These authors studied 103 patients with a rotator cuff tear not exceeding 3 cm who were randomly assigned to primary tendon repair or physiotherapy with optional secondary repair. Blinded follow-up was performed after 6 months and 1, 2, 5, and 10 years. Outcome measures included the Constant score and the self-report section of the American Shoulder and Surgeons Score.
Operative treatment was open or mini-open tendon repair. Following a diagnostic arthroscopy of the glenohumeral joint, the tear was exposed through a deltoid-splitting approach, and an anterior acromioplasty was performed. Tendons were mobilized and repaired by transosseous sutures. Tenodesis of the long head of the biceps was performed in patients with a partial tear of the tendon. Postoperatively, the arm was immobilized in a sling, and passive range-of-motion exercises were started and were continued for 6 weeks. Active range-of-motion exercises were started 6 weeks after the surgical procedure and were supplemented by strengthening exercises after 12 weeks.
Ninety-one of 103 patients attended the last follow-up. After 10 years, the results were better for primary tendon repair, by 9.6 points on the Constant score (p = 0.002), 15.7 points on the American Shoulder and Elbow Surgeons score (p <0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), 19.6 for pain-free abduction (p = 0.007), and 14.3 for pain-free flexion (p = 0.01). Fourteen patients had crossed over from physiotherapy to secondary surgery and had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (p = 0.03).
In 47 patients treated by primary repair, tendon integrity was assessed by MRI after 1 year and by sonography after 5 and 10 years. Full or partial-thickness retears were found in 10 (21%) after 1 year, 13 (28%) after 5 years, and 16 (34%) after 10 years. Five of the retears after 10 years were classified as partial-thickness only. A comparison of the Constant score after 10 years between the 16 patients with a retear at the last follow-up (76.9 points) and the 31 patients with an intact repair (82.9 points) showed a better result for intact repairs, with a between-group difference of 6.0 points (95% CI, 0.2 to 11.8 points; p = 0.04).
Comment: It is not known if the results with arthroscopic repairs using suture anchors are equivalent to these with open transosseous repair.
It is of interest that these structural and functional outcomes for small to medium sized tears repaired with open transosseous repairs are virtually identical to those presented by the late Douglas Harryman 28 years ago using a similar surgical technique:
It is of interest that these structural and functional outcomes for small to medium sized tears repaired with open transosseous repairs are virtually identical to those presented by the late Douglas Harryman 28 years ago using a similar surgical technique:
Repairs of the Rotator Cuff: Correlation of Functional Results with Integrity of the Cuff.
These authors evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. They correlated the functional result with the integrity of the cuff, as determined by ultrasonography.
The size of the rotator cuff defect as seen at surgery (operative type) and as seen at followup by sonography (followup type) was classified as follows:
Type 0 - intact cuff
The function of the patients who had an intact cuff after repair of a large tear was as good as that of the patients who had an intact cuff after repair of a small tear.
These authors evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. They correlated the functional result with the integrity of the cuff, as determined by ultrasonography.
The size of the rotator cuff defect as seen at surgery (operative type) and as seen at followup by sonography (followup type) was classified as follows:
Type 0 - intact cuff
Type lA - thinning or a partial-thickness defect of the supraspinatus tendon.
Type lB - a full-thickness defect of the supraspinatus tendon
Type 2 - a full thickness defect involving the supraspinatus and infraspinatus tendons'
Type 3 - a full-thickness defect involving the supraspinatus ,infraspinatus ,and subscapularis tendons.
The tear size seen at surgery was related to age at the time of repair
Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect.
Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects.
At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect.
The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation.
In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.
The function of the patients who had an intact cuff after repair of a large tear was as good as that of the patients who had an intact cuff after repair of a small tear.
Comment: This study is of interest because of the detailed correlations examined among patient age, tear size, repair integrity at five years and function at five years after surgery.
It is also of interest that this study was published in 1991, bringing up the question "are current methods of cuff repair yielding results that are equal to or superior to those achieved over 25 years ago?"
For further information on our management of cuff tears, see this PDF on rotator cuff surgery.
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For further information on our management of cuff tears, see this PDF on rotator cuff surgery.
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