The high rate of failure of rotator cuff repair and its detection by ultrasonography

Recurrent rotator cuff tear: is ultrasound imaging reliable?

These authors state that failure of rotator cuff rotator cuff repair is common and a major cause of postoperative pain. "Retear rates are approximated at 7% to 17% for small  tears and up to 41% to 94% for large and massive tears."

These authors retrospectively analyzed the data of 39 patients with shoulder pain after arthroscopic rotator cuff repair who had subsequently undergone shoulder sonography, followed by revision arthroscopy.

Sonography was performed by a single experienced shoulder surgeon, who has performed  an average of 30 shoulder sonographic examinations per week for more than 20 years. A Sonosite 180 linear 3- to 11-MHz transducer was used with the depth adjusted to accommodate for differences in soft-tissue mass among the patients with ranges between 3 and 5 cm. 

A rotator cuff retear was found on sonography 21 patients (54%) and on revision arthroscopy in 26 patients (67%). Sonography showed a sensitivity of 80.8% and specificity of 100% in the diagnosis of rotator cuff retears. If partial rehears were excluded, the  sensitivity was 94.7%, and the specificity was 100%.

Comment: Since our original report in 1988 (Sonography of the Postoperative Shoulder (see this link), sonography has been used as cost-effective method for assessing shoulders for failure of rotator cuff repairs.
This study compares sonography to the gold standard of arthroscopic inspection, rather than to MRI.
MRI has been shown to have 84% sensitivity and 87% specificity in detecting recurrent rotator cuff tears in one study and  91% sensitivity and 25% specificity in detecting recurrent tears in another.

In assessing the outcomes of the large number of rotator cuff repairs that are carried out each year, it is essential that imaging of the repair at followup be carried out both in those patients who are improved and those who are not so that we can determine the role cuff integrity plays in the outcome.

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How much money should we spend on imaging rotator cuffs?

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears

These authors sought to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon tear using formal cost-effectiveness analysis. They used a decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected supraspinatus tear to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI.

Their results shown below show a 0.8% increased effectiveness for MRI which costs 16.5% more than ultrasound.

Comment:  What's really interesting in this paper is the first two sentences of the introduction. "Rotator cuff tears are a common source of shoulder pain, especially for older patients, and full-thickness tendon tears have been reported in up to 21% of the general population. Surgical treatment for rotator cuff disease has increased 238% during a span of 14 years (1995-2009), accounting for approximately 250,000 operations in the United States per year."

In 2012 the Unites States population of individuals over the age of 65 years was 41,506,000 (see this link). From these numbers it can be estimated that there are 8,716,200 individuals (21% times 41,506,000) with cuff tears, but less than 3% (250,000 divided by 8,716,200) of these receive surgery each year. One must ask, "how important is imaging in the decision to perform surgery, what percent of the population should have ultrasound or MRI to evaluate cuff integrity?" The reader can do the math of multiplying the cost of imaging by the number of folks at risk for having cuff tears.

The decision to attempt a cuff repair on a patient needs to be highly individualized. Shared patient-surgeon decision making needs to be based on findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without ultrasound or MRI. We first published these guidelines in 1994 and have found them as useful today as back then. Note that the decision is based on considering the patient as well as the shoulder.

ENCOURAGING                                    DISCOURAGING

History 
Age less than 55                                        Age over 65
Acute traumatic onset                                Insidious, atraumatic onset
No relation to work                                   Attribution of tear to work
Short duration of weakness                       Weakness over 6 weeks
No history of smoking                               Many smoking pack-years
No steroid injections                                  Repeated steroid injections
No major medications                                Steroids/antimetabolites
No concurrent disease                                Inflammatory joint disease
No infections                                              History of previous infection
No previous shoulder surgery                     Previous cuff surgery
Benign surgical history                               History of failed tissue repairs

Physical Examination 
Good nutrition                                             Poor nutrition/obesity
Mild weakness                                            Severe weakness
No spinatus atrophy                                    Severe spinatus atrophy
Stable shoulder                                           Anterior superior instability
Intact acromion                                           Previous acromioplasty
No stiffness                                                 Stiffness

Radiographs 
Normal radiographs                                    Upwards head displacement
                                                                    Cuff tear arthropathy

MRI or Ultrasound 
Good tendon quality                                   Thin tendon
One tendon tear                                          Multiple tendon involvement
Small gap to close                                       Severe retraction

In our practice, we are depending less and less on rotator cuff imaging and more and more on the factors that can be discerned from a good history, physical examination, and plain radiographs.


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Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Rotator cuff tears - comfort and function are unrelated to cuff integrity in asymptomatic shoulders

Prevalence of asymptomatic rotator cuff tear and their related factors in the Korean population.

These authors investigated 486 volunteers (70.4% female; mean age, 53.1; range, 20-82 years) without any shoulder symptom complaints. Background data, medical history, clinical self-assessment, and physical examination were recorded.

Cuff integrity was evaluated by ultrasound.Below are the ultrasound images of an intact cuff (a), partial tear (b), and full thickness tear (c).

Full thickness tears (FTRCT) were found in 23 subjects (4.7%) but only in those aged ≥49 years. Subjects aged 50-59, 60-69, and ≥70 years of age had FTRCT prevalence rates of 3.5%, 13.3%, and 11.1%, respectively. The prevalence of FTRCTs was higher in subjects with diabetes (P = .042) and a smoking history (P= .002), but no differences were noted for the presence of thyroid disease (P = .051).

The comfort and function of the shoulders were essentially independent of the cuff integrity (data from authors' Table V):

Comment: In this series of 486 volunteers without any shoulder complaints, the comfort and function were not affected by the integrity of the cuff. This again points to the observation that full and partial thickness cuff tears can be asymptomatic.

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MRI versus Ultrasound in the assessment of the rotator cuff prior to shoulder arthroplasty - are either necessary?

Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty.

These authors suggest that prior to implantation of shoulder prostheses,  imaging techniques

routinely include plain X-rays and computed tomography (CT) for the assessment of the osseous structure whereby magnetic resonance imaging (MRI) is used to evaluate the soft tissues, especially the integrity of the rotator cuff and its degree of fatty degeneration.

In this study, they compared the accuracy of ultrasound to 3 T Tesla MRI for the detection of rotator cuff and long biceps tendon pathologies before joint replacement in 45 patients.

Using MRI as a reference the accuracy of ultrasound was

91% for the supraspinatus tendon

84% for the infraspinatus tendon

78% for the subscapularis

87% for the long biceps tendon

Comment: As pointed out in a prior post, there seems to be a tendency to overimage shoulders prior to arthroplasty resulting in the expenditure of time and money and radiation without changing the surgery or the outcome. In our practice history, physical examination, and standardized x-rays are sufficient to provide the necessary preoperative information necessary to plan surgery in almost all cases.

With respect to the use of sonography to evaluate the rotator cuff, we presented this method back in 1988, long before the current high quality instruments became available. We compared our findings to the surgical findings in 90 shoulders, finding the overall accuracy to be 95%. In our hands, sonography is best performed by the surgeon because only the surgeon can (1) include sonography as a part of the physical examination, (2) direct the examination to the elements of importance, (3) interpret the findings in light of the other information regarding the shoulder and (4) use the sonographic images to inform the patient of the shoulder pathology.

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Assessing rotator cuff integrity - MRI and Ultrasound

Assessment of rotator cuff repair integrity using ultrasound and magnetic resonance imaging in a multicenter study.

These authors sought to compare ultrasound and magnetic resonance imaging (MRI) evaluation of the repaired rotator cuff to determine concordance between these imaging studies in 113 shoulders having repair with the suture bridge technique for rotator cuff tears that were between 1 and 4 cm wide.

They concluded that there was a good degree of  concordance between MRI and ultrasound readings if the individual reading the sonogram was experienced.

Comment: Unfortunately, this study does not provide data on the integrity of the cuff repairs. It would have been most interesting to see how many of the 113 cuff repairs were intact at the different time points.

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Rotator cuff repair - post operative ultrasound

Ultrasound changes after rotator cuff repair: is supraspinatus tendon thickness related to pain?

This is a most interesting study demonstrating the ability of modern shoulder ultrasound (linear ML6-15 MHz transducer) to reveal anatomic details of the rotator cuff after surgery. The authors determined tendon thickness, thickness of the bursa, width of the footprint, tendon vascularity, and capsular thickness after rotator cuff repair, and attempted to correlate supraspinatus tendon thickness with pain in fifty-seven patients having arthroscopic cuff repair of torn supraspinatus tendons.

The postoperative rehabilitation program consisted of six weeks immobilization in a sling with an abduction pillow along with mobilization exercises. Strengthening started at six weeks. 

According to ultrasound imaging, the re-tear rate in this study was 8/57 (14%) at 6 months postoperation. Four patients re-tore their tendons at 6 weeks and 4 retore at 3 months.  In 2 patients having revision surgery for suspected re-tears, intra-operative findings did not correlate with that of ultrasound. The primary repairs were intact in both patients. 

Sequential ultrasounds revealed that repaired tendon thickness remained unchanged, bursal thickness decreased,  anatomical footprint increased, tendon vascularity decreased, and posterior capsule thickness decreased over the six months of the study. Pain did not correlate strongly with tendon thickness.

This investigation revealed the progressive changes in the shoulder after cuff repair as revealed by modern ultrasound.




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Does cuff integrity of cuff repair matter?

Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination

These authors evaluated the functional outcomes and the repair integrity by ultrasound at a minimum of 2 years after a double-pulley suture bridge rotator cuff repair. After surgery patients wore an abduction brace for 6 weeks.

The overall retear rate was 19.5% (50% for massive tears, 18% ( for large tears, 17% for medium tears, and no failures for small tears).  Seventy-five percent  of retears were identified within 6 months after operation and 25% were identified more than 1 year after repair. The functional outcomes of the intact group and the retear group were not different according to the ASES score, the Constant score, the KSS, and the UCLA score.

The authors concluded that the outcome improved independent of the tear size and the cuff integrity. This result is very similar to those shown here, here, here, here, here, here, and here.

Here is a plot of their data comparing Constant Scores for intact and retorn repairs.

While there is much discussion about the relative value of single row, double row, triple row, double-pulley, and transosseous equivalent repairs, the results of these studies that show little difference between intact and retorn repairs pose the question: "what is it about cuff surgery that leads to improved function?".

See also the evidence supporting the idea of stress relaxation after cuff repair.

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Intraoperative Determinants of Rotator Cuff Repair Integrity

Intraoperative Determinants of Rotator Cuff Repair Integrity

This is an individual surgeon experience with 500 arthroscopic cuff repairs evaluated for integrity by ultrasound at 6 months. The best predictor of cuff repair integrity at followup was the size of the tear being repaired as shown in the chart below. Patient age was the next best predictor of integrity. Tendon quality and mobility and repair quality were much less influential on the result.

This study provides valuable information that we can use in our preoperative discussions with our patients, weighing out the different possible approaches for management of cuff tears.  Important to remember that 6 month is early in the recovery of cuff repairs - it is likely that the failure rate would be higher with longer periods of followup.

It would have been more informative if the authors had included clinical outcomes along with their integrity data so the relative influence of integrity on clinical outcome could be determined.

It would have also been of interest to know whether the acuity of the tear had in influence on the outcome (i.e. is the prognosis for acute large tears the same as for chronic large tears?).

Nevertheless, the authors are commended on a robust study design and analysis: "During the study period (between January 2006 and February 2009), 722 rotator cuff repairs were performed. Of these, 667 repairs were performed using the Opus Magnum knotless anchor. A total of 167 patients were excluded on the basis of the exclusion criteria: 14 patients were excluded because of previous shoulder surgery or redo of rotator cuff repair, 22 were excluded for incomplete or partial cuff repairs, 38 were excluded for moderate to severe osteoarthritis of the shoulder, 10 were excluded for isolated subscapularis repair, 1 patient was excluded because of a greater tuberosity fracture, and 82 patients were excluded because they were lost to follow-up or no ultrasound was performed at 6 months. The remaining 500 patients form the study cohort."

As we've suggested in a previous post, so much of what influences the outcome of cuff surgery can be determined without worrying about fatty infiltration on MRI.

We also note that these 6 month retear rates are virtually identical to those reported with other methods of repair, so that the tear size rather than the repair method may be the key determinant of the integrity outcome.

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Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. JSES

Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. JSES

It is always wonderful to have Level I studies in orthopaedics; congratulations to the authors. This study  includes 68 patients with average age of 63 with isolated supraspinatus tears repaired arthroscopically ('transosseous equivalent'). The patients were randomized to either a rehabilitation program that included early passive elevation by a therapist three times a week with home pendulum exercises starting on postop day 2  or a delayed group that had no formal PT for 6 weeks, but did do pendulum exercises for the first six weeks.

The SST scores for the early motion group improved from 5.5 to 11.1 while the scores for the delayed group improved from 5.1 to 11.1. The authors used a value of 2 for the minimal clinically important difference for the SST.

By ultrasound, 8 (12%) of the shoulders had recurrent tears at an average of 12.2 months after surgery with no significance difference between the two different rehab groups. This is consistent with the results previously reported by Harryman et al at 5 years after repair.  Interestingly, three patients were unsatisfied with their result, one of which had an intact repair by ultrasound. The six patients other patients with recurrent tears had satisfactory outcomes with an improvement of the SST from 5.2 to 11.1 (the same as the result of the intact repairs.

So, again we see that (1) even for relatively small (one tendon) tears, one in eight repairs were not intact at a year, (2) patients with recurrent tears can achieve the same level of self-assessed comfort and function as those with intact repairs, and (3) an intact repair does not necessarily mean that the comfort and function of the shoulder is restored.

With respect to the rehab, this study does not seem to provide justification for the expense of formal physical therapy in the first six weeks after cuff repair.

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A Comparison of Outcomes After Arthroscopic Repair of Partial Versus Small or Medium-Sized Full-Thickness Rotator Cuff Tears - JBJS

 rotator cuff disease, and rotator cuff surgery

A Comparison of Outcomes After Arthroscopic Repair of Partial Versus Small or Medium-Sized Full-Thickness Rotator Cuff Tears - JBJS

Over two decade ago, Harryman et al found that 80% of repairs of cuff tears confined to the supraspinatus were intact by ultrasound. The 2012 JBJS paper, using modern arthroscopic repair methods found that 80% of supraspinatus-only tears were intact by ultrasound at 24 months after surgery. Are we getting better or not?  

Unfortunately, the authors did not compare shoulder function in the retear group with that of the cuff intact group.

These authors found that on reexploration, "all retears had occurred by sutures pulling through the tendon", speaking to tendon quality as a major determinant of the durability of repair. Of interest is that the retear rate was 10% at 6 months and that it was twice that at two years after surgery, suggesting that a 'healed' tear may not be as strong as we would wish.

The authors compared the results of repair of full thickness supraspinatus tears to the results of partial thickness tears of the supraspinatus which were converted to full thickness tears and subsequently repaired. The retear rate in these surgically created full thickness tears was half that of the shoulders presenting with full thickness tears, although these differences were not statistically significant. 

Of interest is that postoperative stiffness was noted in half of the shoulders at six weeks after surgery and progressively improved over the subsequent 6 months. 

Of final note is that in this group of patients with repairs of small cuff tears,  the ASES scores were only 75% of normal at 24 months, the supraspinatus strength only 70% of normal,  and the overall shoulder function rated by the patients was on average only 'fair' at 24 months.

Thus, in spite of much work on refining the treatment of rotator cuff disease, we still fall short of the goal of restoring the shoulder to its pre-injury condition.

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Diagnostic Performance and Reliability of Ultrasonography for Fatty Degeneration of the Rotator Cuff Muscles JBJS

 rotator cuff disease, and rotator cuff surgery

Diagnostic Performance and Reliability of Ultrasonography for Fatty Degeneration of the Rotator Cuff Muscles - JBJS

We use basic criteria for estimating the reparability of rotator cuff tears. When we perform cuff surgery, we always assure that the patient understands that repair will only be done if quality tendon can be reapproximated to the normal attachment site without undue tension. Such criteria as the age of the patient, the age of the tear, the degree of trauma that caused the tear, the health of the patient, smoking vs non smoking, the degree of weakness and the presence or absence of upward displacement of the humeral head provide a huge amount of information on cuff reparability. In cases where reparability is uncertain or when the shoulder demonstrates substantial subacromial crepitance, we will offer the patient a surgical exploration through the benign 'deltoid-on' approach and then, based on the quality and mobility of the torn tendon perform a repair or a 'smooth and move' procedure. For us, the degree of 'fatty infiltration' does not influence our decision making as much as the observations listed above.

 Others, however, prefer to base their patient management on imaging criteria.  In this article from Wash U, which specializes in high quality shoulder ultrasonography, the authors compared in a rigorous manner the degree of fatty degeneration seen on MRI (by four independent raters) with that seen by sonography (by one of three radiologists).  There was a high degree of agreement for the supra and infraspinatus and moderate agreement for the teres minor.

What is curious about this study is that while all were initially thought to have cuff tears, the shoulders included in this study had a variety of diagnoses such as tendinitis, labral tears, frozen shoulders, osteoarthritis, tuberosity contusions,  biceps tendinitis, pectoralis major tendinits, etc.  It is even more curious that the authors did not correlate the degree of fatty degeneration by MRI and ultrasound with the characteristics of the cuff (tear or not, size of tear, chronicity).

So we must ask, what factors drive surgical decision making for patients with cuff disease? How important is 'fatty degeneration' in choosing treatment?  If a young patient with a small tear had fat in the supraspinatus, would that preclude repair? Just wondering...

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Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff tears in the general population. JSES

A few days ago, we posted comments on the growing incidence of cuff repairs in the US. In consideration of this escalating rate of surgeon on rotator cuffs, the recent JSES article
Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff tears in the general population. is of importance. The authors found that in a Japanese mountain village, 283 shoulders in 211 individuals had cuff tears by ultrasonography. Of these 283 shoulders, 65% had no shoulder symptoms, that is no pain or disability in performing their usual daily activities within the two weeks prior to the study.

We made a graph showing the cuff tears by age along with the number that were without symptoms.

The bottom line is that we probably should base our indication for cuff surgery on the Mallory Justification ("because it's there") - you know how he wound up!

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