Transoss?re Nahttechnik bei kompletten Rotatorenmanschettenrupturen

In recent years arthroscopic techniques for rotator cuff repair have been successfully developed with technically advanced implants and biomechanically matured suture configurations. Suture anchors have been established as the standard treatment. We describe a special technique for arthroscopic transosseous rotator cuff repair using a hollow needle with simultaneous perforation of tendon and bone. Isolated articular-sided partial or full-thickness tears of the supraspinatus tendon without advanced tendon retraction represent ideal indications. In a prospective cohort study 41 patients with arthroscopic transosseous repair of full-thickness supraspinatus tendon tears were followed up clinically and radiologically using indirect MR arthrography after an average of 45 months. The Constant score improved from 53 to 84 points. In 5 cases a re-rupture was present at follow-up with only 1 patient complaining of poor shoulder function. The arthroscopic transosseous rotator cuff repair represents a reliable alternative to the established techniques using suture anchors or knotless implants with comparable clinical and radiological results. The biological and economical advantages exceed the flat learning curve.     

Arthroscopic rotator cuff repair: a biomechanical comparison of the suture-bridge technique vs. a new transosseous technique using SutureButtons(®)

Background

The suture-bridge technique using anchors as established transosseous-equivalent technique in arthroscopic rotator cuff repair was compared to a modified transosseous technique suitable for arthroscopic cuff repair.

Methods

In 10 fresh-frozen matched pairs of human cadaveric shoulders (mean age 67.1, SD 8.5 years), two different surgical techniques of cuff repair were tested: Group 1, using the suture-bridge technique with suture anchors, and Group 2, using two transosseous tunnels with SutureButtons^®. Lateral row fixation was performed in both groups using knotless implants. Cyclic displacement to gap formation of 2 and 5 mm, linear stiffness, yield load, ultimate load, and mode of failure were recorded.

Findings

Gap formation at the tendon-to-bone interface of 2 mm occurred after a mean of 219.5 (SD 590.7) cycles in Group 1 and after 750.0 (SD 1566.1) cycles in Group 2. Gap formation of 5 mm occurred after 2331.6 (SD 2033.9) cycles (Group 1) and 2364.5 (SD 1994.2) cycles (Group 2), respectively. The yield and ultimate loads were 316.9 (SD 114.1) N and 375.9 (SD 131.2) N in Group 1, and 311.0 (SD 97.2) N and 363.8 (SD 107.6) N in Group 2, respectively. The linear stiffness was 40.3 (SD 10.4) N/mm in Group 1, and 41.6 (SD 13.2) N/mm in Group 2. There were no statistically significant intergroup differences.

Interpretation

The new transosseous technique using SutureButtons^® achieves equivalent biomechanical properties to the established suture-bridge technique using anchors. A tendentially reduced primary gap formation may be of importance for repair healing during the early phase of rehabilitation.     

Arthroskopische Revisionseingriffe nach arthroskopischer Rotatorenmanschettennaht mit Fadenankern

Arthroscopic rotator cuff repair is rapidly becoming the gold standard for cuff surgery and revisions are also performed arthroscopically by preference. We describe 51 arthroscopic revisions 0–18 months after cuff repair from a total of 827 operations (6.2%). The most frequent causes for revision were: rerupture, incomplete healing and frozen shoulder and, less frequently, failure of anchors and suture material, knot impingement and extraosseous anchor position. Revision led to a satisfactory outcome in 82% of the case series. A deterioration of shoulder function after arthroscopic revision is excluded.     

Biomechanical evaluation of rotator cuff repairs in a sheep model: suture anchors using arthroscopic Mason-Allen stitches compared with transosseous sutures using traditional modified Mason-Allen stitches

BACKGROUND: The optimal method for rotator cuff repair of the shoulder is not yet known. The aim of this study was to compare the time-dependent biomechanical properties of the traditional open transosseous suture technique and modified Mason-Allen stitches (group 1) versus the double-loaded suture anchors technique and so-called arthroscopic Mason-Allen stitches (group 2) in rotator cuff repair. METHODS: Eighteen adult female sheep were randomized into two groups: in an open approach in which the released infraspinatus tendon was repaired with group 1, and with group 2. Animals were sacrificed at 6, 12, or 26 weeks; shoulders were harvested and magnetic resonance imaging was performed. Eight untreated contralateral shoulders served as controls. Tendons of 16 additional unpaired cadaver shoulder joints of adult female sheep were identically treated for analysis at time zero. In a biomechanical evaluation all specimens were loaded to failure at a constant displacement rate using a standard universal testing machine. The load-to-failure and stiffness of the healed bone-tendon interface were calculated. RESULTS: Magnetic resonance imaging analysis showed cuff integrity in all cases, and no evidence of foreign body reaction to the anchors. Load-to-failure and stiffness data did not indicate any significant difference between the two treatment groups, neither at 6 weeks nor at 12 or 26 weeks. However, at time zero the group 2 had a higher load-to-failure in comparison to the group 1 (P<0.010), but there was no difference for the stiffness (P<0.121). CONCLUSIONS: This in vivo study showed that, postoperatively, the group 2 technique provides superior stability and after healing would gain strength comparable to the group 1 technique.     

Pullout strength of standard vs. cement-augmented rotator cuff repair anchors in cadaveric bone

BackgroundWe evaluate a novel method of rotator cuff repair that uses arthroscopic equipment to inject bone cement into placed suture anchors. A cadaver model was used to assess the pullout strength of this technique versus anchors without augmentation.MethodsSix fresh-frozen matched pairs of upper extremities were screened to exclude those with prior operative procedures, fractures, or neoplasms. One side from each pair was randomized to undergo standard anchor fixation with the contralateral side to undergo anchor fixation augmented with bone cement. After anchor fixation, specimens were mounted on a servohydraulic testing system and suture anchors were pulled at 90° to the insertion to simulate the anatomic pull of the rotator cuff. Sutures were pulled at 1 mm/s until failure.FindingsThe mean pullout strength was 540 N (95% confidence interval, 389 to 690 N) for augmented anchors and 202 N (95% confidence interval, 100 to 305 N) for standard anchors. The difference in pullout strength was statistically significant (P < 0.05).InterpretationThis study shows superior pullout strength of a novel augmented rotator cuff anchor technique. The described technique, which is achieved by extruding polymethylmethacrylate cement through a cannulated in situ suture anchor with fenestrations, significantly increased the ultimate failure load in cadaveric human humeri. This novel augmented fixation technique was simple and can be implemented with existing instrumentation. In osteoporotic bone, it may substantially reduce the rate of anchor failure.     

Ursachen und Versagensmuster für Redefekte nach Rekonstruktion der Rotatorenmanschette

Background

Recurrent defects of the rotator cuff remain a significant complication after surgical repair.

Objectives

The current review focuses on the etiology of structural redefects with regard to the underlying pathophysiology, structural changes of the musculotendinous unit, patient demographics and implant-specific failure modes.

Materials and methods

Systematic review of the online databases PubMed, EMBASE and Cochrane Library.

Results

The goal of preserving the structural integrity of the rotator cuff after reconstruction has led to a number of improvements of all aspects of rotator cuff surgery and tendon healing. Nevertheless, rotator cuff redefect rates remain high. Structural failure of the reconstructed rotator cuff is multifactorial, but specific risk factors that adversely affect the osteofibroblastic integration at the tendon-bone unit can be identified.

Conclusion

Pathomorphological changes of the musculotendinous unit (fatty infiltration ≥ grade II according to Goutallier, advanced atrophy, or retraction), patient-specific factors (age >?65 years, bone quality, smoking, AHA <?7 mm), choice of the implant or reconstruction technique, and the postoperative rehabilitation (application of NSAIR, patient compliance) are decisive for the outcome of the tendon reconstruction.     

Postural dependence of passive tension in the supraspinatus following rotator cuff repair: a simulation analysis

Background

Despite surgical advances, repair of rotator cuff tears is associated with 20–70% incidence of recurrent tearing. The tension required to repair the torn tendon influences surgical outcomes and may be dependent on the gap length from torn tendon that must be spanned by the repair. Detailed understanding of forces throughout the range of motion (ROM) may allow surgeons to make evidence-based recommendations for post-operative care.

Methods

We used a computational shoulder model to assess passive tension and total moment-generating capacity in supraspinatus for repairs of gaps up to 3 cm throughout the shoulder (ROM).

Findings

In 60° abduction, increased gap length from 0.5 cm to 3 cm caused increases in passive force from 3 N to 58 N, consistent with those seen during clinical repair. For reduced abduction, passive forces increased substantially. For a 0.5 cm gap, tension throughout the ROM (elevation, plane of elevation, and rotation) is within reasonable limits, but larger gaps are associated with tensions that markedly exceed reported pull-out strength of sutures and anchors. Peak moment for a large 3 cm gap length was 5.09 Nm, a 53% reduction in moment-generating capacity compared to uninjured supraspinatus.

Interpretation

We conclude that shoulder posture is an important determinant of passive forces during rotator cuff repair surgery. Choosing postures that reduce forces intraoperatively to permit repair of larger gaps may lead to failure postoperatively when the shoulder is mobilized. For larger defects, loss of strength in supraspinatus may be substantial following repair even if retear is prevented.     

Biologische und biomechanische Grundlagen der arthroskopischen Rotatorenmanschettenrekonstruktion

In the long-term follow-up a successful arthroscopic rotator cuff reconstruction is not solely dependent on the technical restoration of the muscle-tendon-bone-continuity but also on various other factors. In addition to a correct and gentle surgical technique, biological factors such as musculotendineous quality of the rotator cuff and bone quality of the footprint may play an important role for the surgical outcome. In this context, fatty infiltration, atrophy, and retraction of the ruptured rotator cuff as well as tendon degeneration and osteopenia of the insertion area have to be considered. In addition, suture techniques and suture anchor placement must be based on biomechanical principles to avoid technical failure of the refixation.     

Quantification of sonographic echogenicity by the gray-level histogram in patients with supraspinatus tendinopathy

Purpose

The aim of this study was to compare the gray-level value of the supraspinatus tendon of a painful shoulder with that of a normal shoulder measured by ultrasonography, and to investigate whether a low mean gray-level value of the supraspinatus tendon could indicate a partial-thickness or incomplete full-thickness tear.

Methods

Two hundred and ten patients had significant unilateral shoulder pain with the clinical suspicion of rotator cuff tendinopathy. They underwent bilateral shoulder ultrasonography, and the mean echogenicity of the histogram was calculated on the screen. The mean gray-level value of each patient’s contralateral asymptomatic shoulder was compared with that of the painful shoulder.

Results

Based on the scan of transverse and longitudinal planes, a significant difference existed between the symptomatic shoulder and contralateral asymptomatic shoulder (p < 0.0001). The mean gray-level values of symptomatic shoulders showed no statistically significant difference between the patients who underwent surgery and the patients who underwent conservative treatment.

Conclusions

We demonstrated that the ultrasound gray-level histogram is a promising tool for detecting the hypoechogenic appearance of supraspinatus tendinopathy. A decrease in the mean gray-level value on the symptomatic shoulder may be used as an alternative sonographic indicator of rotator cuff partial-thickness tear or tendinopathy.

Level of evidence

Diagnostic level III.     

Biomechanical comparison of double-loaded suture anchors using arthroscopic Mason-Allen stitches versus traditional transosseous suture technique and modified Mason-Allen stitches for rotator cuff repair

BACKGROUND: In recent studies objective evaluations have demonstrated that arthroscopic rotator cuff repairs can have higher failure rates than open repairs. Thus, there is a need for a stronger tissue-holding stitch for arthroscopical repair. The purpose of this study was to compare the biomechanical properties of traditional open transosseous suture technique and modified Mason-Allen stitches versus double-loaded suture anchors and arthroscopic Mason-Allen stitches in rotator cuff repair. METHODS: In 20 sheep shoulders the infraspinatus tendons were dissected from their insertion and were randomized to 2 repair groups: (1) repair with transosseous suture and modified Mason-Allen stitches, (2) repair with double loaded bioabsorbable suture anchors and arthroscopic Mason-Allen stitches: Both groups were coupled with braided, nonabsorbable polyester (Ethibond) suture sized USP No. 2. All repairs were cyclically loaded from 10 to 180N with the use of a materials testing machine. The number of cycles to gap formation of 5 and 10mm at the repair site and the mode of failure were recorded. RESULTS: The number of cycles to 5-mm gap was mean 634 (SD 106) for group 1 and mean 750 (SD 107) for group 2 (P<0.026). The corresponding values to 10-mm gap were mean 1573 (SD 161) for group 1, and mean 1789 (SD 183 cycles) for group 2 (P<0.012). In group 2 the mode of failure occurred by tissue pull-out, whereas in group 1 the failure occurred by a mixture of suture breakage and pull-out. CONCLUSIONS: This time-zero study demonstrates that the combination of bioabsorbable suture anchors and arthroscopic Mason-Allen stitches provides strength superior to that of the modified Mason-Allen transosseous suture technique under isometric cyclic loading conditions. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.     

Tendon fixation in arthroscopic latissimus dorsi transfer for irreparable posterosuperior cuff tears: an in vitro biomechanical comparison of interference screw and suture anchors

Background

The fixation of the tendon to the bone remains a challenging problem in the latissimus dorsi tendon transfer for irreparable cuff tears and can lead to unsatisfactory results. A new arthroscopic method of tendon to bone fixation using an interference screw has been developed and the purpose of this study was to compare its biomechanical properties to the ones of a standard fixation technique with anchors.

Methods

Six paired fresh frozen cadaveric human humeri were used. The freed latissimus dorsi tendon was randomly fixed to the humeral head with anchors or with interference screw after a tubularization procedure. Testing consisted to apply 200 cycles of tensile load on the latissimus dorsi tendon with maximal loads of 30 N and 60 N, followed by a load to failure test. The stiffness, displacements after cyclic loadings, ultimate load to failure, and site of failure were analysed.

Findings

The stiffness was statistically higher for the tendons fixed with interference screws than for the ones fixed with anchors for both 30 N and 60 N loadings. Likewise, the relative bone/tendon displacements after cyclic loadings were lower with interference screws compared to anchors. Load to failure revealed no statistical difference between the two techniques.

Interpretation

Compared to the standard anchor fixation, the interference screw fixation technique presents higher or similar biomechanical performance. These results should be completed by further biomechanical and clinical trials to confirm the interest of this new technique as an alternative in clinical use.     

超声诊断类风湿性肩关节炎肩袖损伤：与关节镜手术对照

目的 探讨超声检查对类风湿性肩关节炎肩袖损伤的诊断价值。方法 应用超声对47例临床拟诊肩袖损伤的类风湿性肩关节炎患者的47侧肩袖进行扫查,依次观察肩胛下肌腱、冈上肌腱、冈下肌腱、小圆肌腱在静止状态和运动状态下有无损伤及撕裂。 在超声检查1周内对所有患者行肩关节镜手术治疗,将超声结果与手术结果进行对照。结果 超声可清晰显示类风湿性肩关节炎肩袖病变的形态学特征,包括有无撕裂和厚度改变;共检出31侧肩袖损伤,其中不完全撕裂18侧,完全撕裂7侧,肩袖肌腱厚度变薄6侧。与关节镜手术结果比较,超声诊断肩袖损伤的总体敏感度为90.62%(29/32),特异度为86.67%(13/15),准确率为89.36%(42/47)。超声对肩袖完全撕裂的诊断准确率为100%(7/7)。结论 超声对检出和判断类风湿性肩关节炎肩袖损伤程度有较高价值,尤其对显示完全撕裂和肩袖肌腱厚度变薄意义更显著。     

Indikation,Technik und Ergebnisse von Sehnentransferoperationen

Background

In the last few decades, tendon transfer procedures have become established for the treatment of younger patients with irreparable rotator cuff tears.

Objectives

Indication, predictive factors and clinical results of tendon transfer procedures in rotator cuff surgery and modified surgical techniques are discussed.

Methods

The current literature and expert opinions are discussed in association with our own case series.

Results

In recent years a number of predictive factors, important to consider for surgical indication, have been analyzed for M. latissimus dorsi transfer (postero-superior defects) and M. pectoralis major transfer (anterior defects). Because the indication is restricted to the short time interval between reparable tear and apparent cuff arthropathy, the number of cases is limited. Clinical results in currently published case series show on average a significant functional improvement, but not complete restoration of shoulder function. Larger case series have been published for M. latissimus dorsi transfer and this technique presents superior clinical results compared to the results observed in patients after M. pectoralis major transfer.

Conclusion

Tendon transfer techniques offer an additional therapeutic option during the time interval between still reparable rotator cuff tear and cuff arthropathy; however, clinical results are highly dependent on correct indication.     

Comparative study of different tendon grasping techniques for arthroscopic repair of the rotator cuff

BACKGROUND: One cause of early failure of rotator cuff repairs is the pull out of the suture through the tendon. The aims of this study were to investigate the initial strength and failure mode of different tendon grasping techniques and to evaluate an alternative stitch proposed for arthroscopic repair of rotator cuff tendons. METHODS: Four different stitches were investigated: simple stitch, Mattress, modified Mason-Allen and simple stitch closed over a horizontal loop. The last stitch was proposed as an alternative to the modified Mason-Allen stitch since the former is simpler to sew arthroscopically than the latter. The experimental procedure was designed to assess the mechanical behaviour of the stitches. Tests were performed using sheep infraspinatus tendons. Two different non-absorbable sutures were used. Each specimen was preloaded with about 30 N and then loaded to failure. RESULTS: No significant difference was found in compliance among the four investigated stitches. Conversely, the tensile strength of the simple stitch and Mattress was lower than the tensile strength of the other two stitches, while no significant difference was observed between the modified Mason-Allen and the simple stitch closed over a horizontal loop. The maximum grasping power of these two 'reinforced' stitches was achieved only with the high-strength suture. INTERPRETATION: The simple stitch closed over a horizontal loop seems to be an attractive alternative to the modified Mason-Allen for arthroscopic repair of the rotator cuff and it seems recommendable instead of simple or Mattress stitches. The use of a high-strength suture would increase the tensile strength of the grasping in the case of good quality tendon tissue.     

Strategien in der arthroskopischen Behandlung von Massenrupturen der Rotatorenmanschette

Shoulder arthroscopy offers several advantages for the treatment of massive rotator cuff tears as it enables exact identification of the geometry of the tendon rupture and thereby allows anatomical reconstruction. This article emphasizes 10 important steps in the arthroscopic treatment of massive rotator cuff tears. We pursue the strategy that every effort should be made to reconstruct, as far as feasible, in symptomatic and functionally demanding patients. Even in case of partial repair, significant improvements in pain relief and function are well documented. Fatty infiltration and tendon atrophy affect the decision-making and the results of reconstructive procedures but the significance seems to depend on the particular rotator cuff tendon affected. The primary goal in massive rotator cuff reconstruction is to repair the balance between the transversal forces of the subscapularis and the infraspinatus. Rehabilitation is time-consuming and rerupture rates are higher than in single tendon injuries, therefore, particular attention must be paid to a carefully explained informed consent.     

M?glichkeiten der Speedbridge-Technik

For successful arthroscopic or open repair of rotator cuff lesions the balance between sufficient fixation strength lasting long enough for tendon healing and no further damage to the degenerative or traumatically compromised biological healing mechanism is crucial. With bridging techniques an advantage is assumed compared to the established techniques. In particular with the Speedbridge technique sufficient tendon healing is expected due to knotless and laminar fixation of the ruptured tendons. Besides the originally described knotless and crossed double row configuration with four anchors this technique can also be applied in a knotless V, W (so-called Cassiopeia) or even VW configuration. The common objective is a tailored and tissue preserving repair of rotator cuff lesions with simultaneous high user friendliness.     

Grundlagen und technische Varianten der arthroskopischen Supraspinatussehnennaht

Arthroscopic rotator cuff repair is gaining popularity on a worldwide level. Accurate intraoperative visualization of all the lesions allows one to take a more distinctive approach regarding reconstruction than do open techniques. Successful repair though requires the knowledge of some important biomechanical principles. The current strategies in supraspinatus tendon repair based on these principles are presented including: operative set-up, portal placement, classification of the lesions and how to perform the technical variants of the reconstruction. Training possibilities, reproducible techniques and reliable materials (suture material, anchors) are equally important to obtain good results as are a minimal number of cases and the surgeon’s individual enthusiasm.     

关节镜下两种缝合方案在冈上肌腱损伤患者中的应用效果对比

目的比较关节镜下两种缝合方案在冈上肌腱损伤患者中的应用效果。方法选取2015年1月-2018年4月该院收治的136例冈上肌腱损伤患者为研究对象,将患者依据1∶1比例随机分为对照组(n=68)和观察组(n=68)。对照组患者采用关节镜下单排改良Mason-Allen缝合技术修复,观察组采用关节镜下改良缝合桥技术修复。比较两组患者肩关节活动度、视觉模拟评分(VAS)、美国肩肘外科协会评分(ASES)和Constant评分。结果治疗前两组患者肩关节内旋、外旋、前屈和外展情况、静息VAS、活动VAS评分、ASES评分和Constant评分比较均无明显差异(P0.05);治疗后两组患者的肩关节内旋、外旋、前屈和外展情况、静息VAS、活动VAS评分、ASES评分和Constant评分较治疗前均明显改善,且观察组优于对照组,差异有统计学意义(P 0.05)。结论冈上肌腱损伤患者经单排改良Mason-Allen缝合技术修复及改良缝合桥技术修复均能够有效缓解疼痛,改善肩关节活动度和功能,且改良缝合桥技术修复效果更佳。     

Pullout strength of cement-augmented and wide-suture transosseous fixation in the greater tuberosity

BackgroundObtaining strong fixation in low-density bone is increasingly critical in surgical repair of rotator cuff tears because of the aging population. To evaluate two new methods of improving pullout strength of transosseous rotator cuff repair in low-density bone, we analyzed the effects of 1) using 2-mm suture tape instead of no. 2 suture and 2) augmenting the lateral tunnel with cement.MethodsEleven pairs of osteopenic or osteoporotic cadaveric humeri were identified by dual-energy x-ray absorptiometry. One bone tunnel and one suture were placed in the heads of 22 specimens. Five randomly selected pairs were repaired with no. 2 suture; the other six pairs were repaired with 2-mm suture tape. One side of each pair received lateral tunnel cement augmentation. Specimens were tested to suture pullout. Data were fitted to multivariate models that accounted for bone mineral density and other specimen characteristics.FindingsTwo specimens were excluded because of knot-slipping during testing. Use of suture tape versus no. 2 suture conferred a 75-N increase (95% CI: 37, 113) in pullout strength (P < 0.001). Cement augmentation conferred a 42-N improvement (95% CI: 10, 75; P = 0.011). Other significant predictors of pullout strength were age, sex, and bone mineral density.InterpretationWe show two methods of improving the fixation strength of transosseous rotator cuff repairs in low-density bone: using 2-mm suture tape instead of no. 2 suture and augmenting the lateral tunnel with cement. These methods may improve the feasibility of transosseous repairs in an aging patient population.