Saturday, January 5, 2013

Rotator cuff repair, what matters?

Outcome of single-tendon rotator cuff repair in patients aged older than 65 years.

This is minimum two year followup of 44 out of 58 patients aged older than 65 years with reparable supraspinatus tears. 22 underwent primary open repair via a superolateral approach with detachment of the deltoid, a biceps tenodesis, anterolateral acromioplasty, and a cuff repair using a transosseous technique. 36 patients had an arthroscopic repair with a biceps tenotomy, an anterolateral acromioplasty, and a single-row mattress suture technique. The postoperative rehabilitation included an abduction brace at 45" for 6 weeks with passive range-of-motion exercises initiated on the first postoperative day. Active range of motion with the elbow fully flexed was allowed after 6 weeks and with the elbow extended at 12 weeks. Strengthening exercises were not allowed for 3 months after surgery.

In spite of the dramatic differences in surgical technique, neither the structural nor the clinical results of repair were significantly different between the open and arthroscopic groups. Ultrasonography revealed intact repairs in 31 shoulders. Of the 17 open repairs, 3 had not healed; 5 of 27 arthroscopic repairs had not healed.

The mean Constant score improved for both healed and unhealed repairs; the mean score was better for healed repairs than for nonhealed repairs. Though not statistically significant, dominance, cortisone injection, smoking, and tendon retraction appeared to favor nonhealing as shown in the figure prepared from their data.

In is of interest that these results are virtually identical to those Harryman presented on our open repairs in 1991.  In both series there was a one in five chance of a recurrent defect by ultrasound at over two years followup after repair of a single tendon tear. This underscores our observation that the outcome of rotator cuff surgery has more to do with the quality of the tendon and the overall health of the patient than the technique of repair.

It is also of interest that the authors emphasize that easy to discern preoperative factors may be clinically useful predictors of the prognosis for achieving a durable repair. This study shows that carefully selected patients over the age of 65 with single tendon supraspinatus tears can obtain good clinical and anatomical results.

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