Massive Rotator Cuff Tears Clinical Trial
Official title:
Do Concomitant Subscapularis Tears in Large to Massive Rotator Cuff Tears
Do concomitant subscapularis tears in large to massive rotator cuff tears affect
postoperative functional and structural outcomes?
Background and purpose:
The subscarpularis tendon is essential force maintaining normal glenohumeral biomechanics.
However, there are few studies which have addressed the outcomes of tears extending to the
subscapularis tendon in massive rotator cuff tears. The purpose of this study was to assess
the clinical and structural outcomes of arthroscopic reapair of massive rotator cuff tears
involving the subscapulrais.
MATRALS AND METHODS This retrospective comparative study was approved by our institutional
review board.
Patient Selection This study targeted patients who had undergone arthroscopic rotator cuff
repair, which was performed by a single surgeon in our institution between January 2010 and
January 2014.
The inclusion criteria were as follows: (1) a full-thickness superoposterior rotator cuff
tear larger than 5 cm(19) or complete superoposterior rotator cuff tear(24) identified on
preoperative MRI and intra operative arthroscopic findings, (2) a follow-up MRI evaluation at
6 months after surgery, and (3) a clinical assessment performed a minimum 2 years
postoperatively. The exclusion criteria were as follows: (1) small, medium, or large
tears(21); (2) a partial-thickness tear; (3) an isolated subscapularis tear; (4) failure of
subscapularis repair at the time of the index procedure; (5) previous rotator cuff surgery of
the affected shoulder; (6) concomitant surgery for glenohumeral joint instability or other
bony procedure; and (7) substantial glenohumeral arthritis (Hamada classification29 grade 4)
or inflammatory arthropathy of the affected shoulder.
Tear Classification Rotator cuff tear patterns were classified into the following 3
categories according to the tear size of the subscapularis tendon on preoperative MRI:
I-massive tear, intact subscapularis tendon; S-massive tear, tear involving half or less than
half of the subscapularis tendon; and L-massive tear, tear extending to more than half of the
subscapularis tendon.
Clinical Assessments Clinical data were recorded on the day before surgery and at final
follow-up (at least 24 months postoperatively) by fellowship trainees. Four outcome measures
were used in this study: VAS pain score, ASES score, Constant score, and active shoulder ROM.
The ASES score involves a score summation using a 100-point system (50 points for daily
function and 50 points for pain).
Radiographic Evaluation A standard set of plain radiographs was obtained as follows:
anteroposterior (AP) views in internal rotation and external rotation, supraspinatus outlet
view, axillary view, and Rockwood view (30 caudally angled AP view). We evaluated fatty
degeneration of the rotator cuff muscle preoperatively with MRI, using the 5-stage grading
system27: grade 0, no fatty deposit; 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. The integrity of
rotator cuff repair was determined by ultrasonographic evaluation. All patients underwent a
postoperative ultrasonographic examination at 4.5 months and 12 months or later after
surgery. One specialized radiologist with more than 10 years of experience in musculoskeletal
ultrasonography performed all follow-up examinations using an HDI 5000 system or an IU-22
system (both from Philips Healthcare). He did not receive any information on intraoperative
findings and subsequent operative procedures. An ultrasonographic evaluation of the rotator
cuff was performed according to the standard protocol.42 The ultrasound criteria for the
diagnosis of full-thickness rotator cuff tears were as follows5,54: (1) absence of
observation of the supraspinatus tendon attributable to retraction under the
acromioclavicular joint; (2) localized absence or focal discontinuity of the rotator cuff
with concomitant loss of the normal anterior arc of the subdeltoid bursa; (3) loss of the
normal supraspinatus substance with widening of the gap between the supraspinatus and biceps
tendons, including exposure of a bare area of bone and cartilage; (4) a hypoechoic or
anechoic cleft extending through the entire substance of the rotator cuff; and (5)
coexistence of fluid in the subacromial-subdeltoid bursa and/or presence of fluid in the
sheath of the long head of the biceps tendon. Partialthickness tears were diagnosed based on
the presence of a focal hypoechoic or anechoic defect in the tendon, involving either the
bursal or articular surface and manifesting in 2 perpendicular planes.54
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