Important News for Surgeons About Rotator Cuff RepairsRotator cuff tears come in all sizes from small to large. Sometimes the larger, more severe tears are referred to as massive tears. For some patients, the tears can't be repaired. But for those who are good candidates for surgery, surgeons have quite a wide range of choices when it comes to surgical approach and technique. In this report, we find out which approach and technique has the best results in terms of retear rates.
The rotator cuff is a group of four muscles and tendons that surround the shoulder joint. Together, these muscles, tendons, and their connective tissue covering keep the shoulder both stable (in the socket) and mobile (moving in all directions). A tear in any one or more of the tendons can cause pain, loss of motion, decreased strength, and reduced function.
Surgery for the shoulder has changed over the years. A wide incision and open surgery has given way now to minimally invasive procedures using arthroscopic techniques. Arthroscopic approaches can be all-arthroscopic or arthroscopic combined with a small incision called mini-open.
Even the type of sutures used has evolved from single-row repairs to double-row stitches. Among suture techniques there's the transosseous, single-row suture anchor, combined transosseous/suture anchor, double-row suture anchor, and suture bridge to choose from.
Surgeons choose the approach and the repair method based on the type of tear, size of tear, location of tear, and their own experience and expertise with repair techniques. Which method works best?
Well, that question can be measured in several different ways. The surgeon could look at patient symptoms (pain, motion, strength, function) before and after surgery to assess the results. Or, the focus could be on the time between surgery and return to full function (different speeds of recovery). In this systematic review the area of concentration was the retear rate.
Let's define a few terms here to help you understand what this means. A systematic review is done when researchers look through all the published studies for data on a particular topic. They analyze and summarize all the data collected from the studies selected. Not all studies are included because some may not be high enough quality.
In this case, the topic of interest was retear rates. Retear rates refers to how many patients who have a rotator cuff repair end up tearing the repair requiring yet another surgery. The authors were particularly interested in finding out which repair technique had the lowest retear rate.
Out of 3335 articles published on the rotator cuff 23 were appropriate for this review. Those articles included data on the type of repairs of interest (open, mini-open, or arthroscopic approach; single-row, double-row repair technique). All 23 articles included follow-up MRIs to show the amount of healing over time.
They found that the repair method did affect the structural healing rate. Specifically, the retear rate was lowest when surgeons used the double-row technique. The best results were obtained when the double-row method of repair was used for tears bigger than one centimeter. But the overall data suggests that the double-row repair method should really be used for all rotator cuff tears.
Results were the same regardless of the surgical approach (arthroscopic versus nonarthroscopic). The authors do suggest a few reasons why the double-row technique yields better results when measured by retear rates. The double-row suture improves the biomechanical performance and contact area and pressure. The double-row technique also applies less tension to the healing tissue, which is important during the rehab phase after surgery.
The authors suggest that before surgeons change from one method to another, they should be aware that there is always a learning curve when trying something new or different. Results vary until the surgeon's technique improves enough to give consistent results from patient to patient. In the case of double-row sutures, the technique requires more extensive releases of the surrounding soft tissue. Getting the right tension on the healing tissue can be a fine art.
Thomas R. Duquin, MD, et al. Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing. A Systematic Review. In The American Journal of Sports Medicine. April 2010. Vol. 38. No. 4. Pp. 835-841.
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