger tears with
more severe retraction of the tendon resulted in the largest number of failures,
suggesting that the tension of the repair is a major factor associated with
failure of the tendon to remain attached to bone. Early failure of the repair
will not allow for sufficient time to achieve an increase in mechanical
strength of the repair by the deposition of new tissue. An opportunity to
achieve better results may exist through the use of improved methods of
fixation of the repair by augmentation of the tendon with a graft material11,
better methods to protect the repair against high tensile loads after surgery,
or growth factors to accelerate the rate or quality of the healing process12.
All of these methods to enhance the mechanical and biologic potential of these
tendons to heal after surgical repair are active areas of research in preclinical
and clinical trials11,12.
In summary, this paper provides excellent clinical
information because it is a well-documented, well-defined clinical case series.
It thereby provides sufficient clinical data, as a historical control, for
developing the study design criteria of a clinical trial to evaluate the
efficacy of any new method of cuff repair when using this surgical technique
for this type of tear.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505-15.
2. 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.
3. Klepps S, Bishop J, Lin J, Cahlon O, Strauss A, Hayes P, Flatow EL. Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med. 2004;32:1716-22.
4. 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;15:290-9.
5. Ide J, Maeda S, Takagi K. A comparison of arthroscopic and open rotator cuff repair. Arthroscopy. 2005;21:1090-8.
6. Warner JJ, Higgins L, Parsons IM 4th, Dowdy P. Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2001;10:37-46.
7. Kreuz PC, Remiger A, Erggelet C, Hinterwimmer S, Niemeyer P, Gächter A. Isolated and combined tears of the subscapularis tendon. Am J Sports Med. 2005;33:1831-7.
8. 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.
9. Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2004;13:333-7.
10. Flury MP, John M, Goldhahn J, Schwyzer HK, Simmen BR. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): when is a repair indicated? J Shoulder Elbow Surg. 2006;15:659-64.
11. Rodeo SA. Biologic augmentation of rotator cuff tendon repair. J Shoulder Elbow Surg. 2007;16:S191-7.
12. Aurora A, McCarron J, Iannotti JP, Derwin K. Commercially available Extracellular Matrix materials for rotator cuff repairs:state of the art and future trends. J Shoulder Elbow Surg. 2007;16:S171-8.
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