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Background: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. Purpose/Hypothesis: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. Study Design: Case series; Level of evidence 4. Methods: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. Results: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) ( P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 ( P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 ( P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years ( P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years ( P≤ .039). Conclusion: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Background: Additional stabilization of the “comma sign” in anterosuperior rotator cuff repair has been proposed to provide biomechanical benefits regarding stability of the repair. Purpose: This in vitro investigation aimed to investigate the influence of a comma sign–directed reconstruction technique for anterosuperior rotator cuff tears on the primary stability of the subscapularis tendon repair. Study Design: Controlled laboratory study. Methods: A total of 18 fresh-frozen cadaveric shoulders were used in this study. Anterosuperior rotator cuff tears (complete full-thickness tear of the supraspinatus and subscapularis tendons) were created, and supraspinatus repair was performed with a standard suture bridge technique. The subscapularis was repaired with either a (1) single-row or (2) comma sign technique. A high-resolution 3D camera system was used to analyze 3-mm and 5-mm gap formation at the subscapularis tendon-bone interface upon incremental cyclic loading. Moreover, the ultimate failure load of the repair was recorded. A Mann-Whitney test was used to assess significant differences between the 2 groups. Results: The comma sign repair withstood significantly more loading cycles than the single-row repair until 3-mm and 5-mm gap formation occurred ( P≤ .047). The ultimate failure load did not reveal any significant differences when the 2 techniques were compared ( P = .596). Conclusion: The results of this study show that additional stabilization of the comma sign enhanced the primary stability of subscapularis tendon repair in anterosuperior rotator cuff tears. Although this stabilization did not seem to influence the ultimate failure load, it effectively decreased the micromotion at the tendon-bone interface during cyclic loading. Clinical Relevance: The proposed technique for stabilization of the comma sign has shown superior biomechanical properties in comparison with a single-row repair and might thus improve tendon healing. Further clinical research will be necessary to determine its influence on the functional outcome.

Background: Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far. Purpose: To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions—(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction—using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair. Results: The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N ( P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N ( P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group ( P≤ .029). Conclusion: While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon. Clinical Relevance: DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

We describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration with the Arthrotunneler device. The technique uses 2 bone tunnels and 4 high-strength sutures and is suitable for medium to large tears of the supra- and infraspinatus that would alternatively need a double-row repair with 4 anchors. Biomechanically, results appear to be similar as for anchored transosseous equivalent techniques. Enhanced biological healing and lower material costs are the possible benefits of this appealing arthroscopic approach that mimics the previous gold standard.

When revising failed double-row and suture-bridge rotator cuff repairs medial failures represent a potential feature. In the presence of a compromised healing environment, patch augmentation becomes a logical adjunct from a mechanical and biological point of view. A reproducible step-by-step revision technique is described that reinforces the weak central cuff area with an absorbable synthetic scaffold.

BACKGROUND: Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.RESULTS: Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).CONCLUSION: A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Aim To compare the outcome of patients operated using either suture anchors vs a new anchorless transosseous (TO) technique for rotator cuff (RC) repair. We hypothesize that healing at the footprint (FP) as observed on MRI might be better with the anchorless approach. Background The former gold standard of open TO RC repair can now be mimicked arthroscopically. Since 5 years we use the Arthrotunneler (AT) system with 2 bone tunnels and 4-5 high strength sutures in an X-Box configuration for medium to large tears of supra- and infraspinatus, which would otherwise require a four anchor construct. Our impression was that the TO technique provides excellent outcomes and high healing rates. Methods We compared 2 cohorts: Cohort A prospectively includes 50 consecutive patients operated since 12/13 with the AT-device (Tornier, Wright); cohort B entails a retrospective series of 35 patients operated earlier. Included were non-retracted tears with a sagittal extension of 2.5 to 4 cm. Group A was operated without, group B with 4 anchors (Speed-bridge, Arthrex). Groups A and B were comparable in regards to age, sex and tear size. After a minimum of 2 years clinical outcome scores and a native MRI were obtained. Tendon quality and FP integration were evaluated using the Sugaya classification by an independent radiologist. Statistics: ANOVA and Wilcoxon test. Results Excluding 9 patients who declined, FU data are available from 44 patients in group A and 32 in B. Constant Score improved from 49 to 89P in group A vs. 46 to 86P in B (p = 0.66). The SSV rose from 45 to 95 % in group A vs from 44 to 93 % in B (p = 0.84). MRI showed no retears in group A vs 3 retears (= 9 %) in B. Comparing the Sugaya types we observed a significant (p = 0.002) shift to the more favorable Sugaya types I and II (normal & near normal) with 82 % in group A vs 50 % in B. Conclusions The study confirms that anchorless TO RC repair is a good alternative to established suture anchor techniques. The technique can easily be learned by the experienced arthroscopist. Clinical outcome data show equivalent results for both techniques. With EUR 700 vs 1100 material costs are lower for the anchorless technique. The healing results as observed on MRI are superior, maybe due to enhanced blood flow at the FP provided by the bone tunnels.

Disabled shoulders of throwing athletes typically present with extended undersurface partial tears of the rotator cuff, which include the posterior supraspinatus and the anterior infraspinatus tendon to a variable extent. We propose a modified transtendon repair technique to adequately treat this subset of patients. The repair includes two double-loaded anchors, at the anterior and the posterior end of the tear, respectively. With the help of an angulated penetrator we create a medial and a lateral band of sutures on top of the cuff, producing a broad contact in the tendon-to-bone interface. All the 9 so far operated patients were young men, 7 of them base-ball pitchers, and 5 active in competitive sports. The Constant Score rose from 72 points preoperatively to 99 points at 12 months follow-up. Three of the still active pitchers were able to return to their previous level in sports after one year. The improved footprint contact of our novel repair construct should allow for better healing and, therefore, a higher chance of return to competition.

Arthroscopic rotator cuff reconstruction (ARCR) is a challenging operative procedure in the treatment of symptomatic cuff tears. The literature does not consistently report on surgical complications after this procedure.

The proximal humerus is a well-known site of predilection for the solitary osteochondroma-the most common benign bone tumor. Subscapularis tears were underreported in the pre-arthroscopic era. Literature about rotator cuff impairment caused by osteochondromas is almost non-existent. We will present the case of a young man, who had a complete non-traumatic subscapularis tear, where the tendon had been peeled off the lesser tuberosity by an osteochondroma. Diagnostic features such as MRI and arthroscopy are emphasized. The patient was successfully treated by open resection of the tumor and reattachment of the tendon with suture anchors.

The standard technique for repairing partial-thickness tears of the supraspinatus tendon includes completion of the lesion to a full-thickness tear. Partial articular-side supraspinatus tendon avulsions (PASTA) form a subgroup deserving special consideration. We present a transtendon suture technique that is able to preserve the intact tendon fibers and to achieve firm attachment of the tendon to the humeral footprint using 1 double-loaded bone anchor. The surgical technique is described in detail, and pitfalls and complications are noted. The clinical results of the first 22 consecutive patients are reported, showing an increase in the UCLA score from 17.1 to 31.2 points and a patient satisfaction rate of 91%.

Introduction Confronted with a failed rotator cuff (RC) repair or a massive tear with compromised tissue quality patch augmentation becomes a logical adjunct from a mechanical and biological point of view. We hypothesize that augmentation of the repair with a novel bioabsorbable scaffold might improve healing rates with few complications and reasonable added costs. Methods A consecutive series of 54 patients was prospectively included since 3/14. The case series includes 38 revision cases (typically medial failures) and 16 primary repairs in massive tears. The operation is technically demanding but reproducible and includes 12 steps (video). The cuff is repaired with a standard suture bridge construct using 1–2 medial and 2 lateral anchors; no additional anchors are needed for patch augmentation. The proposed scaffold (BioFiber, Tornier) consists of biosynthetic fibers woven into a lattice structure and fully absorbing in the Krebs cycle over 18 months. Results Until now 14 patients have completed 24 mo FU including constant score (CS), subjective shoulder value (SSV) and a native MRI. The CS rose from 46 to 85 points, the SSV from 43 to 89%. MR scans showed an intact repair in 12 cases, typically Sugaya type III (intact but thinnend cuff). 2 retears were observed (14%). In this series of 54, one shoulder was revised for infection, one shoulder received a reversed prosthesis and two more were sucessfully revised because of a symptomatic gap formation at the posterior edge of the patch. Reversal of pseudoparesis in massive tears was achieved in 10 cases. The added costs of patch augmention were about 600 Euros, added operation time after the learnig curve less than 30. Patch integration has been observed at repeat arthroscopy. Conclusion We report a learnable technique for patch augmentation in the revision setting and for massive RC tears. Implant costs are reasonable; the material has been succesfully used in abdominal wall hernias and cosmetic breast surgery. The scaffold is made from fully absorbable synthetic fibres degrading without known toxicity and containing no DNA residues. It has good mechanical and biological properties. The preliminary results suggest an improved outcome and higher healing rates in these critical situations.

This study was performed to review and compare the outcome of a consecutive series of 96 rotator cuff repairs performed with an open versus arthroscopic technique. The arthroscopic repairs include the beginning of the learning curve.Case series.In a 24-month period from 1999 to 2001, 95 patients underwent a cuff repair with bony reattachment by 1 surgeon; 4 patients had surgery on both shoulders. We present subjective outcome data from 96 of 99 operated shoulders by the use of a visual analog scale (VAS), the Simple Shoulder Test (SST), and the question of overall patient satisfaction. Thirty shoulders undergoing surgery before February 2000 had open cuff repair (12 classic open, 18 mini-open) and 66 shoulders undergoing surgery after February 2000 had an arthroscopic cuff repair with suture anchors. All but 3 shoulders had the supraspinatus/infraspinatus tendon refixed, 32% had a subscapularis reattachment, and 21% an additional SLAP repair.Groups A (30 shoulders, open repair) and B (66 shoulders, arthroscopic repair) were comparable concerning tear size, cause of the tear, professional shoulder strain, and preoperative pain intensity. At follow-up evaluation (15-40 months after surgery), group B had significantly better pain relief on the VAS (P.05), more yes answers in the SST (9.7 vs. 8.7, not significant), and a higher patient satisfaction rate of 92.4% versus 80% (not significant). From the 12 questions of the SST, all but 1 showed a higher percentage of yes answers in group B; for 3 questions concerning mobility the difference was significant (P.07). There was no correlation between tear size and outcome in the SST.Arthroscopic cuff repair yielded equal or better results than open repair, even at the beginning of the learning curve. Patients with an arthroscopic repair had a significantly better decrease in pain and a better functional result concerning mobility. Arthroscopic repair is successful for large and small tears. Biomechanically, large tears might even benefit more than small ones.Level IV.

We present a simplified and cost-effective method for repair of a type II SLAP lesion that requires only 1 working portal in the rotator interval-the lateral anterosuperior portal (LASP)-which is about 3 cm more lateral than the standard ASP. The rotator cuff tendon or muscle are not violated when using this portal, which provides an unproblematic 30 degrees angle for the drill hole. The biceps root can be firmly reattached anteriorly and posteriorly using 1 double-loaded absorbable bone anchor with a suture eyelet. The first stitch is performed using a straight suture hook to pierce the anterior biceps root from the front. A PDS utility suture helps to shuttle the braided suture in a retrograde manner through the labrum. We then tie a sliding knot seating solidly on top of the labrum. The second stitch is placed with a 45 degrees curved suture hook allowing us to pierce the labrum posteriorly to the biceps from above. Again, a sliding knot will be seated on top of the posterior biceps root, pressing it firmly onto the previously abraded bone. The completed repair looks like a V and produces secure fixation of the biceps, thus eliminating the peel-back phenomenon.