Do rotator cuff repairs heal?

 Non-tendinous healing after repairing of retracted rotator cuff tear- An Imaging Study

These authors note that follow-up magnetic resonance imaging (MRI) after rotator cuff repair can sometimes demonstrate healing with non-tendinous tissue that extends from the footprint to the retracted tendon end, which is inferred as fibrous tissue formation. They investigated 494 cases of superior medium- to massive-sized rotator cuff repairs that had healed as assessed by ultrasound.

MRI appearances were classified as 

Type I=direct ‘healing’ of the tendon to the footprint (22%)

See below. A T1-weighted image shows the direct ‘healing’ of the tendon end (Type 1), but a narrow band of increased signal persists between the reattached tendinous end and the bone(red arrow).

Type II=continuity of non-tendinous tissue from the footprint to the retracted tendinous  portion (54%) 

See below. A T1-weighted image shows Type II healing with the portion of ‘non-tendinous’ tissue continuity without attenuation (red arrows), with the darker/black tendinous end that seemed to have retracted medially (yellow arrow).

Type III=a similar appearance but with obvious thinning of the tissue (24%)

See below. A T1-weighted image demonstrates Type III ‘non-tendinous’ healing with attenuation of the tissues (red arrows). The darker/black tendinous end that had retracted medially is even more obvious (yellow arrow).

Comparing the preoperative tendon retraction, 34.8% and 37.2% of the Patte stages 2 and 3, respectively, resulted in Type III healing, which were significantly higher compared to that of the stage 1 (15.3%, P<0.001). 

The Type III had the highest average preoperative Goutallier grades. 

The average postoperative VAS and the ASES scores improved significantly for all three groups, with the ASES being  86 for Type I, 94 for Type II, and 88 for Type III.

The authors concluded that only a fifth of the rotator cuff repairs led to the direct ‘healing’ to the footprint, and the rest healed with the MRI appearances of non-tendinous tissue formation bridging between the retracted tendinous portions and the footprints. These MRI appearances did not represent the true tendinous tissue formation between the torn end of the tendon and the bone after the tendon had healed as assessed by ultrasound.

These findings are consistent with a prior report: Failure With Continuity in Rotator Cuff Repair "Healing" The American Journal of Sports Medicine (ASJM) published this most interesting study of 13 patients having arthroscopic cuff repairs. The repaired tendon defects were 1-4 cm full thickness tears of the supraspinatus and/or infraspinatus with less than 2 cm of retraction, i.e. these were tears that were relatively small and reparable.

At the time of the repair, tantalum markers were placed in the substance of the tendon. Post operative sequential CT scans were used to measure the distance between each marker and the suture anchor nearest to it.  This 'anchor bead distance' has been shown by the authors to have an uncertainty of +/- 3 mm on repeat positioning and rescanning of patients with cuff repairs. If this distance increases over time after surgery, it indicates separation of the marked segment of the tendon from the tuberosity in which the anchor was placed. 

The authors also obtained sequential MRIs to search for defects in the repaired tendon.

They found that the markers of all repaired tendons retracted away from the suture anchors over the first year. The average retraction was 16.1 mm with a range of 5.7 to 23.2 mm. Tendon retraction correlated with patient age. As reported previously for open repairs, most of the retraction occurred during the early phases of recovery (i.e. 12 weeks). The amount of retraction did not correlate with the Penn score or with the abduction strength. The authors, as have others, suggest  the need for protection of the repair during the early rehab period. However, it is yet to be determined which post operative protocol is ideal.

It is worth pondering why this retraction might occur. When we look a chronic cuff defect, such as the one below, there is loss of some of the length of the torn tendon due to resorption and retraction. Thus  in order to approximate the torn edge to the footprint at the tuberosity, we place the repaired tendon under greater tension than the intact tendon on either side of it. Therefore, with either static or dynamic loading the pull of the cuff muscles is preferentially applied to the repaired tendon. This would tend to accentuate the problem of suture tension overload encountered during recovery. Perhaps if the resulting creep of the tendon away from the repair site took place at a slow rate, it would allow the body to 'backfill' the resulting gap resulting in 'failure with continuity'.

As interesting as the data on retraction are, the more interesting finding is that 30% of the shoulders had recurrent defects, even though these tears seemed eminently reparable. The shoulders with recurrent tears had lower Penn scores than those with intact cuffs at 52 weeks. Patients with larger tears had a greater chance of having a recurrent defect, although all of the tears repaired in this series would generally be classified as small (mean preoperative tear size of those with recurrent defects was 3.5 mm whereas the mean preoperative tear size of those without recurrent defects was 2.6 mm). The observation of tear recurrence after repair is consistent with previous observations (here and here and here and here) and with the report in 1991 by Harryman, that a substantial number of repaired cuffs do not remain intact after surgery. For example, Harryman found that after open repair of cuffs similar to those in this study, 20% of the shoulders had recurrent defects by ultrasound at 5 years after surgery (he also found that 60% of repaired large tears had recurrent defects at 5 years). 

So once again we are faced with the fact that even in the hands of very experienced surgeons using the most modern repair methods, recurrent defects after repair are common (4 out of 13).

On reflection of all of the above, it seems that a stress relaxation hypothesis may be consistent with the observations.

Consider this diagram of a cuff tear where the orange part of the cuff has pulled away from the blue tuberosity leaving the red portions of the cuff intact.

The surgeon repairs the torn (orange) part of the cuff to the tuberosity, but in doing so, takes the normal tension off of the intact (red) portions of the cuff and causing the repaired portion to support the load applied by the cuff musculature.

Stress relaxation must occur so that the normal portions of the cuff are under physiologic load. This can happen by recurrence of the cuff defect, as diagrammed below (this may be the situation in older individuals with larger cuff defects)

or by 'failure in continuity' in which the torn (orange) and intact (red) portions of the cuff progressively return to their original position, but that new regenerative tissue (green) tissue forms as the edge of the torn tendon pulls away from the footprint (this may be the situation for younger patients with smaller defects).

As we know some cuff tears are like the wall in Frost's poem - they just don't want to be repaired

MENDING WALL

Robert Frost

---

Something there is that doesn't love a wall,
That sends the frozen-ground-swell under it,
And spills the upper boulders in the sun,
And makes gaps even two can pass abreast.
The work of hunters is another thing:
I have come after them and made repair
Where they have left not one stone on a stone,
But they would have the rabbit out of hiding,
To please the yelping dogs. The gaps I mean,
No one has seen them made or heard them made,
But at spring mending-time we find them there.
I let my neighbor know beyond the hill;
And on a day we meet to walk the line
And set the wall between us once again.
We keep the wall between us as we go.
To each the boulders that have fallen to each.
And some are loaves and some so nearly balls
We have to use a spell to make them balance:
'Stay where you are until our backs are turned!'
We wear our fingers rough with handling them.
Oh, just another kind of out-door game,
One on a side. It comes to little more:
There where it is we do not need the wall:
He is all pine and I am apple orchard.
My apple trees will never get across
And eat the cones under his pines, I tell him.
He only says, 'Good fences make good neighbors'.
Spring is the mischief in me, and I wonder
If I could put a notion in his head:
'Why do they make good neighbors? Isn't it
Where there are cows?
But here there are no cows.
Before I built a wall I'd ask to know
What I was walling in or walling out,
And to whom I was like to give offence.
Something there is that doesn't love a wall,
That wants it down.' I could say 'Elves' to him,
But it's not elves exactly, and I'd rather
He said it for himself. I see him there
Bringing a stone grasped firmly by the top
In each hand, like an old-stone savage armed.
He moves in darkness as it seems to me~
Not of woods only and the shade of trees.
He will not go behind his father's saying,
And he likes having thought of it so well
He says again, "Good fences make good neighbors."

===

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Rotator cuff repair - failure with continuity

Failure With Continuity in Rotator Cuff Repair "Healing" The American Journal of Sports Medicine (ASJM) published this most interesting study of 13 patients having arthroscopic cuff repairs. The repaired tendon defects were 1-4 cm full thickness tears of the supraspinatus and/or infraspinatus with less than 2 cm of retraction, i.e. these were tears that were relatively small and reparable.

At the time of the repair, tantalum markers were placed in the substance of the tendon. Post operative sequential CT scans were used to measure the distance between each marker and the suture anchor nearest to it.  This 'anchor bead distance' has been shown by the authors to have an uncertainty of +/- 3 mm on repeat positioning and rescanning of patients with cuff repairs. If this distance increases over time after surgery, it indicates separation of the marked segment of the tendon from the tuberosity in which the anchor was placed. 

The authors also obtained sequential MRIs to search for defects in the repaired tendon.

They found that the markers of all repaired tendons retracted away from the suture anchors over the first year. The average retraction was 16.1 mm with a range of 5.7 to 23.2 mm. Tendon retraction correlated with patient age. As reported previously for open repairs, most of the retraction occurred during the early phases of recovery (i.e. 12 weeks). The amount of retraction did not correlate with the Penn score or with the abduction strength. The authors, as have others, suggest  the need for protection of the repair during the early rehab period. However, it is yet to be determined which post operative protocol is ideal.

It is worth pondering why this retraction might occur. When we look a chronic cuff defect, such as the one below, there is loss of some of the length of the torn tendon due to resorption and retraction. Thus  in order to approximate the torn edge to the footprint at the tuberosity, we place the repaired tendon under greater tension than the intact tendon on either side of it. Therefore, with either static or dynamic loading the pull of the cuff muscles is preferentially applied to the repaired tendon. This would tend to accentuate the problem of suture tension overload encountered during recovery. Perhaps if the resulting creep of the tendon away from the repair site took place at a slow rate, it would allow the body to 'backfill' the resulting gap resulting in 'failure with continuity'.

As interesting as the data on retraction are, the more interesting finding is that 30% of the shoulders had recurrent defects, even though these tears seemed eminently reparable. The shoulders with recurrent tears had lower Penn scores than those with intact cuffs at 52 weeks. Patients with larger tears had a greater chance of having a recurrent defect, although all of the tears repaired in this series would generally be classified as small (mean preoperative tear size of those with recurrent defects was 3.5 mm whereas the mean preoperative tear size of those without recurrent defects was 2.6 mm). The observation of tear recurrence after repair is consistent with previous observations (here and here and here and here) and with the report in 1991 by Harryman, that a substantial number of repaired cuffs do not remain intact after surgery. For example, Harryman found that after open repair of cuffs similar to those in this study, 20% of the shoulders had recurrent defects by ultrasound at 5 years after surgery (he also found that 60% of repaired large tears had recurrent defects at 5 years). 

So once again we are faced with the fact that even in the hands of very experienced surgeons using the most modern repair methods, recurrent defects after repair are common (4 out of 13).

On reflection of all of the above, it seems that a stress relaxation hypothesis may be consistent with the observations.

Consider this diagram of a cuff tear where the orange part of the cuff has pulled away from the blue tuberosity leaving the red portions of the cuff intact.

The surgeon repairs the torn (orange) part of the cuff to the tuberosity, but in doing so, takes the normal tension off of the intact (red) portions of the cuff and causing the repaired portion to support the load applied by the cuff musculature.

Stress relaxation must occur so that the normal portions of the cuff are under physiologic load. This can happen by recurrence of the cuff defect, as diagrammed below (this may be the situation in older individuals with larger cuff defects)

or by 'failure in continuity' in which the torn (orange) and intact (red) portions of the cuff progressively return to their original position, but that new regenerative tissue (green) tissue forms as the edge of the torn tendon pulls away from the footprint (this may be the situation for younger patients with smaller defects).

As we know some cuff tears are like the wall in Frost's poem - they just don't want to be repaired

MENDING WALL

Robert Frost

---

Something there is that doesn't love a wall,
That sends the frozen-ground-swell under it,
And spills the upper boulders in the sun,
And makes gaps even two can pass abreast.
The work of hunters is another thing:
I have come after them and made repair
Where they have left not one stone on a stone,
But they would have the rabbit out of hiding,
To please the yelping dogs. The gaps I mean,
No one has seen them made or heard them made,
But at spring mending-time we find them there.
I let my neighbor know beyond the hill;
And on a day we meet to walk the line
And set the wall between us once again.
We keep the wall between us as we go.
To each the boulders that have fallen to each.
And some are loaves and some so nearly balls
We have to use a spell to make them balance:
'Stay where you are until our backs are turned!'
We wear our fingers rough with handling them.
Oh, just another kind of out-door game,
One on a side. It comes to little more:
There where it is we do not need the wall:
He is all pine and I am apple orchard.
My apple trees will never get across
And eat the cones under his pines, I tell him.
He only says, 'Good fences make good neighbors'.
Spring is the mischief in me, and I wonder
If I could put a notion in his head:
'Why do they make good neighbors? Isn't it
Where there are cows?
But here there are no cows.
Before I built a wall I'd ask to know
What I was walling in or walling out,
And to whom I was like to give offence.
Something there is that doesn't love a wall,
That wants it down.' I could say 'Elves' to him,
But it's not elves exactly, and I'd rather
He said it for himself. I see him there
Bringing a stone grasped firmly by the top
In each hand, like an old-stone savage armed.
He moves in darkness as it seems to me~
Not of woods only and the shade of trees.
He will not go behind his father's saying,
And he likes having thought of it so well
He says again, "Good fences make good neighbors."

===

The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

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'See from which cities our patients come.

Subscapularis tendon tearing

Lengthening of the subscapularis tendon as a sign of partial tearing in continuity.

These authors retrospectively identified 92 magnetic resonance arthrography studies of suspected rotator cuff lesions obtained 3 months before shoulder arthroscopy. The myotendinous junction was identified, and the subscapularis tendon and muscle lengths were measured. Findings on arthroscopy performed later were used as the diagnostic gold standard for tendon integrity and compared with the magnetic resonance data.

Arthroscopy showed an intact subscapularis tendon in 43 patients, tendinopathy in 21 patients, and a partial rupture in 28 patients. The mean subscapularis tendon lengths were 40 mm in cases of intact subscapularis musculotendinous units, 45 mm in cases of tendinopathy, and 53 mm in cases of partial tears, whereas the mean subscapularis muscle lengths were 105 mm, 94 mm, and 95 mm, respectively, in these groups.

Partial tears of the subscapularis tendon lead to muscle shortening by approximately 10% and elongation of the tendon by approximately 32%, which may be interpreted as muscle retraction and a tendon rupture in continuity. If the subscapularis tendon has an apparent length of greater than 60 mm, the probability of a tear is 98%.

Comment: The topic of failure in continuity of cuff tears is an interesting one that has been discussed previously in this blog (see this link).

It is of interest that this was not a study of patients suspected of having subscapularis lesions, but rather a retrospective look at shoulders with suspected cuff lesions having subsequent arthroscopy. It would have been of great interest to know the results of physical examination in these patients: Did they have increased external rotation? Did they have diminished strength of internal rotation? Was their palpable thinning of the subscapularis tendon?

The most common clinical situation in which questions arise regarding subscapularis integrity is after shoulder arthroplasty. In this situation, MRI has difficulty in visualizing the integrity of the repaired subscapularis so that physical exam rather than imaginng becomes the main diagnostic tool.

If the tendon is weak and or retracted, it can be reconstructed with a tendon allograft.

==

Consultation for those who live a distance away from Seattle.

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

This is a study of the surgical repair of surgical incomplete (2/3 rds) release and acute repair of the infraspinatus tendon in young dogs. Thus it is not a study of 'rotator cuff repair outcomes' and the model is quite different than the clinical situation we encounter where the issue is usually a chronic defect with tendon tissue loss in individuals older than 60 years. The authors acknowledged support of the Musculoskeletal Transplant Foundation, which makes the patches used in this series of experiments.

Identical lesions were created on each side of the dogs' shoulders, one one side, the repair was reinforced with a "novel poly-L-lactic acid-reinforced (human) fascia patch" and the other without. It is of note that this patch was applied over a robust tendon to bone repair and was not used to bridge a defect in the rotator cuff or to reinforce a tenuous repair.  At 12 weeks, the ultimate load of augmented  repairs was 16% less than nonaugmented repairs.

Curiously, the authors conclude that "... these findings support the possibility that reinforced fascia patches would incorporate and provide (at least early) mechanical augmentation to rotator cuff repair in human patients." However, the value (benefit to the patient/cost) of the patches now commercially in rotator cuff surgery remains to be demonstrated in the clinical situation.

The most interesting aspect of this paper was the retraction of the tendon stump from the osseous repair site - even in this ideal rotator cuff repair model.  As early as three months after the repairs, 4 of 11 non augmented repairs and 6 of 11 augmented repairs had retracted by a centimeter or more! These results again emphasize how difficult it is to achieve durable reconstruction of the anatomy of the tendon insertion - even under idealized circumstances.

----

If you have suggestions for topics you'd like us to address in this blog, please send an email to shoulderarthritis@uw.edu.

Use the "Search the Blog" 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.

See the countries from which our readers come on this post.

Failure With Continuity in Rotator Cuff Repair "Healing"

Failure With Continuity in Rotator Cuff Repair "Healing" The American Journal of Sports Medicine (ASJM) recently published this most interesting study of 13 patients having arthroscopic cuff repairs. The repaired tendon defects were 1-4 cm full thickness tears of the supraspinatus and/or infraspinatus with less than 2 cm of retraction, i.e. these were tears that were relatively small and reparable.

At the time of the repair, tantalum markers were placed in the substance of the tendon. Post operative sequential CT scans were used to measure the distance between each marker and the suture anchor nearest to it.  This 'anchor bead distance' has been shown by the authors to have an uncertainty of +/- 3 mm on repeat positioning and rescanning of patients with cuff repairs. If this distance increases over time after surgery, it indicates separation of the marked segment of the tendon from the tuberosity in which the anchor was placed. 

The authors also obtained sequential MRIs to search for defects in the repaired tendon.

They found that the markers of all repaired tendons retracted away from the suture anchors over the first year. The average retraction was 16.1 mm with a range of 5.7 to 23.2 mm. Tendon retraction correlated with patient age. As reported previously for open repairs, most of the retraction occurred during the early phases of recovery (i.e. 12 weeks). The amount of retraction did not correlate with the Penn score or with the abduction strength. The authors, as have others, suggest  the need for protection of the repair during the early rehab period. However, it is yet to be determined which post operative protocol is ideal.

It is worth pondering why this retraction might occur. When we look a chronic cuff defect, such as the one below, there is loss of some of the length of the torn tendon due to resorption and retraction. Thus  in order to approximate the torn edge to the footprint at the tuberosity, we place the repaired tendon under greater tension than the intact tendon on either side of it. Therefore, with either static or dynamic loading the pull of the cuff muscles is preferentially applied to the repaired tendon. This would tend to accentuate the problem of suture tension overload encountered during recovery. Perhaps if the resulting creep of the tendon away from the repair site took place at a slow rate, it would allow the body to 'backfill' the resulting gap resulting in 'failure with continuity'.

As interesting as the data on retraction are, the more interesting finding is that 30% of the shoulders had recurrent defects, even though these tears seemed eminently reparable. The shoulders with recurrent tears had lower Penn scores than those with intact cuffs at 52 weeks. Patients with larger tears had a greater chance of having a recurrent defect, although all of the tears repaired in this series would generally be classified as small (mean preoperative tear size of those with recurrent defects was 3.5 mm whereas the mean preoperative tear size of those without recurrent defects was 2.6 mm). The observation of tear recurrence after repair is consistent with previous observations (here and here and here and here) and with the report in 1991 by Harryman, that a substantial number of repaired cuffs do not remain intact after surgery. For example, Harryman found that after open repair of cuffs similar to those in this study, 20% of the shoulders had recurrent defects by ultrasound at 5 years after surgery (he also found that 60% of repaired large tears had recurrent defects at 5 years). 

So once again we are faced with the fact that even in the hands of very experienced surgeons using the most modern repair methods, recurrent defects after repair are common (4 out of 13).

On reflection of all of the above, it seems that a stress relaxation hypothesis may be consistent with the observations.

Consider this diagram of a cuff tear where the orange part of the cuff has pulled away from the blue tuberosity leaving the red portions of the cuff intact.

The surgeon repairs the torn (orange) part of the cuff to the tuberosity, but in doing so, takes the normal tension off of the intact (red) portions of the cuff and causing the repaired portion to support the load applied by the cuff musculature.

Stress relaxation must occur so that the normal portions of the cuff are under physiologic load. This can happen by recurrence of the cuff defect, as diagrammed below (this may be the situation in older individuals with larger cuff defects)

or by 'failure in continuity' in which the torn (orange) and intact (red) portions of the cuff progressively return to their original position, but that new regenerative tissue (green) tissue forms as the edge of the torn tendon pulls away from the footprint (this may be the situation for younger patients with smaller defects).

As we know some cuff tears are like the wall in Frost's poem - they just don't want to be repaired

MENDING WALL

Robert Frost

---

Something there is that doesn't love a wall,
That sends the frozen-ground-swell under it,
And spills the upper boulders in the sun,
And makes gaps even two can pass abreast.
The work of hunters is another thing:
I have come after them and made repair
Where they have left not one stone on a stone,
But they would have the rabbit out of hiding,
To please the yelping dogs. The gaps I mean,
No one has seen them made or heard them made,
But at spring mending-time we find them there.
I let my neighbor know beyond the hill;
And on a day we meet to walk the line
And set the wall between us once again.
We keep the wall between us as we go.
To each the boulders that have fallen to each.
And some are loaves and some so nearly balls
We have to use a spell to make them balance:
'Stay where you are until our backs are turned!'
We wear our fingers rough with handling them.
Oh, just another kind of out-door game,
One on a side. It comes to little more:
There where it is we do not need the wall:
He is all pine and I am apple orchard.
My apple trees will never get across
And eat the cones under his pines, I tell him.
He only says, 'Good fences make good neighbors'.
Spring is the mischief in me, and I wonder
If I could put a notion in his head:
'Why do they make good neighbors? Isn't it
Where there are cows?
But here there are no cows.
Before I built a wall I'd ask to know
What I was walling in or walling out,
And to whom I was like to give offence.
Something there is that doesn't love a wall,
That wants it down.' I could say 'Elves' to him,
But it's not elves exactly, and I'd rather
He said it for himself. I see him there
Bringing a stone grasped firmly by the top
In each hand, like an old-stone savage armed.
He moves in darkness as it seems to me~
Not of woods only and the shade of trees.
He will not go behind his father's saying,
And he likes having thought of it so well
He says again, "Good fences make good neighbors."

----

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If you have suggestions for topics you'd like us to address in this blog, please send an email to
shoulderarthritis@uw.edu

Use the "Search the Blog" 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.

See the countries from which our readers come on this post.