Monday, June 29, 2015

Rotator cuff tears - how do they heal: the role of vascularity at the footprint

Does microvascularization of the footprint play a role in rotator cuff healing of the shoulder?

These authors sought to evaluate the relationship between bone microvascularization of the footprint and tendon integrity after a single-row repair of chronic cuff tears in 48 patients (mean age, 59 years; ±7.9). Microvascularization was assessed using immunohistochemistry on core samples obtained from the footprint area of the tuberosity during the procedure. Clinical evaluation was performed at a minimum of 12-months; rotator cuff integrity was assessed with ultrasound.

Ultrasound identified 18 patients with Sugaya type I healing, 27 patients with type II healing, and 3 patients with retears (Sugaya type IV). The rate of microvascularization of the footprint was 15.6%, 13.9%, and 4.2% for type I, II, and IV tendon integrity, respectively (I vs. II, P = .22; II vs. IV, P = .02; I vs. IV, P = .0022). Patients with a history of corticosteroid injection had a lower rate of microvascularization than the others (10.3% vs. 16.2%; P = .03).

They concluded that a lower rate of microvessels decreases the tendon integrity and healing potential after repair.

Comment: This paper emphasizes the important role that vascularity of the bone at the insertion site plays in healing of a rotator cuff repair. Because of the relatively poor vascularity at the edge of a torn rotator cuff tendon, it appears likely that the healing response - notably the ingrowth of micro vessels as well as stem cells and growth factors - comes from the bone at the insertion site. This response would seem to be enhanced by burring the bone, micro fracture or creating a trough at the insertion site. One might also expect that the use of cautery to clean the insertion site may result in poorer healing.

The adverse effect of subacromial corticosteroid injections on the microvascularization at the footprint is worthy of note. This is consistent with the known effects of steroids on tissue quality.

The number of retears in this study was small and did not offer the opportunity to statistically correlate patient age, tear duration, tear size, sex and other factors with footprint vascularity.


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