Patient selection
From January 2013 to January 2014, 92 patients in our institution underwent arthroscopic double-row suture bridge repair for the treatment of full- thickness rotator cuff tear 55 patients who completed the 5 years follow- up were enrolled in this study. There were 36 female and 19 male patients, the average age was 58.6 years (range, 41–70 years). The tears were classified into small (< 1 cm), medium (1–3 cm), large (3–5 cm), and massive (> 5 cm) according to the classification of DeOrio and Cofield. According to the intraoperative measurement, small tears were found in 5 shoulders (9%), medium tears in 19 (34.5%), large tears in 23 (41.8%), and massive tears in 8 (14.5%). The mean follow-up was 71.2 months (range, 66–78 months).
Inclusion and Exclusion Criteria
Inclusion criteria of the study were as follows: (1) only one shoulder was involved; (2) patients were older than 20 but younger than 70; (3) there was full thickness tear of the rotator cuff; (4) AHI was greater than 7 mm and GH joint line was well-maintained; (5) the grade of Goutallier fatty infiltration was less than or equal to grade II, (6) the tendon length was greater or equal to 15 mm, (7) the patients had full PROM under anesthesia, (8) the patients experienced persistent symptoms for more than 6 months even after adequate conservative treatment.
Exclusion criteria of the study were as follows: (1) concomitant with shoulder instability, fracture, labrum pathology and shoulder stiffness, (2) past surgical history of Ipsilateral shoulder, (3) impairment of the shoulder function due to neuropathy, (4) scar diathesis.
Surgical Technique
All of the operations were performed by a single senior surgeon (L.Z.) with the patient under general anesthesia combined with interscalene block in the lateral decubitus position. After diagnostic glenohumeral arthroscopy, acromioplasty was conducted when osteophytes were found under the acromion, or when the type of acromial shape was III. Subsequently, the rotator cuff tendon was débrided, and the footprint was prepared.
Arthroscopic cuff repair was performed using the knot-tying double-row suture-bridge technique. One or two 4.5 mm Healix PEEK anchors (DePuy Mitek, Raynham, MA, USA), depending on the tear size (Figure1), loaded with 2 No. 2 Orthocord sutures, were inserted in the medial side of the cuff footprint of the humeral head. Sutures were passed through the cuff tendon tissue 2mm laterally from the muscle- tendon junction and tied in a horizontal mattress fashion. To establish the lateral row, the suture limbs of the medial-row anchor were crossed over the tendon and fixed laterally by 2 knotless anchors (Versalock; DePuy Mitek, Raynham, MA, USA). Lateral anchors were then inserted perpendicular to the cortical surface of the humerus 5 to 10 mm distal- lateral to the lateral edge of greater tuberosity.
Postoperative Rehabilitation
Patients were placed in a sling with an abduction pillow. The sling was worn continuously for 6 weeks. Cryotherapy was used for pain relief and for reducing the inflammatory reaction. Active elbow flexion and extension, active forearm supination and pronation, and active hand and wrist motions were encouraged on day 1 post operation. For large tears, the shoulder was immobilized for the first 3 weeks, and then the passive range of motion was initiated. For massive tears, the shoulder was immobilized for 6 weeks, and then the passive range of motion was initiated. After 6 weeks, the brace was removed, and active range of motion was initiated. For large to massive tears, the active range of motion was delayed. After 3 months, active resistance muscle- strengthening exercises begun. The patients could perform full activity 6 months after the operation, taking individual differences into consideration.
Clinical and radiologic evaluation
Clinical assessment: At baseline and final follow-up, shoulder functional outcomes were measured using validated, shoulder-specific outcome scores including the Constant-Murley score (CS), and the American Shoulder and Elbow Score (ASES).
Radiologic evaluation: The postoperative repair integrity was analyzed with use of US by two experienced musculoskeletal radiologists. The classification system developed by Barth[2], comparable to Sugaya[20] MRI integrity classification, was used: Type I indicated a repaired cuff that had sufficient thickness (> 2 mm) with normal echostructure as normal ten- don hyperechoic and fibrillar on each image。Type II indicated a repaired cuff that had sufficient thickness (> 2 mm) associated with a partial hypo-echo-genicity or heterogenicity; Type III indicated a repaired cuff that had insufficient thickness (< 2 mm) without discontinuity; Type IV indicated the presence of a minor full-thickness discontinuity of which borders are visible, suggesting a small tear; and Type V indicated the presence of a major discontinuity of which the medial border is not visible under the acromial arch, suggesting a medium or large tear. Sugaya I-III indicated cuff healing, and Sugaya IV or V indicated retear.
Cho[5] et al. described two types of retear patterns after rotator cuff repair according to postoperative MRI: type 1, if the cuff tissue repaired at the insertion site of the rotator cuff was not observed to be remaining on the greater tuberosity; and type 2, if the remnant cuff tissue remained at the insertion site despite the retear. In our study, we evaluated the retear patterns via postoperative US.
Shoulder scaption strength assessment: Shoulder scaption strength was evaluated with the use of a weighing scale proposed by Collin[6] et al. Scaption strength of both shoulders were measured by one physician with the same weighting scale (accuracy: 0.5 Kg) (results expressed by Kg). The difference between the 2 shoulders was calculated as the basis for evaluation.
Statistical Analysis
SPSS 25.0 (SPSS Inc, Chicago, Illinois) was used for statistical analysis. Normal distribution data and non-normal distribution data were assessed by mean plus or minus the standard deviation (x ± s) and median(M).
The differences between pre- and postoperative mean Constant scores and ASES scores were analysed using the Wilcoxon rank sum test. A P-value less than 0.05 was considered to be a significant difference.
Patients were categorized into two separate groups, using Sugaya classification and corresponding percentages of preoperative rotator cuff tear size. Patients with Sugaya I-III indicated cuff healing and were classified into the healing group. Conversely, patients with recurrent tear were classified into the retear group. Postoperative Constant scores and ASES scores were determined significant by Student’s test between the two groups. The Mann– Whitney U test compared muscle strength differences between the two groups. If the test results were P < 0.05, the difference in data between the groups was considered statistically significant.