Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?

doi:10.1016/j.jse.2011.05.027

Journal of Shoulder and Elbow Surgery

Volume 21, Issue 7, July 2012, Pages 859-866

https://doi.org/10.1016/j.jse.2011.05.027 Get rights and content

Background

Some studies have shown that rotator cuff tendon (RCT) retears occur early after surgery and ultimate failure strength is reached at between 3 and 6 months. However, few clinical studies have been reported to support their theory. The purpose of this study was to determine whether the RCT integrity after repair showed any difference at 6 months and at 19 months postoperatively.

Methods

Thirty-one patients who underwent complete repair for full-thickness RCT tears that were medium-sized tears or larger and had 2 postoperative follow-up magnetic resonance imaging (MRI) scans were included in this study. Retear, fatty degeneration, and muscle atrophy were evaluated during the first and second MRI sessions. Clinical assessment was performed by use of the American Shoulder and Elbow Surgeons score, Constant score, and pain visual analog scale preoperatively and at the time of the first and second MRI scans.

Results

The mean time for the two consecutive MRI scans was 5.9 months (range, 3.1-8.3 months) and 19.7 months (range, 10.1-24.3 months). On the first MRI scans, 24 patients had no retear, 5 had partial retears, and 2 had full-thickness retears. In terms of rotator cuff retears, the 2 sets of MRI scans showed exactly the same statuses. The only statistically significant improvement was a reduction in tendinosis on the second MRI scans. In addition, significant improvements in clinical status were observed between the 2 periods.

Conclusion

Our study shows that the structural status of RCTs after arthroscopic repair can be assessed at 6 months after surgery. Furthermore, although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged.

Section snippets

Patient selection and clinical assessment

From April 2006 to October 2009, arthroscopic rotator cuff repairs were performed for partial- and full-thickness rotator cuff tears in 388 patients at our institution. Our inclusion criteria were (1) full-thickness rotator cuff tear that was medium in size or larger and was repaired with suture anchors, (2) complete repair, and (3) the availability of 2 sets of serial postoperative follow-up MRI scans. There were 221 full-thickness tears that were medium in size or larger. Among them, complete

Structural results

Preoperatively, 26 had a medium-sized tear and 5 had a large-sized tear according to the classification of Post et al²⁰ (Table I). On the first postoperative MR images, 4 patients had a type I retear, 20 had a type II retear, 5 had a type III retear, 1 had a type IV retear, and 1 had a type V retear.²² On the second postoperative MR images, 14 patients had a type I retear, 10 had a type II retear, 5 had a type III retear, 1 had a type IV retear, and 1 had a type V retear. A statistically

Discussion

Our results show that rotator cuffs either regain integrity or retear within 6 months of surgery and that they maintain the same status at 19 months postoperatively but that clinical outcomes improve irrespective of postoperative cuff status. This study is the first clinical study performed to date that supports the notion that the rotator cuff either heals or retears within 6 months of repair.9, 17, 25 Furthermore, this study is the first to report the short-term serial follow-up of repaired

Conclusion

Our findings show that the structural status of rotator cuff tendons after arthroscopic repair can be assessed at 6 months after surgery. Furthermore, although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged.

Acknowledgments

The authors give special thanks to Hang Seok Choi, PhD, for statistical analysis.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

References (30)

J. Bishop et al.
Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study
J Shoulder Elbow Surg
(2006)
E. Buess et al.
Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases
Arthroscopy
(2005)
B. Fuchs et al.
Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging
J Shoulder Elbow Surg
(1999)
H.B. Knudsen et al.
Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction
J Shoulder Elbow Surg
(1999)
H.K. Uhthoff et al.
Tensile strength of the supraspinatus after reimplantation into a bony trough: an experimental study in rabbits
J Shoulder Elbow Surg
(2002)
J.C. Yoo et al.
Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage
Arthroscopy
(2009)
J.C. Yoo et al.
Correlation of arthroscopic repairability of large to massive rotator cuff tears with preoperative magnetic resonance imaging scans
Arthroscopy
(2009)
P. Boileau et al.
Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?
J Bone Joint Surg Am
(2005)
T. Colegate-Stone et al.
An analysis of outcome of arthroscopic versus mini-open rotator cuff repair using subjective and objective scoring tools
Knee Surg Sports Traumatol Arthrosc
(2009)
L.M. Galatz et al.
The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears
J Bone Joint Surg Am
(2004)

D.F. Gazielly et al.

Functional and anatomical results after rotator cuff repair

Clin Orthop Relat Res

(1994)

C. Gerber et al.

The results of repair of massive tears of the rotator cuff

J Bone Joint Surg Am

(2000)

C. Gerber et al.

Experimental rotator cuff repair. A preliminary study

J Bone Joint Surg Am

(1999)

D. Goutallier et al.

Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan

Clin Orthop Relat Res

(1994)

D.T. Harryman et al.

Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff

J Bone Joint Surg Am

(1991)

Cited by (49)

Healthcare costs of failed rotator cuff repairs
2023, JSES Reviews, Reports, and Techniques
The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States.
A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period.
The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure.
The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.
Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.
The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis
2023, Journal of Shoulder and Elbow Surgery
Structural integrity after rotator cuff repair is frequently not achieved, but the clinical consequences of a retear remain disputed. The purpose of this meta-analysis was to analyze the relationships between postoperative cuff integrity and shoulder pain and function.
We searched the literature for studies of surgical repair of full-thickness rotator cuff tears published after 1999 describing rates of retear and clinical outcomes and providing sufficient data to estimate effect sizes (standardized mean differences [SMDs]). Baseline and follow-up data of healed and failed repairs were extracted, including shoulder-specific scores, pain, muscle strength, and health-related quality of life. Pooled SMDs, mean differences, and overall change from baseline to follow-up according to structural integrity at follow-up were calculated. Subgroup analysis was performed to assess the influence of study quality on differences.
This analysis included 43 study arms with 3350 participants. The average age of the participants was 62 years (range, 52-78 years). The median number of participants per study was 65 (interquartile range, 39-108). At a median of 18 months’ follow-up (interquartile range, 12-36 months), 844 repairs (25%) were described as retorn on imaging. The pooled SMD between healed repairs and retears at follow-up was 0.49 (95% confidence interval [CI], 0.37 to 0.61) for the Constant-Murley score, 0.49 (95% CI, 0.22 to 0.75) for the American Shoulder and Elbow Surgeons score, 0.55 (95% CI, 0.31 to 0.78) for other shoulder-specific outcomes combined, 0.27 (95% CI, 0.07 to 0.48) for pain, 0.68 (95% CI, 0.26 to 1.11) for muscle strength, and –0.001 (95% CI, –0.26 to 0.26) for health-related quality of life. The pooled mean differences were 6.12 (95% CI, 4.65 to 7.59) for the Constant-Murley score, 7.13 (95% CI, 3.57 to 10.70) for the American Shoulder and Elbow Surgeons score, and 0.49 (95% CI, 0.12 to 0.87) for pain, all below the commonly suggested minimal clinically important differences. The differences were not significantly affected by study quality and were generally modest compared with overall improvements from baseline to follow-up for both healed and failed repairs.
The negative impact of retears on pain and function was statistically significant but judged to be of minor clinical importance. The results indicate that most patients may expect satisfactory outcomes despite retears.
Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique
2023, JSES International
We have tried to create hematoma over the footprint site at the end of arthroscopic rotator cuff repair (ARCR) surgery, expecting to apply biochemical effects of the platelet-related factors. The purpose of this study was to investigate the presence of hematoma-like tissue (HLT) on postoperative magnetic resonance imaging, and to evaluate the relationship between the HLT and the structural outcomes of ARCR.
Twenty-five patients were reviewed with a mean age at surgery of 69.8 years (range, 52-85 years). Postoperative magnetic resonance imaging was performed at 1 week, 6-8 weeks, and >6 months postoperatively. Structural outcomes for the repaired cuff and thickness of HLT were evaluated on coronal T2-weighted images. Signal intensity of HLT was evaluated on coronal T2-weighted fat-suppressed images as the ratio compared to supraspinatus tendon intensity (HLT/SSP ratio).
Structural outcomes showed Sugaya type 1 in 12 shoulders, type 2 in 4, and type 3 in 9. HLT thickness was significantly thicker at 1 week and 6-8 weeks postoperatively in Sugaya type 1 patients than in type 3 patients (1 week; P = .014, 6-8 weeks; P < .001). HLT/SSP ratio gradually decreased (at 1 week; 1.9 ± 0.7, 6-8 weeks; 1.6 ± 0.6, >6 months; 1.2 ± 0.5), and differed significantly between >6 months and both 1 week and 6-8 weeks (P < .001 each).
Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged <65 years
2023, JSES International
Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.
We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients’ Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years.
There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P = .0001 and P = .25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P = .0009 and P = .1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P = .0003 and P = .1). Based on Hamada’s classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another.
Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.
Nontendinous healing after repairing of retracted rotator cuff tear: an imaging study
2021, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
This finding can be correlated to the other studies reporting only small percentages of patients, with normal signals of the tendons after rotator cuff repair and healing,3,6 and the rest mostly demonstrating increased signals that may persist even with long-term follow-up.2-4,6,17,21,22,28 Some report that the initially increased signal can persist for at least 6-9 months,21 and the retears usually occur within the first 6 months postoperation;13,16,17,22 thus, our study only included those with the follow-up MRIs that were performed at least 8 months postoperatively, to ensure that some of the vaguely intense areas were less likely to represent retears or initial inflammatory changes. Despite this effort, some patients in the direct healing type had the persistent MRI appearance of the narrow bands of altered signals, filling up the marginal space from the footprint to the reattached tendinous end under closer observation.
Follow-up magnetic resonance imaging (MRI) after rotator cuff repair can sometimes demonstrate healing with nontendinous tissue that extends from the footprint to the retracted tendon end, which is inferred as fibrous tissue formation. The aim was to investigate this particular finding and its significance.
There were 494 eligible cases of healed supero-posterior medium-sized to massive rotator cuff repairs, after the exclusion of retears. A retrospective review was performed for the 3 groups that were divided according to their MRI appearances of healing: type I described the direct healing of the tendon to the footprint, whereas type II demonstrated the distinctive continuity of nontendinous tissue from the footprint to the retracted tendinous portion, and type III also showed a similar appearance but with obvious thinning of the tissue, without any evidence of defect confirmed on the routine outpatient ultrasonograph.
Only 108 of 494 patients (21.9%) demonstrated type I healing, whereas the signs of nontendinous healing were evident for the rest, with the 116 patients (23.5%) being classified as type III with attenuation. Comparing the preoperative tendon retraction, 34.8% and 37.2% of the Patte stages 2 and 3, respectively, resulted in type III healing, which were significantly higher compared with that of stage 1 (15.3%, P < .001). Type III healing had the highest average preoperative Goutallier grades. The average postoperative visual analog scale and the American Shoulder and Elbow Surgeons (ASES) scores have improved significantly for all 3 groups (P < .05), with the ASES score being 86.1±15.9 for type I, 93.7±36.1 for type II, and 87.8±15.1 for type III without significant differences between the groups (P = .3).
Only a fifth of the rotator cuff repairs led to a direct healing to the footprint, and the rest healed with MRI appearance of nontendinous tissue formation bridging the retracted tendinous portion and the footprint. These MRI appearances did not represent the true tendinous tissue formation between the torn end of the tendon and the bone after healing. Such appearances did not seem to affect the clinical outcomes.
Shoulder stiffness after rotator cuff repair: the fate of stiff shoulders up to 9 years after rotator cuff repair
2020, Journal of Shoulder and Elbow Surgery
Stiffness and retear are 2 common complications of rotator cuff repair. McNamara et al found that postoperative stiffness was associated with lower retear rates at 6 months. This study aimed to determine if stiffness after rotator cuff repair protects the individual from retear up to 9 years after surgery.
Two groups of patients, 69 with stiff and 63 with nonstiff shoulder, who underwent arthroscopic rotator cuff repair were created based on external rotation measurements at 6 weeks postoperatively. Patients had regular follow-up assessments at 6, 12, and 24 weeks and were instructed to return for a follow-up at least 2 years after surgery. Patients were assessed for range of motion, shoulder function, strength, and rotator cuff integrity using ultrasound.
For patients with postoperative stiffness at 6 weeks, the retear rate at 6 months was 3%, whereas the rate for nonstiff patients was 19% (P = .004). This protective effect of postoperative stiffness persisted up to 9 years after surgery (P = .002). Postoperative stiffness resolved by 5 years after surgery for all measurements except external rotation (50° vs. 61°) (P = .006). Patients with postoperative stiffness had continued improvements in abduction (P < .001), internal rotation (P = .020), and all patient-ranked measurements from the 6-month follow-up to 5 years after surgery. Patients with stiff shoulder had greater overall satisfaction by the final follow-up (P = .028).
In patients experiencing stiffness after rotator cuff surgery, the repair is less likely to fail at 6 months. Although the stiffness generally resolves by 5 years, this protective effect still persists at 9 years after surgery.

View all citing articles on Scopus

: This study was approved by the Institutional Review Board of Samsung Medical Center (IRB study 2009-12-002).

View full text

Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?

Background

Methods

Results

Conclusion

Section snippets

Patient selection and clinical assessment

Structural results

Discussion

Conclusion

Acknowledgments

Disclaimer

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

J Bone Joint Surg Am

An analysis of outcome of arthroscopic versus mini-open rotator cuff repair using subjective and objective scoring tools

Knee Surg Sports Traumatol Arthrosc

The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears

J Bone Joint Surg Am

Functional and anatomical results after rotator cuff repair

Clin Orthop Relat Res

The results of repair of massive tears of the rotator cuff

J Bone Joint Surg Am

Experimental rotator cuff repair. A preliminary study

J Bone Joint Surg Am

Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan

Clin Orthop Relat Res

Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff

J Bone Joint Surg Am