Archivio di Ortopedia e Reumatologia

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Vol. 125 - 1-2 Novembre 2014
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Vol. 125 - 1-2 Novembre 2014
EDITORIALE
T
he ARCHIVIO DI ORTOPEDIA E REUMATOLOGIA is an
historic scientific magazine that for our Institute has
always had a major role in helping to spread experiences
and knowledges in the fields of orthopaedics and
reumathology.
This first issue after a lack of pubblications due to a change
of editor, is presented in a graphic totally renewed, more
usable and now similar to the most famous scientific
international publications.
This issue, first with the new format, is totally dedicated
to degenerative shoulder that is represented by all
shoulder diseases that slowly appear after 40yo and
then evolve after 50yo and especially after 60yo.
The index of the present issue follows the stages of a
conference held two years ago in Milan for which I worked
in co-operation with Pierluigi Gambrioli and Alessandro
Castagna, two friends of mine and celebrated shoulder
surgeons. The former idea was to build the congress
following a theoretical evolution of the degenerative
shoulder disease in which the anatomical damage
becomes gradually more and more serious.
Then we will start from basic science and biology, trying
to understand how and why rotator cuff tendinopathy
begins. At the same time we will discuss two particular
shoulder diseases that not infrequently affect the shoulder
like adhesive capsulitis and calcifying tendinopathy.
After the beginning of a real tendinopathy, tendon fibers
deteriorate and torn leading to a partial tear or, in some
case of no-treatment, to a full thickness tendon tear.
A lot of papers will be focused on rotator cuff tear talking
from modern suture techniques to the possibilities
that modern biological science offer in order to
improve rotator cuff healing after surgical repair. We
will also discover that not all kind of ruptures can be
treated arthroscopically, like a complete full thickness
subscapular tear, that requires open surgery, or like
massive irreparable cuff tear requiring latissimus dorsi
or teres major tendon transfer that should be isolated
via open surgery.
Another kind of degenerative shoulder disease affects
cartilage layer. In this case we recognise a shoulder
arthropathy that can be primitive or secondary to a
fracture or to a serious rotator cuff tear that have been
never treated before. When degenerative disease lead
to an arthropathy the treatment can be a modern
shoulder prosthesis that is generally widely adaptable to
the anatomy of the patient and to the pathology.
Last but not least an adequate space has been left to
rehabilitation even in the field of tendinopathy than in
shoulder prosthesis field.
In this issue the reader will find a reference in modern
approaches to surgical treatment and in rehabilitation of
degenerative shoulder.
Roberto LEO
n
4
Vol. 125 - 1-2 Novembre 2014
SOmmarIO
2.
Editoriale
.
Roberto Leo
5.
Tendon disease and rotator cuff tears
.
.
A. Castagna, V. Fogliata, R. Garofalo
8.
Calcific tendinitis of the shoulder
58. Platelet rich plasma in rotator cuff disease
.
P. Randelli, V. Ragone, R. D’Ambrosi, F. Randelli,
P. Cabitza
13 . Adhesive capsulitis: clinical aspects
and treatment
.
R. Leo, PL. Gambrioli
16. Biological enhancement in rotator cuff repairs
.
53. Platelet Rich Plasma in Arthroscopic
Rotator Cuff Repair: State of the Art
P. Randelli, V. Ragone, A. Menon, R. D’Ambrosi,
F. Randelli, P. Cabitza
.
U.G. Longo, A. Berton, G. Rizzello, G. Salvatore,
V. Denaro
61. Biology of rotator cuff tendinopathy
.
A. Murgo, O. De Lucia, C. Crotti, PL. Meroni
64. Scaffold augmentation in rotator
cuff tears repairs
.
A. Castagna, V. Fogliata, R. Garofalo, E. Cesari
R. Rotini, A. Marinelli, E. Guerra, G. Bettelli,
M. Cavaciocchi, L. Zaccarelli, M. Fini, E. Bondioli
23. Partial-thickness rotator cuff tear. Surgery:
72. Rational approach to the irreparable cuff tears -
.
.
when and how
M. Rebuzzi, P. Baudi, M. Gialdini, C. Rovesta,
from “functional” repair to muscle transfer
F. Catani
29. Rotator cuff rehabilitation
.
in reparable rotator cuff tears.
Actual standards and limitations
.
G. Merolla, G. Porcellini
76. Arthroscopically-assisted latissimus
dorsi transfer
M. Conti, R. Garofalo
35. Modern technique of arthroscopic suture
.
E. Gervasi, A. Spicuzza
81. The rotator cuff irreparable tears:
latissimus round muscle transfer
R. Leo, V. Fogliata, A.M. Querenghi, M. Pivetta,
.
B.M. Marelli
85. Reverse shoulder arthroplasty with and without
43. Subscapularis tendon tear.
F. Odella, S. Odella
tendon transfer for arthropathy with massive
rotator cuff tear: personal experience and critical
analysis of the literature
Modern surgical approach
.
F. Campi, P. Paladini, C. Buononato, A. Tartarone,
D. Petriccioli, G. Marchi, C. Bertone
47. Painful shoulder:
.
the Rheumatologist’s point of view
92. Shoulder arthroplasty’s rehabilitation
.
L. Sinigaglia, F. Zucchi, M. Varenna
.
N. Ivaldo, G. Caione, M. Rossoni
R. Costantino, L. Panella, E. Prisco
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Vol. 125 - 1-2 Novembre 2014
Tendon disease and rotator cuff tears
Alessandro Castagna, Valentina Fogliata*, Raffaele Garofalo**
Unità di chirurgia della spalla e gomito, IRCCS Istituto Humanitas, Milano
* Dipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,
Struttura Semplice Dipartimentale Chirurgia Spalla e Gomito, Istituto Ortopedico G. Pini, Milano
**Servizio Chirurgia della spalla Ospedale F. Miulli, Acquaviva delle Fonti, Bari
INTRODUCTION
ABSTRACT
In 1972, Neer coined the term of subacromial impingement to indicate a pathologic condition characterized by
an extrinsic compression of the supraspinatus tendon in
particular by the anterior margin of the acromion, the coracoacromial ligament, and also by acromioclavicular joint
osteophytes 1. This chronic, compression associated with
microtrauma, firstly implied an inflammatory-reactive
framework and therefore a progressive degeneration until the rupture of the tendon itself, with consequent pain
syndrome and shoulder functional impotence. However,
in 1922 Meyer had already suggested that capsular and
tendinous shoulder injuries were the result of the contact
between the greater tuberosity and the acromion2. In support of this theory Bigliani had described 3 different acromion morphologies: type I (flat), type II (curved), and
type III (hooked acromion). This author suggested that
70% of rotator cuff lesions were associated with a type
III acromion 3. Later, Nyffeler has shown how not only the
acromion shape but also its lateral extension could be responsible for an impingement subacromial syndrome and
a consequent lesion of the rotator cuff 4.
In recent years, however, there has been a considerable incentive to the study of the rotator cuff pathology basis. In
particular, these studies have revealed that the injury of
the cuff tendons is the result of a tendon desease that is
associated with specific extrinsic situations (impingement)
and microtrauma. This paper aims to analyze the literature
for intrinsic aspects that could contribute in causing rotator
cuff injuries.
Shoulder impingement syndrome was originally introduced by
Neer in 1972, when he described the compression of the supraspinatus tendon against the anterior edge of the acromion, the coracoacromial arch and the acromioclavicular joint. As a result, for
long rotator cuff tendons lesions were believed to be caused by
extrinsic factors and in particular by subacromial impingement.
Recent studies on rotator cuff pathology reveal that, actually, most
of these injuries result from a multifactorial process in which the
intrinsic factors play a key role. The recognition of these different
factors is very important in order to improve the approach to this
disease. The hope is that, in the future, prevention and treatment
of rotator cuff diseases could be optimized even with pharmacological interventions.
ROTATOR CUFF TENDONS STRUCTURE
The rotator cuff is represented by 4 tendons that are the
supraspinatus, the infraspinatus, the teres minor and the
subscapularis. Each of these tendons is inserted at the level
of the proximal humerus. In particular, the subscapularis
inserts on throchine (lesser tuberosity) and the other three
tendons are inserted on the throchite (greater tuberosity).
Of these tendons, supraspinatus is the most vulnerable;
the cause of this condition is attributed to the fact that this
tendon is located below the coracoacromial arch and also
to the fact that it presents an abnormal vascularization.
The type I collagen accounts for about 85% of the dry
weight of the rotator cuff tendons. In supraspinatus there
is a significant proportion of type III collagen and a relatively high content of glycosaminoglycans (GAGs). The
supraspinatus undergoes significant compression because
of its location and biomechanics, and expressed proteins
of the extracellular matrix (ECM) that are often found in
the cartilage (decorin, biglycan and aggrecan). Since the
most anterior region of the supraspinatus is that which
most frequently undergoes breakage, it is easy understand how the concentration of proteoglycans at the level
of this region is important. At tendon to bone interface
(entheses) there is an interdigitation of several layers of
longitudinally oriented fibers of type I collagen which are
inserted in a gradual manner on the humerus5.
The number of vessels and their size gradually decrease
getting closer to the bone5. At the level of this junction
4 zones are distinguished: tendon, non-mineralized fibrocartilage, mineralized fibrocartilage, and bone. Type
I collagen predominates in zones 1 and 4, while zones
2 and 3 contain mainly collagen I, II and X, as well as
ECM with proteoglycans. With the aging process, the
level of vascularization in this area tends to decrease progressively, altering the intrinsic structure of the tendon to
bone interface.
ECM is constantly being reshaped itself and this is possible thanks to the delicate balance between collagenase
and collagenase inhibitors themselves. This balance is
influenced by genetic factors, functional overload and
extrinsic factors that can influence the activity of these
enzymes. Many studies have emphasized the importance
of ECM in connective tissue homeostasis. Physiological
and pathological ECM changes appear to be involved in
tendinopathy and tendon lesions.
From the biomechanical point of view the articular portion of the supraspinatus is the one that has the highest
modulus of elasticity. Tendon longitudinal bursal bundles
are better able to disperse the tensile loads than the thinner fibers present at the level of the articular portion. This
effect is most noticeable during abduction of the arm.
Mathematical models confirm these data and show that
the concentration of stress is greater in articular insertional
area and increases with abduction.
TENDON DISEASE AND ROTATOR CUFF TEARS
Recent scientific evidence shows that the majority of rotator cuff tears (RCTs) are caused by a degenerative disease
intrinsic in the tendon.
VASCULAR THEORY
One of the causes of this degeneration would be represented by the particular vasculature of certain tendons,
especially the supraspinatus tendon. In particular, an hypoperfusion area was described at about 10-15 mm from
the insertion of the supraspinatus tendon. However it is
not clear whether the hypoperfusion could really contribute to the tendon degeneration.
Furthermore some authors have studied the capillaries
distribution in cadaver cuff samples, and have concluded
that hypovascularization area does not exist 6. Other authors have revealed that at the cuff tendon rupture margin
there is not an hypovascular reaction but an hyperemic
response. Goodmurphy says that the reduced vascularity
that can be seen at the criticism zone may be an artifact
of the technique used7. Taking account of the above, the
etiopathogenetic vascular hypothesis is currently in steep
decline.
DEGENERATIVE THEORY
In the 30s, Codman had already suggested the degenerative theory as an RCTs cause 8. This theory was recently
confirmed by a series of pathological studies performed
on the edge of the tendinous lesion. These studies, in fact,
confirm the presence of thinning of the tendon, disruption
of the collagen fibers, myxoid degeneration, hyaline degeneration, chondroid metaplasia, calcification, angiogenesis and fatty infiltration at the margin of the injured tendon 9. Other authors have also shown how the degenerative
process involves not only the edge of breakage, but also a
medial part of the tendon (1 cm) which apparently shows
to be healthy. This data is very important in consideration
of the cuff tendon repair 10.
The degeneration of the tendon appears to be closely correlated with the age of the patient. Yamaguchi et al. in a
retrospective study showed a difference of about 10 years
among patients without rotator cuff lesion (48.7 years) in
comparison with those with partial lesion (58.7 years), and
patients with full-thickness lesion (67.8 years). Also in this
study is shown that 35.5% of patients with a symptomatic
rotator cuff lesion had a non-symptomatic lesion in the
contralateral limb11.
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Vol. 125 - 1-2 Novembre 2014
ECM and metalloprotease
Tenocytes taken from a tendon inveterate tear are not capable of synthesizing a normal ECM. ECM is the substrate
on which the cells adhere, migrate and differentiate. An
alteration of the ECM seems to be one of the most important factors involved in tendinopathy and tendon tears.
The ECM turnover in a normal tendon is mediated by matrix metalloproteinases (MMPs) 12. In particular, MMP-1,
MMP-2 and MMP-3 seem to be the most involved. An
increase in the activity of MMP-1 leads to a degradation
of the network of collagen fibrils with a consequent weakening of the tendon matrix. The tendon in this manner becomes less stable from a mechanical point of view and this
can contribute to the rupture of the tendon itself.
Some authors have shown that at the level of the edge of
a damaged tendon there is an increased activity of MMPs
(MMP 1,2,3) and a decreased activity of their inhibitors.
Moreover, since even more interesting, this alteration even
manifested itself in the most medial portion of the tendon
that appeared to be intact13. This data shows how likely
the biological degradation processes precede macroscopic
morphostructural alterations and are not a consequence.
Apoptosis
Yuan et al. were the first authors to recognize a role of
apoptosis in rotator cuff pathology14. Apoptosis is a physiological process that leads to a mechanism of programmed
cellular suicide. This process is regulated by a family of
proteases, in particular by caspases. The role of apoptosis
in determining an RCT is not yet completely clear. However, what is certain is that an increase in apoptosis at the
level of the tendon tissue can result in a reduction of the
cell population, the collagen synthesis and in a progression
to tendon degeneration.
It is interesting to note that caspases can also be activated
by oxidative stress derived from overuse and from reduced
vascularity of the tendon itself. The same caspases alter
the ECM composition, weakening the tendon and there is a
stimulus to the increase of MMPs activity, which (in turn)
weakens the tendon itself. In this manner a sort of vicious
circle that leads to the tendon tear is created.
Recently some authors have shown that, in the case of
tendon rupture, the caspases activity is not increased only
at the level of the broken margin of the tendon, but also
1 cm medial to the break15. This is important not only to
understand the tendon degenerative disease, but also for
the considerations that follow for the surgical treatment of
lesions.
Metabolic disorders and RCT
Symptomatic lesions of the rotator cuff have been more
commonly observed in patients with type I and II diabetes
and in patients with glucose intolerance16. In asymptomatic diabetic patients, there were an increased thickness of
the supraspinatus tendon and the long-head biceps tendon
and a higher prevalence of RCT. Recently, Abboud et al.
have found a correlation between hypercholesterolemia
and RCT. In particular it has been found that the levels
of total cholesterol, triglycerides and LDL, were higher in
patients with RCT17.
It is unclear, however, whether this represents an indepen-
dent risk factor for rotator cuff injury or whether it represents an aspect of concomitant disease related to aging of
the patient.
CONCLUSIONS
In light of recent studies it appears that the majority of
RCT are the result of a multifactorial process, where there
is probably not a single cause capable of determining the
wear, and then the rupture of the tendon. Both the patient’s
age and the degenerative tendinous intrinsic process associated with it, are certainly the basis on which may contribute also external factors such as overuse and impingement,
as well as the responsible lifestyle for metabolic diseases.
In choosing the appropriate plan of treatment of this disease, the clinician must be very careful to specifically assess the various factors that contribute to the pathology of
the patient. It is to be hoped that, in the future, a prevention
and treatment of RCT can be optimized with pharmalogical treatments that can avoid surgery or improve the results
of the latter.
REFERENCES
1.Neer CS II Anterior acromioplasty for the chronic impingement
syndrome in the shoulder. J Bone Joint Surg 1972; 54-A:41-50
2. Meyer AW Further observations on use-destruction in joints. J
Bone Joint Surg. 1922; 4:491–511
3. Bigliani LU, Morris DS, April EW The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;
10:216
4.Nyffeler RW, Werner CM, Sukthankar A et al. Association of a
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large lateral extension of the acromion with rotator cuff tears. J
Bone Joint Surg Am 2008; 88:800-5
5. Uhthoff HK, Seki M, Backman DS et al. Tensile strength of the supraspinatus after reimplantation into a bony trough: An experimental study in rabbits. J Shoulder Elbow Surg 2002; 11:504–509
6. Moseley HF, Goldie I The arterial patterns of the rotator cuff of
the shoulder. J Bone Joint Surg Br 1963; 45:780-89
7. Goodmurphy CW, Osborn J, Akesson EJ et al. An Immunocytochemical analysis of torn rotator cuff tendon taken at the time
of repair. J Shoulder Elbow Surg 2003; 12:368-374
8. Codman EA The shoulder. Rupture of the supraspinatus tendon,
Boston, Thomas Todd, 1934: 123-177
9. Chillemi C, Petrozza V, Garro L et al. Rotator cuff re-tear or nonhealing: histopathological aspects and predictive factors. Knee
Surg Sports traumatol Arthrosc 2011; 19:1588-96
10. Longo UG, Franceschi F, Ruzzini L et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med 2008;
36:533-8
11. Yamaguchi K, Ditsios K, Middleton WD et al. The demographic
and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint
Surg Am 2006; 88:1699-1704
12. Garofalo R, Cesari E, Vinci E, Castagna A. Role of metalloproteasi
in rotator cuff tear. Sports Med Arthrosc 2011; 19:207-12
13. Castagna A, Cesari E, Garofalo R et al. Matrix metalloproteases
and their inhibitors are altered in torn rotator cuff tendons, but
also in the macroscopically and histologically intact portion of
those tendons. Muscles Ligaments Tendons J 2013; 3:132-8
14. Yuan J, Murrell GA, Wei AQ, Wang MX Apoptosis in rotator cuff
tendinopathy. J Orthop Res 2002; 20:1372–1379
15. Lee HJ, Kim YS, OK JH, Song HJ. Apoptosis occurs throughout the
diseased rotator cuff. Am J Sports Med 2013; 41: 2249-2255
16. Longo UG, Franceschi F, Ruzzini L et al. Higher fasting plasma
glucose levels within the normoglycaemic range and rotator cuff
tears. Br J Sports Med 2009; 43:284–7
17.Abboud JA, Kim JS. The effect of hypercholesterolemia on rotator cuff disease. Clin Orthop Relat Res 2010; 468:1493-97
PRESERVATION.
FIXATION.
CONVERSION.
PERFORMANCE.
TORNIER. WE EXPECT MORE THAN OTHERS THINK IS POSSIBLE.
www.tornier.com
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Vol. 125 - 1-2 Novembre 2014
Calcific tendinitis of the shoulder
Pietro Randelli, Vincenza Ragone, Riccardo D’Ambrosi, Filippo Randelli,
Paolo Cabitza
Dipartimento di Scienze Medico-Chirurgiche, Università degli Studi di Milano,
IRCCS, Policlinico San Donato, Milano
Introduction
Calcium deposits within the tendons of the rotator cuff are a common shoulder disorder 1. The incidence in the healthy population is 2.7%, rising to 6.8% in patients with shoulder pain 2. The
predominant age is 30–60 years and women are affected slightly
more often than men. Bilateral involvement is not uncommon (in
10% to 25% of patients). Calcifications occur commonly in the
supraspinatus tendon (51%–90%) and least commonly in the subscapularis tendon (3%) 3. Up to 50% of cases are asymptomatic
and run a self-limiting course 4-5.
Two different etiological processes have been proposed. The first
is degenerative calcification, in which Codman6 proposed that degeneration within the tendon fibers precedes calcification. This
was later adopted by Moseley and Goldie, 7 who defined the tendon-bone insertion area as the ‘‘critical zone’’. The second cause
proposed is reactive calcification within a healthy tendon 8.
Other theories have been introduced in recent years involving
chemical factors causing the deposit of calcium, cell proliferation
and production of inflammatory agents, metabolic factors and genetic predisposition to the formation of calcific deposits.
formative phase, the deposits exhibit a chalk-like
consistency.
b) Resting phase: occurs when fibrocollagenous tissue
borders the foci of calcification without evidence
of inflammation, thereby indicating termination of
deposition.
c) Resorptive phase: is marked by the appearance of
thin-walled vascular channels at the periphery of
the deposit. Macrophages and multinucleated giant
cells then surround the deposit and phagocytose debris with calcium removal. In this phase the deposit
exhibits a thick, creamy, or tooth- paste-like material that is often under pressure.
3) Postcalcific stage: as the tissue undergoes healing during
the post-calcific stage, new vascular channels promote fibroblasts to form type III collagen that becomes replaced
by type I collagen. The tendon is healed subsequently with
fiber realignment and resolution of the calcium deposit.
Clinical presentation
Classification
There are numerous classifications that have been proposed by various authors.
Anatomical9: small (< 0.5 cm), medium (from 0.5 to 1.5
cm) and large (>1.5 cm). Patte and Goutallier10 have distinguished calcifications in localized and diffuse.
Clinical: depending on the symptomatology can be divided
into acute, subacute and chronic.
Pathological: Uhthoff 8 proposes that the evolution of the
disease can be divided into three distinct stages:
1) precalcific, 2) calcific, and 3) postcalcific.
1) Precalcific stage: fibrocartilaginous transformation begins within the tendon at the site of predilection for calcification. This metaplasia of tenocytes into chondrocytes
is accompanied by metachromasia, indicating the elaboration of proteoglycan.
The onset of symptoms is chronic, with very low noise and
discomfort content. The initial state of formation of the
deposits has no vascular neo-formation, cellular reaction
and there is no change in tension of the tendon tissue. The
clinical presentation becomes very painful, however, in
the phase of resorption because the vascular neoformation,
together with the exudative state, can bring a substantial
increase in the volume of tissue with consequent increase
of intratendinous pressure. The pain typically exacerbates
overnight, radiates to the outside face of the ipsilateral
arm, with the forearm extension. In some cases, this is also
reflected radiation to the cervical region.
Symptoms are accompanied by functional impotence of
variable degree in relation to pain.
Three symptomatic phases can be distinguished:
1. The acute phase may occur in 1 to 5-6 weeks. In
this phase an intense pain causes important discomfort and loss of function.
2) Calcific stage that follows is subdivided into three phases 11: a) formative, b) resting, and c) resorptive.
2. The chronic phase can occur for many months with
a continuous, dull and of fixed intensity pain. This
pain is significantly lower than the acute form.
a) Formative phase: separated by chondrocytes and
fibrocartilaginous tissue septae, calcium crystals
are deposited primarily in matrix vesicles that coalesce to form large foci of calcification. In this
3. Persistent chronic phase characterized by periods of
pain and periods of complete well-being. Its minimum duration of 1-2 months can extend for more
than 6 months.
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Vol. 125 - 1-2 Novembre 2014
Figure 1:
Rx anterior-posterior left shoulder.
Clearly visible calcification in the context
of the supraspinatus tendon.
Several methods of treatment are listed in the literature.
Among the most known are Shockwaves, US lavage, Needling and Arthroscopy (Figure 2).
Imaging
Calcium deposits can be seen on plain radiographs with
a full series of shoulder films that include AP, (Figure 1),
internal and external rotation, scapular Y, and axillary lateral views. These views help to localize the deposit to a
specific tendon and show signs of possible impingement.
For the recognition of calcifications is also very useful ultrasound examination.
Hartig and Huth12 have shown that ultrasound allows to
detect the totality of calcifications while radiography permits only in 90% of cases. Magnetic resonance imaging
(MRI) evaluation can lead to diagnostic errors and it is not
indicated routinely.
Extracorporeal shock wave therapy
In the last two decades, several studies have demonstrated
the effectiveness of extracorporeal shockwave therapy
(ESWT) in treatment of calcifying tendinitis of the rotator cuff15-18. One study even stated that ESWT should be
preferred to arthroscopy due to its non-invasiveness at
equivalent outcome. A single high-level middle-energetic
ESWT was found as effective as two applications of a lower-dosed middle-energetic ESWT for calcifying tendinitis
of the rotator cuff after failure of other conservative treatment options (physiotherapy, infiltrations or NSAIDS)19.
A literature review20 suggests that ESWT is moderately
effective in reducing pain and improving function in individuals with chronic shoulder calcific tendinitis, for up to a
year after its application. Although satisfaction results are
been associated to this treatment there is no clear evidence
regarding the optimal dosage in energy level, intervals between sessions, and number of sessions required for optimal recovery from the condition. Clinicians should also
record the intervention parameters because these provide
important clinical audit information for future investigations. Future studies of level 1 of evidence are needed to
dry definitive conclusions on ESWT treatment for shoulder calcific tendinitis.
Needling
Needle lavage has been described as an effective treatment
that can be performed either in the operating room or in
the radiology suite. This technique is best used in patients
Treatment
The choice of treatment should be evaluated and placed in
relation to each other the medical history, symptoms and
radiographic findings.
In some cases, calcifications will resorb during the natural
progression of disease. Gärtner13 followed the natural evolution of calcific deposits, finding that radiologically dense
deposits disappeared in 33% compared with 85% of fluffy
deposits over 3 year.
Unfortunately it’s known that up to 38% of the calcification do not disappear with time5.
In particular medial and anterior localization of the calcification is a negative prognostic factor for self reabsorption
of the deposit14.
The persistence of the calcification is detrimental to the
tendon biology and resistance.
Thus is mandatory to follow-up the calcification and to
treat it in case it would not reabsorb spontaneously.
Figure 2:
Arthroscopic image.
Removal of calcification of the
supraspinatus tendon.
with an acutely painful shoulder in the resorptive phase,
and it can help decrease the intratendinous pressure. Clinical studies that have analyzed the US-guided percutaneous treatment of calcific tendonitis have reported generally
satisfactory results. Serafini et al.21 compare short and long
term outcomes of patients with rotator cuff calcific tendonitis who did and did not undergo ultrasonographically
(US)-guided percutaneous treatment. Of 219 patients referred for US-guided treatment of rotator cuff calcific tendonitis, 68 patients refused treatment and served as control
subjects. Compared with control group, treated patients
reported a significant decrease in symptoms at 1 month, 3
months and 1 year. Clinical scores were not significantly
different between the two groups at 5 years and 10 years.
The authors conclude that US-guided percutaneous treatment facilitated prompt shoulder function recovery and
pain relief.
Another study22 compares 2 regularly applied calcific rotator cuff treatments: ultrasound (US)–guided needling and
lavage combined with a US-guided corticosteroid injection
in the subacromial bursa (barbotage group) versus an isolated subacromial bursa injection (control group). Patients
were randomly assigned to the 2 groups. Shoulder function
was assessed before treatment and at regular follow-up intervals (6 weeks and 3, 6, and 12 months). Additionally,
calcification location, size, and Gärtner classification were
assessed on radiographs. On average, there was improvement at 1-year follow-up in both treatment groups, but
clinical and radiographic results were significantly better
in the barbotage group.
Furthermore ultrasound-guided needling in combination
with high-energy shock-wave therapy (treatment group)
was found more effective than shock-wave therapy alone
(control group) in patients with symptomatic calcific tendonitis23. A higher rate of elimination of the calcium deposits was seen in treatment group (60%) than in control
group 2 (32.5%) (p < 0.05). Arthroscopic removal of the
deposit was avoided in 32 patients of treatment group and
in 22 of control group (p < 0.05) .
Platelet-rich plasma therapy
Platelet-rich plasma therapy (PRPT) has been advocated
for the treatment of muscle, tendon as well as joint pathologies24. Seijas et al.25 reported the use of PRPT in a 44year-old female with chronic calcific tendinopathy of the
supraspinatus that was nonresponsive to traditional conservative therapy. The patient received three treatments at
2-week intervals. After 6 weeks, the patient was reportedly
asymptomatic. Follow-up at 1 year confirmed the patient
remained pain-free and was able to return to unrestricted
activities. This isolated case study (level V) suggests PRPT
may be of value for intractable cases of calcific tendinopathy. However evidence from clinical studies of Level 1 are
required.
Surgery
Surgery is indicated for patients who have progression of
their symptoms, constant pain that interferes with activities
of daily living, and absence of improvement after conservative therapy. Surgical treatment is helpful for the chronic
formative phase patients (radiological dense calcification
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Vol. 125 - 1-2 Novembre 2014
and sharp edges) and especially those with impingement
symptoms.
Harrington and Codman performed the first operative
procedure for removal of calcific deposit in 1902 6. Since
the 1930s many investigators have supported this procedure 26--28.
Rochwerger et al.29 reported on 22 patients who underwent
open removal of a calcific deposit and acromionplasty
and found the Constant-Murley assessment score was increased 23 months after the treatment. They concluded that
the most favorable results are obtained in patients with the
longest interval between onset of the disease and intervention (more than 1 year) and with a progressive course of
the disease.
Arthroscopic treatment has been shown to have outcomes
that are equivalent to those of open procedures, and it has
the added benefits of improved cosmesis and possibly a
shorter hospital stay, which leads to decreased cost (Figure 2). Rehabilitation consists of a simple home exercise
program to regain muscle tone and to prevent adhesive
capsulitis.
In 1987 Ellman30 first described his arthroscopic technique,
involving blind needle aspiration to locate the deposit, followed by excision, and the acromionplasty.
Jerosch et al.31 evaluated 48 patients treated arthoscopically with deposit removal, resection of the coracoacromial ligament and acromionplasty. Results showed
patients with post-operative radiographic elimination or reduction of the deposits had significantly better outcomes than those without radiographic change
and that acromionplasty did not improve the results.
Even more recent studies support the arthroscopic technique in patients with persistence or progression of symptoms and constant pain.
Seil et al.32 have analyzed the outcome of arthroscopic removal of calcifying tendinitis of the rotator cuff on 58 patients. Every patient was evaluated by using the Constant
score, pre and post-operative radiographs and ultrasonoography to assess integrity of rotator cuff. Shoulder function
improved according to Constant score, and ultrasonography revealed minor structural changes of the supraspinatus
in 66% patients. 92% of the patients were very satisfied.
The study confirmed previously reported successful results of arthroscopic treatment of calcifying tendinitis of
the rotator cuff.
El Shewy33 studied the results of arthroscopic removal of
the calcium deposits within the rotator cuff, without rotator cuff repair after a minimum follow-up of 7 years. On
56 patients everyone improved their shoulder’s activity
(measured by ASES, UCLA and Costant). Only 3.7% of
cases developed rotator cuff tears over the period of follow-up. The author concludes that arthroscopic removal
of as much as possible of symptomatic calcium deposits
of the rotator cuff is a safe and effective treatment when
nonoperative methods fail.
Yoo et al.34 also substained that complete removal of calcium deposits in tendon cuff provides good clinical results
and earlier pain relief when it was compared to previous
literature of minimal removal technique.
Porcellini et al.35 demonstrated results of arthroscopic removal of calcifications and an acromioplasty only when
the coracoacromial ligament was rough and the acromion
was exposed. They concluded that a successful outcome
seemed strongly related only to the absence of calcium deposits in the tendon cuff.
Other studies have advocated the surgical removal of deposits, either by an open or artrhoscopic procedure.
Balke et al.36 reported the results on 70 shoulders of 62
patients with a mean age of 54 years, after arthroscopic removal of calcium deposits of the supraspinatus tendon. In
44 shoulders, additional subacromial decompression was
performed. After a mean follow-up of 6 years, patients
were clinically investigated, and function was statistically
evaluated using Constant and ASES scores. Affected and
contralateral shoulders were examined by ultrasound in
48 shoulders, and rotator cuff tears were documented. The
mean Constant scores of the operated shoulders were significantly lower than those of the healthy shoulders. The
ASES scores significantly increased after surgery but were
still lower than the ASES scores of the healthy shoulders.
Pain was found significantly better in patients with the
subacromial decompression. Ultrasound examination at
last follow-up showed a partial supraspinatus tendon tear
in 11 operated and 3 contralateral shoulders. The results of
this study indicate that although the good clinical results
after arthroscopic treatment of calcifying tendinitis of the
shoulder persist midterm, the affected shoulders present
significantly lower clinical scores than healthy shoulders.
The rate of partial supraspinatus tendon tears seems to be
higher after calcium removal. Additional subacromial decompression seems to reduce postoperative pain. Tillander and Norlin37 compared two groups with an impingement
syndrome, one group showing deposits in the rotator cuff
and the other not showing such deposits. Both groups performed arthroscopic acromioplasty, with no difference in
results or calcification dissolution. They suggested that
calcifications may not cause pain and are an insignificant
observation on radiographic evaluation regarding treatment indication.
Hofstee and collagues38 evaluated two groups of patients
after 3 years. The first group treated with acromioplasty
and removal of calcification, the second only with acromioplasty. There was no difference in clinical outcomes
between surgical subacromial decompression with or
without removal of the calcifications.
Treatment Algorithm
Calcific Tendinitis represent a treatment challenge since
there is no consensus on its treatment.
Most studies concerning treatment of rotator cuff calcifications are uncontrolled. Moreover, most studies focus
on symptom disappearance, more than calcification disappearance, after conservative or operative therapy. Therefore, although symptoms may improve, the pathology (intratendinous degeneration and calcification) remains.
Patients compliance is the key in the treatment algorithm
for this disease. As a matter of fact shockwaves are not
well tolerated by patients, as like as the surgical treatment
is not well perceived. Recently US guided lavage offers
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Vol. 125 - 1-2 Novembre 2014
an easy way of treatment of the tendinitis, washing out the
entire deposit. Unfortunately US lavage is suitable only in
acute calcific tendinitis when the deposit is pretty fluid. On
the other hand the arthroscopic treatment allows to repair a
cuff tear related to a chronic calcific tendinitis.
A practical Treatment Algorithm has been developed following the main concepts of: 1) reduce the pain, 2) treat
the tendon avoiding a subsequent cuff tear.
1. In case of acute onset of calcific tendonitis diagnosed by X-Rays, the patients are sent to the radiology dept for US lavage. The lavage is performed in
local anesthesia and in an outpatient way.
2. Two days after the treatment the patients start physical therapy, for passive range of motion (ROM)
exercises, with a full ROM recovery at 7 days after
treatment. Active ROM exercises will start only 1520 days after treatment depending on the residual
pain.
3. The patients will repeat an X-rays at 2 months after
treatment plus an MRI in case of persistent pain. If
the tendon is torn the patients are scheduled for surgery, if not they continue follow-up surveillance.
4. In case of Chronic calcific tendonitis we suggest an
arthroscopic treatment with/out rotator cuff repair.
Conclusions
The calcific tendonitis is a cell-mediated pathology, multiphasic, which creates a calcium deposit particularly in the
supraspinatus tendon, or subacromial bursa, and a subsequent resorption.
Most cases resolve spontaneously. In the literature, several conservative treatments have been reported with varying levels of evidence on their effectiveness. A very well
accepted and successful technique is the US lavage. The
arthroscopic surgery is the last option available to the orthopedic specialist; should be noted that the post-surgical
pain may be present for several weeks after surgery. Arthroscopic treatment should be reserved for chronic cases
or for cuff ruptures due to the deposit.
References
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15) Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck
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K, Lampe R, Seil R et al. Extracorporeal shock wave therapy for
the treatment of chronic calcifying tendonitis of the rotator cuff.
JAMA 2003; 290:2573–2580
17) Ogden JA, Toth-Kischkat A, Schultheiss R. Principles of shock
wave therapy. Clin Orthop Relat Res 2001; 387:8–17
18) Speed CA, Richards C, Nichols D, Burnet S, Weiss JT, Humphreys
H, Hazleman BL () Extracorporeal shock wave therapy for tendonitis of rotator cuff. J Bone Joint Surg Br 2002; 84-B:509–512
19) Farr S, Sevelda F, Mader P, Graf A, Petje G, Sabeti-Aschraf M.
Extracorporeal shockwave therapy in calcifying tendinitis of the
shoulder. Knee Surg Sports Traumatol Arthrosc 2011; 19:2085-9
20) Lee SY, Cheng B, Grimmer-Somers K. The midterm effectiveness
of extracorporeal shockwave therapy in the management of
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20:845-54
21) Serafini G, Sconfienza LM, Lacelli F, Silvestri E, Aliprandi A,
Sarda- nelli F. Rotator cuff calcific tendonitis: short-term and
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22) de Witte PB, Selten JW, Navas A, Nagels J, Visser CP, Nelissen RG,
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sound guided needling combined with shock-wave therapy for
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24) Podd D. Platelet-rich plasma therapy: origins and applications
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18:1694-9
35) Porcellini G, Paladini P, Campi F, Paganelli M: Arthroscopic treatment of calcifying tendonitis of the shoulder: clinical and ultrasonographic follow-up findings at two to five years. J Shoulder
Elbow Surg 2004; 13:503-508
36) Balke M, Bielefeld R, Schmidt C, Dedy N, Liem D. Calcifying tendinitis of the shoulder: midterm results after arthroscopic treatment. Am J Sports Med 2012; 40:657-61
37)Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg
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41:832-5
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Vol. 125 - 1-2 Novembre 2014
Adhesive capsulitis: clinical aspects and treatment
Roberto Leo, PierLuigi Gambrioli
S.S. Dipartimentale Diagnosi e Chirurgia Patologia Spalla e Gomito,
Istituto Ortopedico Gaetano Pini, Milano
PL. Gambrioli
DEFINITION
ABSTRACT
Adhesive capsulitis, also called frozen shoulder (in Italian
literature “capsulite retrattile”, a definition that suggests
inflammatory capsular contracture responsible of pain and
stiffness) is a self-limiting syndrome of unknown etiology that produces progressive shoulder pain and mobility
deficits for a period of about six months followed, in most
of cases, by a pain resolution and mobility recovery in
about four-six months, which is the average healing time.
However, it is not infrequent to observe healing over a longer period of time, one–two years, with variable residual
shoulder stiffness.
Adhesive capsulitis is a complex shoulder pathology characterized by increasing pain related to synovial inflammatory reaction and loss of passive mobility due to a fibrosis and contracture of the articular capsule. The etiology is unknown and this
particularity is the main obstacle to the identification of an effective treatment.
Adhesive capsulitis is a self-limiting condition, which typically
has three stages and ends in resolution in a variable period of
about one year, but can also last longer. The duration of symptoms and the level of pain and stiffness are variable for every
patient.
The etiologic knowledge of this pathology is limited. Consequently also the treatment is controversial and, at present, no
treatment can stop the evolution of the pathology at the beginning or to significantly shorten the period of pain and stiffness.
Over the years, many types of treatments have been proposed.
Many of these have been abandoned and today the preferred
options are non-operative treatments including analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections, mainly performed in early stages of
the pathology. Operative options, including manipulation under
anaesthesia and arthroscopic release, are generally reserved for
refractory cases, with severe residual stiffness at the end of inflammatory stages.
INCIDENCE
Adhesive capsulitis occurs in 2% to 5% of the population,
but prevalence and incidence figures seems to be increasing, the majority of patients are female ranging in age
from 40 to 60 years old 1. The non dominant hand is more
frequently involved. In 20% to 30% of cases the pathology will also affect the opposite shoulder after a variable
period of one or more years. In our experience, concurrent involvement of both shoulders is extremely rare. At
present, this pathology is considered not recurrent in the
same joint.
ETIOLOGY AND ANATOMO-PATHOLOGICAL
ASPECTS
The etiology for primary frozen shoulder remains unknown. The onset of adhesive capsulitis is usually spontaneous, without any relevant trauma.
About 30% of patient reports a doubtful history of minor
trauma, without immediate consequences. Bunker et al 2
considered adhesive capsulitis a Dupuytren like disease
because this condition can be associated with shoulder
capsulitis in some patients.
In histological studies of adhesive capsulitis, capsule and
synovial membrane showed a matrix of type I and type
III collagen populated by fibroblasts and myofibroblasts
in capsular tissue, with no significant inflammation.
Rodeo et al 3, from a biological point of view found the
presence of inflammatory cytokines and their receptors
in capsular tissue with involvement of growth factors
and TGF- beta but inflammatory test and HLA-B27 were
negative.
Intercellular adhesion molecule-1 (ICAM-1, CD54), which
are more abundant in diabetes mellitus, are also present in
capsular tissue of patients with adhesive capsulitis 4 and
this association seems to explain the frequent association
between diabetes and adhesive capsulitis.
According to Hagiwara et al 5 the number of chondrogenic cells and gene expressions related to fibrosis, inflammation, and chondrogenesis was significantly higher and
the capsular tissue was significantly stiffer in idiopathic
frozen shoulders compared with shoulders with rotator
cuff tears.
CLINICAL ASPECTS AND PATHOLOGICAL
ASSOCIATIONS
In shoulder surgery, adhesive capsulitis may complicate
the outcome of minor interventions such as arthroscopic
treatment of small or partial supraspinatus tears and arthroscopic removal of tendon calcium deposits. In these
cases is difficult to understand if the pain leading to the
operation was related to the pre-existence of an undiag-
nosed early stage of adhesive capsulitis without stiffness
or the capsulitis has been declenched by the trauma related
to the surgery. In these patients, to avoid a complicated
and long post-operative convalescence it is wise to evaluate the passive mobility of the shoulder and if the joint is
painful and stiff; one or two months of physical therapy allows physician to decide if the symptomatology is related
to an adhesive capsulitis or not.
Adhesive capsulitis is frequently associated with other
systemic conditions, most commonly diabetes mellitus,
thyroid dysfunction or epilepsy in treatment, but also with
immobilization e.g. stroke disease, Dupuytrens and Leddherose pathologies, autoimmune diseases and treatment
of breast or pulmonary cancer.
The risk of developing shoulder adhesive capsulitis in
diabetes mellitus in a large longitudinal population-based
follow-up study was 1,2% in diabetics and 0,95% in non
diabetic subjects 6.
Clinical evolution
Adhesive capsulitis progresses through three stages characterized by clinical aspects and related with anatomopathological articular changes, as demonstrated by arthroscopic examination.
Stage 1, painful stage, is characterized by a gradual onset of shoulder pain, which can worsen rapidly or evolve
slightly for weeks or months. In this Stage, the pathognomonic symptom of adhesive capsulitis i.e. the limitation of movement by capsular contracture is not clearly
present.
The early loss of external rotation is the clinical hallmark
of adhesive capsulitis. At this Stage, the low level of painful stiffness limits the possibility of a clinical diagnosis and
makes the choice of the treatment uncertain. Arthroscopically, at Stage 1, only a fibrinous synovial inflammatory
reaction without capsular adhesion or contracture has been
observed.
Stage 2 is characterized by acute synovitis and progressive
capsular contracture. The pain is present also at night and
in many patients is particularly severe, not influenced by
analgesic or non steroidal anti-inflammatory drugs. Only
oral or intra-articular steroid therapy has some efficacy for
the severe pain. The loss of motion is correlated to contracture of the axillary capsular pouch, fibrous metaplasia
of the capsule and hypertrophic synovitis. This is the stage
of “freezing” of the shoulder that reach the highest level
of stiffness.
Stage 3 is sometimes divided in “frozen”, or in its late
phase, “thawing” stage because the principal complaint
is stiffness and nocturnal pain and severe pain during the
normal activities is decreased or disappeared, and, in the
late period of this stage, the absence of pain favours more
aggressive rehabilitation with minimal pain. Arthroscopy
shows mature adhesion of articular structures, with a tick
fibrous capsule but a minimal synovitis. The gradual recovery of the movement allows better use of the arm and
frequently patients stop the assisted physical therapy when
they reach the minimum of mobility required for the normal day life activities and, consequently are satisfied even
if at clinical examination a variable amount of stiffness is
still present.
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Vol. 125 - 1-2 Novembre 2014
Clinical and instrumental diagnosis
The diagnosis of frozen shoulder can be difficult at the initial stage, before the onset of the capsular retraction and
the stiffness. When stiffness is clinically evident the diagnosis is easily established and does not require particular
instrumental investigations. Patient’s history and clinical
exams are sufficient for a reliable diagnosis of adhesive
capsulitis in Stage 2 and usually an x-ray of the shoulder is
required to detect the presence of calcifying tendinitis, gleno-humeral arthritis or other osteo-cartilagineous pathologies that could cause both pain and stiffness. The recent
interest in treatment with intra-articular cortisonic injection in the Stage 1, before the capsular contracture, to stop
inflammatory process of synovial tissue, has increased the
use of contrast-enhanced MRI for early recognition of capsular damage.
Arthro-MRI with gadolinium is useful to detect reduced
joint capsule volume of the axillary recess. Also a simple
MRI in T2 outlines the fibrous capsular thickening and
offers a valuable imaging for the diagnosis of adhesive
capsulitis 7, but, in current practice MRI-arthrography is
utilized only when clinical aspects are confused by the
presence of an associated cuff pathology.
TREATMENT
The traditional treatment based on mobilization under anesthesia has been substituted by a more conservative approach with treatments including analgesia, physiotherapy,
oral or intra-articular corticosteroids, and intra-articular
distension injections, mainly performed in early pathology
stages. Surgical options, including manipulation under anaesthesia associated to arthroscopic release, are generally
reserved for refractory cases, with severe residual stiffness
at the end of inflammatory stages.
Physiotherapy is a conservative treatment usually based
on early and prolonged physical therapy. Treatment must
be adapted to the patient’s symptoms, stage of the condition, and recognition of different patterns of motion loss,
avoiding painful or forced mobilization during the painful
Stages 1 and 2. Forced mobilization of a stiff shoulder can
be too painful and potentially harmful to the glenohumeral
joint. Physiotherapeutic interventions can reduce pain and/
or increasing mobility, but there is little evidence that the
disease prognosis and evolution is affected. A prolonged
therapy and the use of a static progressive stretching device
at home in combination with traditional therapy seems to
improve long-term range of motion.
Non steroidal anti-inflammatory drugs (NSAID) are largely used to decrease the level of pain. The efficacy is very
limited and indipendent from the different type of NSAIDs
and the treatment doses. Usually patients report a mild and
temporary reduction of pain but no significant reduction of
stiffness and of time of evolution of the pathology is recognizable for these treatments.
Oral steroid treatment has shown a great efficacy on pain
relief and a beneficial effect also in mobility of the shoul-
der but this improvement ceased after the suspension of
the therapy and the course of the pathology is the same of
patients treated only with physical therapy and NSAIDs.
Oral steroid treatment can be proposed to patients that
need some temporary relief from acute pain but the wellknown side effects of a prolonged steroid therapy are an
important concern to be seriously evaluated.
Intra-articular steroid injections: is the therapy most frequently practised and reported in literature. This treatment
offers good results both for the pain and mobility improvement, but only if is started in Stage 1 or early Stage 2 of
the pathology, before the capsular contracture. Usually, the
injection in the glenohumeral joint is conducted blindly.
If the surgeon is not accustomed to shoulder arthroscopic
techniques an ultrasound-guided technique may be useful.
Although ultrasound guidance may improve the accuracy
of the injection to the site of the pathology in the shoulder,
it is not clear that this technique improves its efficacy.
Patients treated with a single corticosteroid injection in
different locations of the shoulder showed that the efficacy
of a single corticosteroid injection was not related to the
site of injection 8.
Yoon SH et al 9 reported that there was no significant difference between patients treated with high- or low-dose
corticosteroid injection, indicating the preferred use of a
low dose in the initial stage.
Manipulation under anesthesia and arthroscopic release:
even if is still utilized in refractory stiffness in Stage 3, isolated manipulation under anaesthesia has been substituted
by the arthroscopic release. Arthroscopic capsulotomy,
more or less complete, circumferential or limited to the anterior part and axillary pouch of the capsule, is less prone
than closed manipulation to complications such humeral
or glenoid anterior rim fractures, subscapularis or long biceps ruptures and allows a controlled final mobilization at
the end of arthroscopic procedure 1.
CONCLUSIONS
The published literature about adhesive capsulitis is at the
same time increasingly abundant and controversial. In this
situation we can only conclude with some suggestions
of treatments based on our experience, waiting for better
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etiologic knowledge of the biological mechanism of this
pathology.
The clinical stages of adhesive capsulitis reflects different
pathological aspects of this disease.
In Stage 1 or at beginning of the Stage 2, the problems are
related to synovial and capsular inflammation. The rationale treatment is based on intra-articular corticosteroids,
analgesic or NSAIDs for controlling the pain and gentle
mobilization of the shoulder within the pain free zone to
lessen the capsular contracture. In late Stage 2 oral or intra-articular steroids are of limited efficacy and the objectives are the analgesic control of the pain and the assisted
mobilization of the shoulder. In Stage 3, in our experience,
it is rarely necessary to face stiffness that severely limits daily activities. In patients with severe limitations, arthroscopic release provides good benefits with less risk of
complications compared to the closed manipulation under
anaesthesia.
REFERENCES
1. Neviaser AS, Hannafin JA. Adhesive Capsulitis. A Review of Current Treatment. Am J Sports Med. 2010; 38:2346-2356
2. Bunker TD, Anthony PP. The pathology of frozen shoulder: a
Dupuytren-like disease. J Bone Joint Surg Br. 1995; 77:677–680
3. Rodeo SA, Hannafin JA, Warren RF, Wickiewicz TL. Immunolocalization of cytokines and their receptors in adhesive capsulitis of
the shoulder. J Orthop. Res. 1997; 15: 427-436
4. Kim YS, Kim JM, Lee YG et al. Intercellular adhesion molecule-1
(ICAM-1, CD54) is increased in adhesive capsulitis. J Bone Joint
Surg Am. 2013; 95:181-188
5. Hagiwara Y, Ando A, Onoda Y, Takemura T et al. Coexistence of
fibrotic and chondrogenic process in the capsule of idiopathic frozen shoulders. Osteoarthritis and Cartilage. 2012; 20:241-249
6. Huang YP, Fann CY, Chiu YH, Yen MF et al. Association of diabetes mellitus with the risk of developing adhesive capsulitis of
the shoulder: a longitudinal population-based follow-up study.
Arthritis Care Res. 2013; 65:1197-1202
7. Gondim Teixeira PA, Balaj C, Chanson A et al. Adhesive capsulitis
of the shoulder: value of inferior glenohumeral ligament signal
changes on T2-weighted fat-saturated images. AJR Am J Roentgenol. 2012; 198:589-596
8. Shin SJ, Lee SY. Efficacies of corticosteroid injection at different
sites of the shoulder for the treatment of adhesive capsulitis. J
Shoulder Elbow Surg. 2013; 22:521-527
9. Yoon SH, Lee HY, Lee HJ, Kwack KS. Optimal dose of intra-articular
corticosteroids for adhesive capsulitis: a randomized, triple-blind,
placebo-controlled trial. Am J Sports Med. 2013; 41:1133-1139
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Biological enhancement in rotator cuff repairs
Alessandro Castagna, Valentina Fogliata*, Raffaele Garofalo**, Eugenio Cesari
Unità di chirurgia della spalla e gomito, IRCCS Istituto Humanitas, Milano
* Dipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,
**Servizio Chirurgia della spalla, Ospedale F. Miulli, Acquaviva delle Fonti, Bari
ABSTRACT
Rotator cuff injuries are a common source of pain and imply an
important decrease in patient’s life quality. It is estimated that
40% of individuals over the age of 60 years experience rotator
cuff injuries. Despite surgical techniques advances, after surgical
repair there is a high rate of recurrent tears (up to 96% for massive and large tear). Tendons healing process make inferior quality tissue at the level of the tendon-bone unit and this is related
to the fact that the healing process is a reparative process and not
a regenerative process. Due to the frequency of these injuries, as
well as the rate of re-tear, it is not surprising that biological strategies have become more appealing. There are different biological
means like creation of bone marrow vent, microfracture or other
strategies using tissue engineering. Tissue-Engineering strategies
involve the use of PRP, mesenchymal stem cells, use of protease
inhibitor, biomimetic or biological scaffolds, to promote tendon
regeneration via natural process.
The present paper reviews the current state of knowledge regarding the biological enhancement strategies to improve the rotator
cuff healing after repair.
functional outcome and tendon healing, but recent meta-analysis demonstrate that there are no differences in
terms of pain or functional score between patients whose
tendon is healed than those where the tendon has not
been healed3.
However, patients with a complete tendon-healing show
a significant improvement of the strength during followup examination3-4. The weakest link in repair system of
the rotator cuff is to be found at the level of the biology
of tendon-bone healing process and therefore, current efforts are also directed to the study of the biological mechanisms of tendineous tissue healing and the possibility
to improve healing of the tendon-bone system. However,
when the biology of the repair of the rotator cuff is considered, the etiology of the rupture itself must be kept in
mind, as this lies in a degeneration of tendon and tendonbone junction5 in most cases.
The purpose of this manuscript is to draft a literature review of healing processes of the rotator cuff tendons and
point out, in light of recent discoveries, if there are biological possibilities to influence in a positive way these
processes.
INTRODUCTION
THE BONE-TENDON JUNCTION (ENTHESIS)
Rotator cuff injuries are a common source of pain and
imply an important decrease in patient’s life quality.
The incidence of this pathology tends to increase with
age, however, symptomatic rotator cuff lesions could
also be found in young subjects above 30 years. Cadaver
studies have shown that the incidence of full-thickness
tears of the rotator cuff is equal to 40% in people older
than 60 years1.
Many patients undergo surgery to repair these lesions, in
order to improve symptomatology and function. However, despite the continuous development of suture materials and repair techniques (use of titanium and absorbable
anchors, “tension band”, “single-row”, “double row”,
“transosseous equivalent repair”), recurrence of tendon
rupture is not uncommon, regardless of the technique
(open or arthroscopic) or the type of material used.
The rate of recurrence or non-healing has been reported
in a percentage varying from 20% to 94%, and is a multifactorial process2.
The causes of this failure are various and depend on the
characteristics of the lesion (size, shape), the degree of
degeneration of the muscle-tendon system, the characteristics and the lifestyle of the patient2.
Although some studies showed a correlation between
The physiological tendon-bone interface consists of an
inter-digitation of several layers of longitudinally oriented fibers of type I collagen which are inserted in a
gradual manner on the humerus6. The vascularization is
also organized within the tendon; the number of vessels
and their size gradually decrease as they get closer to the
bone6. At the level of this junction there is a gradual transition from tendon to bone and stand 4 zones: tendon,
non-mineralized fibrocartilage, mineralized fibrocartilage and bone. Type I collagen predominates in zones 1
and 4, while zones 2 and 3 contain mainly collagen I, II
and X, as well as extracellular matrix with proteoglycans.
With the aging process, the level of vascularization in
this area tends to decrease progressively, altering the intrinsic structure of the tendon-bone interface.
The healing process of the tendon is very complex. Experimental studies have shown that the healing process
is initiated mainly by mesenchymal cells that originate
from the bone footprint and the subacromial bursa7. However, the terminal structure of the tendon-bone junction is
quite different from the native insertion. In fact, instead
of the four distinct areas, bone and tendon are linked by
a layer of fibrovascular tissue predominated by collagen
type III6. It is therefore a non-regenerative but reparative
process which resulted in a bone-tendon junction that is
sub-optimal from a physiological point of view. This difference is substantial. Immediately after injury, the gap
is bridged by a blood clot that acts as a scaffold for repair and release a variety of chemotactic and mitogenic
growth factors (haemorrhagic phase). Cytokines released
within the clot activate polymorphonuclear leukocytes
and lymphocytes that reach the site of the lesion within a
few hours. These cells respond to autocrine and paracrine
signals expanding the inflammatory response and recruiting other types of cells. The macrophages reach the site
of the lesion within 48 hours and predominate for several
days (inflammatory phase). They are responsible for the
phagocytosis of necrotic tissue and with epitenon and endotenon cells (intrinsic cells) they secrete various growth
factors, especially Transforming Growth Factor-ß1 (TGF
ß1) that increase the activity of protein kinases and the
collagen formation. After three days, at the site of the lesion will be present platelets, macrophages, polymorphonuclear leukocytes, lymphocytes, and multipotent mesenchymal stem cells. Platelets release Platelet-Derived
Growth Factor (PDGF), TGF-β and Epidermal Growth
Factor (EGF); instead macrophages release PDGF, Transforming Growth Factor-α (TGF-α), TGF-β, and Basic
Fibroblast Growth Factor (bFGF). These factors are not
only chemotactic for fibroblasts and other cells but also
stimulate the fibroblasts proliferation and the synthesis of
collagen type I, III and V and non-collagenous proteins.
The last to arrive are fibroblasts that are recruited from
surrounding tissues and systemic circulation (proliferative phase). Fibroblasts begin to produce collagen and
other matrix proteins within one week from the injury.
Although the reparative phenomena begin at the end of
the first week, Randelli et al. have noted that some of
these cytokines may appear immediately after the surgical repair of the rotator cuff if associated acromioplasty8.
In this study the author noted that by taking a sample of
3 ml of the fluid of the shoulder 15 minutes after the end
of the surgery, PDGF-β, TGF-1, and bFGF levels were
significantly higher than in venous blood of the same
patient. These observations indicate that growth factors
may be important at the beginning and at the end of the
tendon healing process. After two weeks, the blood clot
is more organized and begin to shape the first capillaries.
The total content of collagen is greater than that of a normal tendon, but the density is lower and the extracellular
matrix is d isorganized.
The last phase is characterized by the reduction of cellularity and by increase in collagen density (remodeling
phase). Biochemical and biomechanical signals regulate the expression of structural and enzymatic proteins,
including collagenase, activation of plasminogen and
stromelysin. The healing process continues for several
months, and the maturation of the tendon will be completed only one year after. Despite the remodeling phase,
the healed tendon does not reach mechanical properties
and morphological characteristics of a normal tendon.
The tension force remains lower than 30% compared to
a normal tendon even after several months or years9. The
reduction of the mechanical properties is associated with
a lower diameter of collagen fibers and with an alteration
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Vol. 125 - 1-2 Novembre 2014
of the proteoglycans profile in the matrix. This reduction
of the mechanical properties of the tendon will make the
tissue weaker and more susceptible to recurrence of lesions10.
GROWTH FACTORS
Growth factors are proteins used for communication
among cells of an organism and they are able to stimulate cell migration, proliferation and synthesis of proteins.
Their action depends on the bond of specific membrane
receptors. Once activated, receptors trigger a cascade of
chemical reactions in the cytoplasm that cause the activation of genes in the nucleus and thus the DNA synthesis.
Growth factors are synthesized and secreted by a wide variety of inflammatory cells, platelets, fibroblasts, epithelial cells and vascular endothelial cells. They can activate
neighboring cells (paracrine action) or the same cells that
released them (autocrine action). Numerous studies have
shown that growth factors (basic fibroblast growth factor (bFGF), Insulin-Like Growth Factor (IGF-1), PDGF,
TGF-1, Vascular Endothelial Growth Factor (VEGF), Epidermal Growth Factor (EGF)) may be involved in tendinous and ligamentous tissue repair. TGF-β exists in three
isoforms (TGF-1, TGF-2, TGF-3). It is a cytokine secreted
by most cells involved in healing process. Together with
IGF, TGF-β1 is rapidly released at the site of the lesion,
during the inflammatory phase. TGF-β3 plays a decisive
role in fetal healing process that occurs without scar and is
regulated by mechanisms of regenerative type.
However it is not found in adult typical cicatricial healing
processes, where TGF-β1 is present6. IGF-1 (somatomedin
C) is secreted by osteoblasts and fibroblasts. This growth
factor too is secreted immediately after injury, but reaches
its peak after 3 weeks and it is important in inflammation,
proliferation and remodeling processes7. It inhibits the
migration of inflammatory cells during the inflammatory
phase exerting a mechanism of modulation of the inflammation itself.
PDGF is secreted not only by platelets, but also from macrophages and other cells. This protein stimulates and regulates the synthesis of other growth factors and stimulates
the synthesis of type I collagen and non-collagenous proteins. Its peak of expression is reached during the formation phase as well as for bFGF: the latter stimulates the
production of collagen type III. VEGF stimulates angiogenesis and vasculogenesis. There are no studies to date
that have evaluated the efficacy of this growth factor in
rotator cuff repair.
Other important proteins involved in tendon-to-bone healing processes are the BMP (bone morphogenetic proteins). These proteins, in particular BMP 2,7,12,13,14, are
a group of factors that belong to the TGF-β superfamily
and stimulate bone formation, but also tendinous cells
mitogenesis and healing. Although it is clear that BMPs
stimulate tendon healing, the mechanism remains unclear.
Animal studies have revealed that recombinant BMP 12
accelerates healing of the cuff tendons and, more importantly, improves the formation of fibrocartilage at tendonbone junction10. In addition, BMP 2, 7 and 12 are together
involved in improving the tendon to bone healing, enhancing insertion resistance itself.
Ultimately different growth factors work in concert appearing with different concentration at different times
in order to create an appropriate interface for tendon-tobone healing.
For this reason there is a great deal of attention to the
use of growth factors in tendon pathology, especially in
rotator cuff diseases. Platelets concentrate and preparations rich in growth factors are obtained by centrifugation of autologous blood. The term of PRP (Platelet Rich
Plasma) could be used for every fraction of autologous
blood showing a platelets concentration above basic level. The centrifugation process removes from the serum
red blood cells that do not bring any benefit to the healing
process. However, this simple definition does not accurately reflect the different possible formulations of PRP.
There are in fact different PRP (6 categories available for
sale) that vary according to the presence or absence of
leukocytes, the need for exogenous activation of platelets
with thrombin or calcium chloride and the presence or
absence of fibrin. The presence of leukocytes also means
having cells that stimulate inflammatory cytokines and
metalloproteases. Platelets are very important as they are
the first cells to arrive at the site of injury where they
release growth factors that are stored in cytoplasmic organelles (α-granules). Growth factors released include
PDGF, TGF-β, bFGF, Epidermal Growth Factor, VEGF.
It is believed that approximately 70% of growth factors
is released in the first 10 minutes and almost 100% within
1 hour. In this regard the presence of a fibrin matrix can
serve to trap the platelets allowing a more gradual growth
factors release (5-7 days). In a study with 14 patients who
underwent arthroscopic repair of the rotator cuff who received locally, immediately after surgical repair, a solution of PRP in combination with autologous thrombin,
the authors concluded that the use of PRP in arthroscopic
repair of rotator cuff is safe and effective, with no side effects, but have not been proven improvements in healing
tendon11. Other prospective studies do not support the use
of PRP in small and medium size cuff tears. Moreover,
the problem is to control the expression of growth factors
in some phases of healing12.
Interesting results have been obtained in an animal model
study, in which a mixture of growth factors (BMP 2.7,
TGF and FGF) within a collagen scaffolds have been
used at the tendon-to-bone junction, causing an increase
of the tensile strength13.
Current doubts concerning the use of PRP in rotator cuff
surgery, as well as the lack of effectiveness shown by recent studies, are related to the fact that different types of
PRP could be found for sale, and indications vary in relation to the age of the patient, the site and the manner of
inoculation, the decay kinetics, the use of various growth
factors which in practice are administered all at time zero.
METALLOPROTEASES AND THEIR INHIBITORS
Besides growth factors, there is a great interest for the
role of metalloproteases in repair rotator cuff tears.
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MMPs are proteases that regulate extracellular matrix
and connective tissue homeostasis, through the degradation of collagen and elastin. MMPs are regulated by inhibitors proteins (TIMP). Some authors have shown that
some of these MMPs, especially MMP-2, are activated
during the healing process of the supraspinatus tendon;
moreover MMPs 1, 2 and 3 and their inhibitors are altered in patients with rotator cuff tears. This element was
also found in an interesting manner in tendons apparently
intact, showing that biological processes that lead to tendon rupture precede structural alterations14. MMPs inhibitors are 4 and in particular TIMP 2 and 4 appear reduced
in rotator cuff lesions with a consequent increase of the
MMPs activities that would be responsible for tendon degeneration and rupture, by altering the extracellular matrix. Some experimental studies about pharmacological
MMPs inhibitors, such as Doxycycline, show some potential in improving the structural aspect of the repaired
tendons; however there are at present time few clinical
data that could support the use of these substances.
MESENCHYMAL CELLS
Mesenchymal stem cells (MSCs) are multipotent cells that
differentiate into cell lines capable of forming tissue such
as osteoblasts, adipocytes, chondrocytes, tenocytes and
myocytes. MSCs can be isolated from bone marrow and
the fact that some authors have recently demonstrated the
possibility to isolate them from proximal humerus during rotator cuff repair and bring them to differentiate into
tenocytes if treated with insulin, makes this therapeutic
option extremely fascinating15. This could be considered
as a crucial finding in our opinion because the first experimental study carried out on the use of MSCs showed no
differences in bone-tendon junction when the use of MSCs
was compared to control cases. This phenomenon was explained by the fact that MSCs require signals in order to be
able to better differentiate to create an enthesis with similar characteristics to the normal one. Even those works that
implied micro-fractures at the level of the greater tuberosity in order to improve tendon healing, provided conflicting results16-17; this data too may be related to the fact that
MSCs coming from the greater tuberosity need not only
to be isolated but also need some differentiation signals.
Previously, other authors had published preliminary data
on cuff repair with the same concept using the “crimson
duvet.” This technique consisted in performing a series of
lateral drilling to what would have been the insertion of the
repaired tendon (Fig 1).
In this way a sort of a big clot is generated containing
MSCs and growth factors that together with the vascular
channels created by the perforations (bone marrow vent)
give their contribution to the tendon healing18. Many other
authors have also recently demonstrated that MSCs can
be isolated from the subacromial bursa19 or from rotator
cuff tendons or the long head of the biceps20. Other studies, however, are necessary in order to study the complex
mechanisms of cellular signals that regulate MSC differentiation and biological substrates that must be used to
convey this kind of cells.
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don, of the region of mineralized and non-mineralized
enthesis fibrocartilage.
Studies on animals have shown that the use of these type
of scaffolds stimulates the formation of a non-calcified
and calcified matrix in a continuum at enthesis level, unlike the fibrovascular tissue that was observed in the control group. The use of these scaffolds, however, is still
very experimental.
BIOLOGICAL SCAFFOLDS
Figure 1A: Before the tendon repair,
laterally to the region where it will
be reinserted (lateral footprint), a
series of small medullary canals are
performed with perforations in order
to create a bed of bleeding
(Crimson Duvet).
Figure 1B: upper cuff repair with
2 double suture anchors and
“Crimson Duvet” laterally
(Courtesy of Dr. SJ Snyder)
BIOMIMETIC SCAFFOLDS
Different bio-engineering studies enabled the development of biomimetic scaffolds, that have the potential to
achieve functional integration with the host tissue. Recent research focus on biphasic scaffolds compounds
of nanofibers of polylactic-glycolic acid (PLGA) and a
composite of PLGA and nanoparticles of hydroxyapatite21. The purpose of this type of biphasic formation is
to promote the regeneration, after the repair of the ten-
The use of extracellular matrices (ECM) is the most common method to improve the healing biology of the rotator cuff tendons. An ECM is a complex structure that
consists of structural proteins (collagen type I), specialized proteins (fibrillin and fibronectin) and a variety of
proteoglycans. The purpose of using these matrices is to
improve the mechanical properties of the repaired tendon
at time zero and the biological quality of the repair performed. Furthermore, since the ECM is very similar to
the one which is present in the human body, for chemical
and structural characteristics, it can works as a biological
“scaffold” and can stimulate tenocytes to multiply and
improve the quality of the repair.
Into the past some authors tried to use autologous tissue taken from the fascia lata as a biological scaffold and
quite recently from the long head of the biceps tendon.
The basic science studies on the use of scaffolds to repair
rotator cuff include the evaluation of host response, characteristics of remodeling, biomechanical behavior and
applicability in humans using animal or in vitro studies.
Actually, the most studied group is that of the ECM such
as “allograft” or “xenograft”, obtained through decellularization processes. These processes, which are chemical, physical or enzymatic, often used in combination,
aim to eliminate the cellular components (and therefore
immunogenic components), preserving the three-dimensional structure and the collagenous and non-collagenous
ECM components.
Xenografts are membranes derived from animal (porcine
or bovine) dermis, intestinal submucosa or equine pericardium, while allografts are typically membranes from
human dermis.
After implantation of these scaffolds, during the healing process of the tendon, the gradual degradation of
the scaffold shall issue a series of molecules that play a
key role in recruitment and proliferation of different cell
types, important for the remodeling of the rotator cuff
tendons itself.
It should be noted that each array implanted leads to a
macrophage type host inflammatory response, which
seems to be a crucial factor for future of the implanted
scaffold.
The inflammatory response is dependent on the chemical process of crosslinking and the nature of the scaffold
itself. The problem is that nobody knows yet what is the
limit of acceptable reaction linked to these scaffolds. The
chemical crosslinking process of the collagen structure
reduces the recognition of the surface epitopes, and then
the degradation process operated by the host. A recent
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TABLE I: In summary the main features of commercially available scaffolds
ZCR: Zimmer Collagen Repair
PRODUCT NAME COMPANY
GraftJacket
ORIGIN
CROSSLINKING
SIZE
Wright Medical
(Allograft)Technology, Inc
Human dermalNo
Various
Restore Ortobiologic Soft Tissue
Implant; Depuy Orthopaedics
Submucosa of the small intestineNo
6x2 cm
Arthrotek, Biomet Sports
Medicine, Inc, Submucosa of the small intestine
(Xenograft)
TissueMend
Stryker Corporation
Dermis of fetal bovineNo
5x6 cm
Zimmer Inc
Porcine dermis collagen
Yes
5x5 cm
Tornier Inc
Porcine dermis collagenNo
Multiple
Wright Medical Porcine dermis collagenNo
(Xenograft)Technology, Inc
4x7 cm
6x8 cm
OrthADAPT
Various (Xenograft)
CuffPatch
Yes
6.5x9 cm
(Xenograft)
Permacol ZCR Patch (Xenograft)
Conexa
(Xenograft)
Biotape
Pegasus Biologics, IncNative equine pericardium
Yes
(Xenograft)
study on animals that compared the use of porcine crosslinked dermis compared with intestinal non-crosslinked
porcine submucosa (SIS), showed a lower presence of
cellular infiltrate in the case of the SIS.
Consequently, regardless of the source of the ECM, the
presence of a chemical crosslinking is associated with an
absolutely not favorable host response. The presence of
crosslinking at the level of the scaffolds was associated
with the presence of foreign body gigantocellular reactions, chronic inflammation, accumulation of dense and
poorly organized fibrous tissue.
Furthermore, also the nature of the scaffold appears to be
responsible for the different degradation and remodeling.
In fact, scaffolds derived from SIS undergo rapid degradation and remodeling (days or weeks), while those of
the dermal origin undergo a more slow remodeling and
are gradually incorporated into the host tendon tissue.
A recent laboratory study conducted to evaluate the response of cultured human tenocytes with different extracellular membranes (the same as the ones commercially
available) showed that the major inflammatory responses
were obtained in the presence of SIS scaffolds or from
crosslinked dermis, while the best response was present
in the case of uncrosslinked human or porcine dermis.
This study confirms the clinical observations of the high
rate of failure and inflammatory reactions founded in the
case of grafting with SIS or crosslinked dermis. In two
different clinical studies in which a non-crosslinked SIS
ECM was used, it was observed the presence of a severe postoperative inflammatory reaction in 20%-30%
of patients22-23. As a consequence, the use of this type of
scaffold is no longer recommended.
The ideal scaffold must meet 10 core requirements:
1. Extremely low rates of rejection.
2. Minimum inflammatory response.
3. Mechanical properties such as to reinforce the repair at time zero.
4. Being biological supportive and conduct the tendon
structure and enthesis.
5. Moderate elasticity to avoid the suture cut-out.
6. Handiness.
7. Reasonable cost.
8. Stimulate cell proliferation.
9. Optimal duration of storage.
10. Easy to insert arthroscopically.
Table 1 summarizes the different scaffolds currently present commercially.
The scaffold can be used as biological augmentation
when a repaired tendon seems to have little biological
healing capacities, or as a “bridging” when cuff injury is
not repairable.
The clinical use of crosslinked dermal scaffolds (ZCR:
Zimmer Collagen Repair) has been reported in two retrospective studies with conflicting results24-25. Bond reported a series of 16 patients with massive tear of the rotator
cuff treated arthroscopically with graft scaffold (GJA)26.
At 26.8 months follow-up, 15 patients were satisfied
with the surgery and 13 patients showed a complete healing of the repair in MRI examination after 1 year. Dopirak et al. reported the results of 16 patients with massive
and irreparable rotator cuff lesion. At 2-year follow-up,
75% of patients were satisfied with the surgery. MRI
showed 3 recurrence of injury, 2 of which occurred in
the first 6 months27. Burkhead has evaluated 17 patients
treated with “GJA graft augmentation” for a massive tear
greater than 5 cm. At 1.2 years follow-up, 3 recurrences
were observed on 111 patients who underwent MRI or
CT arthrography28. Barber, in a recent prospective study,
evaluated the effectiveness of GJA used as augmentation for chronic posterosuperior cuff tears (2 tendons).
In this study it was shown that patients in which the scaffold has been used showed functional score and percentage of tendons healing significantly higher than the control group29.
A recent clinical study has compared the use of biological scaffolds with a synthetic scaffold. As far as biological scaffolds is concerned, a patch of collagen has been
used, while polypropylene has been used for synthetic
scaffolds. At a 3 years follow-up was demonstrated the
superiority of synthetic scaffolds in terms of lesion recurrence and functional scores30.
CLINICAL STUDY
In the period between 2005 and 2011 a series of 21 patients with degenerative full-thickness tear of the superior
or posterosuperior rotator cuff (supraspinatus and infraspinatus) were selected preoperatively and intraoperatively to
undergo arthroscopic repair surgery associated with biological graft scaffold.
Eight patients had a non-traumatic recurrence of rotator
cuff lesion after previous repair. The average age at surgery time was 57.6 years (range 45-65), and there were 8
males and 13 females. The patients were clinically evaluated preoperatively with the study of their arc of movement and with the UCLA (University of California, Los
Angeles) shoulder scale, the VAS and the Constant score.
All patients underwent an MRI to assess the tendon healing. The surgery was performed with the patient under
general anesthesia and in lateral decubitus position, with
arthroscopic technique.
Different types of scaffolds have been used. In particular,
it has been used: the Matrix Graft Jacket (decellularized
human dermis) (Wright Medical Technology, Inc, Arlington, Tenn) in 4 cases, the Biotape (porcine dermis) (Wright
Medical Technology, Inc, Arlington, Tenn) in 3 cases and
the Conexa (porcine dermis) (Tornier Edina MN) in 14
cases. In all cases, the scaffold has been used as augmentation (Fig. 2).
The minimum follow-up was 2 years.
We did not observe any complication in terms of infection,
fibrosis, and adverse reactions to scaffold or mechanical
lock symptoms, nor in the immediate postoperative period nor during the period of follow-up in the study group.
The patients showed a significant improvement of clinical
scores. In particular, the UCLA went from an average of
14.5 preoperatively to 25.2, while the Constant score by an
average of 37.2 to 66.5 at 2 years after surgery follow-up.
Regarding the healing of the performed repair, the 1-year
follow-up MRI showed a rupture recurrence or a non-healing of the performed repair in 4 of 21 patients.
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Figure 2: Final image of a repair
where the scaffold was used as
augmentation. After removing the
water flow, it could be appreciated the
blood coming from the holes of the
anchors that tends to form clots on
the scaffold.
CONCLUSIONS
The integrity of the repair performed for the rotator cuff tears
is influenced by several biological and surgical variables. In
fact this surgery has reported in the literature a recurrence
or not healing rate despite high innovation in surgical techniques and improved understanding of the biology.
The repairs fail for scarce biological capacities of the tendon in the throes of a degenerative lesion type. The problem is that at present time we are unable to replicate the
complex anatomy of tendon-to-bone junction. To achieve
this process, we should stimulate a healing regenerative
process that is different from the reparative one that is currently performed.
As a consequence, all the biological procedures in study at
time, should aim not only at improving the mechanical properties of the tendon, but especially at influencing a healing
process that involves the least possible presence of a scar.
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1. Kinsella K, Velkoff VA. An Aging World: 2001. Washington, DC,
US Government Printing Office, 2001
2. Le BT, Wu XL, Lam PH, Murrell GA. Factors Predicting Rotator
Cuff Retears: AN analysis of 1000 consecutive rotator cuff repair. Am J Sports Med 2014: E-Pub
3. Russell RD, Knight JR, Mulligan E, Khazzam MS Structural integrity after rotator cuff repair does not correlate with patient
function and pain: a meta-analysis. J Bone Joint Surg Am 2014;
96:265-271
4. Slabaugh MA, Nho SJ, Grumet RC et al. Does the literature confirm superior clinical results in radiographically healed rotator
cuffs after rotator cuff repair? Arthroscopy 2010; 26:393-403
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aspects of rotator cuff tears. Muscles Ligaments Tendons J 2013;
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6. Galatz LM, Sandell LJ, Rothermich SY, et al. Characteristics of the
rat supraspinatus tendon during tendon-to-bone healing after
acute injury. J Orthop Res. 2006; 24:541–550
7. Uhthoff HK, Seki M, Backman DS, et al. Tensile strength of the supraspinatus after reimplantation into a bony trough: An experimental study in rabbits. J Shoulder Elbow Surg 2002; 11:504–509
8. Randelli P, Margheritini F, Cabitza P, et al. ��
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9. Kobayashi M, Itoi E, Minagawa H, et al. Expression of growth
factors in the early phase of supraspinatus tendon healing in
rabbits. J Shoulder Elbow Surg 2006; 15:371
10. Seeherman HJ, Archambault JM, Rodeo SA et al. rhBMP-12 accelerates healing of rotator cuff repairs in a sheep model. J Bone
Joint Surg Am 2008; 90):2206-2219
11. Randelli PS, Arrigoni P, Ragone V, et al. Platelet rich plasma inr
arthroscopic rotator cuff repair: a prospective RCT study, 2 years
follow-up. J Shoulder Elbow Surg 2011; 20:518-528
12. Zhang Q, Ge H, Zhou J, Cheng B. Are platelet-rich products necessary during the arthroscopy repair of full-thickness rotator
cuff tears: a metanalysis. PLoS One 2013; 8:e69731
13. Rodeo SA, Potter HG, Kawamura S, et al. Biological augmentationof rotator cuff tendon-healing with use of a mixture of osteinductive growth factors. J Bone Joint Surg Am 2007; 89:2485-2497
14. Castagna A, Cesari E, Garofalo R, et al. Matrix metalloproteases
and their inhibitors are altered in torn rotator cuff tendons, but
also in macroscopically and histologically intact portion of those
tendons. Muscles Ligaments Tendons J 2013; 3:132-138
15. Mazzocca AD, McCarthy MB, Chowaniec DM, et al. Bone marrow derived mesenchymal stem cells (MSCs) obtained during
arthroscopic rotator cuff repair surgery demonstrate potential
for tendon cell differentiation following treatment with insulin.
Arthroscopy 2011; 27:1459-1471
16. Osti L, Del Buono A, Maffulli N. Microfractures at the rotator
cuff footprint: a randomised controlled study. Int Orthop 2013;
37:2165-2171
17. Milano G, Saccomanno MF, Careri S, et al. Efficacy of marrowstimulating technique in arthroscopic rotator cuff repair: a prospective randomized study Arthroscopy 2013; 29:802-810
18. Snyder SJ, Burns J. Rotator cuff healing and the bone marrow
“Crimson Duvet” from clinical observations to science. Tech
Should Surg 2009; 10:130-137
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19. Utsunomiya H, Uchida S, Sekiya I, et al. Isolation and characterization of human mesenchymal stem cells derived from shoulder tissues. involved in rotator cuff tears. Am J Sports Med 2013;
41:657-668
20. Randelli P, Conforti E, Piccoli M, et al. Isolation and characterization of 2 new human rotator cuff and longhead of biceps tendon
cells possessing stem cell-like selfrenewal and multipotential
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21. Zhang X, Bogdanowicz D, Eriksen C, et al. Biomimetic scaffold
design for functional and integrative tendon repair. J Shoulder
Elbow Surg 2012; 21:266-277
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submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears: a randomised, controlled trial. J Bone
Joint Surg Am 2006; 88: 1238-1244
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porcine dermal xenograft as an augmentation graft in the treatment of extensive rotator cuff tears. J Shoulder Elbow Surg
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26. Bond JL, Dopirak RM, Higgins J, et al. Arthroscopic replacement
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24:403–409
27. Dopirak R, Bond JL, Snyder SJ. Arthroscopic total rotator cuff replacement with an acellular human dermal allograft matrix. Int
J Shoulder Surg 2007; 1:7-15
28. Burkhead W, Schiffern S, Krishnan S. Use of Graft Jacket as an
Augmentation for Massive Rotator Cuff Tears. Semin Arthroplasty 2007; 18:11-18
29. Barber FA, Burns JP, Deutsch A, et al. A prospective, randomised
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30. Ciampi P, Scotti C, Nonis A et al. The Benefit of Synthetic Versus
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Med Mar 2014: E-pub
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Vol. 125 - 1-2 Novembre 2014
Partial-thickness rotator cuff tear.
Surgery: when and how
Manuela Rebuzzi, Paolo Baudi, Mauro Gialdini, Claudio Rovesta, Fabio Catani
Department of Orthopaedics - Policlinico of Modena
Introduction
Abstract
Rotator cuff tears are a common cause of shoulder pain
and disability. The partial-thickness rotator cuff tears are
those that do not communicate with both the gleno-humeral joint and the sub-acromial space. Currently the informations about the management of partial-thickness rotator
cuff tears available in literature are few. Above all it needs
to be improved some knowledge, their incidence and prevalence, the risk factors, the tears long-term progression,
to choose the appropriate treatment indication and to gain
the better outcome. The prevalence is underestimated and
growing 1, 2.
Unfortunately, the data about this kind of partial tears show
how the spontaneous healing is unlikely 3, 4.
To date information about the management of partial-thickness
rotator cuff tears available in literature are few. The prevalence
is underestimated, most can only be identified as surgery findings and also the imaging diagnosis is difficult. Partial cuff tears
divided into three types: bursal, intratendinous and articular.
The pathogenesis is multifactorial, with an interplay of intrinsic
and extrinsic factors.
In the young over-head athletes there are some peculiarities, like
the symptoms onset and mechanisms involved.
The patient presents with shoulder pain and dysfunction.
The natural history is that of limited spontaneous healing and
trend of tear progression.
Most surgeons agree that the initial treatment should be conservative regardless of size and location.
Articular-sided cuff tears do better conservatively than bursal-sided, which present more painful; when the conservative management failed, the first approach must be a diagnostic arthroscopy.
Surgical treatment can involve two approaches: debridement
alone or with acromioplasty, and tissue repair that may be transtendon or after completion tear with or without acromioplasty.
Current thinking is that partial thickness rotator cuff tears less
than 50% of the medial-lateral tendon depth at footprint, < 7 mm
basing on anatomic studies, could be successfully in the short
term treated with debridement +/- acromioplasty. The deeper partial tears sould be repair, above all if they are bursal sided. All
treatment resulted in significant improvement in shoulder pain
and function; however, long term results are more uncertain.
There is yet no evidence to support a treatment algorithm for partial thickness tears.
Incidence
The incidence of partial-thickness tears is unknown, because most can only be identified as surgery findings and
also the imaging diagnosis is difficult. Some data are from
cadaveric studies that demonstrate these tears are more
common than full-thickness. Fukuda et al 1 found 13%,
with 18% bursal sided, 55% intratendinous and 27% intraarticular sided tears. But the clinical reports are slightly
different. Sher et al 5 reported 20% of prevalence of partial-thickness tears in 96 asymptomatic shoulders by RMI.
The incidence of partial tears increases with age, and the
average age of operated population is about 50 years 6. A
recent study moreover reported that patients treated for
partial(and full)-thickness cuff tears have a significantly
higher risk of having a tear also on the contralateral shoulder 7. The supraspinatus tendon is almost exclusively interested by partial tears, that rarely may extend to the infraspinatus3.
Pearls of anatomy, biomechanics,
pathogenesis and classification
Cuff tendon insertion is divided in 3 parts: bursal, intratendinous and articular. The footprint anatomy is quite important to assess the depth of cuff tears and so their severity.
Ruotolo et al 8 reported an average medial-lateral (coronal
plane) footprint supraspinatus insertion from 11.6 to 12.1
mm confirming the data of other authors in the past.
The biomechanical features are different: the bursal side
is more strain tolerant and resistant, while the articular
side is made of capsule-ligaments-tendon fibers that are
unstretchable and resists less to the rupture. This different composition leads bursal and articular side tears behave differently causes easily intratendinous lamination by
shear stress 9.
In presence of partial-thickness cuff tears the strain patterns with the intact cuff are altered, with increased strain
on the tendon adjacent to the damaged tissue leading to
tear progression 10, 11, 12, 13.
The pathogenesis is multifactorial, with an interplay of intrinsic and extrinsic factors. Intrinsic could be: age-related
tissue metabolic and vascular degeneration, different shear
stresses during movements; extrinsic: subacromial impingement, repetitive microtrauma, single traumatic event,
gleno-humeral instability, internal impingement 1, 2, 3.
The incidence of a traumatic event is higher in articularside and intratendinous tears as reported by Fukuda3.
A
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Vol. 125 - 1-2 Novembre 2014
B
Figure 1 A-B: Articular partial tears.
A) Ellman 2; B) Ellman 3
Moreover the traumatic onset seems to correlated with the
severity of tear depth.
The subacromial impingement is intuitively much more
responsible of bursal tears, however some studies have
showed that subacromial impingement could generate
strain sufficient to cause tear at any level 1, 3. Nevertheless,
Ozaki et al 14 in 200 cadaveric shoulders have recorded that
acromion was almost always intact in articular-side tears.
Subacromial impingement can lead to cuff tear primarily
or secondarily.
The useful classification system is that of Ellman 15 that divided into 3 types the partial-thickness cuff tears basing on
the location and the medial-lateral depth: A, articular - B,
bursal – C, intratendinous; grade 1, <3 mm – grade 2, 3-6
mm – grade 3, >6 mm (Figure 1).
Subsequently, Snyder et al16 have introduced the PASTA lesion, a partial articular supraspinatus tendon avulsion correlated with its traumatic aetiology; Conway17 described
the PAINT one, a partial articular tear with intratendinous
extension.
Focus on partial-thickness cuff tear
in young over-head athletes
In the young over-head athletes there are some peculiarities. The tears occur on the articular side of the supraspinatus tendon at the interval with the infraspinatus 6.
There are different mechanisms involved: excessive eccentric forces during deceleration of throwing; internal
impingement 18, 19, exacerbated by anterior laxity; posterior-inferior capsular contracture; scapular dyskinesis; poor
technical throwing act 6, 20. Often others pathological findings are associated: labral lesion, capsular laxity, internal
rotation deficit, bone defects, instability.
Clinical and natural history
The patient presents with shoulder pain and dysfunction.
The approach is similar to that of any patient with shoulder
pathology. It is important a solid history and physical examination, signs and symptoms are often not specific 3. Patients with Ellman grade 1 or 2 have more pain than grade
3 lesions 1, moreover bursal-side tears are significantly
more painful than articular-side and intratendinous ones.
Gotoh et al 21 found higher levels of substance P and immunoreactive nerve fibers in subacromial bursae in partial
thickness tears compared with full-thickness ones. These
findings leading to the conclusion that the pain has a positive correlation with the degree of subracromial bursitis
and not with the degree of tear size 2.
In young athletic patients laxity and instability should be
assessed.
Little is known about the natural history, but many studies 3, 22, 23 showed a limited potential for spontaneous healing after the development of tear and the trend is that of
a tear progression.
Imaging
To date the initial evaluation include X-ray to assess acromial morphology and exclude other shoulder pathology. US
and MRI have become the modalities of choice with high
sensitivity and specificity. It is difficult to distinguish partial
tear from a small full-thickness tear. Small cuff defects can
be missed with a detection rate of 41% for partial tear 24.
MRI offers a large amount of details, should be closed and
the strength of the magnetic field almost 1.5 Tesla.
If the findings on US and/or MRI are not specific, should
not be used alone as an indication for surgery: in these cases the correct diagnosis is possible only with arthroscopic
inspection, that is the gold standard for the assessment of
partial thickness rotator cuff tears.
Treatment
When?
After the suspected diagnosis of partial thickness rotator cuff tear the patient needs medications for pain: these
should included steroidal anti-inflammatory drugs at low
doses and mild narcotic analgesics, it is preferable not to
administer non-steroidal anti-inflammatory medications
because of their potential damage on the rotator cuff tendons.
Most surgeons agree that the initial treatment should be
conservative regardless of size and location: rest, ice,
modification of activities, exercises to recover the range of
movement, time. The purpose of conservative approach is
to relieve inflammation and restore muscle balance.
Articular-sided cuff tears do better conservatively than
bursal-sided, which present more painful 1, 3.
The use of subacromial injections deserves attention, these
should be take into consideration when: the oral medications have not given a significant relief from pain or as
coadjuvant of physical therapy regimen. The first could be
corticosteroid injection, then it is preferable to use two or
three ialuronic acid preparations. The available literature
does not show real evidence about injections efficacy 2, but
most patients reported benefit.
Unfortunately, the spontaneous healing of the partial thickness cuff tears is infrequent.
When the partial cuff tears are developed by overhead athletes the conservative treatment is indicated for a long period, because the surgical results reported in literature are
poor, with few throwing athletes that return to the same
or higher level of sporting activities: Reynolds et al 25 and
Budoff et al 26 showed similar findings about 50% of return
to play. Nevertheless, some overhead athletes continue to
refer shoulder discomfort also after conservative treatment
because of the concurrent symptomatic pathologies as micro-instability.
When symptoms persist of sufficient intensity for a long
time regardless physical exercises and clinical examination and imaging findings suggest the diagnosis of partialthickness or small full-thickness rotator cuff tear, there is
the indication to surgical management. The timing varies
in literature 3, but surgical approach should be consider
after 4-6 months; some authors including Fukuda 1 have
taken into consideration the possibility to operate soon after diagnosis the bursal-sided tears because more painful
and disabling.
How?
The first approach must be a diagnostic arthroscopy. The
open surgery must be avoided because of many disadvantages as deltoid split, coracoacromial ligament division and
impossibility to assess intra-articular findings associated
specially, although it has shown good results in the past 3.
With the development of arthroscopic technique there is
no doubt regarding its superiority. Arthroscopy is the gold
standard for diagnosis of partial thickness tears: it permits
a direct evaluation of rotator cuff from an intra-articular
and a sub-acromial point of view, providing the advantage
to assess directly the quality of the rotator cuff tissue and
diagnose the concurrent pathologic findings.
You have to determine the depth of the tear as the exposed
footprint with a know size arthroscopic instrument, palpate
the tissue for softening or thinning areas distinguishing
also false partial thickness tears from small full-thickness
ones, investigate the tendon surface for identification of
the “bubble sign” in case of intratendinous tears that remain the most difficult diagnosis to do 2, 27.
Also for the surgical treatment the arthroscopy is the gold
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Vol. 125 - 1-2 Novembre 2014
standard if the partial thickness diagnosis is confirmed,
without a second step with mini-open technique.
Surgical treatment can involve two approaches: debridement alone or with acromioplasty, and tissue repair that
may be trans-tendon or after completion tear with or
without acromioplasty. Several factors influence surgical
decision-making: patient’s features as occupation, sport,
comorbidities; type and size of the tear; surgeon’s skills 3.
Debridement with or without subacromial
decompression
When a partial thickness cuff tear is identified, debridement with the shaver is to performed to assess the effective
size and excised the torn tendon until normal tendon fibers
are visualized. In bursal-sided tears synovial proliferation
can mask small defects of the cuff 3.
After debridement a subacromial decompression may be
performed, including a flattening of the acromion undersurface and a partial removal of its antero-lateral part depending on acromion morphology, with the goal of creating a flat acromion free of impingement. In a systematic
review by Strauss et al6 including studies reporting clinical
outcomes after surgical treatment with a minimum of 12
months follow-up, 7 studies treated partial tears with debridement, 4 of these with acromioplasty in all patients.
Overall good to excellent results were obtained. It does not
appear, based on the current evidence, that subacromial
decompression leads to better outcomes when compared
with debridement alone2, 6. Instead, acromioplasty alone
has been shown to be inadequate2.
Park et al28 reported on 37 Ellman 1 and 2 partial thickness
tears treated with debridemnt and acromioplasty that pain
and function were better in bursal-sided, but no difference
at 1 and 2 years. Cordasco et al 29 reported on 105 Ellman
1 and 2 partial tears treated similarly followed up for 2 to
10 years that articular-sided fared better regards to failure
rate with 3% compared to 29% of bursal-sided tears. Findings of these studies support that bursal partial tears have
worse outcomes than articular tears and Ellman grade 3
tears are not adequately treated with debridement alone.
Similar, Liem et al 30 and Kartus et al 31 showed that arthroscopic debridement and acromioplasty in patients with
partial thickness cuff tears do not protect cuff tendon from
degeneration progression until a full-thickness tear, and
that the bursal-side clinical outcomes were worse.
Current thinking is that partial thickness rotator cuff tears
less than 50% of the medial-lateral tendon depth at footprint, < 7 mm basing on anatomic studies 7-8, could be
successfully in the short term treated with debridement
+/- acromioplasty. However, long term results are more
uncertain 2, 3, 31, 32.
So Ellman grade 1 and 2 articular side tears could be approached with this technique, performing subacromial decompression if necessary, instead bursal tears should be
approached more aggressively with this technique only in
grade 1 as suggested by literature 2, 6. Budoff et al 33 found
that after debridement alone grade 2 had significantly
better results than grade 3: 86% of good to excellent outcomes compared with 54%. The grade 3 articular tears (>
6 mm) and grade 2 and 3 bursal sided (> 3 mm) shoul be
repaired.
Figure 2: Articular sided tear
targeting by spinal needle
for visualization from
subacromial space
Trans-tendon repair
Some surgeons prefer intra-tendinous repair techniques,
that have been reported with good clinical results and biomechanical properties 2, 6. In particular a proposed advantage is the maintenance of the rotator cuff footprint still
attached, which allows for a more accurate anatomic repair
and so minimizing any length-tension mismatch created
by repair 2, 20, 34. Trans-tendon repairs believe that provide
a more accurate restoration of the footprint, increasing the
mechanical strength 32.
If an articular partial thickness cuff tear is found, a gentle
debridement of the torn surfaces is needed, to evaluate
the real extent of the tear. Then arthroscope can pass in
the subacromial space and the bursa must be completely
excised, so that the sutures can be easily visualized subacromially without having to shave around. To localise
the joint tear from the bursal side, use a spinal needle (18
gauge) for marking on the bursal surface the partial tear
as the technique developed by Snyder et al 16 (Figure 2).
This spinal needle becomes also the guide to percutaneous suture anchor placement through the intact bursal side
into the medial portion of the great tuberosity 6. Prepare
the footprint, then place one or two anchors according to
the anterior-posterior size. Ide et al 35 used a single anchor
when tear size was less than 1.5 cm, and two anchors when
was more. Use a suture passer to pass suture limbs from
the anchor through rotator cuff, tie the sutures subacromially searching the best angle of approach, a supero-lateral
portal near to the acromion 27. In this way you performed
a sort of double-row repair, exploiting the tendon yet attached. To judge the final outcome you have to assess two
features: subacromial, the good indentation of the tendon
by knots; intra-articular, the good restoration of the footprint 27.
If a bursal partial thickness cuff tear is found, a gentle debridement of the torn surfaces is anyway necessary. Palpate
the defect to assess and confirm the intact medial wall of
cuff, prepare the footprint to a bleeding base and perform
a single or double row repair 27. Use suture passer for antegrade or retrograde passage of sutures.
26
Vol. 125 - 1-2 Novembre 2014
Figure 3: Articular tear completion
before repair
Completion tear and repair
Some surgeons prefer tear completion and more traditional repair techniques, that have been reported with
good clinical results too. In case of an articular or bursal partial thickness cuff tear, the torn poor quality tissue must be excised by shaver to complete tear to a full
thickness (Figure 3): the palpation of tissue is necessary
to judge which kind of repair carry out. The bone bed
at footprint should be prepare until bleeding removing
residual soft tissue all the way to the cartilage margin27.
The repair both of articular or bursal sided could be execute using a single (Figure 4) or double row, a suture
bridge or a transosseous repair technique.
Intra-tendinous partial tear: pearls and pitfalls
Their diagnosis is quite difficult: the key is the assessment of cuff surface from the joint and bursal points of
view by palpation searching if tissue plane is entered by
probe and if relative motion between layers is present.
If you suspect this tear, connect a syringe with saline to
a spinal needle and put the tip in this defect: as the cuff
defect fills with fluid (1-2 ml saline), it forms a dome
shaped “bubble” 27. Another important possible sign is
the capsular “dimple” at rotator crescent portion. Often
these intratendinous laminations are associated with bursal or articular partial tears 36. After diagnosis you have to
debride the torn tissue and complete the tear. The laminations have not been excised totally, as demonstrated
by Sonnabend et al 37, who suggest to remove only the
synovial lining. Then you should perform the repair with
single or double row techniques.
Treatment in over-head athlete
The partial thickness cuff tear of an overhead athlete is
often associated with other pathologies. The approach
should be an aggressive trial of nonoperative management. If this conservative course fails, cuff debridement
with the treatment of concurrent symptomatic pathologies is indicated 2, 10. The subacromial decompression is
rarely needed 3. In general, the outcome of cuff tears re-
A
27
Vol. 125 - 1-2 Novembre 2014
B
Figure 4 A-B:
Ellman 3 bursal partial tear.
A) prepared footprint;
B) repair after completion
with single row
pair in overhead athletes have been discouraging, with
few athletes able to return to the same or higher level of
competition 2.
Discussion
All treatment resulted in significant improvement in
shoulder pain and function. However a 6.5 to 34.6% of
tear progression to full-thickness tears is present6 regardless operative or not operative treatment. The patients with
tear progression had poorer outcomes6, and retear rate increases with time 4.
There is no reliable report on the conservative treatment
of partial thickness, because real incidence of diagnosis
is unknown. For partial thickness less than 50% subacromial decompression does not lead to better outcomes when
compared to debridement alone 2, 6, and the results of debridement alone are quite variable 3. The literature suggests
that there is no significant difference between transtendon
and tear-completion repair, as reported also in a prospective comparative study by Castagna et al 38. In this study
they noted only one difference not statistical significant: an
higher improvement in strength in tear-completion repair
group, and they have just reported a 41% incidence of persistent shoulder pain after trans-tendon repair 39. In articular partial tears trans-tendon repairs require the placement
of anchors through a tissue that is already poor in quality
and thinned, moreover the anchor positioning is more difficult 32. On the other hand this surgical technique provides
the avoidance of potential length-tendon mismatch 20, 34.
Both repairs have been shown effective in restoring the
anatomic footprint: a recent study reported that using a
magnetic resonance arthrography to assess cuff structural
integrity the rate of retear was not significantly different
between articular and bursal sided tears at 6 months, respectively 8% and 11% 40. Another more recent study by
Kim KC et al 41 showed post operative rate of retear that
differs but not significantly between high grade articular
0% and bursal 9.5% sided tears treated with full thicknessconversion and repair at 35.5 months mean follow up. Another complication mentioned in some studies is that of
stiffness: partial thickness cuff tear repairs seem to lead a
higher incidence of stiffness if compared with full-thickness repairs, 18% to 8%, but only few cases need capsular
arthroscopic release4.
Comparing the post operative clinical outcomes between
articular and bursal sided tears it seems that there is no
significant difference regard to pain and functional scores,
and both guarantee a good to excellent result ranging from
86% to 94.1% 6.
Conclusion
There is to date no evidence to support a treatment algorithm for partial thickness tears: surgical techniques provide good to excellent clinical results.
We need prospective studies with long-term follow up:
these kind of tears may be complicated by progression in
long term, regardless of a correct and adequate treatment.
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19. Jobe CM. Superior glenoid impingement. Orthop Clin North
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in subacromial bursa and shoulder pain in rotator cuff diseases.
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22. Wolff AB, Sethi P, Sutton KM, et al. Partial-thickness rotator cuff
tears. J Am Acad Orthop Surg 2006; 14:715-725
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cuff. A followup study by arthrography. Clin Orthop Relat Res
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24. Brenneke SL, Morgan CJ. Evaluation of ultrasonography as a
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26. Budoff JE, Rodin D, Ochiai D, et al. Arthroscopic rotator cuff debridement without decompression for the treatment of tendinosis. Arthroscopy 2005; 21:1081-1089
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Sports Med 2014; 42:451-6
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Rotator cuff rehabilitation
Marco Conti, Raffaele Garofalo*
Unità di Riabilitazione Funzionale, Istituto Clinico “Humanitas”, Milano
* Unità Chirurgia della Salla, Ospedale “F. Miulli”, Acquaviva delle Fonti, Bari
In the framework of shoulder pathologies the rotator cuff
tendon lesions are pathology frequently found [1], especially among patients aged over 45. However younger
people are increasingly subjecting their scapular-humeral
joints to significant stress and can therefore suffer from
this type of lesion, especially in sports and overhead
working activities, but the presence of a rotator cuff tendon lesion does not necessarily suggest the need for surgical operations [2–5].
There is in fact increasing agreement that surgery is indicated after failure of preventive rehabilitation treatment
carried out for a period of at least 3–4 months, or in the
cases in which significant and progressive rotator cuff
tendon insufficiency occurs [6], or in relationship with dimension of lesions related to the patients expectations or
needs.
The progression of technology allows surgeon to perform today surgical repair of a rotator cuff tendon tear
(RCT) using a variety of methods, open, mini-open
and arthroscopic techniques [7], and the post-op results
are generally good and substantially comparable [8–11]. A
great topics of discussion is not therefore today the surgical technique to use but rather post-surgery recurrence.
When minor re-ruptures occur, patients may still show
improvement of the clinical symptoms compared with
the pre-operative period, while patients with massive
re-ruptures do not benefit in any way from the surgical
operation [5–12].
Therefore the level of healing of the repaired tendon [13],
seems to be increasingly the key point for therapeutic
success and clinical result.
Many factors can influence The healing of the repaired
tendon seems to be influenced by many factors [14, 15]: we
can in fact distinguish between surgical factors associated with recognition of the type of lesion (forms and
number of tendons involved), the size of the lesion, the
technique such as the mobilisation of the tendon tissue
that was possible to obtain intra operatively, the tendon
quality, the degree of muscular hypo-atrophy, as well
as adequate subacromial decompression, correct preparation of the humeral tuberosity, and the anchoring and
suturing method. Then a series of factors related to the
patient such as age, lifestyle and the presence of other
shoulder complaints or systemic illnesses [7] that either
must be taken in account (such as diabetes, thyroid pathologies, hormonal imbalances).
In this light, the post-surgery rehabilitative treatment assumes great importance as it must be able to protect the repair in the early stages, to prevent post-op stiffness and then
restore the function of the scapular-humeral joint [15, 16].
Abstract
A variety of types or extensions of cuff lesions in patients from
a wide range of age groups who have different kinds of jobs and
participate in different kinds of sports, and who have widely
different expectations in terms of recovery of functions and pain
relief can be today addressed by advances in techniques and materials for rotator cuff surgery. Instead a large number of factors
must be taken into account before implementing a rehabilitation
protocol after rotator cuff surgery. Mainly the surgery technique
(materials and procedure) used by the surgeon. Moreover, tissue
quality, retraction, fatty infiltration and time from rupture are
important biological factors while the patient’s work or sport or
daily activities after surgery and expectations of recovery must
also be assessed.
A tailored rehabilitation protocol should also take into account
the timing of biological healing of bone to tendon or tendon to
tendon interface, depending on the type of rupture and repair.
This timing should direct the therapist’s choice of correct passive or assisted exercise and mobilisation manoeuvres and the
teaching of correct active mobilisation movements the patient
has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling
rest with passive and small self-assisted arm motion in phase
one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular
mobilisation and stabiliser reinforcement, are done. Phase three
consists of progressive active arm mobilisation dry or in water
integrated with proprioceptive exercise and “core” stabilisation.
In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol.
Because of the multi-factorial aspects of the problem, the best
results can be obtained through a full transfer of information
from the surgeon to the therapist to optimise timing and sizing
of the individual rehabilitation protocol for each patient.
Many rehabilitation protocols have been proposed, often
based only on empirical experiences, without fully taking
into account biological aspects relative to the healing steps
of the repaired tendon [17-19-44-49]. Furthermore post-surgical
rehabilitation of the suture of rotator cuff tendons can vary
from patient to patient, bearing in mind (all together in the
same time) the surgical technique, the patient’s expectations and functional demands, the number of tendons repaired and therefore the grade of the lesion, the quality of
the tissue and any associated surgical actions [16].
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Tendon healing
Immobilisation and sling
The biological time for the tendon to heal must be taken
as the one of the most important aspects the rehabilitation protocol must take into account is. This process
involves tendon healing at the bone footprint if the tendon has been reinserted into its anatomical place using a
technique with anchors and sutures or trans osseous suture technique or alternatively tendon with tendon healing if a suture technique with latero-lateral stitches has
been carried out.
The reparative phenomena follow a cascading series of
mechanisms one after another in healthy individuals [20].
The first stage is the inflammatory one: during the first
week it is characterised by an increasing number of
inflammatory cells like leukocytes, lymphocytes and
monocytes, which release histamine and bradykinin,
which increase vascular permeability and therefore allow
the plates to reach the level of the repair site. The fibrin
with the fibronectin form a fragile scar which reduces the
haemorrhagy process without any real adhesion between
tendon and bone. The inflammatory stage lasts for a period which varies between 1and 2 weeks and which is
generally transformed into the proliferative stage.
During the proliferative stage a tighter adhesion between
the tendon and the bone surface is obtained thanks to
the inflammatory tisssue that is gradually replaced by
fibroblasts, myofibroblasts and endothelial cells, which
organise themselves with a new extracellular matrix to
form a granulation tissue which guarantees the adesion
between two so different tissues. Then the fibroblasts
starts to produce type III collagens fibers , which are
therefore immature, and glycosaminoglycans; then there
is significant neoangiogenesis. This stage lasts about 10
days and commences after the first 15 days after surgical
repair.
The last stage of maturing and remodelling then follows,
which therefore begins around the third week and is characterised by maturing of the scar tissue. The immature
type III collagen is replaced by type I with the formation
of dense connective tissue. By now the fibroblastic cells
will have replaced the inflammatory cells. The process
continues during the following weeks until the tendon
is completely integrated with the bone surface. Tendon
healing studies have mainly been carried out on animal
models and therefore the remodelling and maturing stages have been seen to vary in duration depending on the
animal model used. Some authors have described periods of 12–16 weeks for the tendon to recover its tensile
strength [20], while other authors who have studied sheep
models have reported times of as much as 26 weeks (4
months) [21]. These studies obviously reveal a set of limits
linked to the model studied while, furthermore, human
ruptured tendons reveal a series of degenerative alterations which can negatively influence and therefore prolong the healing time.
The recognition of the role of the biological timing is
very important and must be properly recognised by the
doctor and the therapists to modulate the rehabilitative
timing.
On the basis of the biological healing stages of the repaired cuff tendon tissue, it is clear that precocious and
aggressive mobilisation or violent muscular contraction
can exceed the mechanical strength of the repair and damage it, even though precocious mobilisation could reduce
the risks of articular stiffness. The purpose of a reasoned
rehabilitative process after a rotator cuff repair is therefore to obtain cuff tendon healing by recovering mobility
and shoulder function gradually. From this starting point
an adequate immobilisation of the limb is crucial during
the initial post-operative stage in order to guarantee effective tendon healing. Study on rats highlighted that the
cuff tendons that were immobilised after surgical suturing revealed excellent orientation of the collagen fibres
and enhanced organisation of the extracellular matrix
compared with rats that were left free after the repair [22].
Adequate immobilisation must however take into account
the vascular and biomechanical characteristics of the rotator cuff [23]. The use of an abduction sling during the
early weeks seems capable of reducing tension at suture
level and improving vascularisation of the scar. In fact we
know that the hypovascular zone of a healthy supraspinatus tendon is about 1.5 cm from the greater tuberosity of
the humerus and the position of the head of the humerus
influences tendon vascularisation significantly [24].
Assessing tendon microcirculation in relation to the head
position, Rathbun and Macnab showed that there is a reduction of the haematic flow to the tendon when the arm
is in a total adduction position [25]. Based on these observations, it seems prudent to recommend post-op immobilisation in a sling with the arm abducted at least to 30
for the first 4–6 post-operative weeks in order to improve
microcirculation and reduce the stress on the operated
tendon, especially in the case of a repair carried out on an
inveterate tendon lesion [26, 27].
A recent study of our group (still in printing at this time)
compared, in patients treated for RCT repair for the same
lesion with the same type of repair, the use of a sling in
abduction 30° and external rotation 15° with a sling in
abduction 30° and internal rotation 15°. The data demonstrated in the group of Abd 30° and ER 15° sling a
significantly greater passive mobility at 1 and 3 months,
a significantly greater Constant score at 3 months and a
minor VAS for pain still at 3 months. Same results for the
two groups at 6 months. This study suggest that the use of
a sling in Abd 30° and ER 15° seems to be more suitable
for the patient.
Continuous passive mobilisation
Few studies in the literature help us to understand if this
therapeutic aid (obtained today with electronically controlled automatic programmable mobiliser) can be of benefit in the rehabilitation of patients operated by suturing
the rotator cuff. As a general rule this continuous passive
mobilisation (CPM) can be applied in the immediate postop period applying a low mechanical stress on the repair.
Hatakeyama et al. have shown that the safety position after
this surgery is 30° of elevation on the scapular plane with
an external rotation range between 0 and 60° [28].
In a double-blind randomised study of patients treated with
repair of the cuff and subacromial decompression, Raab et
al. [29] showed that three months after the surgical operation
there were no differences in the various scores between
patients treated with physical therapy and CPM and those
treated with physical therapy only; however the range of
movement and pain level were better in patients in the first
group. Recently, Michael et al. [30] seemed to confirm these
data and also showed how the recovery of the range of
movement is faster in patients treated with CPM in the
post-operative period. In another randomised prospective
study on 31 patients operated for repair of the rotator cuff,
Lastayo et al. [31] compared 2 groups, one treated with CPM
in the first 4 weeks while the other was subjected in the
same period of time to a physical therapy programme with
passive recovery of mobility. A follow-up carried out after
22 months found that there were no statistically significant differences in the scores of the two groups or in pain
and isometric muscular strength. Our figures [32] relating to
a randomised prospective study on 100 patients seem to
indicate that the precocious use of CPM for at least two
hours daily overall, for one month after the operation, can
permit better recovery of the passive ROM in both abduction and external rotation and in forward flexion with significant data already at two and a half months. It therefore
seems, from the analysis of the literature, that in the medium and long term, CPM succeeds in substantially influencing the recovery of the range of movement only, while
it remains to be seen whether it can have a positive effect
on faster recovery of working activities or of common everyday activities. It is also not yet known if the use of CPM
can influence healing of the repaired tendons to any extent.
Certainly, however, this method can be used in patients
who have a cuff lesion associated with adhesive capsulitis
in the pre-operative period and who can therefore benefit
from a recovery, or at least from a non-loss, of the range of
movement already gained during the surgical operation.
Post-operative functional
rehabilitation
Multiple factors, which the surgeon and rehabilitation
therapist must share, are the variables that, from what we
have said so far, the rehabilitative management after RCT
repair must take into account. On top of the processes and
biological timing of tendon healing also must be taken in
account the size of the tendon lesion treated, the quality
of the treated tendon, the type of repair made (type of cuff
suture made, if partial or total, if a mono or pluri-tendon
suture, and if the repair is tendon–tendon or tendon–bone
type; knowledge of the type of implant used – reabsorbable or not reabsorbable – is also important), any associated surgical actions (acromion plastic surgery, resection
of the distal clavicle or, in younger patients, repair of an
associated lesion of the SLAP type, tenotomy or tenodesis
of the long end of the biceps and possibly knowledge of
the type of tenodesis technique – whether static or dynamic – to the soft parts of the cuff), the physiological age and
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expectations of the patient, and the range of pre-op movement of the operated shoulder.
The degree of fatty degeneration of the tendon and of muscular atrophy, the size of the lesion treated and the extent
of reduction of the range of movement in the pre-op period
In particular, must be also seen with particular attention
because of the fact that the prognosis after repair can be
significantly related to [12, 13, 35].
In this sense, communications and coordination between
the surgeon, physiatrist and physiotherapist are fundamental in order to obtain an optimum result for the patients
themselves.
The current general consensus in the literature [14, 15, 19, 36–39]
is to subdivide the post-operative rehabilitative treatment
into four stages, each one with different aims.
The aim of the first stage is to prevent articular stiffness
because of post-surgical adherences by means of exercises
of the passive type, which help to minimise loading at the
repair site.
The aim of the second stage is the progressive recovery of
the passive range of movement without scapular compensation by means of exercises of the assisted /active type
which begin gradually to apply work loads on the repaired
tendons.
The aim of the third stage is to recover strength and physiological scapular-humeral rhythm by means of toning exercises focusing on the recovery of power and the strength
of the rotator cuff tendons.
The aim of the fourth stage is the best recovery of the
strength and normal actions for both work and sports.
These stages naturally interweave and overlap without any
break and it is possible, in the same stages, to find a series
of variables linked to all the conditions regarding the patient and type of lesions treated and to the type of surgical
technique used.
The first rehabilitation stage runs from the immediate
post-op period until the 4th–6th week. During this stage
the patient will be asked to wear the abduction/er sling (up
to 5-6 weeks for complete lesions; up to 4-5 weeks for
partial and incomplete lesions) and it is only removed 3–4
times per day to carry out passive abduction, front flexion
and external rotation mobilisation exercises, as pendulum
exercise. During this stage the loads on the repair made
must be minimal and, in fact, this stage is characterised
biologically by a slight coagulation of fibrin with type III
collagen; therefore exercises with active muscular contraction on the operated limb must be avoided at this stage.
The recovery of the passive movement must be carried out
inside a safety range and the patient must work without
pain and with the avoidance of maximum stretching. In
the case of an associated subscapular repair, external passive rotation must be limited to 0°. Therefore patients can
make active movements of the wrist, hand and elbow. The
active flexion–extension of the elbow must be modulated
and limited in this stage if a tenodesis of the long end of
the biceps has been carried out, especially if of the dynamic type at the rotator cuff. Pendulum exercises are useful at this stage, to be carried out with extreme relaxation
of the musculature and with the trunk tilted 30° forward.
Furthermore, preference must be given to active and proprioceptive work of the scapular/thoracic joint. Once the
skin suture stitches have been removed the passive mobilisation and slight stretching exercises can also be carried
out in a pool [26]. Ice is an useful anti-inflammatory aid for
use in this stage, especially in the first 10–15 days and after
the physiotherapy sessions [39]. Also CPM can be useful in
this stage, particularly with patients who have had a reduction of the physiological range of movement or capsulitis
in the pre op phase.
The second stage runs from the 4th–6th week until the
end of 3rd month. This is because, from the 6th week
after the operation, the extent of healing of the tendon
to the bone and of the tendon to tendon begins to be sufficient to allow the introduction of active movements at
a minimum load. The mobilisation exercises can also be
carried out by a therapist at this stage and it is possible to
begin greater and greater stretching, with decoaptation of
the humeral head in order to begin to recover the range
of movement towards the greatest angles without inducting a subacromial iatrogenous conflict. It is possible at
this stage to begin to use aids such as pulleys and sticks.
In this case too it is necessary to continue to take care of
some strategies. If, for example, the top fibres of the subscapular muscle have been sutured, the recovery of external rotation should preferably be obtained by means of an
abduction of the limb to 45° (and with the elbow raised
4–6 cm from the couch to reduce stress on the sutures to
a minimum if the execution is carried out in a supine position). Hydrotherapy is very useful from the 6–8 weeks
to begin the active mobilisation exercises in a condition
of reduced mechanical stress for the repair because the
reduced force of gravity. The patient can be allowed to
swim breaststroke and when front passive flexion reaches around 130° some modified backstroke can be added,
without submerging the limb but ending the movement
at surface level. At this stage, therefore, it is possible
to start active movements without important loads and
therefore the use of the arm is permitted in everyday
activities. The proprioceptive exercises on the scapularthoracic joint are intensified as the active toning of the
active scapular stabilizer muscles. Particularly important
at this stage is the use of neuromuscular biofeedback systems which, help the therapist to get the patient to “relearn” the ability of voluntary and coordinated control
of the fundamental muscle groups for scapulo-humeral
stabilization and which, have been mal-functioning for
some time because the profound alteration of the motor
patterns induced by the cuff lesion, by the pain and by the
compensation mechanisms implemented instinctively to
permit the spatial positioning of the hand on the basis of
living needs.
At the end of the third month (10th–12th week) can start
the third stage : is the muscular toning stage with progressive functional recovery. The start of this stage obviously depends on various factors. As we have already
said, one of the most important factors is the type of lesion repaired. This is because more serious is the tendon
lesion repaired, more this stage is delayed.
Furthermore, the start of this rehabilitation stage is secondary to recovery of a satisfactory range of active movement of the operated limb, especially in terms of front
flexion and external rotation. This is because repeated
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attempts to tone a shoulder which is still stiff can give
rise to pain, subacromial conflict and excess stress on the
repair itself. Patients who are still unable to actively raise
the arm against gravity at this stage should begin to carry
out reinforcement exercises without resistance in a supine position that virtually eliminate the gravity weight
and the patient can begins to raise the limb over 90° and
reinforce the deltoid. This exercise can be carried out at
the beginning with the elbow flexed and then gradually
increasing the lever arm by extending the elbow progressively with a small weight in the hand or using an elastic
resistance system [40]. At this rehabilitation stage it is
important to respect the pain while the intensity of the
exercises must be properly monitored staring with submaximal isometric contractions which permit the application of controlled force through the repaired tendon.
If the supraspinatus has been repaired, toning must be
carried out first attempting to reinforce the pair of front
(subscapular) and rear (subspinatus) forces by means of
exercises with the limb abducted to 30°– 45° and then
60°, to limit the possibility of a subacromial conflict that
can entail pain as well as mechanical stress on the repair
made.
Isometric reinforcement is followed by a isotonic reinforcement stage with elastic bands initially concentrate
on the execution of many repetitions with low loads. Remembering that muscular toning is dependent on the articular angle, it is necessary to seek different angular positions of the humerus at which to carry out the same exercises so that with each exercise all fibers of the involved
muscle will be involved then changing the exercise and
the humerus spatial position the infraspinatus, the teres
minor, the subscapular, the deltoid (first front and then
rear), the mid and inferior parts of the trapezius and the
rhom- boideus or costoscapularis muscles could be progressively involved [45]. The exercises must be modulated
to spare the repaired tendon as much as possible at the
beginning. Takeda et al. [41] have shown that with the arm
abducted on the scapular plane the supraspinatus is isolated and that this would therefore be the ideal position
for the reinforcement of this tendon, if not involved in
the repair or in the late stages of the process of healing.
However it is necessary to be very careful with the humeral rotation in this position. Some NMR studies have
shown that in the abduction and internal rotation position
the subacromial space is reduced in a dynamic manner
and gives rise to stress on the repair [42], and this is why
abduction positions of less than 90° are recommended
if internal or external rotations are associated with them
[26]
. At this stage it is also necessary to continue to improve the range of movement with exercises for stretching the capsulo-ligamentous structures, in particular on
the antero-inferior and postero-inferior capsule that is
always stiff at this stage. The proprioceptive work of the
scapular stabilisers must be intensified without forgetting
“core” stabilisation (the muscular system of the abdominal, oblique, dorsal and gluteus muscles), fundamental
for correct positioning of the scapula [48].
A crucial role in progressive functional recovery is played
by proprioceptive exercises in a closed kinetic chain first
below and then above the breast .
Around the 16th week, and always on the basis of the
functional recovery attained by each patient, generally
begins the fourth and last rehabilitation stage of the rehabilitation process that last until the 6th month. This
stage is a progression of the third stage, and its end point
is different depending on the type of patient [43]. This is
because at this stage a patient with a low functional demand will continue to improve in a progressive manner
in a programme of exercises prevalently home based with
an increasingly complete recovery of the normal activities of everyday life and the resumption, with great caution, of overhead activities.
With regard to young patients and athletes [47], generally
more high demanding, these last stage begin with exercises first in an open kinetic chain with increasing ARoM
and velocity and then go on to specific sports recovery
exercises first for the gesture and then with force applied
to the specific sports gesture itself, while workers begin
to carry out activities which simulate the working activity in a specific and progressive manner. Is a therapist’s
job to teach patients appropriate strategies for limiting at
the minimum the stress on the repaired tendon during the
sports or work activities.
Conclusions
Evident is the consensus about how post-operative rehabilitation is a progressive, integrated and tailored process
(rather than a “protocol”) in which a fundamental role is
played by the passage of information between the surgeon and the physiotherapist, as well as the sharing of
knowledge regarding the characteristics of each individual operation both in terms of surgical technique and in
terms of the biological and anatomical characteristics of
the repaired tissues. Only through the integration of this
information with data regarding the patient’s lifestyle and
expectations it will be possible to establish a tailored rehabilitation programme which can not ignore the times
and processes of biological tissue healing in order to
achieve the best possible result both in terms of functional recovery and of management of the symptoms.
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13. Boileau P, Brassart N, Watkinson DJ et al Arthroscopic repair of
full-thickness tears of supraspinatus: does the tendon really heal?
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on rotator cuff healing using modified Mason- Allen stitches: a
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22.Thomopoulos S, Williams GR, Soslowsky LJ Tendon to bone healing: differences in biomechanical, structural, and com- positional
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23. Rathbun JB The microvascular pattern of the rotator cuff. J Bone
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the rotator cuff: an evaluation-based approach. J Am Acad Orthop Surg 2006; 14:599–609
27. Hersche O, Gerber C Passive tension in the supraspinatus musculotendinous unit after long-standing rupture of its tendon: a
preliminary report. J Shoulder Elbow Surg 1998; 7:393–396
28. Hatakeyama Y, Itoi E, Pradhan RL et al Effect of arm elevation
and rotation on the strain in the repaired rotator cuff tendon: a
cadaveric study. Am J Sports Med 2001; 29:788–794
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treatment after rotator cuff repair with a continuous passive motion device (CPM)]. Z Orthop Ihre Grenzgeb 2005; 143:438–445
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36. Rubin BD, Kibler WB Fundamental principles of shoulder rehabilitation: conservative to postoperative management. Arthroscopy
2002; 18:29–39
37. Kibler WB, McMullen J, Uhl T Shoulder rehabilitation: strategies,
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38. Kibler WB Rehabilitation of rotator cuff tendinopathy. Clin Sports
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postoperative shoulder. J Shoulder Elbow Surg 1996; 5:62–68
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for strengthening the supraspinatus muscle. Evaluation by resonance imaging. Am J Sports Med 2002; 30:374–381
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Trapezius muscle timing during selected shoulder rehabilitation
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Kokmeyer D., Millet P.J, Rehabilitation after arthroscopic rotator
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VENERDÌ 20 MARZO 2015
PRIMA SESSIONE: anello pelvico
A.I.P.
Associazione Italiana
per lo studio della Traumatologia della Pelvi
CORSO DI ISTRUZIONE AIP
Anello Pelvico e Acetabolo
Presidente : Alberto Ferreli
Dal luogo dell’incidente alla sala d’emergenza: criteri di
centralizzazione primaria e secondaria.
Situazione in Sardegna/DEA di secondo livello A.O. Brotzu
Analisi delle lesioni dell’anello pelvico: clinica, esami strumentali
e diagnosi
Damage control nel politraumatizzato con frattura pelvica
Ruolo della fissazione esterna, della C-clamp e della fascia pelvica
Il trattamento definitivo o il trasferimento del paziente
Il trattamento riabilitativo nel territorio
Risultati a distanza, costi sociali
SECONDA SESSIONE: discussione interattiva di casi clinici
SABATO 21 MARZO 2015
PRIMA SESSIONE: acetabolo
Diagnosi delle fratture acetabolari
Quando e come centralizzare
Pianificazione pre-operatoria e timing
Vie d’accesso standard
Principi di trattamento
Cosa fare negli anziani
Il trattamento delle complicazioni
SECONDA SESSIONE: discussione interattiva di casi clinici
PRIMO ANNUNCIO
Segreteria Organizzativa
KEYWORD Europa
20-21 marzo 2015 - Hotel Regina Margherita, Cagliari
Via L. Mancini 3 - 20129 Milano Tel 02/54122513 Fax 02/54124871
e-mail: info@keywordeuropa.com - www.keywordeuropa.com
35
Vol. 125 - 1-2 Novembre 2014
Modern technique of arthroscopic suture
in reparable rotator cuff tears.
Actual standards and limitations
Roberto Leo, Valentina Fogliata, Amos Maria Querenghi, Marco Pivetta, Bruno Michele Marelli
Dipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,
INTRODUCTION
ABSTRACT
The treatment of rotator cuff lesions got great improvements through the decades. In fact, before 1970s these
lesions weren’t treated surgically. Afterwards, between
1970s and 1980s, open surgical treatment of rotator cuff
tears was the gold standard for treating this kind of lesion.
More recently, from 1990s and the beginning of the new
century, open surgical treatment was slowly and progressively replaced by the new mini-invasive arthroscopic
treatment.
Over the years, several studies compared the outcomes of
open-surgical technique and arthroscopic one1,2,3 demonstrating that there is no difference between the two techniques, considering both the possibility of repairing wide
lesions and the quality of tendon-to-bone fixation4.
The effectiveness of tissue repair, apart from biological responses, depends also on the mechanical resistance of the
construct including anchor fixation, knot reliability, stability of the suture loop, and suture configuration. All of these
are key points in a good tendon healing process.
The aim of this paper is to describe how the modern arthroscopic surgery developed in order to achieve results
comparable to the one of the traditional open techniques.
First of all, we’ll analyse the tools used by the surgeon
to obtain the suture, considering hardware and materials. Then we will also analyse suture techniques used to
achieve the best tendon-to-bone repair.
The aim of this paper is to describe how the modern arthroscopic
surgery developed in order to achieve results comparable to former traditional open techniques.
New materials available in shoulder surgery, new surgical tools
and new suture techniques developed by surgeons lead today to
better final outcomes than at the beginning of arthroscopic surgery. For this reason in our paper we described the main used
suturing techniques (single row, double row, transosseous equivalent suture bridge, triple row, and transosseous) comparing their
virtues and vices.
Finally me must conclude that modern mini-invasive techniques
are based not only on the surgeon learning curve but also on the
improvement of suture materials and tools that are available for
surgery. In the future, by one side better understanding of the biological processes causing tendon damage and, in the other side,
better knowledge of the processes that lead to tendon to bone
reparation after surgery seems to be the key for improving clinical results and then patient satisfaction.
EVOLUTION OF SURGICAL TOOLS
AND MATERIALS
The evolution of materials comprises: 1) Surgical tools; 2) Anchors; 3) Sutures.
Figure 1: Single step suture passer
1) Surgical tools
There are mainly 3 kind of suture passing instruments:
- Single step suture passer: it is a tool that grasps the
tissue and, at the same time, thanks to a needle, it
passes the suture through the tendon. Nowadays,
this 3rd generation of suture passer is available and
it increases the rate of success in passing the suture
through the tendon (Figures 1, 2),
Figure 2: Single step suture passer
perforating tendon
36
Vol. 125 - 1-2 Novembre 2014
Figure 4: Perforating tool
Figure 3: Double step suture passer
- Double step suture passer (for example Spectrum®
- Conmed TM or Accu-Pass® Suture Shuttle –
Smith & Nephew): it is a perforating tool that, after
passing through the tendon, releases a shuttle suture wire that works as a real shuttle for anchorwire (Figure 3).
- Perforating tool (also called ‘Bird beak’): it is a
tool that penetrates the tissue, grasps the suture and
makes it passing through the tendon with a retrograde movement. In the beginning this tool was
straight or slightly curved but, nowadays, ‘bird
beaks’ are available curved in different directions,
in order to make this device suitable for almost all
cases (Figure 4).
Each surgeon has his favourite set of tools, so an ideal instrumentations for performing a suture doesn’t exist. However, it is compulsory to understand all the characteristics,
indications and limitations of every single tool to make
possible the best repair of every kind of lesion.
2) Anchors
Different kinds of anchor exist, from metallic to entirely
resorbable ones. This evolution is due to the need to improve the tendon-to-bone healing5.
The first models of anchors produced were made up of
metallic alloy with non-resorbable suture-wires and, in
the beginning, they made possible to achieve good results
even if further studies demonstrated presence of complication such as incarceration or migrations of the anchors6-8.
For that reason non-resorbable anchors were produced9,10.
The materials with the greatest history and most commonly used are polyglycolic acid (PGA) with a degradation time of 3 to 4 months and polylactic acid enantiomers
(PLA, naming levo-stereoisomer PLLA and dextro-stereoisomer PDLA) with a degradation time between 10 to
over 30 months.
One of the first use of this anchors was Suretac® system,
made of PGA and used in arthroscopic Bankart repair.
Even if a few authors describe a good long term results
using this device,9 there are several studies that showed as
it produced massive synovitis, loose fragments spread in
joint cavity and induced a foreign-body reaction11,12.
After this one, PLLA anchors were presented; they
showed a longer time of reabsorption. Several studies, e.g.
Dejong et al.13, stated that the reabsorbable PLA suture
anchor construct, tested in an in vivo intra-articular model,
had similar strength over a 12-week period of implantation with a comparable metal anchor construct. So they
showed that resorbable anchors are a good alternative to
metallic ones, since they have a function and a pull-out
resistance comparable to metallic ones, in addition to the
advantage linked to the resorbable materials (e.g. no interference to MRI). But we must notice that using this
biomaterial there were concerns that an excessively long
period of degradation would not allow a complete osseous
replacement leading potentially to complications similar
to metallic anchors 14.
In order to reduce the anchor degradation time, the amorphous nature of PLLA has been increased, using copolymers of the levo- and dextro-stereoisomers of lactic acid
and PGA the polylactide-co-glycolide (PDLLA-co-PGA)
or PLGA, in which the composition range of the polymers
can be variable15-17.
This evolution led to the introduction of biocomposite
anchors made by new generation materials, improving
stimulation of reabsorption and subsequent stimulation of
bone ingrowth. They are generally a blend of tricalcium
phosphate (TCP) and PLA. One of this copolymer is composed by 30% TCP and 70% PLGA. Another one copolymer of this family is composed by 15% TCP and 85%
PLA. Both are reported to produce a few tissue reaction
and sub sequential good bone ingrowth.
Polyetheretherketone (PEEK) is a stable material, highly
unreactive, that is resistant to chemical, thermal, and radiation-induced degradation. It has been widely used in
trauma and orthopedics. PEEK-based anchors are strong,
relatively inert, radiolucent, and can be easily removed
during revision surgery 18..
More recently have been introduced the so-called “soft
anchors” made by all-soft flat-braided high-strength
polyester non resorbable suture wire (for example JuggerKnot®, Biomet - Y-knot®, Conmed Linvatec - Suturefix Ultra®, Smith&Nephew). In these devices the
construct does not require a rigid body for bone engagement. In fact after they are inserted into the pilot hole, as
soon as they are released, the suture wire forms a “ball”
inside the tunnel immediately under the humeral cortical
layer. This “ball” can function as a real biosorbable stiff
anchor. The key point in these types of anchors is that
they eliminate every kind of tinny and stiff material inside the joint. All these great new anchors biomechanical
properties are suitable for several cases in arthroscopic
shoulder surgery.
3) Sutures
The ideal suture wire would be strong but biologically
inert and must simply dissolve in body fluids loosening
resistance at the same time that repaired tissue gains mechanical resistance. Modern sutures are close to the above
mentioned ideal suture.
At the same time we must say that even if there have been
great improvements in suture materials, no single suture
can be perfect in all circumstances.
We must distinguish from absorbable and non-absorbable
suture noticing that in any case suture wire act as a foreign
body inside our tissues.
Talking about rotator cuff surgery the most used sutures
are yet the non-absorbable ones who keep the same resistance for all the period during which the tendon is repairing on the bone.
One of the most famous non-absorbable suture is Ethibond®.
Ethibond® is a ��
non-absorbable, braided and sterile surgical suture composed of Polyethylene terephthalate. It
is prepared from fibers of high molecular weight, longchain, linear polyesters. It is uniformly coated with polybutilate and this highly adherent coating acts as a lubricant to mechanically improve the physical properties of
sliding and flexibility, improving in this way his handling
qualities. The pitfall of this suture is the lower mechanical
resistance during the knot tightening and, sometimes, the
suture is sheared by using the knot pusher.
Nowadays companies improved the quality of sutures
used in rotator cuff repair and so now they offer high resistance wires that are able to withstand much better to
the strength applied while tightening the knot. In fact the
37
Vol. 125 - 1-2 Novembre 2014
resistance of the construct and consequently the quality of
the repair depend on the reliability of the knot and on the
elongation of the system (suture and loop); therefore, the
increased material resistance may minimize suture breakage due to either “sharp” devices or overthightenig19.
Biomechanical tests made by companies demonstrate that
the resistance to traction of the knot pusher in this new
kind of suture is doubled than in Ethibond®.
As following, we analize the characteristics of four kind
of high-resistance sutures produced by four of the main
companies:
- Orthocord® (De Puy Mitek): it’s a braided and
synthetic suture composed of resorbable polydioxanone (PDS®) and non-resorbable non-colored
polyethylene fibers. The suture is covered by a partially resorbable copolymer (90% Polycaprolactone
and 10% Glycolide) to facilitate the sliding during
the tightening of the knot.
- FiberWire® (Arthrex): it’s a multi strand structure
suture composed by a central core of ultra high molecular weight polyethylene (UHMW) covered in
a braided coating composed of fibers of ultra high
density polyester and polyethylene. This pattern
gives a high resistance to rupture and friction. However, this suture has a high stiffness that must be
considered in case of tendon-to-bone suture since
the excessive tightening of the knots could reduce
the tissue blood supply and so worsen the healing
process.
- Hi-Fi® (Conmed Linvatec): it’s a braided suture
composed of ultra high molecular weight poly ethylene fibers without central core. It offers high resistance to the rupture caused by the knot pusher
and it is mainly non-resorbable.
- Ultrabraid Suture® (Smith&Nephew): It’s once
again a non-absorbable suture composed of a special ultra high molecular weight (UHMW) polyethylene fiber featuring a unique braid configuration
without central core.
SUTURE TECHNIQUES
One of the most important thing to consider in arthroscopic
repair is to understand the shape of the lesion: partial (articular or bursal) or complete, usually divided in crescentshaped, U-shaped, L-shaped and massive tears20. In fact,
understanding the shape of the lesion allow the surgeon to
use the most reliable and suitable technique to restore the
normal anatomy of rotator cuff if possible.
The main purpose of the surgical procedure is to re-attach
tendons to��
the bone ��
at their anatomical insertion.��
The
��
stability of the tendon-to-bone fixation and its tight contact (a
so called ‘watertight cuff repair’) are the essential assumptions for an appropriate tendon-to-bone healing and so for
good clinical outcomes.
For this reason in arthroscopic surgery there has been an
evolution of the technique, both considering the devices,
the wires and the surgical managing, in order to adapt��
surgery to the anatomy of the��
tendinous lesion, after evaluating its shape, width and the quality of the tissue.
38
Vol. 125 - 1-2 Novembre 2014
Figure 5: Single row construct
Figure 6: Mason Allen stitch modified
for arthroscopy
The main used suturing techniques could be divided into
5 types:
- single row,
- double row,
- transosseous equivalent suture bridge,
- triple row,
- transosseous.
Single Row
In this technique the surgeon implant��
s��
a single row of anchors parallel to each others and perpendicular to the glenoid articular surface. ��
As in other techniques ��
right placement of the anchor is very important for the biomechanics
of the final construct.
Firstly, considering the superior surface of the great��
er��
tuberosity, the inclination of the angle should comply the concept
of the ‘deadman angle’ by Burkhart21. Also the distance from
the articular humeral cartilages must be considered and it depends on the grade of retraction of the tendon: the more is the
tendon retracted, the more the anchor should be medialized.
There are different ways of passing suture wire through the
tendon: ‘simple’ (only a wire into the tendon – Figure 5),
‘double’ or ‘mattress’ (both sides of the suture pass through
the tendon), and more complex ones, such as the arthroscopic Mason-Allen (Figure 6) or the Italian modification of the
latter, the Alex stitch22.
Usually, this technique doesn’t need high duration of surgery
and it has lower costs compared to the techniques described
below. In our experience, we get very good outcomes, even
though several studies23,24 demonstrated that not always this
technique achieves a good tendon-to-bone fixation on the
anatomical footprint if compared to double row or transosseous equivalent technique.
39
Vol. 125 - 1-2 Novembre 2014
Figure 7: Double row construct
Figure 8: Suture bridge transosseous
equivalent
Double Row
This kind of suture is performed using 2 rows of anchors,
one near to the articular border of the humeral head and
the other one��
more��
lateral��
near��
to the ��
top of the ��
greater tuberosity. It is possible to perform simple knots for
every anchors or to perform simple knots for the medial
anchors and a mattress knot for every lateral anchor, as
described by Lo and Burkhart25 (Figure 7). In this way,
every anchor acts like an independent point of support
with the advantage of increasing the area of tendon-tobone contact and, as a consequence, the process of tendon-to-bone healing.
Disadvantages of this technique are higher costs (it needs
a doubled amount of anchors than single row technique)
and higher duration of surgery. Another disadvantage
is that the high number of sutures could excessively increase the compression of the tendon resulting in a ��
poten-
tial decrease of blood supply and, as a consequence, of all
growth factors involved in the process of tendon-to-bone
healing.
There are several studies that compared single row to
double row techniques. Kim et al26 evaluated both techniques in terms of cyclic loading, gap formation and failure loads and they stated that double row technique got
42% less gap formation, 46% more stiffness and 48%
higher ultimate load to failure. The strain experienced in
the footprint of double-row repair was 1/3 of that seen in
single row.
In their study, Saridakis and Jones27 stated that doublerow sutures get a more stable structural repair than single
row, but there isn’t a significant statistical difference in
term of clinical outcomes in lesion of less than 3 cm if
compared with single-row suture. Instead, Duquin et al28
stated that in case of lesions of more than 1 cm, double-
40
Vol. 125 - 1-2 Novembre 2014
Figure 9: Triple row construct
row technique has a much lower rate of recurrence of lesions if compared to single-row technique. In their study,
Ma et al29 showed that patients with lesions of more than 3
cm repaired with a double-row suture have a higher value
of strength if compared with a repair with a single-row
suture; however, after repairing every kind of lesions, they
didn’t find a significant statistical difference in rotator cuff
integrity at a 2-years follow-up.
Transosseous equivalent suture bridge
In this technique, presented by Park et al.30, the surgeon
knots the sutures of the medial anchors at the lateral ones
after crossing them (Figure 8 - Transosseous equivalent suture bridge). In this technique simple knots are performed
at the medial anchors and then the insertional part of the
tendon is pulled till the great tuberosity and it is fixed here
by special anchors (like for example PushLock® by Arthrex) that lock the terminal part of the sutures into the
holes inside the anchors without further knots .
Nasson et al.31 demonstrated that this technique brings to a
more water-tightening repair if compared with single row
technique. The main pitfalls are the increase of surgical
time and of costs of the procedure.
Triple Row
This technique was introduced by Ostrander and McKinney32 in 2012 considering that the most anatomical repair
could lead to a decrease of recurrence in massive lesions.
This technique, a sort of suture bridge-modified, requires
a further anchor in median position between the row of
medial anchors and the row of the lateral ones (Figure 9).
Ostrander and McKinney32 demonstrated that this technique showed a higher pressure at the area of contact with
a larger tendon-to-bone area at the footprint if compared
to double rows and to suture bridge techniques.
However this technique needs a longer duration of the surgery and it is burdened by considerable costs.
Furthermore, from our point of view, the use of 5 anchors
for performing this technique could considerably weaken
the bone increasing the risk of iatrogenic or late fractures.
Arthroscopic transosseous technique
The transosseus repair of rotator cuff lesions was largely
used when it was performed with open surgery. Since this
technique is able to achieve a good seal respect��
ing��
anatomy without using anchors, a specific tool was developed to
perform the arthroscopic transosseous suture33. Recently,
Garofalo et al.34 tested a new device (ArthroTunneler®
device by Tornier) that makes possible to perform an arthroscopic transosseous tendon repair taking advantage of
mini-invasive surgery and the reliability of transosseous
open repair. Furthermore, without using anchors, this technique avoids all complication linked to it, such as pullout or osteolysis of great tuberosity. Moreover, Park et al.
(2007) demonstrated that all techniques of tendon repair
with anchors lead to an increase of circumferential tension
but a low compression at the tendon-bone interface35.
In this technique, the lateral tunnel is performed 1,5 cm
distally to the superior border of the great tuberosity but,
Figure 10: Schematic drawing of the
suture wire through the tendon and
inside the transosseus tunnels
41
Vol. 125 - 1-2 Novembre 2014
Figure 11: Transosseous construct
in order to increase the mechanical strength of the transosseous suture of the tendon, this tunnel could be performed at more than 10 mm far from the extremity of the
great tuberosity36 (Figure 10, 11).
This technique represents surely an effective alternative to
the use of anchors for the treatment of rotator cuff lesions
but, nowadays, biomechanical and clinical evaluations
should be performed again.
Several authors described different techniques for arthroscopic transosseous repair such as Fleega37, Fox38,
Frick39 et al. whom presented techniques in which they
used needle of great dimension to perform the transosseous
suture. The pitfalls of these techniques are the reproducibility, the possible breakdown of the bone-tunnel, the rupture of the needle inside the tunnel and possible lesions of
the axillary nerve depending on the angle of insertion used
by the surgeon that is very variable.
Indeed, this new device (ArthroTunneler® device – Tornier) could perform the transosseous tunnels in a very reproducible way avoiding most of the pitfalls and complications caused by the free-hand techniques previously
presented.
CONCLUSIONS
In the last 40 years, the surgery of the tendinous lesions got
a significant evolution and nowadays the shoulder surgeon
performers arthroscopically almost all kind of cuff repair
with the same reliability
��
of the older��
open surgical techniques. The only lesion that already requires, in the majority
of the cases, an open technique is the traumatic complete
full thickness subscapularis tendon tear.
In any case one can say that modern arthroscopic techniques
are based not only by the completion of the surgeon learning
curve but also by the improvement of suture materials and
tools��
now��
available.
��
The surgeon skills lead today to realize even more effective sutures that increase tendon-to-bone
adhesion minimally affecting tendon vascularisation.
Last but not least, we must consider the increased knowl-
edge about biological mechanisms that are at the base of
tendon-to-bone healing processes, that is essential for good
clinical outcomes.
In the future better understanding of the biological processes that lead to tendinous rupture and then that lead to
restoration of the cuff anatomy after surgery seems to be
the key for improving clinical results and then patient satisfaction.
REFERENCES
1. Walton JR, Murrell GA. A two-year clinical outcomes study of
400 patients, comparing open surgery and arthroscopy for rotator cuff repair. Bone Joint Res 2012; 1: 210-217
2. Kim SH, Ha KI, Park JH et al. Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6
years’ follow-up. Arthroscopy 2003; 19: 746-754
3. Severud EL1, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Arthroscopy 2003; 19: 234-238
4. Buess E1, Steuber KU, Waibl B. Open versus arthroscopic rotator
cuff repair: a comparative view of 96 cases. Arthroscopy 2005;
21: 597-604
5. Mueller MB, Fredrich HH, Steinhauser E et al. Biomechanical
evaluation of different suture anchors for the stabilization of
anterior labrum lesions. Arthroscopy 2005; 21: 611-619
6. Kaar TK, Schenck RC Jr, Wirth MA, Rockwood CA Jr. Complications of metallic suture anchors in shoulder surgery: A report of
8 cases. Arthroscopy 2001; 17: 31-37
7. Silver MD, Daigneault JP. Symptomatic interarticular migration
of glenoid suture anchors. Arthroscopy 2000;16: 102-105
8. Gaenslen ES, Satterlee CC, Hinson GW. Magnetic resonance imaging for evaluation of failed repairs of the rotator cuff. Relationship to operative findings. J Bone Joint Surg Am 1996; 78:
1391-1396
9. Marquardt B, Witt KA, Götze C et al. Long-term results of arthroscopic Bankart repair with a bioabsorbable tack. Am J Sports
Med 2006; 34: 1906-10
10. Tan CK, Guisasola I, Machani B et al. Arthroscopic stabilization
of the shoulder: a prospective randomized study of absorbable
versus nonabsorbable suture anchors. Arthroscopy 2006; 22:
716-720
11. Burkart A1, Imhoff AB, Roscher E. Foreign-body reaction to the
bioabsorbable suretac device. Arthroscopy 2000; 16:91-95
12. Edwards DJ, Hoy G, Saies AD, Hayes MG. Adverse reactions to
an absorbable shoulder fixation device. J Shoulder Elbow Surg
1994; 3:230-233
13. Dejong ES, DeBerardino TM, Brooks DE, Judson K. In vivo comparison of a metal versus a biodegradable suture anchor. Arthroscopy 2004; 20: 511-516
14. Ticker JB, Lippe RJ, Barkin DE, Carroll MP. Infected suture anchors
in the shoulder. Arthroscopy 1996; 12: 613-615
15. Middleton JC, Tipton AJ. Synthetic biodegradable polymers as
orthopedic devices. Biomaterials 2000; 21: 2335-2346
16. Athanasiou KA, Agrawal CM, Barber FA, Burkhart SS. Orthopaedic applications for PLA-PGA biodegradable polymers. Arthroscopy 1998; 14:726-737
17.��
��
Ciccone WJ 2nd, Motz C, Bentley C, Tasto JP. Bioabsorbable��
��
implants in orthopaedics: New developments and clinical applications. J Am Acad Orthop Surg 2001; 9:280-288
18. Kurtz SM, Devine JN. PEEK biomaterials in trauma, orthopedic,
and spinal implants. Biomaterials 2007; 28:4845-4869
19. Li X, King M, MacDonald P. Comparative study of knot performance and ease of manipulation of monofilament and braided sutures for arthroscopic applications. Knee Surg Sports Traumatol
Arthrosc. 2004; 12:448-452
20. Burkhart SS, Lo IK.Arthroscopic rotator cuff repair. J Am Acad
Orthop Surg 2006; 14:333-346
21. Burkhart SS, The deadman theory of suture anchors: observations along a south Texas fence line. Arthroscopy 1995; 11:119123
22. Castagna A, Garofalo R, Conti M et al. Arthroscopic rotator cuff
repair using a triple-loaded suture anchor and a modified Mason-Allen technique (Alex stitch). Arthroscopy 2007; 23:440
23. Ma CB, Comerford L, Wilson J, Puttlitz CM. Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared
with single-row fixation. J Bone Joint Surg Am 2006; 88:403410
24. Baums MH, Spahn G, Steckel H et al. Comparative evaluation of
the tendon-bone interface contact pressure in different singleversus double-row suture anchor repair techniques. Knee Surg
Sports Traumatol Arthrosc 2009; 17: 1466-1472
25. Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair:
re-establishing the footprint of the rotator cuff. Arthroscopy
2003; 19:1035-1042
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26. Kim DH, Elattrache NS, Tibone JE et al. Biomechanical comparison of a single-row versus double-row suture anchor technique
for rotator cuff repair. Am J Sports Med 2006; 34:407-414
27. Saridakis P, Jones G. Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review. J Bone Joint
Surg Am 2010; 92:732-742
28. Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic
review. Am J Sports Med 2010; 38:835-841
29. Ma HL, Chiang ER, Wu HT et al. Clinical outcome and imaging
of arthroscopic single-row and double-row rotator cuff repair: a
prospective randomized trial. Arthroscopy 2012; 28:16-24
30. Park MC, Elattrache NS, Ahmad CS, Tibone JE. “Transosseousequivalent” rotator cuff repair technique. Arthroscopy 2006;
22:1360
31. Nassos JT, ElAttrache NS, Angel MJ et al. A watertight construct
in arthroscopic rotator cuff repair. J Shoulder Elbow Surg 2012;
21:589-596
32. Ostrander RV 3rd, McKinney BI. Evaluation of footprint contact
area and pressure using a triple-row modification of the suturebridge technique for rotator cuff repair. J Shoulder Elbow Surg
2012; 21:1406-1412
33. Rossouw DJ, McElroy BJ, Amis AA, Emery RJ. A biomechanical
evaluation of suture anchors in repair of the rotator cuff. J Bone
Joint Surg Br 1997; 79:458-461
34. Garofalo R, Castagna A, Borroni M, Krishnan SG. Arthroscopic
transosseous (anchorless) rotator cuff repair. Knee Surg Sports
Traumatol Arthrosc 2012; 20:1031-1035
35. Park MC, ElAttrache NS, Tibone JE et al. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff
repair technique compared with a double-row repair technique.
J Shoulder Elbow Surg 2007; 16:461-468
36. Caldwell GL, Warner JP, Miller MD et al. Strength of fixation with
transosseous sutures in rotator cuff repair. J Bone Joint Surg Am
1997; 79:1064-1068
37. Fleega BA Arthroscopic transhumeral rotator cuff repair: Giant
needle technique. Arthroscopy 2002; 18:218-223
38. Fox MP, Auffarth A, Tauber M et al. A novel transosseous button
technique for rotator cuff repair. Arthroscopy 2008; 24:10741077
39. Frick H, Haag M, Volz M, Stehle J. Arthroscopic bone needle: a
new, safe, and cost-effective technique for rotator cuff repair.
Tech Should Surg 2010; 11:107–112
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Subscapularis tendon tear.
Modern surgical approach
Dario Petriccioli, Giacomo Marchi, Celeste Bertone
Department of Orthopedics, Istituto Clinico Città di Brescia, Brescia
For a long time, the subscapularis tendon, was not considered as a basic structure in the shoulder biomechanics,
gaining the term “forgotten tendon” with a high percentage
of unrecognized injuries (hidden lesion) 1.
Over the past 10 years, thanks to authors like Walch, Gerber, Bennet and others, we realized its real importance and
considerable disability in the case of its breakage2,3.
The etiology can be both traumatic and degenerative, often in association with LHB instability, dislocations or
impingement, mainly with coracoid process. We can find
isolated lesions or in association with other rotator cuff
tendons in percentages ranging from 3.5 to 20.8%4.
A correct and modern surgical approach to the subscapularis lesions, needs their systematic staging through the
many classifications that literature offers.
Generally we use the 2007 Lafosse classification (CT or
MRI) to select an appropriate surgical treatment:5
ABSTRACT
Operative treatment on the subscapularis tendon tears has become more minimally invasive and selective over the past decade. This requires high-quality preoperative imaging evaluation for better knowledge of the relevant anatomical considerations. Arthroscopic repair has become the operation of choice
for most patients presenting with small and not retracted tear.
In case of larger tears the open operative treatment remains the
unique solution, especially in irreparable tears who requires a
tendon transfer.
STAGE I-II 6, 7, 8 (PIC. 1)
I Partial lesion of superior one-third
II Complete lesion of superior one-third
III Complete lesion of superior two-thirds
IV Complete lesion of tendon but head centred
and fatty degeneration classified as less than or
equal to Goutallier stage III
V Complete lesion of tendon but eccentric
head with coracoid impingement and fatty
degeneration classified as more than or equal
to Goutallier stage III
we can summarize the surgical protocol that we have chosen, in the following way:
STAGE I-II: Arthroscopic repair or conservative
treatment, in elderly patients with low functional
demands and limited pain
STAGE III: Arthroscopic or open repair with possible reinforcement using pectoralis minor transfer
(Wirth procedure)
STAGE IV: Open repair and, if necessary, augmentation with synthetic scaffold or pectoralis minor
transfer
STAGE V: lesions that tend to be non-repairable requiring pectoralis major transfer (Gerber or Resch
technique)
The arthroscopic approach can be made in lateral decubitus, with about 40° limb abduction, or in beach chair position (best technique for the author) with back reclined
approximately 60° and in general anesthesia associated
with interscalene block.
The technique involves first posterior portal, approximately 1 cm medial and 1 cm under rear corner of the acromion, and anterior-superior and lateral portals. Sometimes it can be useful an antero-medial portal near the
lateral margin of the conjoint tendon.
The next step is the intra-articular evaluation of capsuleligament and tendon structures with particular attention
to the subscapularis insertion, sometimes can be useful
internal rotation motion to relax the foot-print fibers and
obtain better visualization.
Particular attention must be paid to the biceps tendon and
its groove, trying medial and lateral dislocation with a
probe.
In instability situation (Walch classification), is necessary LHB tenotomy or tenodesis, in order to improve
the visualization of the subscapularis and to protect its
suture.
In frying situations (partial tear) we do a simple debridement of the tendon top edge and lesser tuberosity in
the footprint area; in the case of superior one-third tear,
its repair through a double suture anchor in the bicipital
groove is performed. (Figure 1) Sometimes a triple suture anchor can be used to realize
both subscapularis repair and LHB tenodesis.9
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Vol. 125 - 1-2 Novembre 2014
Figure 1: Arthroscopic surgical repair of subscapularis tendon superior one-third. Once the tenotomy of
the biceps has been done, the visualization for subscapularis repair is greatly improved (A). Using traction
sutures to pull the subscapularis as far laterally as possible (B), the tendon is fixed on the lesser tuberosity.
Figure 2: Open subscapularis repair with synthetic augmentation. The biceps tendon is found medially
subluxed out of its groove with subscapularis complete ruptures (A). The subscapularis is fixed on the lesser
tuberosity using simple transosseous sutures (B, C) and then reinforced with a synthetic augmentation (D)
STAGE III 10, 11 (PIC. 2)
In this situation it is essential to evaluate the tendon quality and muscle trophism at the pre-operative exams (usually MRI). In situations of good tendon and muscle quality, with preserved thickness and trophism, we prefer to
perform an arthroscopic approach, always in the beach
chair position. Always evaluate and eventually treat LHB
tendon pathology. In the upper two thirds tears is crucial evaluate the possibility of a proper reduction of the
tendon to avoid any tensions; in this case it may be necessary its release with detachment of LGOM from the
subscapularis deep surface, and remove any adhesions
with the conjoined tendon superficially. In this case, it
is recommended to pay special attention medial to the
conjoined tendon, for the presence of the circumflex and
musculo-cutaneous nerve, axillary artery and the cords of
the brachial plexus.
The repair is carried out, generally, using 2 double suture
anchors. First one with “U” stitches to fix the lower part
of the tendon, and the second one, always in correspondence of the bicipital groove for its upper third. In the
case the MRI showing a poor quality tendon or muscle
we prefer an approach in open surgery (deltoid-pectoral),
always in the beach chair position, in order to perform
a best release of the tendon and a fixation with multiple
trans-osseous stitches, using synthetic augmentation, to
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Vol. 125 - 1-2 Novembre 2014
increase the tightness of the suture in a poor tissue. In a
poor and atrophic muscle, at the end of the subscapularis
repair, we perform pectoralis minor transfer sec. Wirth as
a biological augmentation 12.
STAGE IV 10,11
In the case of the full subscapularis tendon tear (all thickness and all length) our choice is always directed towards
an open deltoid-pectoral approach. The surgical technique
is the same described in stage III, with multiple trans-osseous stitches and synthetical augmentation (Figure 2) or
pectoralis minor transfer. At this stage it’s not always possible direct repair, especially in advanced tendon retraction
(over the glenoid). The open surgery technique permits
more chance of mobilization and release of muscle-tendon
complex and, in a case of failure, allows us to perform
pectoralis major transfer, to supply the lack of the subscapularis tendon, reducing the progressive anterior displacement of the humeral head, and its arthropathy.
STAGE V 10,11,12 (PIC. 3)
These lesion are generally old, previously unrecognized,
with important tendon retraction and fatty infiltration of
Figure 3: Subscapularis Reconstruction with Pectoralis Major Transfer over (Gerber technique, A)
or under (Resch technique, B) the conjoined tendon.
muscle. These are non-repairable lesions and our choice
is directed to the palliative treatment of pectoralis major transfer in an attempt to reduce the inevitable and
progressive anterior humeral head displacement and arthropathy, improve active intrarotation and strength. Surgery is performed in beach chair position (30 ° of back
flexion), with general anesthesia and interscale brachial
plexus block. Using a delto-pectoral approach we detach
the 2/3 of pectoralis major sternal part from the humerus.
The transfer to the less tuberosity can be performed in
according to the Gerber technique13, above the conjoint
tendon or (author favorite), as in Resch technique14, under the conjoint tendon after isolation and protection of
the musculocutaneous nerve (Figure 3).
In way you can create a pulley effect that permits (especially in male) to reach strength values slightly higher.
The humeral fixation is obtained using trans-osseous
stitches or charging high resistence wires used to prepare
the tendon, in one or more impact anchors. The treatment
algorithm just described, required a correct “timing” in
diagnostic and surgical path. After the literature and our
daily evaluation, the subscapularis tendon should always
be repaired in a short time, especially in young patients
with traumatic injuries. This problem is an urgent surgery
situation, because the fast retraction of the tendon can
lead to a not raparable tear. In this case is necessary, in
young and adult patients, a tendon transfer to supply the
subscapularis actions.
REFERENCES
1) C.Gerber, R.J.Krushel Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg
Br 1991; 73:389-394
2) Bennett WF Subscapularis, Medial, and Lateral Head Cora-
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cohumeral. Ligament Insertion Anatomy: Arthroscopic Appearance and Incidence of “Hidden” Rotator Interval Lesions. Arthroscopy 2001; 17: 173–180
3) Walch G, Nove-Josserand L, Levigne C, Renaud E. Complete
ruptures of the supraspinatus tendon associated with “hidden
lesions” of the rotator interval. J Shoulder Elbow Surg 1994;
3:353-360
4) Lo IK, Burkhart SS The Etiology and Assessment of Subscapularis
Tendon Tears: A Case for Subcoracoid Impingement, the RollerWringer Effect, and TUFF Lesions of the Subscapularis. Arthroscopy 2003; 19:1142-1150
5) L. Lafosse, B. Jost, Y.Reiland et al. Subscapularis Tear Classification. J Bone Joint Surg Am. 2007; 89:1184-1193
6)Adams CR, Schoolfield JD, Burkhart SS The Results of Arthroscopic Subscapularis Tendon Repairs. Arthroscopy 2008;
24:1381-1389
7) Burkhart SS, Brady PC Technical Note. Arthroscopic Subscapularis Repair: Surgical Tips and Pearls A to Z. Arthroscopy 2006;
22:1014-1027
8) Lafosse L, Jost B, Reiland Y et al. Structural Integrity and Clinical
Outcomes after Arthroscopic Repair of Isolated Subscapularis
Tears. J Bone Joint Surg Am 2007; 89:1184-93
9) Walch G, Nové-Josserand L, Boileau P, Levigne C Subluxation
and dislocation of the tendon of the long head of the biceps.
1998; 7:100-108
10) Sewick A, Kelly JD, Leggin B Subscapularis Tears: Diagnosis and
Treatment. University Of Pennsylvania Orthopaedic Journal.
2011; 21:25-30
11)Edwards TB, Walch G, Sirveaux F et al. Repair of Tears of the
Subscapularis. J Bone Joint Surg Am 2006; 88:1-10
12) Wirth MA, Rockwood CA Operative treatment of irreparable
rupture of the subscapularis. J Bone Joint Surg Am. 1997;
79:722-31
13) Jost B, Puskas GJ, Lustenberger A, Gerber C Outcome of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis
Tears. J Bone Joint Surg Am. 2003; 85:1944-51
14) Resch H, Povacz P, Ritter E, Matschi W Transfer of the Pectoralis
Major Muscle for the Treatment of Irreparable Rupture of the
Subscapularis Tendon J Bone Joint Surg Am 2000; 82:372-382
TOPICS
LESIONI TRAUMATICHE E
POST-TRAUMATICHE
DEL POLSO E DELL’AVAMBRACCIO
ALL AROUND THE WRIST AND FOREARM
Convegno Internazionale
Wrist trauma ‹
TRAUMI DEL POLSO
Forearm fractures ‹
FRATTURE DELL'AVAMBRACCIO
Interosseous membrane ‹
LA MEMBRANA INTEROSSEA
LA RADIOULNARE PROSSIMALE
Proximal radio-ulnar joint ‹
Distal radio-ulnar joint ‹
LA RADIOULNARE DISTALE
ARTROSCOPIA
Arthroscopy ‹
OSTEOSINTESI
Internal fixation ‹
Arthroplasty ‹
PROTESICA
SEGRETERIA SCIENTIFICA
U. Dacatra
S. Odella
P. Del Bò
Presidenti Onorari
Bruno Marelli
Giuseppe V. Mineo
Presidenti
Jane Messina
Virgilio Pedrini
SEGRETERIA ORGANIZZATIVA
!"#$%&'(")*+,!"#$%&'&(")&$*#+)"+"$,$-$./0.1$*"2#+&$-$34#25
672$/.89:0..90,$;#<$/.89:0.:=>0$
7-?#"2@$"+A&BC75D&E'7FE&G#H)&?
!!!"#$%!&'($)'&*+",&-
PRIMO ANNUNCIO
Aula Magna - Istituto Ortopedico Gaetano Pini
Milano, 17 ottobre 2015
Provider ECM 472
Sistema UNI EN ISO
9001 SC 10-2679EA 37
Abbiamo scelto di utilizzare
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47
Vol. 125 - 1-2 Novembre 2014
Painful shoulder: the Rheumatologist’s
point of view
Luigi Sinigaglia, Francesca Zucchi, Massimo Varenna
Division of Rheumatology DH, Gaetano Pini Orthopedic Institute, Milan
Inflammatory arthritides affecting
the shoulder
Introduction
Shoulder pain is one of the most common musculoskeletal complaints and may arise from diverse causes. Accurate diagnosis of
shoulder pain is made difficult by the unique anatomy and position of the shoulder, which serves as a link between the upper extremity and the thorax. A variety of Rheumatological conditions
can affect the shoulder and when examining the patient , a preliminary approach includes topography of pain, mono or bilateral
localization, circumstances of occurrence of pain ( inflammatory
or mechanical pain), existence of accompanying pain related to
other structures of the musculoskeletal system and the presence of
constitutional signs and symptoms which can drive the clinician
to a definitive diagnosis. Such a preliminary approach can help
the clinician in the differential diagnosis of shoulder pain which
includes not only common local disorders but also consideration of etiologies arising from distant anatomic sites by referred
pain-mediated pathways. Furtherly, systemic arthropathies can
occasionally present with shoulder disease and often involve the
shoulder over time. Early assessment in these patients is essential
in order to reach a definitive and correct diagnosis, thus avoiding waste of time and therapeutic unfinalized efforts. This paper
provides a practical overview of painful shoulder disorders that
may be encountered in a rheumatology or general practice. The
majority of these clinical entities are as well commonly encountered by the Orthopedic, suggesting that a combined approach,
when directed by a high level of suspicion, can be the best way to
diagnose ad treat the patient.
Rheumatoid Arthritis (RA) of the shoulder not only affects synovium within the gleno-humeral joint but also
involves the distal third of the clavicle and various bursae and rotator cuff. Usually shoulder involvement is seen
preferably in the most severe forms of the disease. Pain in
the shoulder(s) is a common onset in elderly patients with
RA. Severe shoulder pain is often bilateral and can lead to
sleep disorders because of difficulty to find a comfortable
position. In a series of 200 consecutive patients with RA
studied by arthrography, 21% had rotator cuff tears and an
additional 24% had evidence of frayed tendons 1. The most
likely mechanism leading to rotator cuff tears is that tendon insertion is vulnerable to erosion by the proliferative
synovitis. Marked soft tissue swelling of the anterolateral
aspect of the shoulders commonly accompanying RA may
be caused by chronic subacromial bursitis rather than by
glenohumeral joint effusions. Synovial proliferation of the
subdeltoid bursa might explain the resorption of the distal
end of the clavicle. Rarely the shoulder joint may rupture,
with symptoms resembling those of obstruction of venous
return from the arm.
A true gleno-humeral involvement in Psoriatic Arthritis
(PsA) is rare. PsA should be suspected in a patient with
an asymmetric joint involvement who may have additional
clinical features such as dactylitis, enthesitis or inflammatory type back pain and who is negative for rheumatoid
factor. Since PsA presents a prominent entheseal involvement, rotator cuff enthesitis can be a manifestation of the
disease.
The girdle or “root” joints (hips and shoulders) are the
most frequently involved extra-axial joints in Ankylosing
Spondylitis (AS), and pain in these areas is the presenting symptom in up to 15% of patients. Shoulder involvement may cause considerable physical disability. Hips and
shoulders are involved in the course of the disease in up to
35% of patients. In these patients coexisting inflammatory
back pain is the usual clue to the early diagnosis of AS or
of axial spondyloarthritis.
except in elderly women. ��
It is the joint site with the oldest age of onset in OA. Apart from age and sex there are
no obvious associations, except with the link with rotator
cuff damage which is also very common in the elderly.
Most OA of the shoulder presents with pain on movement
and a restricted range of motion, especially external rotation and elevation. The radiograph shows evidence of OA,
with joint space narrowing, subchondral sclerosis, cysts in
the glenoid and often large inferior osteophytes on the
glenoid.
Osteoarthritis
Septic arthritis
The shoulder is a common source of pain in patients with
Osteoarthritis (OA), although the symptoms are more often
due to osteophytosis and narrowing of the acromioclavicular and/or sternoclavicular joints than the glenohumeral
joint itself. Primary OA of the shoulder joint is uncommon,
Septic arthritis of the shoulder can mimic any of the conditions affecting gleno-humeral joint. Sepsis must be included in any differential diagnosis of shoulder pain because
early recognition and prompt treatment are mandatory to
achieve a good functional result. The diagnosis is con-
firmed by joint aspiration with synovial fluid analysis and
culture. Cultures should include aerobic, anaerobic, mycobacterial and fungal studies.
Milwaukee shoulder syndrome
Milwauke shoulder syndrome was first described by Robert Adams in 1857, subsequently well defined and called
“chronic rheumatic arthritis of the shoulder”2 and later on
also named l’épaule sénile hémorragique 3, cuff-tear arthropaty 4, idiopathic destructive arthritis 5, apatite associated destructive arthritis 6, arthropatie destructrice rapide
de l’épaule 7. It is a destructive shoulder arthropathy associated with deposition of basic calcium phosphate (BCP)
crystals, characterized by the presence of large amount of
synovial fluid and a complete rotator cuff tear. It is predominantly found in elderly women and is bilateral in more
than 50% of cases 8, predominantly affecting the dominant
side. Some predisposing factors have been demonstrated,
as high energy trauma or recurrent microtrauma, recurrent
sub-luxations, concurrent calcium pyrophosphate dehydrate (CPPD) crystal deposition, neurological diseases
(syringomyelia, cervical root compression) or renal failure
with hemodialysis 9-12, but a lot of cases are idiopathic. The
incidence in the general population is not known as well as
the pathogenesis. Some Authors speculated that BCP crystals are phagocytosed by synovial lining cells stimulating
them to produce metalloproteinase (MMP), and also causing them to proliferate, which contribute to progressive
joint damage 13. In vitro studies have shown that calciumcontaining crystals contribute to mitogenic and inflammatory responses in various cell types 14. BCP and CPPD
crystals can also stimulate fibroblast to produce various
MMP; matrix metalloproteinase-8 has now been identified
as another enzymatic product of fibroblast stimulation by
calcium-containing crystals 15.
The patient generally refers moderate shoulder pain lasting
several months or years, but in some cases the pain may
be acute and rapidly progressive, usually most apparent at
night and on joint use with functional impairment. Characteristically, large joint effusion is present extending into
the subdeltoid region and the synovial fluid is frequently
blood tinged, containing low, predominantly monuclear,
cells count. Rupture of the effusion can lead to a massive
extravasation of blood and synovial fluid into the surrounding tissue. The extensive destruction of periarticular tissue, including the rotator cuff, leads to instability of
the shoulder. Although the shoulder predominates, knees,
hips, elbows and other joints may be involved 6, 16.
Generally, the plain radiograph findings can be sufficient
for the diagnosis, showing upward subluxation of the
homerus, causing subcromial impingement that in time can
erode the anterior portion of the acromion and the acromion-clavicular joint. Other findings may include cystic degeneration of the humeral tuberosities, erosion of cortical
bone at the side of insertion of rotator cuff, degenerative
changes of the humeral head and/or glenoid of the scapula,
degenerative changes of the acromion-clavicular joint and
calcifications of the tendineous rotator cuff. Eventually the
soft, atrophic homerus head can collapse and an extensive
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Vol. 125 - 1-2 Novembre 2014
atrophic destruction and loss of bone of both the acromion
and the glenohumeral joint can be recognized 4,17.
Further imaging tools as ultrasound and MRI can provide
more information about cartilage damage, bone marrow
edema, synovial hypertrophy, joint effusion, calcifications,
tendineous and soft tissue damage 18.
The natural history of this condition has not a standard feature, but many cases seem to stabilize after a year or two,
with reduction of symptoms, joint effusions and no further
radiographic changes. No specific therapies are nowadays
available 19 and the treatment of symptomatic phase is generally unsatisfactory. A conservative approach, including
analgesics and NSAIDs, repeated shoulder aspirations followed by injection of methylprednisolone acetate 20 can be
sometimes useful. As pain subsides, functional rehabilitation must be started. Anatomic damage of the joint needs
an orthopedic evaluation for surgical approach.
Osteonecrosis
Osteonecrosis of the humeral head is seen in association
with a variety of conditions. Apart from traumatic causes,
the commonest condition leading to this complication is
steroid therapy provided in conjunction with organ transplantation, systemic lupus erythematosus, systemic vasculitides, miscellaneous steroid-sensitive diseases or asthma.
Other conditions associated with necrosis of the humeral
head include hemoglobinopathies, pacreatitis, hyperbarism or alcohol abuse. Symptoms arise from synovitis and
joint incongruity resulting from resorption, repair and remodeling. Early diagnosis is difficult because the presence
of symptoms is often delayed. Magnetic Resonance Imaging is highly sensitive and more specific than scintigraphy.
Plain radiographs show progressive phases of necrosis
and repair. In early stages the x-ray may be normal or may
show osteopenia or bone sclerosis. A crescent sign representing subchondral fracture ( Fig. 1) or demarcation of
the necrotic segment appears during the reparative process.
Patients who fail to remodel show collapse of the humeral
Figure 1:
Osteonecrosis of the humeral head
(Crescent sign)
head with secondary degenerative changes. A considerable
discrepancy is usually noted between symptoms and radiographic involvement.
Polymialgia Rheumatica
Polymialgia Rheumatica (PMR) is a syndrome of unknown etiology characterized by aching in the proximal
portions of the extremities, often involving the neck and
girdles. There are no specific diagnostic tests or pathologic findings, so that the syndrome is defined on a clinical
ground. PMR is relatively frequent with an average annual
incidence rate of 52.5 cases per 100.000 persons aged 50
years or older 21. The prevalence of PMR (active plus remitted cases) is approximately 600 per 100.000 persons
aged 50 years and older. The features included in most
definitions of PMR are as follows: (1) aching and morning stiffness lasting half an hour or longer in the shoulders,
hip girdle, neck or some combination; (2) duration of these
symptoms for 1 month or longer; (3) age older than 50
years; (4) laboratory evidence of systemic inflammation
with increase in acute phase reactants; (5) rapid response
to small doses of glucocorticoids such as prednisone 10 mg
per day. Nearly half of the patients have systemic manifestations such as malaise, low-grade fever and weight loss at
disease onset. Pain may develop abruptly or evolve insidiously over weeks or months. In most patients the shoulder
girdle is the first to become symptomatic. The discomfort
may arise in one shoulder or hip but usually becomes bilateral within weeks. Symptoms are located at proximal
limbs, axial musculature and tendon attachments. Morning
stiffness resembling that of RA and “gelling” after inactivity are usually prominent. Distal joint pain and swelling occur only in some cases. Pain at night is extremely
common and movement during sleep usually awakens the
patient. Muscle strength is generally unaffected. Pathogenesis include bursal inflammation and synovitis. Diagnostic
and classification criteria for PMR have been proposed in
1982 22, reviewed in 1984 23 and recently redeveloped to
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Vol. 125 - 1-2 Novembre 2014
incorporate informations provided by ultrasound evaluation 24 (Table 1). Diagnostic criteria underscore that the diagnosis of PMR is clinical and depends on eliciting symptoms. Distinguishing PMR from early RA with proximal
joints onset can be difficult especially in patients who are
rheumatoid factor negative and in those who have not yet
developed prominent synovitis of the small joints of the
hands and feet. Furtherly, distal joint pain and swelling occur in some cases of PMR including diffuse distal extremity swelling with pitting edema. Patients with polymiositis
complain much more of weakness than pain. Although
patients with neoplasms may have generalized musculoskeletal aching, there is no association between PMR and
malignancy. Therefore a search for an underlying tumor
is not necessary except in cases of “atypical PMR” and
poor response to low-dose prednisone. This therapeutic
approach is usually sufficient to control pain and leads
to normalization of laboratory tests. Usually prednisone
must be tapered slowly, according to acute phase reactants
and a full drug-free recovery is achievable in 9-12 months.
Flares are common, and are seen in 30% of cases necessitating dose increase to achieve remission. Some, but not
all, studies suggest that oral Methotrexate can reduce the
long-term need for corticosteroids.
A large body of evidences support the idea that PMR is
related to Giant Cell Arteritis (GCA). Since these patients
are considered at high risk for vascular complications such
as vision loss or ischemic events including irreversible
blindness, stroke or large artery disease, a high index of
suspicion must be kept in mind since early treatment of
this disease can prevent these dramatic complications. Between 30 and 50% of patients with GCA develop PMR
and approximately 10 to 15 % of patients with PMR have
positive temporal artery biopsies. For these reasons a temporal artery biopsy is strongly recommended in the presence of accompanying symptoms such as headache, jaw
claudication, visual symptoms or high fever. Color duplex
ultrasonography can be of aid in these situations, showing
abnormalities of the temporal artery with a sensitivity of
93%. Glucocorticoid therapy must be commenced as soon
Table 1. PMR classification criteria scoring algorithm. Pre-required criteria: age ≥50
years, bilateral shoulder aching and abnormal CRP and/or ESR 24
Points without
US (0-6)
Points with
US (0-8)*
Morning stiffness duration >45 minutes
2
2
Hip pain or limited range of motion
1
1
Absence of RF or ACPA
2
2
Absence of other joint involvement
1
1
At least 1 shoulder with subdeltoid bursitis and/or biceps tenosynovitis and/or glenohumeral synovitis (either posterior or axillary) and at least 1 hip with synovitis and/
or trochanteric bursitis
NA
1
Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis
NA
1
A score of 4 or more is categorized as Polymyalgia Rheumatica (PMR) in the algorithm without ultrasound (US) and a score of
5 or more is categorized as PMR in the algorithm with US. CRP = C-reactive protein; ESR = erytrocyte sedimentation rate; RF
= Rheumatoid Factor; ACPA = anti-cytrullinated protein antibody; NA = not applicable
*optional US cyteria
as the diagnosis of GCA is strongly suspected with prednisone doses between 40 and 60 mg/day in order to prevent
loss of vision.
Neuralgic Amyotrophy
(Parsonage-Turner syndrome)
Neuralgic Amyotrophy (NA) was first clinically defined
by Parsonage and Turner in 1948 25 and is typically characterized by attacks of neuropathic pain and subsequent
patchy paresis in the upper extremity. The reported incidence is 2-3 per 100,000 individuals per year in the general population but the true annual incidence, considering
underdiagnosis and misdiagnosis, seems to be 20 to 30
cases per 100.000 26,27,28; the highest incidence is between
the third and seventh decades of life and male are predominantly affected 26,29. The cause of NA is still unknown but
the available evidences suggest that neuralgic amyotrophy
has a complex pathophysiology that includes an underlying predisposition, a susceptibility to dysfunction of some
peripheral nerve structures, and an autoimmune trigger for
attack 30. Available literature suggests that possible triggers
include viral infections, immunization, and the perioperative and peripartum periods as well as a previous period
of strenuous exercise 26, 31. The few histological studies
have demonstrated evidence of an autoimmune etiology,
with mononuclear inflammatory infiltrates in the brachial
plexus biopsies 32,33 or increase in complement-fixing antibodies to peripheral nerve myelin in the acute phase of
the disease 34.
NA occurs in both idiopathic and hereditary forms; the
second one, ten times less common than the first one, is
an autosomal dominant monogenic disorder with high but
incomplete penetrance, caused by mutation in the gene
septin 9 on chromosome 17q23 35,36.
In most cases patients affected by NA present acute, severe
shoulder pain that radiates to the arm or neck and lasts for
several hours to weeks; the pain frequently can awaken
patients from sleep and may be exacerbated by shoulder
and elbow motion. As the pain subsides, a flaccid paralysis
with muscle weakness, muscle atrophy, and sensory loss
of shoulder girdle and arm develops, with a characteristic patchy distribution. The most common sites of sensory
loss are over the deltoid, the lateral aspect of upper arm,
and the radial aspect of the forearm. Bilateral brachial
plexus involvement occurs in 10 to 30% of cases, although
symptoms are usually asymmetric 25,37-39. In about 17% of
sporadic NA and 56% of hereditary NA, involvement of
nerves outside brachial plexus can occur, most commonly
the lumbosacral plexus, phrenic nerve and/or recurrent laryngeal nerve and occasionally the facial, hypoglossus or
intercostal nerves 26,31. In approximately 15% of patients
signs of involvement of the peripheral autonomic nervous
system were documented, such as vegetative and trophyc
skin changes, edema in the involved extremity at the onset
of the attack, temperature dysregulation, increased sweating, and changes in nail growth 31.
At the beginning, clinical presentation of NA is not specific; the differential diagnosis must include not only neurologic and orthopaedic condition, but also thorax diseases.
50
Vol. 125 - 1-2 Novembre 2014
Despite of a complete clinical examination, no currently
available tests can unequivocally confirm or exclude the
diagnosis of NA. MRI can demonstrate edema involving one or more muscles innervated by brachial plexus in
early phase of the disease, and signal suggesting atrophy
with fatty infiltration in one ore more muscle groups of the
shoulder in the late phase 38,40. EMG examination can be
abnormal and suggesting NA revealing acute denervation
(with positive sharp waves and fibrillation potential) 3 to
4 weeks after the onset of the disease, present in both a
peripheral nervs and nerve root distribution 37; an EMG
performed 3 to 4 months after the onset of initial symptoms may show chronic denervation and early reinnervation with polyphasic motor unit potentials 26,37.
No specific treatment is nowadays available; early corticosteroids therapy may have a positive effect on pain in
some patient as well as opioid in combination with longacting NSAIDS 36 . The patient should be encouraged to
use the affected limb as fully as possible. The disease can
last 2-3 years before symptoms and impairment fully disappear.
Shoulder-hand syndrome
Complex regional pain syndrome type I (CRPS-I), formerly known as reflex sympathetic dystrophy, is a severely disabling pain syndrome characterized by sensory
and vasomotor disturbance, edema and functional impairment 41 that in most cases developed following a trauma or
surgery42. The pathogenesis is still unknown and no specific test is currently available for the diagnosis. Recently
updated Budapest Criteria are widely accepted to make
a clinical diagnosis 43, 44 (Table 2). In 1947 Steinbrocker
first described the shoulder-hand syndrome 45, a CRPS-I
involving the shoulder and the hand. The clinical course
was historically described as divided in three main stages,
according to the clinical manifestations: stage 1, lasting
3-6 weeks to 6 months, with painful shoulder, swelling,
pain and stiffness in the hand; stage 2, lasting from 3 to
6 months, with gradual lessening of shoulder pain and
resolution of the swelling at the hand with increasingly
stiff with flexion deformity of the fingers and atrophy of
subcutaneous tissue and thickening of the palmar fascia;
stage 3, that may last many months, characterized by a
smooth, glossy skin with trophic changes and atrophy with
thickened palmar fascia and Dupuytren-like contracture.
The main predisposing factor to hand-shoulder syndrome
is stroke (12.5%-27%) 46 but also other conditions are recognized (myocardial infarction, thoracic disease, injury
as glenohomeral subluxation, Herpes Zoster infection)
45
. The relationship with shoulder-hand syndrome and
the assumption of Phenobarbital is historically important.
Pathology, patient’s age, prior motor deficit, and duration
from onset of stroke may affect the appearance of this syndrome. Diagnosis of CRPS in stroke patients is more difficult than in other diseases since the paretic upper limb
is frequently painful, edematosus, with altered heat and
tactile sensitivity and slight dystrophic skin secondary to
non-use syndrome.
Conventional radiology may reveal the classic patchy os-
51
Vol. 125 - 1-2 Novembre 2014
Table 2. Proposed clinical diagnostic criteria for CRPS type I
To make the clinical diagnosis, the following criteria must be met:
1. Continuing pain, which is disproportionate to any inciting event
2. Must report at least one symptom in three of the following categories:
Sensory: Reports of hyperesthesia and/or allodynia
Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or
trophic changes (hair, nail, skin)
3. Must display at least one sign at time of evaluation in two or more of the following categories:
Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or
deep somatic pressure and/or joint movement)
Vasomotor: Evidence of temperature asymmetry (>1°C) and/or skin color changes and/or asymmetry
Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/
or trophic changes (hair, nail, skin)
4. There is no other diagnosis that better explains the signs and symptoms
teoporosis at the shoulder and/or at the hand that may appear generally within 4-8 weeks or later, after the onset
of the disease, a feature present in only 40% of patients.
Three-phase scintigraphy with technetium has been reported to have high sensivity but low specificity. At MRI
bone marrow edema is the most frequent finding, with soft
tissue anomalies and skin thickening, subcutaneous edema
and muscular atrophy.
Several therapeutic approaches have been employed in
CRPS-1 with different results but recent studies provide
conclusive evidence that the use of i.v. bisphosphonate is
the treatment of choice 47. A well-planned physiotherapy
program after stroke can help to prevent the late complications of the disease 48.
Miscellaneous conditions affecting
the shoulder
In the increasing group of patients undergoing chronic hemodyalisis, a shoulder pain syndrome known as Dyalisis
Shoulder Arthropathy (DSA) has been described. It is
characterized by shlouder pain, weakness, loss of motion
and functional limitation. The pathogenesis of this condition is not fully elucidated although rotator cuff disease,
pathologic fracture, bursitis and local amyloid deposition
have been implicated as causative factors. Patients generally respond poorly to local steroid injections or NSAIDs,
but their condition may improve with the correction of underlying metabolic disorders such as ostemalacia or secondary hyperparathyroidism.
Primary neoplasms can cause shoulder pain by direct invasion of the musculoskeletal system or by compression with
referred pain. Primary tumors are more likely to occur in
younger individuals. More common lesions have a typical distribution such as the predilection of a chondroblastoma for the proximal humeral epiphysis or an osteogenic
sarcoma for the metaphysis. Neoplasms also may involve
the shoulder through metastases to the region. Pancoast tu-
mor may manifest as shoulder pain or cervical radiculitis
caused by invasion of the brachial plexus or invasion of
the last cervical roots.
Cervical pathology may manifest with associated shoulder pain. The area of referred pain has a dermatomal pattern, consistent with the distribution of dermatomal nerve
roots. Because conditions causing cervical neck pain and
conditions causing shoulder pain may coexist it is often
difficult to distinguish which lesion is responsible for the
symptoms.
The thoracic outlet syndromes often manifest as a vague
shoulder pain and deserve a deep clinical evaluation.
Finally, from a clinical standpoint, it must be remembered
that shouder pain may be unrelated to musculoskeletal diseases and can be a manifestation of referred pain linked
to a variety of visceral causes. The main gastrointestinal
diseases causing shoulder pain are gallstone disease, liver
cancer or abscess and splenic breakage. In all of these cases
pain referral depends on the innervation of the diaphragm.
Furtherly, the most common cardiological causes of shoulder pain are related to myiocardial ischaemia, pericarditis,
aortic dissection and pulmonary embolism. These conditions underscore the value of a full-blown clinical evaluation of the patient with shoulder pain which represent a
true critical challenge in clinical practice.
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Platelet Rich Plasma in Arthroscopic Rotator Cuff
Repair: State of the Art
Pietro Randelli, Vincenza Ragone, Alessandra Menon, Riccardo D’Ambrosi,
Filippo Randelli, Paolo Cabitza
Dipartimento di Scienze Medico-Chirurgiche, Università degli Studi di Milano;
IRCCS, Policlinico San Donato, Milano
Clinical evidence
Surgical use of PRP in arthroscopic rotator
cuff repair
The rotator cuff literature has shown that PRP can be applied by either direct injection or physical application of
a PRP matrix scaffold to repaired tissues. The main characteristics of clinical studies analyzed in this paper are
reported in Table 1.
Randelli and colleagues6 demonstrated in a pilot study
of 14 patients who underwent arthroscopic repair of the
rotator cuff, that the use of PRP in combination with autologous thrombin, injected locally in the surgical repair
is a safe procedure and effective, no side effects.
Later the same authors published7 the results of a randomized controlled trial on the effectiveness of the use
of PRP in the intraoperative arthroscopic repair of rotator
cuff injuries. The pain in the treatment group was significantly lower compared to the control group at 3, 7, 14 and
30 days after surgery. The clinical scores were significantly better in the treatment group compared to the control group at 3 months after surgery. There was no difference between the two groups after 6, 12 and 24 months.
The MRI performed 12 months after surgery showed no
significant difference in the rate of re-injury of rotator
cuff (treatment group: 40%, control group: 52%).
Ruiz-Moneo and colleagues8 using a different technology for the preparation of platelet concentrate, at clinical
evaluation did not observe any difference between the
group treated with the platelet preparation in the absence
of leukocytes (N = 32) and the control group (N = 31).
Patients of both groups were subjected to arthroscopic
repair of lesions with the difference that in patients randomized to the treatment group the plasma rich in growth
factors was injected at the site of repair. The healing of
the repair of the cuff occurred in 34% of cases in the
treatment group and in 25% of cases in the control group
(p > 0.05).
9
Antuna and colleagues have recently investigated whether the platelet-rich fibrin improves healing of arthroscopic repair of massive cuff lesions (> 50 mm). The authors
applied the fibrin rich in platelets at the site of repair of
the lesion in 14 patients and compared the clinical and
radiological results with a control group of 14 patients.
The clinical score and the rate of re-injury (71% in the
treatment group versus 64% in the control group) were
similar in the two groups at 24 months after surgery.
Introduction
Rotator cuff tendinopathies represent the vast majority of shoulder injuries in adult patients and are a common contributing factor to shoulder pain and occupational disability, which prevalence
in the population is rising 1.
The use of platelet-rich plasma (PRP) as a biological solution to
improve rotator cuff tendon healing has gained popularity over
the last several years.
Platelet rich plasma (PRP) is a whole blood fraction containing
high platelet concentrations that, once activated, provides a release of various growth factors that participate in tissue repair
processes: transforming growth factor beta (TGF-b), fibroblast
growth factor (FGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), connective tissue growth
factors, and epidermal growth factor (EGF) 2.
Platelets also have dense granules that contain a variety of important bioactive molecules. These proteins function in an autocrine
or paracrine fashion to modulate cell signaling and chemotaxis
promoting tendon healing 3.
There are clear differences in PRP formulations in terms of growth
factor concentration and catabolic enzyme content4. A PRP classification system exists which is based on the presence or absence
of white blood cells and whether the PRP is used in an activated
or unactivated form. PRP may be prepared via centrifugation
as a pure platelet concentrate suspended in plasma (leukocytepoor PRP) or as a mixture with white blood cells (leukocyte-rich
PRP)5. Platelets can be activated ex-vivo with thrombin and/or
calcium. Use of PRP in an unactivated manner, without thrombin
or calcium relies on in-vivo activation via endogenous collagen.
This paper discuss and explores the available evidence to determine the efficacy of the PRP in treatment of rotator cuff injuries. Emphasis will be placed on published, peer review data
investigating the role of this biologic tool in rotator cuff tendon
healing.
Gumina and colleagues10 have more recently evaluated
the clinical results obtained from the magnetic resonance
of the arthroscopic repair of rotator cuff with and without
the use of a membrane enriched of platelets and leukocytes in patients with a large posterior-superior cuff tear.
Eighty consecutive patients were randomized to treatment with membrane-enriched leukocytes and platelets
(PRP group: 40 patients) or without (control group: 40
patients) inserted between the tendons of the rotator cuff
and its insertion. At a follow-up post-operative mean of
54
Vol. 125 - 1-2 Novembre 2014
Authors
Evidence
PRP formulation
Surgical technique
No. patients
Randelli et al.
(2011)
Level 1
Randomized controlled
Injectable PRP
(GPS system)
Single row
53
Ruiz-Moneo et
al. (2013)
Level 1
Injectable PRP
(PRGF Endoret System)
Double row
63
Antuna et al..
(2013)
Livello 2
Injectable PRP
(Vivostat system)
Single row
28
Gumina et al.
(2012)
Level 1
Suturable PRP
(RegenKit-THT system)
Single row
76
Jo et al.
(2011)
Livello 2
Prospective cohort
Suturable PRP
(COBE spectra system)
Transosseous equivalent
42
Jo et al.
(2013)
Level 1
Suturable PRP
(COBE spectra system)
48
Zumstein et al.
(2014)
Level 1
Suturable PRP
(PRF Process)
20
Castricini et al.
(2010)
Level 1
Livello 2
Suturable PRP
(Cascade system)
Double row
88
Suturable PRP
(Cascade system)
Single OR Double row/
Transosseous-equivalent
67
Barber et al.
(2011)
Livello 3
Case control study
Suturable PRP
(Cascade system)
Single row
40
Bergeson et al
(2012)
Livello 3
Cohort study
Suturable PRP
(Cascade system)
Single OR Double row
37
Weber et al.
(2013)
Level 1
Suturable PRP
(Cascade system)
Single row
60
Rodeo et al.
(2012)
Table 1: Studies investigating the use of PRP in arthroscopic rotator cuff repair.
13 months, were observed re-cuff lesions only in the control group.
A prospective level II cohort study11 has shown that PRP
application during arthroscopic rotator cuff repair did not
accelerate recovery with respect to pain, range of motion,
strength, functional scores, or overall satisfaction when
compared with controls at any follow- up time point. The
investigators did, however, note a reduced retear rate in
the PRP group compared with the control group, but this
difference did not reach statistical significance. The same
authors12 have recently published the results of a randomized controlled trial on the use of 3 platelet rich fibrin
clots in the arthroscopic repair of massive cuff lesions
(lesion size:> 30 mm). The rate of re-injury was 20%
(4/20) in the group treated with PRP and 55.6% (10/18)
in the control group (p=0.02).
Recently Zumstein et al.13 hypothesized that arthroscopic
rotator cuff repairs using leukocyte- and platelet-rich
fibrin (L-PRF) results in a higher vascularization response and watertight healing rate during early healing.
They have treated 20 patients, 10 with arthroscopy plus
L-PRF and 10 only with arthroscopy. Clinical examinations including visual analogic scale (VAS), Constant,
and Simple Shoulder Test scores and measurement of
the vascularization with power Doppler ultrasonography
were made at 6 and 12 weeks. The study concludes that
arthroscopic rotator cuff repair with the application of LPRF is technically feasible and yields higher early vascularization. Increased vascularization may potentially
predispose to an increased and earlier cellular response
and an increased healing rate.
Several authors used the Cascade Autologous Platelet
System (Cascade Medical Enterprises, Wayne, NJ) to
create a platelet rich plasma from autologous blood.
Castricini and colleagues14 conducted a study in prospective randomized controlled double-blind trial of 88 patients who underwent arthroscopic repair of the rotator
cuff with the addition of platelet-rich fibrin matrix autologous (43 patients) and without (45 patients). The autologous fibrin membrane was integrated into the suture
and placed at the interface between the tendon and the
greater tuberosity under continuous arthroscopic lavage.
For an evaluation of 16 months follow-up, there was no
statistically significant difference in terms of Constant
and magnetic resonance imaging. However, the rate of
re-injury resulted of 10.5% in the control group compared
to 2.5% in the treatment group with a trend curve which
approaches the significance. Arnoczky15 has re-evaluated
the data of magnetic resonance imaging in this work using the chi-square test for binomial and concluded that
PRP improved the results of cuff repair compared to control.
Using the same technology for the preparation of the fibrin matrix rich in platelets autologous Weber and colleagues16 have revealed no statistical difference in the
percentage of re-injury between the treatment group and
the control group (43% and 29%, respectively) after an
average of 3-5 months after surgery.
A randomized controlled study from Rodeo et al.17 supported the work of Castricini and questioned the early
healing benefits of PRP by showing no differences between repairs augmented with autologous fibrin membrane and the control group in terms of vascularity and
clinical outcomes. In addition, the authors found that 67%
of the repairs in the PRP group were intact compared with
81% of the repairs in the control group (p=0.2) which
suggests that autologous fibrin membrane may in fact be
detrimental to tendon healing in the rotator cuff.
In a case-control study performed by Barber and colleagues18 clinical outcomes were no difference between
the PRP-augmented arthroscopic rotator cuff repair group
and the control group. This study did find, interestingly,
that the observed incidence of retears on magnetic resonance imaging was significantly lower in the PRP group
than in the control repairs. Of note, a total of 3 and 2 PRP
fibrin gels were used in each study, respectively.
A similar cohort study performed by Bergeson and colleagues19 showed no improvement in terms of retear rates
or functional outcomes in the PRP-augmented repair
group compared with controls. Two platelet-rich fibrin
matrix (PRFM) clots were used to augment cuff repair
of 16 patients with rotator cuff tears at risk for retears
inserted into the repair site in this study.
The PRP group was compared to a historical control
group of 21 patients with similar at risk tears who underwent standard repair without PRP augmentation. Single or
double row techniques were performed at the discretion
of the surgeon in both the PRP and control group. Passive
range of motion was started at 4 to 6 weeks postoperatively. MRI studies at a minimum of one year follow-up
showed a significant difference in the re-tear rate in favor
of the control group (PRP group: 56%, Control group:
38%, p=0.024). The significant difference remained when
double row repairs were removed from the analysis (PRP
group: 62%, Control group: 40%, p=0.022).
PRP injections for rotator cuff tendinopathy
Rha and colleagues20 reported a study comparing PRP injection (Prosys PRP Platelet Concentration System) with
dry needling in patients with tendinosis or a partial tear
less than 1.0 cm, but not a complete tear. Two procedures
in both groups were applied at a 4-week interval. The injection of PRP was superior to dry needling with respect
to pain, function, and range of motion over a 6-month period. These findings suggest that treatment with plateletrich plasma injections is safe and useful for rotator cuff
disease.
55
Vol. 125 - 1-2 Novembre 2014
Kesikburun and colleagues21 investigated the effect of
PRP injections on pain and shoulder functions in patients
with chronic rotator cuff tendinopathy. Forty patients
were randomized to a PRP group (n = 20) or placebo
group (n = 20). Patients received an ultrasound-guided
injection into the subacromial space that contained either
5 mL of PRP prepared from autologous venous blood
(GPS system) in
��
an unactivated manner��
or 5 mL of saline solution. All patients underwent a 6-week standard
exercise program. Clinical outcomes were assessed at
baseline and at 3, 6, 12, and 24 weeks and 1 year after
injection. This study sustains a PRP injection is no more
effective in improving quality of life, pain, disability, and
shoulder range of motion than placebo in patients with
chronic rotator cuff tendinopathy.
Recently Scarpone and colleagues22 recruited from an
outpatient sports medicine clinic patients with rotator
cuff tendinopathy refractory to physical therapy and corticosteroid injection. They received one ultrasound-guided injection of 3.0 mL of 1% xylocaine followed by 3.5
mL of PRP at the lesion and surrounding tendon. The authors found that a single ultrasound-guided, intralesional
injection of PRP resulted in safe, significant, sustained
improvement of pain, function, and MRI outcomes.
Discussion
Surgical use of PRP in arthroscopic rotator
cuff repair
Clinical studies have produced conflicting results on the
effectiveness of the use of PRP in tendon repair of the
rotator cuff, making it now difficult to draw definitive
conclusions.
The clinical studies published to date have different experimental designs and with a level of evidence that varies from 1 to 3. Moreover 7 different systems of preparation of PRP were used between studies (Table 1). The
experimental protocol presents variations between different, as regards the volume of autologous blood, speed
and time of centrifugation, method of administration,
activating agent, the presence of leukocytes, the final
volume of PRP and final concentrations of platelets and
factors growth. The surgical technique (transosseous
equivalent, single or double row) and the rehabilitation
protocol (standard or rapid) were not the same among the
different studies.
Despite the differences in surgical techniques, in the
formulation of the PRP, the sizes of the lesions, the reinjury rate has been recalculated by combining the available data from studies in order to determine the potential
of the PRP to improve the healing of surgical repair of
the rotator cuff. The analysis of all 12 studies examined
showed that there was no significant difference in the rate
of re-rupture between the PRP and the control group. The
re-injury rate was 31% (90 of 292) and 36.6% (103 of
281), respectively (p-value > 0.05).
Three studies have identified small and medium tears
of rotator cuff such as those measuring less than 3 cm
in length11,14,18. Randelli and colleagues7 have classified
the lesions according to the amount of retraction. If the
lesion exposed the head of the humerus, but the tendon
retraction did not come to the surface of the glenoid, was
defined as a small or medium injury.
A significant difference was found when a stratified analysis was performed to analyze the results of small and
medium lesions of the rotator cuff. The rate of re-injury
was 7.9% among patients treated with PRP compared to
26.8% of those treated without PRP (p-value = 0.002,
Chi-square test).
It is important to emphasize that with the exception of
two cases of infection, has not been reported any complication from the use of PRP. Bergeson and colleagues19
showed an infection rate of 12% among patients treated
with fibrin matrix rich in platelets (Cascade Autologous
Platelet System) compared to 0% in the control group.
However, this difference did not reach statistical significance, and no difference in the rates of infection or complication rates was found in the remaining studies.
Although clinical studies have produced conflicting results, the data on PRP suggest a beneficial effect on the
healing process when applied during the repair of the rotator cuff.
The stratified analysis of small or medium lesions showed
a significant rate of re-injury overall lower in the group
PRP. Therefore currently it seems the PRP can improve
the healing of arthroscopic repair of small and medium
lesions that seem more prone to a biological response to
treatment with growth factors.
Namazi has recently highlighted the main mechanisms
by which PRP can reduce the rate of re-injury of the rotator cuff 23. The level of interleukin 1��
β��
(IL-1��
β��
) is correlated with the degeneration of the tendons of the cuff. In
contrast, TGF-β can improve the strength of the repair of
these tendons. Recent studies have shown that the PRP
can not only inhibit the inflammatory effects of IL-1β,
but also enhance the production of TGF-β24,25.
A recent in vitro studies on the effect of PRP on human
tenocytes from rotator cuff with degenerative lesions,
have shown that the growth factors released by platelets
may enhance cell proliferation of tenocytes and promote
the synthesis of extracellular matrix tendon26,27. Furthermore an in vivo animal study has shown than that the
type of application, injection or absorption from a sponge
did not influence the effect of PRP on rotator cuff healing28.
The PRP is certainly a source of bioactive growth factors,
however the optimal preparation, activation, as well as
the quantification of the various growth factors present
in the PRP is a controversial subject. Further prospective
randomized controlled trials (level 1 evidence) will be
necessary.
PRP injections for rotator cuff tendinopathy
Injections of PRP have gained popularity in the treatment
of tendinopathy based on its promoting effects on tendon cell proliferation, collagen synthesis, and vascularization, which have been shown in animal and in vitro
studies29,30.
As regards the use of PRP for chronic rotator cuff tendinopathy there is a limitation of well designed studies
56
Vol. 125 - 1-2 Novembre 2014
testing the effectiveness of PRP injections in the subacromial space.
In a systematic review of the literature we have found
only two randomized controlled trials evaluating the use
of PRP injections in rotator cuff tendinopathy20,21.
These studies have reported controversial results on the
effectiveness of the use of PRP injection in chronic cuff
tendon diseases.
The systems of preparation of PRP were not the same
across the trials and different treatment protocols were
used (single or double PRP injections). Furthermore the
presence of some bias including the concomitant standard exercise program and the needle stimulus effect can
have influenced the results of studies.
Furthermore rotator cuff tendinopathy has a multifactorial origin. Extrinsic factors including anatomic problems and alterations in kinematics of the joint or intrinsic
factors including age-related degenerative changes and
vascularity changes may play a role in developing such
disease. The effect of PRP can change according to different mechanisms underlying rotator cuff tendinopathy.
The nature of rotator cuff disease was not the same across
the studies and patients who didn’t respond to physical
therapy and corticosteroid injection seem to be advantaged from the PRP use. Whether PRP may be beneficial
in a more specific group of patients ��
refractory ��
to a standard exercise therapy needs of additional research.
More studies with a high level of evidence are required to
justify PRP injections in rotator cuff tendinopathy.
References
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findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5
2.Eppley BL, Woodell JE, Higgins J. Platelet quantification and
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3. Coppinger JA1, Cagney G, Toomey S, Kislinger T, Belton O, McRedmond JP, Cahill DJ, Emili A, Fitzgerald DJ, Maguire PB. Characterization of the proteins released from activated platelets leads to
localization of novel platelet proteins in human atherosclerotic
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4. Sundman EA, Cole BJ, Fortier LA. Growth factor and catabolic
cytokine concentrations are influenced by the cellular composition of platelet-rich plasma. Am J of Sports Med 2011; 39:21352140
5. Dohan Ehrenfest DM, Bielecki T, Mishra A, Borzini P, Inchingolo
F, Sammartino G, Rasmusson L, Evert PA. In Search of a Consensus Terminology in the Field of Platelet Concentrates for Surgical
Use: Platelet-Rich Plasma (PRP), Platelet-Rich Fibrin (PRF), Fibrin
Gel Polymerization and Leukocytes. Curr Pharm Biotechnol.
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6. Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N. Autologous
platelet rich plasma for arthroscopic rotator cuff repair. A pilot
study. Disabil Rehabil 2008; 30:1584-9
7. Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza P. Platelet
rich plasma in arthroscopic rotator cuff repair: a prospective RCT
study, 2-year follow-up. J Shoulder Elbow Surg 2011; 20:518-28
8. Ruiz-Moneo P, Molano-Munoz J, Prieto E, Algorta J. Plasma rich
in growth factors in arthroscopic rotator cuff repair: a randomized, double-blind, controlled clinical trial. Arthroscopy 2013;
29:2-9
9.Antuna S, Barco R, Martinez Diez JM, Sanchez Marquez JM.
Platelet-rich fibrin in arthroscopic repair of massive rotator cuff
tears: a prospective randomized pilot clinical trial. Acta Orthop
Belg 2013; 79:25-30
10. Gumina S, Campagna V, Ferrazza G, et al. Use of platelet-leukocyte membrane in arthroscopic repair of large rotator cuff tears:
a prospective randomized study. J Bone Joint Surg Am 2012;
94:1345-52
11. Jo CH, Kim JE, Yoon KS, et al. Does platelet-rich plasma accelerate recovery after rotator cuff repair? A prospective cohort
study. Am J Sports Med 2011; 39:2082-90
12. Jo CH, Shin JS, Lee YG, et al. Platelet-rich plasma for arthroscopic
repair of large to massive rotator cuff tears: a randomized, singleblind, parallel-group trial. Am J Sports Med 2013; 41:2240-8
13. Zumstein MA, Rumian A, Lesbats V, Schaer M, Boileau P. Increased vascularization during early healing after biologic augmentation in repair of chronic rotator cuff tears using autologous leukocyte- and platelet-rich fibrin (L-PRF): a prospective
randomized controlled pilot trial. J Shoulder Elbow Surg. 2014;
23:3-12
14. Castricini R, Longo UG, De Benedetto M, et al. Platelet-rich
plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med 2011; 39:258-65
15.Arnoczky SP. Platelet-rich plasma augmentation of rotator cuff
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16. Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet-rich
fibrin matrix in the management of arthroscopic repair of the
rotator cuff: a prospective, randomized, double-blinded study.
Am J Sports Med 2013; 41:263-70
17. Rodeo SA, Delos D, Williams RJ, Adler RS, Pearle A, Warren RF.
The effect of platelet-rich fibrin matrix on rotator cuff tendon
healing: a prospective, randomized clinical study. Am J Sports
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18. Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair
healing influenced by platelet-rich plasma construct augmentation. Arthroscopy 2011; 27:1029-35
19. Bergeson AG, Tashjian RZ, Greis PE, Crim J, Stoddard GJ, Burks
RT. Effects of platelet-rich fibrin matrix on repair integrity of atrisk rotator cuff tears. Am J Sports Med 2012; 40:286-93
20. Rha DW1, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the
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therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized
controlled trial. Clin Rehabil. 2013; 27:113-22
21. Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioğlu K. Platelet-rich
plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up.
Am J Sports Med. 2013; 41:2609-16
22. Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard
P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich
Plasma Injection for Rotator Cuff Tendinopathy: A Prospective
Open-label Study. Glob Adv Health Med. 2013; 2:26-31
23.Namazi H. Rotator cuff repair healing influenced by platelet-rich
plasma construct augmentation: a novel molecular mechanism.
Arthroscopy; 2011:1456; author reply -7
24. Kakudo N, Minakata T, Mitsui T, Kushida S, Notodihardjo FZ,
Kusumoto K. Proliferation-promoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal
fibroblasts. Plast Reconstr Surg 2008; 122:1352-60
25. Savitskaya YA, Izaguirre A, Sierra L, et al. Effect of angiogenesisrelated cytokines on rotator cuff disease: the search for sensitive biomarkers of early tendon degeneration. Clin Med Insights
Arthritis Musculoskelet Disord 2011; 4:43-53.
26. Hoppe S, Alini M, Benneker LM, Milz S, Boileau P, Zumstein MA.
Tenocytes of chronic rotator cuff tendon tears can be stimulated
by platelet-released growth factors. J Shoulder Elbow Surg 2013;
22:340-9
27. Jo CH, Kim JE, Yoon KS, Shin S. Platelet-rich plasma stimulates
cell proliferation and enhances matrix gene expression and synthesis in tenocytes from human rotator cuff tendons with degenerative tears. Am J Sports Med 2012; 40:1035-45
28. Ersen A1, Demirhan M, Atalar AC, Kapicioğlu M, Baysal G. Arch
Orthop Trauma Surg. Platelet-rich plasma for enhancing surgical rotator cuff repair: evaluation and comparison of two application methods in a rat model. 2014;134:405-11
29. Jo CH, Kim JE, Yoon KS, Shin S. Platelet-rich plasma stimulates
cell proliferation and enhances matrix gene expression and synthesis in tenocytes from human rotator cuff tendons with degenerative tears. Am J Sports Med. 2012; 40:1035-1045
30. de Mos M, van der Windt AE, Jahr H, et al. Can platelet-rich
plasma enhance tendon repair? A cell culture study. Am J Sports
Med. 2008; 36:1171-1178
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KEYWORD Europa
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58
Vol. 125 - 1-2 Novembre 2014
Platelet rich plasma in rotator cuff disease
Umile Giuseppe Longo, Alessandra Berton, Giacomo Rizzello,
Giuseppe Salvatore, Vincenzo Denaro
Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Roma
Abstract
Platelet-rich plasma (PRP) is an emerging strategy to enhance
tendon healing. Its increased used in the clinical setting is due to
its safety. However, definitive evidence on PRP potentiality still
need to be clarified. Only some molecular mechanisms have been
described and many others need to be studied. The knowledge of
the healing process will also help to identify optimal formulations
and protocols for the clinical use.
The available clinical studies on PRP for rotator cuff disease not
only reported conflicting results but they are difficult to compare
because of different experimental designs, level of evidence, PRP
formulations, surgical technique, rehabilitation protocol, size of
the lesion or nature of the disease. To date, clinical benefits of
PRP are not demonstrated and powered randomized controlled
trials are necessary.
PRP BIOLOGY
Platelet-rich plasma (PRP) gained popularity over the last
years thanks to its potential as a biological solution to improve rotator cuff tendon healing.
It is a blood fraction containing high platelet concentrations,
high density of growth factors and structural proteins.
PRP acts upon tendon healing by modulating inflammation, activating fibroblast migration, promoting angiogenesis, and increasing cell proliferation1.
Platelets become activated at the site of tissue injury and
release intracellular stores. They are predominantly alphagranules (50-80 alpha-granules per platelet), dense granules (3-5 granules per platelet) and lysosome 2.
Alfa-granules contain more than 300 proteins. Basic
growth factors identified include PDGF, TGF, FGF, endothelial growth factor (EGF), hepatocyte growth factor (HGF), connective tissue growth factor (CTGF) and
VEGF. Those play important roles in cell proliferation,
chemotaxis, cell differentiation, and angiogenesis. Specifically, TGF-β promotes matrix synthesis PDGF, together
with platelet factor-4 and CXCL7, activates fibroblasts’
migration3, PDGF-B, bFGF and CXCL5 are involved in
the homing of precursor cells4, HGF is a potent antifibrotic that may help to reduce scar formation around tendon
tissues5 and, together with VEGF promote angiogenesis6.
The role of platelets in angiogenesis is complex because
a-granules also contain anti-angiogenic proteins such as
Thrombospondin-1 (TSP-1), angiostatin, endostatin, fibronectin and the tissue inhibitors of metalloproteinases
(TIMPs -1 to -4)7. They are stored separately and should
be released differentially thanks to an agonist-specific
mechanism 8.
Platelets also modulate inflammation by secreting high
levels of chemokine such as CXCL1/GRO, ENA78/
CXCL5, monocyte chemoattractant protein-1 (MCP-1),
CCL5, IL8 9. Moreover, platelets secrete platelet basic
protein (PBP) and connective tissue activating peptide-III
(CTAP-III)). Those are precursors of b-thromboglobulin
[(CXCL7 or neutrophil activating peptide-2, (NAP-2)], a
strong chemoattractant and an activator for neutrophils.
Dense granules contain bioactive factors that have important effects on biologic aspects of wound healing. Histamine and serotonin increase capillary permeability, allowing inflammatory cells to migrate toward the area of
inflammation. Moreover, they activate macrophages10,11.
Studies show that the nature of the stimulants or the combination of stimulants on macrophage can lead to different
kind of activation. ‘classical’ macrophage activation may
determine an anti-inflammatory environment compared to
‘innate” activation 12.
PRP therapies also contain cell adhesion molecules including fibronectin, fibrin, and vitronectin. Those add to
the potential biologic activity of PRP by forming threedimensional scaffolds where cells can adhere and begin
the wound healing process.
PRP COMPOSITION
PRP therapies includes several formulations that differ in
their pharmacological and material characteristics. Those
characteristics influence the biology and potential effects.
The main difference between plasma concentrates is leucocytes content and fibrin network. Four categories have
been identified: leucocyte-poor or pure platelet-rich plasma (P-PRP), leucocyte- and platelet-rich plasma (L-PRP),
leucocyte-poor or pure platelet-rich fibrin (P-PRF), leucocyte- and platelet-rich fibrin (L-PRF).
A further division is between activated (ex vivo activation
with thrombin and/or calcium) and unactivated form (in
vivo activation via endogenous collagen)13,14.
There are no definitive data to support the use of L-PRP
or PRP. Studies showed L-PRP had pro-inflammatory effect when injected in rabbits15 and increased the levels of
MMPs when assayed in tenocyte cultures compared with
pure PRP16.
On the other hand, leucocyte in PRP has a positive role as
anti-infectious and immune regulatory agents 17-20. Studies
showed decreased pain and inflammation when used for
treatment of tendonitis 21,22.
The ratio between fibrinogen and thrombin concentrations
is another aspect that ��
is still under-researched. It is responsible for fibrin polymerization and its biochemical architecture that represent the support cytokine enmeshment
and cellular migration23-25.
Further studies are needed define the optimal PRP formulation to manage rotator cuff lesions.
Clinical studies on PRP in rotator cuff
lesions and tendinopathy
There are still many questions about the biologic mechanisms of the action of PRP, however the safety and feasibility of PRP therapies allowed clinical studies and patientoriented research to be performed.
PRP has been used both on acutely injured tendon and degenerative tendon. The underlying cellular and molecular
processes are quite different between these two disparate
clinical conditions, thus they should be considered separately.
Clinical studies on PRP in rotator cuff lesions not only reported conflicting results but they are difficult to compare
because of different experimental designs, level of evidence,
PRP formulations, surgical technique, and the rehabilitation
protocol. At the moment, studies that have been published
are: seven level 126-32 and two level 233,34 randomized controlled trials , one level 2 prospective cohort study 35, two Level
3 case control studies 36,37 and one level 3 cohort study38. Four
of them investigated the effect of injectable PRP in arthroscopic rotator cuff repair26,27,33,36 while the others applied suturable PRP28-32,34,35,37,38. Plasma products were heterogenic,
in terms of volume of autologous blood collected, speed and
time of centrifugation, method of administration, activating
agent, presence of leukocytes, final volume of PRP, and final concentration of platelets and growth factors. The surgical technique was single row26,28,32-34,37,38, double row27,31,34,36
or transosseous equivalent29,30,35. The rehabilitation protocol
was could be standard or rapid. All those factors might have
important implications for clinical outcomes and arise the
need for comparative effectiveness research.
Clinical outcomes were no different between PRP group
and control group in all studies. Only Randelli et al26 detected a statistically significant improvement in the Constant, SER, UCLA, SST at the 3 month follow-up and Barber et al37 detected a statistically significant difference in
the Rowe score (mean follow-up of 31 months).
Postoperative tendon healing showed no significant difference both at MRI26,31,37 or ultrasound34 imaging.
Re-rupture rates between PRP and control group was not
significantly different in all studies. However, Barber et
al37 showed a statistically significant difference in the rates
of tendon re-rupture (60% vs 30%; P = 0.03) at 4 months
from surgery. Moreover, a stratified analysis the results of
small and medium lesions of the rotator cuff showed lower
rate of reinjury (7.9%) among patients treated with PRP,
compared to those treated without PRP (26.8%)39.
To date, there are not definitive evidence to support the
routine use of PRP in rotator cuff repair. ��
Further randomized prospective trials are necessary to achieve definitive answers in this field.
59
Vol. 125 - 1-2 Novembre 2014
Clinical studies on PRP injections for rotator cuff tendinopathy are just few despite the great popularity in the clinical setting40,41. Also in this case there are methodological
limitations and difficulties in comparisons.
There are two randomized controlled trials on PRP injections for rotator cuff tendinopathy, one supporting PRP
superiority with respect to pain, function, and range of
motion over a 6-month period40, the other showing no difference for quality of life, pain, disability, and range of
motion at 1 year41. They used different treatment protocols, Rha et al.40 used 2 PRP (3 mL) injections at a 4-week
interval, and Kesikburun et al.41 used 1 injection of PRP (5
mL) with concomitant standard exercise program. Moreover the nature of the disease was not the same, maybe influencing the results.
Further studies are needed to acquire higher level of evidence and define the role of PRP injection for rotator cuff
tendinopathy.
CONCLUSION
Platelet-rich plasma (PRP) ��
is an emerging strategy to enhance tendon healing42-46. Its increased used in the clinical
setting is due to its safety. However, definitive evidence on
PRP potentiality still need to be clarified. Only some molecular mechanisms have been described and many others
need to be studied. The knowledge of the healing process
will also help to identify optimal formulations and protocols for the clinical use.
The available clinical studies on PRP for rotator cuff disease not only reported conflicting results but they are difficult to compare because of different experimental designs,
level of evidence, PRP formulations, surgical technique,
rehabilitation protocol, size of the lesion or nature of the
disease. To date, clinical benefits of PRP are not demonstrated and powered randomized controlled trials are necessary.
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Biology of rotator cuff tendinopathy
Antonella Murgo, Orazio De Lucia, Chiara Crotti, Pier Luigi Meroni
Divisione e Cattedra di Reumatologia, Istituto Ortopedico Gaetano Pini, Milano
Genetic associations
Introduction
Although it has been suggested that some individuals display a genetic predisposition to the development of tendinopathy (variants of tenascin-C gene with 12 and 14
guanine-thymine repeats or COL5A1 BstUI restriction
fragment length polimorphisms), a specific genetic association is still matter of research. The difficulty in finding
such association may be explained by the existence of a
complex interactions between multiple genes 3.
Tendinopathy is a frequent condition and cause for referral to
orthopedics and rheumatologists. Rotator cuff tendons (especially the supraspinatus) are the most vulnerable and commonly
involved structure; the incidence increases with age up to 40% in
subjects aged >70 years 1. The etiopathogenesis of the rotator cuff
tendinopathy is still poorly defined despite its high frequency.
Better understanding of the biological processes lying behind the
tendon-bone junction damage is needed in order to have more
therapeutical options.
The clinical syndrome characterized by pain, impaired performance and swelling due to the increased thickness of tendons
and/or the surrounding structures, is called tendinopathy. Because
of the presence of symptoms usually related to inflammation, the
term “tendinitis” had been used to describe this condition for long
time. However, the evidence of degenerative lesions, characterized by disorganization of tendon ultrastructure, not always accompanied by a significant inflammatory component, has led to
prefer the generic term tendinopathy 2.
Rotator cuff tendinopathy is mediated by extrinsic mechanisms
(i.e. anatomical, biomechanical) and intrinsic processes (i.e. alterations in biological and mechanical properties, in morphology,
in vascularization), both responsible for the possible damage of
the whole tendon. It is commonly described as a progressive disorder, beginning with an acute phase followed by a condition in
which degenerative aspects are prevalent and potentially ending
in a complete rupture.
Cellular and molecular pathogenesis
Cell infiltrates, thinning and disorganization of the tendon
fibers, granulation tissue and fibrocartilage alterations have
been described in rotator cuff tendinopathy and linked to
tension force decrease and rupture tendency 4. Histopathological changes are consistent with a generalized hypoxia.
Immunohistochemical and microarray studies have demonstrated the presence of neo-vascularization and the increase of neurotransmitters (in particular substance P),
which would partially explain the origin of chronic pain
in tendinopathy 5.
The definition of cellular infiltrate is a milestone in the
acknowledgment of rotator cuff tendinopathy. The early
stages of tendon damage could result from an inflammatory response to a mechanical stress. The difficulty in
achieving appropriate experimental models leads to a lack
of information concerning the role of inflammatory cells
and mediators. A significant increase of neutrophils, macrophages and mast cells can be found in the early stages
of tendinopathy; inflammatory cells produce different angiogenic, pro-inflammatory and degenerative factors, that
promote degenerative and reparative processes into the
extracellular matrix 6.
An increasing number of studies suggest that cytokines
(TGF-β, IL1, IL6, IL15, IL18) are active in various steps
of tendinopathy, affecting cell-chemotaxis, proliferation
and differentiation, matrix synthesis throught an autocrine
or paracrine signaling. These effects are particularly remarkable under the influence of transforming growth factor β (TGF-β) produced by macrophages. The family of
TGF-β is required for proper fetal development of tendons
and plays a major role in the healing process.
It has been shown that TNF-β increases the production
of collagen and proteinase activity 7, with the result of
stimulating the formation of small fibrovascular scars.
This event initially would play a protective and reparative
role, but later it could cause a weakening of the structure,
facilitating tendon rupture. TGF-β helps the production
of matrix proteins (fibronectin, glycosaminoglycans) and
the maturation of monocytes into macrophages, amplifying the inflammatory response. The role of IL-6 has been
recently investigated: its expression is up-regulated in
pathological tendons. IL-6 has both pro-inflammatory and
anti-inflammatory effects and its expression, as a mediator of cyclooxygenase-2 (COX2) in pathological tendon,
its expression does not necessarily support an inflammatory state. IL-6 expression is different in the Achilles and
posterior tibial tendinopathy; it remains unclear whether
this finding is related to differences in load, structure or
progression of tendinopathy 8. Although this study does not
analyze the rotator cuff tendons, in our opinion, it suggests
the complexity of tendinopathy biomechanical processes.
IL-1β increases the synthesis of COX-2, PGE2 production
and matrix metalloproteinases (MMP-1, MMP-3, MMP13) which cause matrix destruction, a loss of tendon biochemical properties. Moreover IL1β displays pro-apop-
totic activity and strongly down regulates several gene
expression 9.
The role of the extracellular matrix
Extracellular matrix (ECM) is a complex entity that surrounds and supports the tendon cells; it is composed by collagen fibers and elastin. In addition to structural proteins it
contains specialized proteins (eg fibronectin and fibrillin)
and proteoglycans. In order to play its physiological role,
ECM undergoes to a continuous remodeling process, mediated by some enzymatic activities (mainly MMP). Since
the interaction between cells and matrix is bi-directional,
extracellular changes may arise from cellular processes
(proliferation, migration, apoptosis, and morphogenesis),
or may originate from extracellular microenvironment 10.
According to several Authors, the imbalance between synthesis and degradation of ECM components would lead to
the deterioration and degeneration of the tendon structure.
The balance between MMP and their inhibitors is essential in the maintenance of tendon ECM homeostasis and
an imbalance may result in uncontrolled tendon damage.
These enzymes play a major role in the matrix degradation during development, repairing process and may play a
key role in the pathogenesis of tendinopathy. An in vitro
study demonstrated that MMP inhibitors can prevent the
activation of MMp-13 and inhibit pericellular matrix degeneration and the loss of material properties associated
with stress deprivation 10.
Collagen is the main component of the tendon. The collagen portion is made up of 95% type I collagen with small
amounts of 27 other types of collagen. Following TGF-β1
secretion, there is an increase in collagen production, especially in favor of less represented variants (type I, III,
V) and of “altered” forms (high percentage of denatured
collagen) 11.
The loss of balance between synthesis and degradation of
ECM has also a negative impact on proteoglycans, which
are protein/polysaccharide complexes. Proteoglycans,
and their constituent glycosaminoglycans (GAGs), are
involved in several physiological processes and may display both a structural and signaling role. Unfortunately the
changes occurring in proteins different from collagen are
still poorly known in tendinopathies. It has been documented that some GAGs, such as fibronectin and tenascin-C,
promote the migration of fibroblasts and their adherence
to fibrin. A persistent increase in expression of fibronectin and tenascin-C has been reported in tendinopathies and
may contribute to the pathogenic remodeling 12.
A disintegrin-like and metalloprotease with thrombospondin motifs (ADAMTS), a novel family of extracellular
proteases, seems to play an important role in proteoglycan turnover in tendon, although the informations on this
mechanism are not enough 13.
Tenocytes, a fibroblast-like cell type, are the regulators
of the ECM remodeling process. Before the development
of tendinopathy, tenocytes undergo significant changes in
morphology and proliferation, become necrotic or apoptotic and increase the local expression of insulin-like
growth factor (IGF-1) 10. IGF-1 increases DNA synthesis
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Vol. 125 - 1-2 Novembre 2014
in tenocytes, GAG production and collagen synthesis; its
stimulating effects affect other cell types such as cartilage,
bone and muscular cells.
It has been observed that rotator cuff tendon cells display
a fibrochondrogenic phenotype nearby the affected areas.
An increased expression of cartilage genes, such as COL2A1, SOX9 and aggrecan, has been described in animal
models of supraspinatus tendinopathy 9.
The role of apoptosis
Apoptosis, or programmed death of tenocytes, plays a
definite role in the genesis of rotator cuff tendinopathy.
Apoptosis is triggered and tuned by intrinsic and extrinsic
mechanisms. Fibroblast or fibroblast-like apoptosis may
play a critical role in the maintenance of the extracellular matrix of rotator cuff tendons. BNip3, a pro-apoptotic
member of the BcL-2 family, has been specifically linked
with hypoxia and inflammation-induced apoptosis. Benson et al. reported an almost 3-fold increase in apoptosis
within full-thickness rotator cuff tears compared with control groups 14.
Mechanical causes
Repetitive microtraumas/stressing conditions are thought
to play a main pathophysiological role in tendinopathies.
More recently it has been demonstrated that repeated traumas and the related stromal tissue damage can affect cell
responses through the receptor recognition of intracellular proteins released by necrotic cells. Among them, heat
shock proteins (HSPs), also called damage-associated molecular patterns (DAMPs), are rapidly released following
non-programmed cell death, are key effectors of the innate immune system and restore homeostasis of the tissue.
HSPs, released from stressed tenocytes, play a role in early
tendon damage as they regulate both the tissue healing response and the inflammatory reaction with a fine balance
between reparative versus degenerative changes 6.
Repetitive micro-traumas/stresses are also responsible
for ischemia, and consequent hypoxia, which represents
potential trigger and cause of rotator cuff tendinopathy,
recently correlated with an increased apoptosis. Cytokines play a key role in oxidative stress-induced cellular
apoptosis, which is mediated by the activation of caspases
(cysteine-dependent aspartate-directed proteases, a group
of proteolytic enzymes) 15.
Hypoxia also triggers the expression of vascular endothelial growth factor (VEGF), which promotes angiogenesis
and increases the expression of MMPs. Both these events
can cause weakening of the tendon structure.
VEGF and von Willebrand factor messenger RNA
(mRNA) expression levels were significantly increased in
a rat model of sovraspinatus tendon overuse injury, but it is
unclear whether the increase in these angiogenic cytokines
is part of the early healing response cascade or just reflects
the response to injury 16.
Hypoperfusion is also responsible for the increase of free
radicals, which can cause a direct cell damage. In fact, the
expression of peroxiredoxin 5, an antioxidant enzyme that
protects cells from free radicals- induced damage, is increased in tenocytes during tendinopathy. However small
amounts of free radicals can be harmless and stimulate the
fibroblast proliferation. For example, nitrix oxide (NO),
can enhance tendon healing. NO is synthesized by a family of enzymes, the nitric oxide synthases (NOSs) that can
be induced by bacterial cell wall products and proinflammatory cytokines (eg. IL-1 and TNF).
Three NOS isoforms are expressed by fibroblasts during
tendon healing and NO production increase seems to be
related to an improvement in mechanical properties of
damaged tendons, through the stimulation of fibroblast
proliferation and ECM synthesis.
Existing data indicate that several proinflammatory agents
(e.g. cytokines, prostaglandins, growth factors and neuropetides) may initiate rotator cuff tendinopathy and that
apoptosis play a key role in the development and progression of the process.
Our understanding of the biology of tendinopathy is poor,
mainly because of the difficulties in defining the sequence
and chronology of the pathogenic events taking place in
such a complex process.
References
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4. Blevins FT, Djurasovic M, Flatow EL, Vogel KG. Biology of the rotator cuff tendon. Orthop Clin North Am 1997; 28:1-16
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7. Hays PL, Kawamura S, Deng XH, Dagher E, Mithoefer K, Ying L, et
al. The role of macrophages in early healing of a tendon graft in
bone tunnel. J Bone Joint Surg Am 2008; 90:565-79
8. Legerlotz K, Jones ER, Screen HRC, Riley GP. Rheumatology 2012;
51:1161-1165
9.Archambault JM, Tsuzaki M, Herzog W, Banes AJ. Stretch and
interleukin-1beta induce matrix metalloproteinases in rabbit
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or under-stimulation of tendon cells? Int J Exp Pathol 2007;
88:217-226
11. Riley G. The pathogenesis of tendinopathy. A molecular perspective. Rheumatology 2004; 43:131-142
12. Xu Y, Murrel GAC. The Basic science of Tendinopathy. Clin Orthop Relat Res 2008; 466: 1528-1538
13. Jones GC, Riley GP, ADAMTS proteinases: a multi-domain, multifunctional family with roles in extracellular matrix turnover and
arthritis. Arthritis Res Ther 2005; 7:160-169
14. Benson RT, McDonnell SM, Knowles HJ, Rees JL, Carr AJ, Hulley
PA, Tendinopathy and tears of the rotator cuff are associated
with hypoxia and apoptosis. Journal of bone and joint surgery.
2010; 92B:448-53
15. Yuan J, Murrell GAC, Trickett A, Wang MX. Involvment of cytochrome c release and caspase-3 activation in the oxidative
stress-induced apoptosis in human tendon fibroblasts. Biochimica et Biophysica Acta. 2003; 1641:35-41
16. Perry SM, McIlhenny SE, Hoffman MC, Soslowsky LJ. Inflammatory
and angiogenic mRNA level are altered in a supraspinatus tendon
overuse animal model. J Shoulder Elbow Surg 2005; 14:79S-83S
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Scaffold augmentation in rotator cuff tears repairs
Roberto Rotini, Alessandro Marinelli, Enrico Guerra, Graziano Bettelli,
Michele Cavaciocchi, Lorenzo Zaccarelli, Milena Fini*, Elena Bondioli**
Shoulder and Elbow Unit, Rizzoli Orthopaedic Institute, Bologna
* Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopaedic Institute, Bologna
** Burn Intensive Care Unit and “Regione Emilia Romagna” Skin Bank, Bufalini Hospital, Cesena
Abstract
The high incidence of recurrent tendon tears after repair of massive cuff lesions is prompting the research of materials aimed at
mechanically or biologically reinforcing the tendon. Among the
materials studied so far, the Extracellular Matrix (ECM) scaffolds of human origin have proved to be the safest and most
efficient, but the current legislations on grafts and transplants
preclude their use in Europe.
In order to overcome this condition in 2006 we started a project
on the production of an ECM scaffold of human origin which
could be implanted in Europe too.
In 2009 the clinical study began with the implantation of dermal
matrix scaffolds in 7 middle-aged patients affected with wide/
massive cuff lesions and tendon degeneration. Out of 5 cases
followed for at least 1 year in which the scaffold was employed
as an augmentation device, there were 3 patients with complete
healing, 1 partial re-tear and 1 total recurrence.
The absence of adverse inflammatory or septic complications
allows to continue this research line with a prospective controlled study in order to define which might the real advantages
and correct indications offered by scaffold application.
Introduction
The lesion of the rotator cuff is present in 40% of patients
over the age of sixty, in a high percentage, the injury causes
disability due to pain and functional limitation or because
it demonstrates evolutionary causing a progressive loss of
strength.1 Remarkable advances in the surgical technique of
rotator cuff tears over the last 15 years offer nowadays the
opportunity to effectively repair most of the lesions. Progress has either involved manufacturing suture anchors that
now present higher pull-out strength and are treated with
multiple reinforced sutures, as well as improvement in repair
techniques.2-6 In particular margin convergence techniques,
that allow to reduce the stress of the repair, better “suture
grasping” techniques and double row or transosseous equivalent repair techniques, that permit to widen the contact surface between tendon and foot-print, allow to obtain suture
repairs mechanically stronger than in the past.7
However there are still several conditions where limits of
reparative surgery are evident. A high incidence of failure
follows repair of wide/massive lesions, particularly when
the lesion is old and the tendon shows degenerative changes.8 Failure can happen after a time (re-tear), but in many of
these cases it can be the effect of missed healing. The main
factors that can cause a missed tendon-to-bone healing are
mechanical (low strength of the tendon or of the suture, excessive tension on the repair) or biological (low quality and
vitality of tendon and bone). Recently, in order to overcome
the limits of traditional reparative surgery, techniques of regenerative medicine are under investigation; they are aimed
at enhancing and directing the tissue repair with formation
of a tendon tissue having histological and mechanical properties resembling those of the native tendon. Most of the
research studies are focused on obtaining scaffolds able to
provide an initial mechanical augmentation to the repaired
cuff, absorbing part of the stresses and thereby protecting
the suture. At the same time the scaffold should be, already
in the initial phases, a ground for hosting cells colonization,
leading to the formation of a tendon structure with the same
histological, architectural and mechanical features of the native one, but with a higher thickness. Additional requisites
for these scaffolds should be a full biocompatibility and
tolerability, a complete resorption at the end of the healing
process, high suture retention properties and being easily to
handle and fit for arthroscopical application.
The materials that have been studied and employed as augmentation devices can be divided into synthetic and biologic
(Tab. 1).
A. Synthetic scaffolds, as Mersilene meshes or Polytetrafluoroethylene patches, have been used for rotator cuff repair, but regardless of their excellent tensile strength9-10 they
are not recommended due to the lack of biological properties, the possibility to obstacle the tissue tendon growth and
the risk of foreign body reactions. In recent years the novelty among synthetic scaffolds has been the development of
absorbable materials obtained through the electrospinning
techniques (electrospinning). This method, through the processing of synthetic nanofibers, allows to create a three dimensional structure that mimics the normal orientation of
collagen fibers;11 on these materials, so far only tested in
vitro, can also be applied growth factors or stem cells.
B. Biologic scaffolds can be classified into:
B1) autologous tissues from fascia lata 12 or biceps tendon; 13-15
B2) homologous tissues from rotator cuff 16-17 or patellar
tendon allografts, Achilles tendon allografts and quadriceps tendon allografts18 that were used to treat massive,
irreparable rotator cuff tears have been associated with unsatisfactory or variable not reproducible results;
B3) allografts or xenograft from extracellular matrices
(ECM scaffolds) obtained through decellularization pro-
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Vol. 125 - 1-2 Novembre 2014
Table. 1 Materials employed as augmentation devices for rotator cuff repair.
A. SYNTHETIC: Use regulated by FDA (USA) or CE (Europe)
ProductTissue type & Source
SportMesh Soft Tissue Reinforcement
X-Repair
Poly (urethanaeurea)
Poly-L-Lactide
Company
Biomet Sports Medicine
Synthasome
B. BIOLOGIC:
1) Autografts (Long Head fo the Biceps, Fascia Lata)
2) Allografts unprocessed tissues (Rotator cuff, Achilles, Cutis, Fascia Lata)
3)Allograft or Xenograft decellularized tissues (Small Intestinal Submucosa, Derma,
Pericardium, Fascia Lata)
a) Xenografts Use regulated by FDA (USA) or CE (Europe)
Company
Restore
CuffPatch
Conexa
TissueMend
Permacol
Bio-Blanket
OrthADAPT bioimplant
Depuy Orthopaedics
Biomet
Tornier
Stryker Orthopaedics
Zimmer
Kensey Nash
Pegasus Biologics
SIS-Porcine
SIS Porcine Dermis Porcine
Fetal Dermis Bovine
Dermis Porcine
Dermis Bovine
Pericardium Equine
b) Allograft Use regulated by National Transplantation Centers
Company
Wright Medical Technology
Muskulosk. Foundation
Graft Jacket
Allopatch
Human Dermis
Human Fascia Lata
cesses. This group is nowadays the most extensively studied
to obtain biologic scaffolds. The decellularization process
based upon chemical or physical processes eliminates the
cellular DNA containing the immunogenic components, but
preserves unaltered the extracellular matrix with its threedimensional structure and its content in collagen fibres.
The three-dimensional architecture, the presence of collageneous and not collageneous proteins and growth factors
(GFs) are fundamental to create an adequate environment
for cell adhesion, proliferation and differentiation. During
the healing process the progressive degradation of the scaffold releases molecules that also play a role in determining
the recruitment and proliferation of appropriate cell types
during tissue remodeling.
ECM scaffolds available on the market for surgical repair of
cuff lesions can be divided into:
B3.a) Xenografts – membranes deriving from animal dermis, intestine, pericardium
B3.b) Allografts – membranes deriving from human dermis
or fascia lata
Scaffolds from animal origin (B.3a) meet the criteria dictated by FDA; the EU approve which approves their use as devices for reinforcement after tendon repair (augmentation),
but not as devices to patch the rotator cuff hole (bridging).
In some cases this kind of scaffolds has proven to be immunogenic, so their use in cuff repair surgery is now discouraged (Fig. 1).19-23
Human-derived membranes (B.3b), like the human dermal
matrix - Graft Jacket (GJA) or Allopatch, are classified as
human tissues for transplantation and each Country has to
follow National Regulatory Transplantation Center rules for
the control of human-derived tissue transplants. Due to the
differences between transplant laws between Europe and
USA, commercial membranes derived from human tissue
and produced in USA currently cannot be implanted all
over Europe.
In 2005, before Italian and European laws forbid its use, we
obtained good results in some patients treated with GJA (unpublished data). Confirmations on the effectiveness of acellular human dermal matrix come from several researches. A
study performed at our Istitute confirms that GJA presents
suitable biological properties for in situ tissue engineering
and in vitro bioengineering of rotator cuff tendons24 and has
been shown to increase the mechanical strength of the repair.25 In two different animal studies where GJA was used
to bridge large full thickness tendon tears, Adams and Ide
noted the histological evidence of native cell infiltration and
neotendon development already at 6 weeks; moreover in
few months after surgery histological incorporation of the
acellular dermal matrix graft into a structure resembling
A
B
Figure 1. MRI image DP Fat Sat, coronal
oblique, sagittal and axial. Patient of
28 aa with important inflammatory
arthrosynovitis 6 months after implantation
of a scaffold equine that required a
re-operation for removal of the membrane
in arthroscopy and joint lavage.
normal tendon was evident.26-27 Even if no one is a casecontrol study, in all clinical studies published so far GJA
showed good results either if used asaugmentation28, or as
bridging29-31 device. Snyder led in 2010 a clinical study of
45 patients with massive and irreparable rotator cuff tear
treated with arthroscopic implantation of Graft Jacket used
as bridging, resulting in more than two years of follow-up
significant clinical improvement in the absence of inflammatory reactions and discards.31 In one of his histological
study on a biopsy specimen taken from a rotator cuff augmented 3 months earlier with GJA scaffold, incorporation
and remodelling was demonstrated, with alignment of collagen fibers, presence of revascularization signs, repopulation
with host cells and little or no inflammatory response.32
Methods and Materials
The need to have a decellularized bioactive collagenic membrane available in our clinical practice for the treatment of
large/massive rotator cuff lesions with high risk of retear
induced us in 2006 to organize a multidisciplinary group
aimed at its production. This led to a cooperation between
the Rizzoli Orthopedic Institute in Bologna and the Cutis
Bank of the Burns Unit of the Bufalini Hospital in Cesena.
From 2008 this activity is included in the Research Program
Regione Emilia Romagna-University 2008-2011: “Regenerative Medicine in Osteoarticular Disease”.33 The study
included 4 steps:
1) Development of a proprietary decellularization technique of dermis coming from multiorgan and multitissue donors. Such technique is protected by an
international patent of AUSL Cesena and Rizzoli
Orthopedic Institute and allows to produce an Acellular Human Dermal Matrix (AHDM) that fits the
indications of the Italian and European laws about
grafts and transplants.
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C
2) Evaluation of the biologic properties and features of
the membrane:24, 35
- the product was analyzed with optic and electronic
microscopy techniques to confirm the conservation
of the tridimensional collagenic structure which is
necessary for tendon tissue regeneration
- optic and electronic microscopy techniques as well
as biochemical tests were employed to rule out the
persistence of residual vital cells, an important aspect to avoid possible immunological reactions
- the anabolic activity of tenocytes grown on the
AHDM was investigated through the analysis of
Cell Proliferation (WST-1), the ECM production
tissue, Collagen I (CICP), Proteoglycans (PG), Fibronectin (FBN), and Transforming Growth Factor β1 (TGFß1), Interleukin 6 (IL-6) evaluation.
From a comparison between AHDM and control
cultures a significant higher amount of collagen
I, fibronectin, proteoglycans, and TGFβ1 was observed in AHDM cultures.34
3) Evaluation of adequate mechanical properties:
- through traction test (Sintech-1/M, MTS Adamel
Lhomargy, Ivry sur Seine, France) both the direct
resistance and the resistance between suture stitch
and AHDM were tested (Fig. 2).
A comparison with some other commercially available membranes showed that AHDM had a failure
mode similar to other membranes as described in literature and has superposable mechanical properties.
4) Evaluation of the membrane histocompatibility by
implantation of membrane samples in rats subcutis.
No inflammatory reaction was observed.
After obtaining these laboratory results and with the approval of the Hospital Ethical Committee, in 2009 we started
the clinical application of the AHDM in a selected group of
patients. The study was aimed at reporting the preliminary
results of our experience with AHDM membrane implanted
as augmentation in a subset of rotator cuff lesions having a
high recurrence risk. This group consisted of middle-aged
high-demand patients affected with large/massive and old
postero-superior cuff lesions. Patients were controlled both
clinically and with imaging techniques to evaluate safety,
excluding adverse reaction of inflammatory or septic nature,
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Vol. 125 - 1-2 Novembre 2014
Figure 2. Mechanical Test of tensile
strength between suture and membrane
AHDM (Instron machine).
and efficacy of the membrane.36 Between March 2009 and
December 2010 in our Shoulder and Elbow Unit about 400
surgical procedures of cuff repair have been performed. In
7 patients with specific clinical and imagine characteristics
we employed the AHDM, as an augmentation in 6 cases and
as a bridging device in 1 case with the cuff proved to be irreparable. One of the 6 augmentation cases was excluded
due to insufficient follow-up. The remaining 5 cases satisfied the following pre-operative selection criteria.
Inclusion criteria:
- healthy subjects with high functional requests
- age below 55, affected with large to massive lesion
according to Gerber involving supraspinatus and infraspinatus tendons, tendon retraction ≤ 3 according
to Thomazeau and fatty degeneration ≤ 3 according
to Goutallier, with possibility at surgery to obtain
tendon reduction.
- Follow-up 1 year or more
Exclusion criteria:
- arthritic degeneration even mild according to Samilson
- frozen shoulder
- symptomatic acromioclavicular arthritis
- inability to cope with an adequate post-operative rehabilitation regimen
- autoimmune connective tissue disease
- allergy for penicillin and pork meat
The patients had the same preoperative workout and the same
postoperative regimen that we use for normal cuff repair surgery. Preoperative study included standard clinical examination, x-ray and MRI. Anaesthesia consisted of interscalenic
block and intraoperative sedation. Antibiotic prophylaxis
was done with single shot cefazolin administration.
Figure 3a, 3b.
Implantationof AHDM in open surgery
after rotator cuff repair
A
AHDM harvesting, processing and distribution was performed according to national rules on tissues for transplantation. Then sample of human dermis 1.5-mm thick was first
taken from multi-organ and/or multi-tissue donors and then
transported to the Skin Bank of Bufalini Hospital, CesenaItaly for processing; here the tissues were processed to dermis separation from epidermidis, decellularization and storage in nitrogen vapors at -180 °C. Twenty-four hours before
surgical implantation a sample of tissue of requested sizes
was prepared, and then sent in a sterile condition from Skin
Bank of Bufalini Hospital to our Hospital, and here conserved at a temperature of 4° C until its use.
Surgical technique
The tendon repair and scaffold implantation was performed
with an open technique in 3 cases and with arthroscopic technique in 2 cases. In all cases Peek (Poly-Eter-Eter-Keton)
anchors were employed, to allow better MRI visualization
at follow-up controls. The anchors were in 3 cases a 5.5 mm
Healix anchor [DePuy Mitek, Raynham, MA] loaded with 3
Orthocord sutures and in 2 case a 4.5 mm CrossFT anchor
[ConMed Linvatec, Largo, FL] loaded with 3 Hi-Fi sutures.
The surgical technique was the same for open and arthroscopic repair (Fig. 3a, 3b), with two of the three anchor sutures
B
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Vol. 125 - 1-2 Novembre 2014
Results and complications
Figure 4. Arthroscopic surgical
technique: the scaffold is sutured
with STIK (Short-Tailed Knotted
Interference), nodes for the transport
of the membrane within the shoulder.
used for the rotator cuff repair and the other suture used to fix
laterally the scaffold. Additional stitches were used to fix the
scaffold to the cuff medially, as well as anteriorly and posteriorly. In arthroscopy for the transport of the scaffold within the
shoulder was used the Snyder’s technique (Fig. 4).31
The patients wore an abduction pillow sling for 30 days and
then started gentle rehabilitation, with standard rehabilitation protocol for the repairs of the rotator cuff.
Patients were seen at follow up at 1, 3, 6 and 12 months.
Clinical evaluation was done by the Constant-Murley scoring system. A control MRI was performed at about 12
months after surgery in all cases.
All 5 patients were male with mean age 48 years old (range
from 37 to 55).
At the latest follow up of at least 1 year all the patients
showed symptoms improvement after surgery. The average
Constant score raised from 64 pts (range 55-75) in the preoperative evaluation to 87 pts (range 77-95) postoperatively,
with an average increase of 23 pts (range 20-30).
None of the 5 patients treated with AHDM showed adverse
inflammatory or septic reactions. Between 3 and 5 months
all the patients, in spite of prudential recommendations, took
on again full heavy work or sport activity.
On the basis of MRI study and clinical evaluation in 3 cases
it was possible to assist to a tendon repair integrity (Fig.
5a, 5b), with patients showing excellent shoulder function
with also strength recovery; 1 patient, agonist yachtsman,
felt a tear sensation during a sailing competition at 4 months
postoperatively, with shoulder ache for 2 weeks. In the MRI
at 1 year it is possible to observe a partial lesion with MRI
images showing substantial scaffold integrity and presence
of re-tear of the tendon cuff (Fig. 6a, 6b). In one case, without any history of trauma postoperatively, a complete re-tear
was present; this case was the only one with pre-operative
Goutallier stage 3 muscle-fatty degeneration.
The patients data are summarized in Table 2.
Conclusions
The research on materials capable of increasing the biological and mechanical response of the tendon after the repair
is in continuous development. Indeed, the repair of lesions
of the rotator cuff is often a challenge both mechanical and
biological healing. It is increasingly clear that a thinned and
Table 2. Patients treated data
Patient
Age
Shoulder
trauma
Preop
Test
Pre-oper
MRI
Surgery
Activity
resumption
F.U.
SCORE
Preop to
postop
Postop MRI
Opposite
shoulder
R.S.
37
2005
Jobe +
Patte +
T 2/3
G1
Open repair, large lesion, thin tendon, LHB
tenodesis, 1 anchor
4 months
18
months
75 à 95
Repair integrity, scaffold
incorporation
Tendinopathy
Jobe +
Patte +
T3
G3
Scope repair, massive
lesion, sub-optimal
tendon repairability: 2
anchors, LHB ok and
untreated
4 months
13
55 à 77
Complete
rerupture
Partilal lesion
T 2/3
G1
Scope repair, massive
lesion, complete reducibility: 2 anchors, LHB
tenotomy
5 months
13
66 à 90
incorporation
Partial lesion
5 months
12
55à85
ERLS –
Jobe e
Patte +
incorporation
Tendinopathy
3 months
(trauma at
4th month)
12
70 à 95
Partial tendon
rerupture,
graft incorporation
Partial lesion
B.R.
R.C.
50
2008
55
2005
Patte +
F.G.
54
No
trauma
reported
Jobe +
Patte +,
ERLS
+
T3
G2
Open repair, large
lesion, degenerative
tendon, complete
reducibility, 1 anchor
LHB tenotomy
M.V.
48
2008
Jobe +
T2G
2 LHB
spontaneous
tenotomy
Open repair, large
lesion, degenerative
tendon, complete
reducibility, 1 anchor
A
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Vol. 125 - 1-2 Novembre 2014
B
Figure 5a.
3 months follow up Magnetic Resonance
paracoronal image, T2-weighted Fast
Spin-Echo Fat Suppression: integrity of
the repair with integration between
tendon and scaffold;
degenerated tendon cannot heal even if is performed a technically correct repair and mechanically valid. If the failure
in elderly patients can be tolerated, in young patients with
high functional demands the problem remains open.
In the past 15 years have been studied and tested various
materials to improve healing of the tendon repaired by moving gradually attempts to stimulate a biological response of
host tissues.
The ideal scaffold for rotator cuff repair should comply with
the following ten characteristics:
- Biologically active
- Biocompatible
- Absorbable
- No risk of disease transmission
- Mechanically resistant to traction
- High resistance to seal the suture
- Available in different sizes (size and thickness)
- Easy to handle both in arthroscopic surgery and in
open surgery
- Can be used as augmentation that as bridging
- ready available in the operating room
Among the various materials studied, the human-derived dermal matrices (AHDM) now appear to be able to get closer to
the ideal characteristics of the scaffold while the scaffold of
animal origin and the scaffolds of synthetic origin produced
disappointing results due to frequent tissue reaction events.
Preclinical studies on the AHDM confirmed excellent biologic characteristics as scaffolds, mechanical tests confirmed good mechanical strength and suture retention quali-
Figure 5b.
1 year follow up Magnetic Resonance
paracoronal image, T2-weighted
Fast Spin-Echo Fat Suppression:
Integrity of the repair.
ty, animal studies showed excellent tolerability. MRI studies
showed the reabsorption of the material with an incorporation with the native tendon. Differently from animal scaffold, the human one can be also used for bridging, if needed.
Even if the possibilities to transmit infectious diseases is extremely low, either for the strict control of the human donors
and for the physical and chemical treatments of processation
and conservation, a blood control after 6 months from operation is mandatory to rule out infectious diseases, like B
or C hepatitis or HIV infection. All the analyses conducted
on the patients treated until now gave negative response. At
the moment the AHDM is available in different sizes, but
not in different thicknesses. Another negative aspect is that
AHDM needs to be prepared 24 hours before surgery, and
this aspect can condition and limit the use of that scaffold.
The use of scaffolds with feature augmentation is in our
opinion indicated in the young patient (under age 55) who
has a lesion of the rotator cuff large or massive but repairable (negative hornblower’s signs), with high functional
demands and poor quality of the tendon, in this group of
patients alternative “replacement” surgeries like tendon
transfers or shoulder prosthesis have no indication; in our
experience we have observed that a case with muscle atrophy of the supraspinatus Goutallier 3° prematurely failed
and is currently considering candidates for this surgery
only patients with fatty degeneration with Goutallier <3°.
The group of patients candidate to augmentation represents
about 2-3% of the patients operated for rotator cuff repair
in our Unit in the recent years and less than 1% of patients
with a diagnosis of complete rotator cuff lesion who seek
for treatment in our outpatient ward. These patients deserve
A
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B
Figure 6a.
3 months follow up magnetic
resonance paracoronal:
Integrity of the repair with
scaffold still visible.
Figure 6b.
1 year follow up paracoronal image,
Fast Spin-Echo T2-weighted Fat
Suppression: small and partial articular
leasion with apparent integrity of the
bursal side of the tendon and scaffold.
the wider efforts also on an economic point of view to reduce the incidence of re-rupture. The scaffold with bridging function can be implanted as first responders or in the
treatment of recurrences in patients highly symptomatic under the age of 60-65 years suffering of irreparable injury of
the supraspinatus, with negative horn-blower sign and the
subscapularis tendon valid. In our Department an algorithm
was developed to guide treatment indication on the basis of
patient age, size of lesion, and tendon quality (Tab. 3).
From the point of view of surgical technique we believe
it is technically possible to use the membrane AHDM ar-
throscopically, although we believe that the technique up to
now used by us should be improved; are in fact currently
being studied techniques that facilitate the transport of the
scaffold inside of the shoulder and its fixation to the tendon. The open technique is definitely more reproducible,
especially in the correct tensioning of the scaffold, which is
useful to reduce the mechanical stress acting on the newly
repaired tendon sutures.
MRI is the gold standard for the study of evolution of the
scaffold and its integration. In particular, the sequences in
T2 FatSuppression coronal oblique and sagittal oblique ap-
Table. 3: Symptomatic Rotator Cuff Tear Treatment Algorithm
Lesion size
< 55 ys
55/65-70 ys
> 65/70 ys
Partial
Conservative treatment*
Conservative treatment *
Small
Repair
Large/massive
Repair
Augmentation°
Margin convergence
Irreparable
Tendon transposition
Bridging
Repair
Repair
Margin convergence
Bridging
* at least for a period non less than 6 months
° chronic lesion, degenerative and thin tendon, hypotrophic muscle, Goutallier < 3
Repair
Reverse arthroplasty
if arthropathy
pear to be the most useful; anchor made of PEEK compared
to titanium allow you to see better the MRI healing signs of
the repaired tendon and the incorporation of the scaffold.
Only through close cooperation between research and surgery will be possible to produce a scaffold well tolerated
able to promote tendon healing. Multicentre randomized
controlled studies will clarify the many questions still open
about the type of scaffold to be used, indications and the
surgical technique of application.
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Rational approach to the irreparable cuff tears from “functional” repair to muscle transfer
Fabrizio Campi, Paolo Paladini, Carlo Buononato, Antonio Tartarone,
Giovanni Merolla, Giuseppe Porcellini
Shoulder and Elbow Unit - Cervesi Hospital - Cattolica, Rimini
Introduction
The rotator cuff tears are very frequent diseases affecting 20.7%
of the population, but few patients are symptomatic. Lesions are
more frequent in elderly subjects (especially after 60 age), male,
heavy workers and the dominant limb is most often affected 1.
Rotator cuff tears are often the result of a chronic lesion, associated with myotendinous retraction, loss of elasticity, muscle fatty
infiltration, superior subluxation of the humeral head and, ultimately, osteoarthritis. Acute trauma is a less frequent cause 2,3,4.
A universally accepted definition of massive irreparable injury
to the rotator cuff does not exist. Cofield and Rockwood et al.
defined irreparable a massive tear (>5 cm) that cannot be repaired
for size or retraction 3, 5. Gerber classificates as irreparable a tear
that cannot be reduced without excessive tension with shoulder
abducted to 60°, in a cuff with a massive lesion (> 5 cm or with
two tendons completely broken) 6. The treatment of these lesions
is extremely pleomorphic, ranging from conservative treatment
to arthroscopic debridement with biceps tenotomy, partial suture,
tendon transfer or reverse arthroplasty 4, 7, 8, 9, 10, 11, 12, 13, 14.
IRREPARABILITY CRITERIA
There is no precise algorithm for the treatment of irreparable
rotator cuff tears (RCTs). Surgical treatment should always
be suggested in symptomatic patients, even if a complete
repair is not possible 15, 16. However, there are clinical and
imaging predictors:
Clinical criteria:
in anterosuperior chronic tear with anterosuperior subluxation of the humeral head, head under the skin and pseudoparalytic arm flexion the tear cannot be repaired. In posterosuperior chronic tears the inability to flex the shoulder is
a irreparability sign, it is often not associated with pain and
in this lesions if the arm is abducted passively to about 90
degrees, the patient should not be able to maintain the arm
in the abducted position. A true dropping sign indicates fatty
infiltration of Goutallier 17 stage 2 and cannot be repaired.
Imaging criteria:
a simple anteroposterior X-Ray in neutral rotation may
show a acromionhumeral gap less than 7 mm, indicative of
a irreparable RCTs. The gold standards to assess tendon lesions and muscle fatty
infiltration are the CT and, especially, the MRI 18. A grade 3
or greater indicates irreparable tear of the tendon involved.
Finally, another important factor is the time elapsed between
injury and observation because affect the tissue quality.
Criteria for functional demands:
a RCT may not cause disability when the limb rests on the
side. The problem arises when the patient tries to move the
limb in space. So many patients, informed of the possible
benefits and risks, with poor functional life activities decide
to avoid surgery.
THE FUNCTIONAL REPAIR
The glenohumeral joint is particularly unstable so rotator
cuff represents an essential stabilizer, especially in the mid
range of movement. There is a continuous balance between
agonist and antagonist muscles (like between the infraspinatus / teres minor complex and subscapularis), because
an important role of the entire cuff is to center the humeral
head in the glenoid during deltoid contraction to give the
right fulcrum. On the basis of these notions, Stephen Burkhart dictated five criteria which must have a functional
rotator cuff 19:
1. Force couples must be intact in the coronal and transverse planes.
2. A stable-fulcrum kinematic pattern must exist.
3. The shoulder’s “suspension bridge” must be intact.
4. The tear must occur through a minimal surface area.
5. The tear must possess edge stability.
Based on these insights, Burkhart developed the idea of
“suspension bridge” in order to balance the force couple
without repair the entire rotator cuff, thus providing an anatomically deficient but biomechanically intact shoulder.
The surgical treatment of large or massive RCTs can be
technically difficult, and the results are less reliable20,21,22,23.
The size of the tendon tear and fatty infiltration of the
muscles are strictly correlated to clinical outcomes. In particular, arthroscopic repair of large and massive RCTs can
lead to excellent pain relief and improvement in the ability to perform daily life activities at short-term follow-up,
despite the high rate of recurrent defects; however, at a
minimum follow-up of 2 years, the clinical results seems
to deteriorate. Although many RCTs and the majority of
massive RCTs can be completely repaired to bone, a significant part of these cannot be sutured by these traditional
techniques for the size of tendon tear and the tendon retraction. Numerous operative techniques have been described
for the treatment of massive RCTs with severe retraction
when anatomic repair is impossible, such as arthroscopic
debridement and/or biceps tenotomy, tendon transfers and
grafting, partial repair of the remaining rotator cuff ten-
dons. Burkhart et al first introduced the concept of “functional repair” of the cuff to restore the force couple of the
humeral head and to increase the acromion-humeral distance (AHD). In these arthroscopic procedures, complete
cuff repair was not considered essential to restore the normal biomechanics. The technique allows the repair of the
peripheral margins of the tear to restore the force couples,
anterior and posterior, and the ‘‘suspension bridge’’ system of force transmission in the shoulder. Outcomes are
obviously inferior than in complete rotator cuff repair but
remain stable for AHD in medium-term follow-up. Previous authors have introduced the radiographic evaluation of
the AHD as a standard exam before orthopaedic treatment.
A decreased AHD is the most reliable radiographic finding
for RCTs; an AHD of less than 6 mm has been considered
proof of an RCT and narrowing of the AHD is strictly related to the size of the cuff tear.
We wrote a study to evaluate clinical results and radiologic
changes of AHD in patients treated with arthroscopic partial suture of irreparable tears of the supraspinatus tendon
at long-term follow-up (5 years) 24, 25. Our initial hypothesis
was that arthroscopic partial suture of the cuff leads to pain
relief and functional improvement for patients with restoration of the AHD. In our case-series study, 153 consecutive patients with irreparable RCTs were arthroscopically
treated with partial repair from January 2000 to March
2004. All patients had a symptomatic shoulder treated
conservatively at least for 6 months, 51 with poor results.
Of the patients, 72 (47%) had a posterior-superior lesion
involving supraspinatus and infraspinatus tendons and 38
(25%) had an anterior- superior lesion involving supraspinatus and subscapularis tendons, whereas 43 (28%) had a
global lesion involving infraspinatus, supraspinatus, and
subscapularis tendons. We considered only patients affected by posterior-superior cuff lesion with grade I or II
fatty degeneration of the infraspinatus and grade III or IV
fatty degeneration of the supraspinatus (72 patients). None
of these patients had a Hornblower sign, drop-arm sign,
or pseudo-paralysis of the shoulder. The teres minor was
intact in all cases.
Exclusion criteria were:
• Age older than 70 years
• Fatty degeneration of the infraspinatus of grade III or IV
• Fatty degeneration of supraspinatus of grade 0 or I
• All subscapularis tears
• Previous surgery
• Nerve palsy
• Cuff tear arthropathy (CTA) and arthritis of grade II or
more following the Samilson-Prieto classification
• Inflammatory arthropathy and diabetes or hypercholesterolemia
This study indicates that, in cases of massive RCT with no
subscapularis tear, long-term results of partial repair of the
posterior cuff with covering of the infraspinatus footprint
showed improved outcome scores. In addition, AHD increased minimally and was stable at final follow-up. These
results were superior to those of a simple arthroscopic debridement in active patients. The target patient for partial
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Vol. 125 - 1-2 Novembre 2014
Figure 1
repair of the cuff has good balancing of the cuff without
signs of complete disruption of the posterior cuff, with no
drop-arm or Hornblower sign, and with good function of
the subscapularis.
PECTORALIS MINOR TRANSFER
When an irreparable anterior-superior RCTs occours, a
transfer of the pectoralis minor should be indicated to replace the function of the subscapularis tendon and to restore
the anterior functional sling (Fig. 1). The subscapularis
muscle is the largest and most powerful of the rotator cuff
providing alone about 50% of the rotator cuff strength and
it is important for the elevation of the limb. The rupture of
the subscapularis tendon may also cause an imbalance on
the forces couple acting on the shoulder, causing pain and
disability. The lesions of the subscapularis tendon are uncommon, representing in agreement with the literature 5%
of all lesions of the rotator cuff. Subscapularis injuries usually occur more frequently in association with other lesions
of the rotator cuff, rarely are isolated 26. The reparability of
rotator cuff lesion is influenced by tendon retraction, atrophy muscle and fatty infiltration. Lafosse classification has
an important prognostic value too, some lesions allow an
open or arthroscopic repair with good results that are maintained over time. In addition, the subscapularis tendon repair appears to reduce the stress on a supraspinatus tendon
repaired, protecting it, in anterior superior rotator cuff lesions. The irreparable injury represents a difficult problem
to treat, an option is represented by muscle transfer. One of
the historical options was the transfer of the acromial portion of the trapezius. Recent experiences have shown that
the transfer of the pectoralis major appears to be the most
reliable option in the treatment of irreparable subscapularis
lesions. The transfer of the pectoralis major and pectoralis
minor muscles have been described for the first time by
Wirth and Rockwood in 1997 27, in a study with 13 patients
suffering for recurrent anterior dislocation of the shoulder
associated with an irreparable subscapularis tear. Of the 13
cases, 7 were treated with pectoralis major transfer, 5 with
pectoralis minor transfer and 1 of both. The result to 5 years
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Vol. 125 - 1-2 Novembre 2014
toralis minor transfer would improve short-term functional
outcomes in patients with lesions of the upper portion of the
subscapularis tendon 30. The objectives of this study were
therefore to explore the following:
1. The anatomic feasibility to use the pectoralis minor
tendon as a graft to repair lesions of the upper portion of the subscapularis tendon, given the elongation that the muscle must withstand and the length
of the neurovascular pedicle.
Figure 2
of follow-up was good in 10 patients and poor in 3 cases. In
the work of Wirth and Rockwood the pectoralis minor was
transferred with coracoacromial ligament, before disconnected from its acromial insertion, to compensate the poor
length of tendon. Several authors have used the transfer of
the pectoralis major for the treatment of irreparable lesions
of the subscapularis. Jost et. al in 2003 28 reported the results of the transfer of the pectoralis major performed in 28
patients for a total of 30 shoulders treated with a mean follow-up of 32 months. The results showed an increase of the
CS from 47% preoperatively to 70% postoperatively with
statistically significant increases for pain, anterior elevation
and strength in abduction. In addition the Constant score
value, in patients whit an irreparable injury of the supraspinatus tendon, was minor compared to those with supraspinatus repairable lesions with value respectively of 49 % and
79%. The pre-operative lift-off test was positive in all 30
shoulders and continues to be positive in 23 postoperatively.
Resch et al29 reported their experience in the treatment of irreparable lesions of the subscapularis using pectoralis major
transfer with a modified surgical technique: passing the 2/3
upper tendon of the pectoralis major posted below the conjoined tendon to recreate the ubscapularis anatomy. Results
showed a statistically significant improvement in terms of
pain (mean 1.7 and 9.6, respectively, pre-and post-operative), with an improvement in functional score of 43 points
(23 pre- post). Moreover, no nerve injury was reported as
complication. We decided to investigate whether open pec-
Figure 3
2. The safety of the procedure in relation to the proximity of the brachial plexus and the musculocutaneous nerve.
3. The scope of this technique in improving the function of the (healthy) lower portion of the subscapularis tendon.
After careful debridement of the subscapularis footprint and
of the interval between the coracoid and the humeral head,
the pectoralis minor tendon was detached from the coracoid
with a bone fragment (Fig. 2) to foster the healing process
and avoid muscle wasting. Two stay sutures placed over the
osteotomy were used to drag the pectoralis minor tendon,
which usually reaches the lesser tuberosity without excessive tension, under the coracoid. The pectoralis minor was
then carefully released, the musculocutaneous nerve was
identified and protected, and the tendon was finally sutured
in areas 2 and 3 described by Arai et al 31, 32 (Fig. 3).
Preoperative functional status was evaluated in relation to
a number of outcome measures that included active ROM
as part of the Constant score, total Constant score, Simple
Shoulder Test (SST) score, liftoff test, and belly-press test.
There were no cases of musculocutaneous nerve or brachial
plexus injury or graft failure. Active forward flexion improved from 127° to 177°; external rotation with the arm
on the side declined by 11°. The Simple Shoulder Test score
improved by 5 points and the Constant score by 41 points,
although the strength subscore did not rise significantly.
This study showed that it is anatomically feasible to use the
pectoralis minor tendon as a graft to treat upper subscapularis lesions; the procedure is safe for brachial plexus and
musculocutaneous nerve injury; and pectoralis minor transfer can improve shoulder function and provide pain relief
in patients with Lafosse grade III subscapularis tears, likely
through a tenodesis effect, even in the the presence of irreparable supraspinatus tears.
LATISSIMUS DORSI TRANSFER
Massive and irreparable postero-superior cuff tears actually represent a difficult problem for treatment. Combined
latissimus dorsi transfer and teres major transfer were used
by L’Episcopo in 1934 to regain external rotation in obstetric plexus paralysis 33. Gerber in 1988 34 was the first to use
latissimus transfer to treat massive and irreparable posterosuperior cuff tears in active patients with pain, weakness or
loss of overhead elevation, with an external rotation lag sign
and with integrity of subscapularis tendon. In the original
tecnique patient was in beach-chair position, through two
incisions and the anchoring point of the tendon was there
by the tip of great tuberosity. The results in patients undergone to latissimus dorsi tranfer show an improvement in the
shoulder function, range of motion, strenght and pain relief.
Subscapularis muscle insufficiency, advanced teres minor
muscle atrophy and need for revision surgery were correlated with poor functional outcomes in some studies35, 36.
A more complete discussion of the topic will be developed
in another section of this text.
CONCLUSION
To determine the best treatment for each individual, adequate radiologic images and a careful examination of an
experienced shoulder surgeon are required. Treatment options and the results depend on many factors, not least the
rehabilitation team.
Despite all the previous options, massive irreparable rotator
cuff tears are difficult to manage, treat effectively and with
a limited goal.
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11. Klinger HM, Spahn G, Baums MH, Steckel H. Arthroscopic deb
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Bone Joint Surg Am. 2007; 89:747-57
13. Bond JL, Dopirak RM, Higgins J, Burns J, Snyder SJ. Arthroscopic
replacement of massive, irreparable rotator cuff tears using a
GraftJacket allograft: technique and preliminary results. Arthroscopy. 2008; 24:403-409. e1
14. Cordasco F, Bigliani L. Large and massive tears: technique of open
repair. Orthop Clin North Am 1997; 28:179-93
15. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A.
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Partial repair of irreparable rotator cuff tears. Arthroscopy 1994;
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16. Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression.
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17. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty
muscle degeneration in cuff ruptures. Pre- and post-operative
evaluation by CT scan. Clin Orthop Relat Res 1994; 304:78-83
18. Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder
Elbow Surg 1999; 8:599-605
19. Burkhart SS, Athanasiou KA, Wirth MA Margin convergence: a
method of reducing strain in massive rotator cuff tears. Arthroscopy. 1996; 12:335-8
20. Bigliani LU, Cordasco FA, McIlveen SJ. Operative repair of massive
rotator cuff tears: long-term results. J Shoulder Elbow Surg 1992;
1:120-30
21. Cho NS, Yi JW, Rhee YG. Arthroscopic biceps augmentation for
avoiding undue tension in repair of massive rotator cuff tears. Arthroscopy. 2009; 25:183-91
22. Duralde XA, Bair B.: Massive rotator cuff tears: the result of partial
rotator cuff repair. J Shoulder Elbow Surg. 2005; 14:121-7
23. Rhee YG, Cho NS, Lim CT, Yi JW, Vishvanathan T. Bridging the gap
in immobile massive rotator cuff tears: augmentation using the
tenotomized biceps. Am J Sports Med. 2008; 36:1511-8
24. Porcellini G., Campi F., Castagna A., Paladini P. Functional partial
cuff repair: five years follow-up. Shoulder Arthroscopy & Arthroplasty - Current Concepts Tome I. Editor: Pascal Boileau Nice
Shoulder Course 2012
25. Porcellini G, Castagna A, Cesari E, Merolla G, Pellegrini A, Paladini
P.: Partial repair of irreparable supraspinatus tendon tears: clinical
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Elbow Surg. 2011; 20:1170-7
26. Karas SE, Giachello TL.: Subscapularis transfer for reconstruction
of massive tears of the rotator cuff. J Bone Joint Surg Am 1996;
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27. Wirth MA, Rockwood CA Jr.: Operative treatment of irreparable
rupture of the subscapularis. J Bone Joint Surg Am. 1997; 79:72231
28. Jost B, Puskas GJ, Lustenberger A, Gerber C. Outcome of pecto
ralis major transfer for the treatment of irreparable subscapularis
tears. J Bone Joint Surg Am. 2003; 85:1944-51
29. Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis
major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am 2000; 82:372-82
30. Paladini P., Campi F., Merolla G., Pellegrini A., Porcellini G. Pectoralis minor tendon transfer for irreparable anterosuperior cuff
tears. J. Shoulder Elbow Surg. 2013; 22:e1-5
31. Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008; 24:997-1004
32. Arai R, Nimura A, Yamaguchi K, Yoshimura H, Sugaya H, Saji T,
Matsuda S, Akita K. The anatomy of the coracohumeral ligament
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Surg. 2014; S1058-2746
33. L’Episcopo JB Tendon transplantation in obstetrical paralysis. Am.
J Surg 1934; 25:122-5
34. Gerber C, Vinh TS, Hertel R, Hess CW Latissimus dorsi transfer for
the treatment of massive tears of the rotator cuff. A preliminary
report. Clin Orthop Relat Res. 1988; (232):51-61
35. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for
the treatment of irreparable rotator cuff tears. J Bone Joint Surg
Am 2006; 88:113-120
36. Habermeyer P, Magosch P, Rudolph T, Lichtenberg S, Liem D.
Transfer of the tendon of latissimus dorsi for the treatment of
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J Bone Joint Surg Br 2006; 88:208-12
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Arthroscopically-assisted latissimus dorsi transfer
Enrico Gervasi, Alessandro Spicuzza
Ospedale Civile di Latisana, Udine
INTRODUCTION
Epidemiology
The majority of the rotator cuff tears can be repaired with surgery,
either open or arthroscopically.
Although relatively to the total amount the percentage of the irreparable lesions is low, these are frequently symptomatic, as
much as to require a solution: surgical, rehabilitative, or both.
The frequency of the rotator cuff lesions increases with age; this
is due to biological laziness of the tendon, age-related, or due
to toxic factors (e.g. smoke), or even to the damage consequent
to mechanical stresses: local factors (subacromial impingement)
or external ones (heavy working activities or strenuous sports).
Acute post-traumatic onset of symptoms, mainly pain and loss of
function, typically reveals the extension of a pre-existing injury,
even if asymptomatic. The resultant functional disability is a true
ataxia, with loss of spatial control of the hand in the most severe
cases.
Assuming that the percentage ratio between massive irreparable
tears and the repairable ones does not vary with the age, the majority of lesions occur in the elderly population; its patients’ need
is to reduce pain and improve the function for the daily-live activities. The goal for young people is often challenging, aiming to
achieve power for re-start a stressful manual job. The heterogeneity among different needs and expectations gives rise to different
treatment options, although the massive tears can be similar to
each other.
History
The surgery of the rotator cuff in the 80s enters a phase of
evolution of orthopaedics, where immobilization, repeated
infiltrations of corticosteroids (the same way as tonics),
manipulation, give way to the scalpel.
The surgeon is careful to repair the anatomical damage
of the rotator cuff; only after he will shift the attention to
restore the function rather than to repair the “hole in the
tendon.” The “evidence based” medicine, the attention in
the analysis of the results, checked by imaging, demonstrate the ineffectiveness of techniques of direct repair of
the rotator cuff documenting the failures or the recurrences
in many massive injuries, even when at the time of surgery
the tendons appear firmly repaired to the bone. The role of
Figure 1:
position of the transposed
latissimus dorsi tendon on the
greater tuberosity
biology in the healing process is getting to be understood;
the functional one of each motor unit throughout the kinetic chain is analysed. The goal of the surgery is aimed at
restoring the function rather than to repair the injured tissues. The search for effective alternatives to direct repair
leads to consider the muscle-tendon units transfer, used in
the past to treat neurological injuries, obstetrical paralysis
consequences of dystocic births. In these the external rotation is impaired, the fifth cervical root being more often the
one involved. In this affection the internal rotators become
predominant over the external rotators, resulting in the inability of the patient to bring the hand to the mouth or neck.
The L’Episcopo surgical technique 1, that proposed balancing the postero-superior rotator cuff deficit, is forerunner
of modern transpositions: it provides for the separation of
both tendons, latissimus dorsi and teres major, off from
the edge of the bicipital groove and their reinsertion to the
diaphyseal cylinder, rotated in the opposite direction: from
medial and posterior to lateral and anterior. At the end of
the 80s Gerber remakes it 2, modifying and adapting it to
the repair of the rotator cuff; in 2003 we translated it for
use in endoscopy 3. Why does the arthroscopic choice? The
arthroscope reaches any district, better than the scalpel and
with less damage to the tissues being passed through. This
principle led our group to conceive and establish arthroscopic techniques for “at distance” tendon transfers. The
deltoid sparing thus obtained also guarantees a way out in
case of failures, when the pathology rises towards a cuff
tear arthropathy and the joint replacement with a reverse
prosthesis becomes necessary. Finally we abandon the
idea of using part of the transferred tendon to close the
hole, fixing it to the residual medial cuff as proposed by
other authors until then; we fix it, vice versa, to the most
anterior part of the greater tuberosity in an autonomous
way, thus acting as stabilizer of the humeral head, even
passively Figure 1. In a similar way to the constraint of a
reverse prosthesis, this favours the action of the deltoid;
only partially the transposed latissimus dorsi acts as active
external rotator.
METHODS
Patient selection
The ideal candidate for surgery is the patient with massive,
irreparable, rupture of the rotator cuff with a limitation of
the function of the upper limb incompatible with the dailylive activities. If local anaesthetic injected into the subacromial space act as painkiller regaining function, then a
different, limited procedure as the biceps tenotomy and the
smooth contouring of the greater tuberosity can be considered. It could be defined that the muscle-tendon transfer is
therefore recommended when is impossible or inadequate
by direct repair to recover the function, lost and functionally essential, of the native rotator cuff. The function that
has to be resuscitated depends on topography of the cuff
lesion. The brain is set by function rather than by activity
of individual muscles. The transposed tendon is not affected by regressive phenomena (degeneration), as conversely
happens to the cuff tendons working in the subacromial
space. The success of the “tendon-transfer surgery” is less
influenced by the typical “lazy biology” of the torn cuff.
The age also is not crucial in the decision-making: other
factors as important as tendon vitality should be considered: patient activity, his involvement in recreational sports
(if any), the expectations. Furthermore is important the patient’s intellectual capacity to understand objectives and
limits of the rehabilitation program, in order to take part to
one, lasting several months. It is based on reprogramming
the neuro-motor skills, with stimulation of the transposed
unit. At the early rehabilitation phase is used the mechanical improvement given by the tenodesis effect of the transfer. However patients “over 70” must be carefully drafted
to a complex surgery also in terms of rehabilitation, since
the implantation of a reverse prosthesis is a viable alternative, which requires a simpler and shorter rehabilitation
program. The choice between the two procedures beyond
the boundary of the age of 70 years, when the prosthesis is rarely indicated, is played on other factors: integrity
of cartilage, biological age (transfer indicated in youths),
subscapularis integrity or reparability. The damage of articular surfaces orient toward the prosthesis. Coexisting lesions of the subscapularis and previous surgeries can lead
to significant improvement despite the final outcome is
less satisfactory compared to the average.
Some patients have a large size or massive cuff lesion
functionally compensated.
If at medical examination their concern is pain, whilst the
function is preserved, the long head of biceps tenotomy
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can be a viable solution, even palliative. In this case the
transfer is rarely the procedure of choice, because it lacks
the pre-requisite of loss of the essential function. These
shoulders have a relatively stable humeral epiphysis. The
contact surface between humerus and the acromion is the
fulcrum acted by the deltoid to elevate the limb. The radiographic examination performed in patients with massive rupture of the rotator cuff shows different patterns of
images: by the cranial migration of the humeral head with
minimal signs of bone adaptation to others in which the
acromion and its anterior osteophyte, large, gets to contact
the humeral head, thus limiting either the humeral migration and the loss of relation between its centre of rotation
and the centre of the glenoid. The intact acromial arc opposes to the cranial migration of the humeral head; thus,
preventing the excessive shortening of the deltoid muscle
fibres, the linear movement produced by the contraction
shifts in a rotational one. The described effect is greater
the more congruent are the surfaces of the neo acromialhumeral articulation, modified by taking an acetabular pattern. Even the remaining rotator cuff takes advantage of
it, not depriving muscle strength to the rotations, which
would be spent, vice versa, by the humeral head centring
action. This explains how the acromiplasty sometimes
leads to a functionally catastrophic result: the shoulder
with weakness in elevation becomes pseudo paretic following the surgery. The transformation towards the neocotyloid appearance is given from wear by friction of the
bone surfaces, related to their mutual movement. Patients
with valid movement and massive cuff tear can be expected to show at radiographic examination that “compensatory” aspect of centred glenoid wear, rather then off centre,
light of the movement itself. Individuals with acute onset
of severe deficit are often the ones affected by traumatic
extension of an existing lesion; it happens in the absence
of gradual adaptation, thus the bone surfaces are anatomically regular. According to some authors, the reduction of
the humeral-acromial space and cranial migration of the
humeral head is a contraindication to tendon transfer; they
report that it cannot contribute in any way to the distal
re-centering of the humeral head. Surgery is contraindicated when the humeral-acromial contact determines bone
changes, humeral, of the glenoid (cotyloid aspect) Figure 2
or acromialis. The rounding of the greater tuberosity after
all is acceptable.
The impossibility to repair the subscapularis tendon gets
the latissimus dorsi transfer ineffective. This rule has anecdotal exceptions, whose biomechanical justification (why
sometimes the transposed tendon is still effective) is not
yet clear. The combined transfer, anterior and posterior, is
definitively rare in the literature and the reported results
are unsatisfactory. It requires the about impossible reorganization of a motor engram reprogramming either, the
external and internal rotation.
The transfer is not suitable for patients who need to recover
the function of the limb for a repetitive manual work: because the force is only partially restored, is exhaustible, has
no resistance to fatigue or to cyclic loading. The weight of
the limb itself, when significant, adversely affects prognosis. I give the patient the example of those who suffer a serious heart attack: the recovery, even when good, is never
Figure 2:
cotyloid aspect of the
gleno-acromial arch
complete and the considerable effort must be avoided.
The goals of surgery, limitations, as well as the possible
complications should be discussed during the visit with the
patient.
Choosing the graft
Several solutions have been suggested to treat chronic
rotator cuff deficiency: debridement4, partial rotator cuff
repair5, subscapularis tendon transfer6, transfer of the subscapularis and teres minor7, transfer of the long head of
triceps8, teres major transfer9,10, interposition of a biceps
tendon autograft11, freeze-dried rotator cuff allograft12, and
use of synthetic grafts13.
The muscle-tendon unit candidate to be transferred (substitute) must replicate the lost function.
The suitability depends on the amounts of certain qualities: strength (size and the plane on which lies the vector),
the excursion, and synergy, present when substitute and
replacing are naturally agonists for the function to be vicariate. Besides these is specially relevant the accessibility, which makes possible withdrawing and transferring the
graft with the lowest damage to healthy structures to pass
through and with the lowest risk of damage to vessels and
nerves. By the term “consistent” we mean the structure
that has characteristics suitable to the specific transposition. The study of Herzberg shows an analysis essential for
the choice of the graft, the one among various transplants
in use today, ideal for to take place of specific functions of
the torn cuff. The bias is that this study is based on preparations obtained from cadavers. Possible substitutes are
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categorized into three series: thoraco-scapular, thoracohumeral and scapular-humeral. Of each muscle are analysed the following characteristics: the length at rest, the
potential range of elongation in cm. and the relative basal
tension, related to a ratio of its sectional area and that of
the whole group of muscles acting on the shoulder. The
relative basal tension and the excursion of the units to be
replaced are compared with those of the transfer, to estimate its suitability to the new work. The analysis considers, however, the action on just two planes: the sagittal section, for the measurement of the cross-sectional size of the
muscle belly, and the coronal one, for to assess length and
elongation. The third plane of the space, where the vector
of force lies on, is not considered. Some of the energy produced by the graft is in fact is dissipated by spready forces,
inconsistent with those to be replaced. From this study it
appears that the problem lies in the strength rather than in
the intended stretchability of the graft. Let us now consider
the latissimus dorsi, isolated or combined with the teres
major pro posterior cuff. The latissimus dorsi isolated lacks
basal relative tension, recoverable with the simultaneous
transfer of the teres major. Our choice, of transposing the
latissimus dorsi isolated, is given by the limited elongation
capacity of the teres major. If the teres major is transferred
as a unit along with the non-autonomous latissimus dorsi,
the teres restrains the possibility that the latissimus reaches
the very anterior area of the greater tuberosity, wrapping
itself on this as on a flywheel. The volume of both muscle
bellies, moreover, would be likely to compete for space
with the circumflex nerve, putting it at risk of a canalicular
disease. In conclusion, the latissimus dorsi isolated seems
at the moment the more “consistent” transfer for massive
“irreparable” postero-superior cuff tears.
The transfer of the latissimus dorsi
assisted by endoscopy
Patients eligible for transfer of the latissimus dorsi are
those set by the posterior cuff deficiency. When associated
the lesion extends to the subscapularis and has to be repaired. Absolute contraindications to transfer are: humeral-scapular evolved arthropathy, the chronic dehiscence
and irreparability of the deltoid, the axillary nerve palsys.
The preoperative diagnostic imaging includes a series of
radiographic projections: AP “normalized”, “outlet” of
Lamy and axillary view. Examination reveals, if any, signs
of arthropathy (glenohumeral space reduced) and acetabular transformation of the acromial arch, with changes of
the upper glenoid profile. Those factors make this surgery
contraindicated. Magnetic resonance imaging is routinely
performed: it evaluates the tendon defect on coronal and
axial planes; the sagittal plane allows to get the occupation
index of the scapular fossa (Zanetti) and the degree of fatty
infiltration (Thomazeau) Figure 3, expression of the trophism of the muscle and of the eventual irreversibility of
the changes. When planning is important to know whether
you should repair the subscapularis: that because the setup
of the operating room is then set by placing the patient in
the “ modified beach chair “ rather than in lateral decubitus
position , as a rule. The physical examination assesses the
integrity of the deltoid and the presence of rigidity, this
relatively frequent in patients who come to the transfer
as revision of a previous surgery or in trauma cases. The
expected results in revisions are less favourable. The stiffness, even inconspicuous, prejudices the possibility of humeral re-centring with respect to the glenoid and then the
functional effectiveness of the transfer.
Postoperative treatment
The postoperative protection of the transfer follows the
general rules of the surgery for massive rotator cuff injuries. Before surgery and in preparation to it, patients
are instructed to perform analytic exercises for the various muscles. After the surgery, because of pain (however
slight) and awe to use anatomical elements involved in the
surgical trauma, learning would be very difficult.
During the first period the active movement is under strict
control. The adoption of a mini-sling in 15° of external
rotation or an abduction pillow is continued for 6 weeks.
Meanwhile patients are allowed for few pendulum exercises to limit adhesions between teres minor and deltoid.
Elbow flexion and hand exercises are encouraged, as well
as those for the scapulothoracic articulation, trunk and
lower limbs. The maintenance of kinetic chains of joints
not involved by the surgery promotes functional recovery.
The rehabilitation in water (hot pool) is useful since the
sixth week and throughout the period of functional recovery. The exercises are performed with both limbs to use
the “mirror” effect, favouring the trophism and the recovery of motor engram. In the rehabilitation program the
limb lifting against gravity is carried out gradually. The
patient starts the exercises lying on the unoperated side,
the back tilted 30 degrees backward, in order to place the
glenoid parallel to the ground and thereby reducing shear
forces acting on the humeral head. The elbow maintained
is flexed at first, reducing the lever arm. The gradual erection of the trunk gets ready to perform exercises in a full
upright position. Rehabilitation takes many examples from
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Vol. 125 - 1-2 Novembre 2014
Figure 3:
oblique sagittal
MR view
shows fatty
degeneration of
posterior superior
rotator cuff (a:
supraspinatus
muscle, b:
infraspinatus
muscle, c: teres
minor muscle)
the actions of everyday life to motivate the patient. Functional recovery takes place ranging from a few months to
a year after surgery. The transposed latissimus dorsi gets
ability to work actively, as shown in the transpositions carried out for obstetric paralysis, in which it is moved around
the diaphyseal cylinder.
RESULTS
Results and complications
We evaluated a first cohort of 25 patients who underwent
to latissimus dorsi transposition assisted by endoscopy,
performed by the senior author, with at least three years
of follow up (data being published). In this series there
were no major complications, as conversely recorded in a
more recent one (two neurological involving the circumflex nerve: one primary, one subsequent to infection and
Figure 4:
Humeral head re-centered.
a) preoperative X-ray
b) postoperative X-ray
debridement). The infection occurred in one patient affected by acne. Few patients developed blood or serous effusion in the area subject to release of the latissimus dorsi
muscle. Superficial tissues for a first time after the release
do not adhere to the muscle, thus leading to “third space”
progress. Our attention to coagulate the vessels crossing
distally from muscle to subcutaneous made negligible this
complication. When it occurs, the drainage through a skin
incision in the most distal part of the collected fluids solves
the problem.
As already reported in the literature for the revision of
previous failed cuff surgery gets less favourable results,
especially after large acromioplasty. The integrity of the
subscapularis is crucial although some patients with a tear
found to be irreparable at the time of surgery equally benefit from the procedure. The weight of the limb seems to
play as disadvantage. The postoperative centring of the humeral head over the glenoid, even if partial, is favourable
to functional recovery. Postoperative radiographic study
quantifies it Figure 4. The comparative long term rx studies show the reduction of the space humerus-acromial over
time and the progression of arthritic changes14. These also
show an impression on the tuberosity, as it would be carved
by the action of the transposed tendon. The humeral centring is greatly favoured by the capsuloligamentous release
we currently perform extensively. Gain about the external
rotation strength is moderate. In conclusion we consider
the technique of latissimus dorsi transfer assisted by arthroscopy as the procedure of choice for the irreparable
posterior superior rotator cuff tears functionally disabling.
The basal tension of the latissimus dorsi is insufficient to
replicate the whole force of the postero-superior cuff; the
position we choose for the fixation improves elevation
more than external rotation. The combined transfer with
that of the teres major as a single not separated unit, limits
the graft possibility of sliding and crowds the passage from
the armpit to the subacromial space. It increases the risk of
compression of the circumflex nerve or need for fixing the
graft at back site with respect to the desired point.
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Vol. 125 - 1-2 Novembre 2014
REFERENCES
1 L’Episcopo JB. Tendon transplantation in obstetrical paralysis.
Am J Surg. 1934; 25:122–125
2 Gerber C, Vinh TS, Hertel R, Hess CW Latissimus dorsi transfer
for the treatment of massive tears of the rotator cuff. A preliminary report Clin Orthop Relat Res 1988; 232:51–61
3 Gervasi E, Causero A, Parodi PC et al Arthroscopic latissimus
dorsi transfer, Arthroscopy 2007; 23:1243.e1-4
4 Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr. Debridement
of degenerative, irreparable lesions of the rotator cuff. J Bone
Joint Surg Am 1995; 77:857-66
5 Duralde XA, Bair B. Massive rotator cuff tears: the result of partial rotator cuff repair. J Shoulder Elbow Surg 2005; 14:121-7
6 Cofield RH. Subscapular muscle transposition for repair of
chronic rotator cuff tears. Surg Gynecol Obstet 1982; 154:66772
7Neviaser JS. Ruptures of the rotator cuff of the shoulder. New
8 Malkani AL, Sundine MJ, Tillett ED, Baker DL, Rogers RA,
Morton TA. Transfer of the long head of the triceps tendon
for irreparable rotator cuff tears. Clin Orthop Relat Res 2004;
428:228-36
9 Wang AA, Strauch RJ, Flatow EL, Bigliani LU, Rosenwasser MP.
The teres major muscle: an anatomic study of its use as a tendon transfer. J Shoulder Elbow Surg 1999; 8:334-8
10 Celli L, Rovesta C, Marongiu M et al Transplantation of teres
major muscle for infraspinatus muscle in irreparable rotator
cuff tears, J Shoulder Elbow Surg 1998; 7:485-490
11Neviaser JS. Ruptures of the rotator cuff of the shoulder. New
12Neviaser JS, Neviaser RJ, Neviaser TJ. The repair of chronic
massive ruptures of the rotator cuff of the shoulder by use
of a freeze- dried rotator cuff. J Bone Joint Surg Am 1978;
60:681-4
13 Ozaki J, Fujimoto S, Masuhara K, Tamai S, Yoshimoto S. Reconstruction of chronic massive rotator cuff tears with synthetic
materials. Clin Orthop Relat Res 1986; 202:173-83
14 Hamada K, Fukuda H, Mikasa M, Kobayashi Y Roentgenographic findings in massive rotator cuff tears. A long-term observation, Clin Orthop Relat Res 1990; 254: 92-6
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The rotator cuff irreparable tears:
latissimus round muscle transfer
Ferdinando Odella, Simona Odella*
Istituto Clinico San Siro, Milano
* Ortopedia Traumatologica per la Chirurgia della Mano, Istituto Ortopedico G. Pini, Milano
INTRODUCTION
ABSTRACT
The factors that affect the type of treatment of lesions of
the rotator cuff are the patient’s age the functional requirements, the painful symptoms and the type of lesion.
The repairability of the lesion depends on three main elements:
The transfer of the tendon of the muscle large round is one of the
surgical solutions used in the treatment of the massive irreparable
supero-posterior rotator cuff tears. The purpose of this retrospective study is to report the long-term validity of the results with
the change in the treatment characterized by suturing the tendon
of the subscapularis tendon also transferred intact as well as the
greater tuberosity.
• the extension of the lesion, we distinguish partialthickness tendon injuries (bursal, intratendinous,
joints) and those with full-thickness which we believe should not be evaluated on the basis of cm
but in view of the number of tendons involved, we
define a lesion as massive if affecting two or more
tendons, you must also consider the location of the
lesion which, according to Patte1 can be higher, superior- posterior, superior- anterior or massive;
• retraction of the tendon which we evaluate the entity in three grades:
Grade 1: slight retraction, occurs only in small
tears;
Grade 2: Average tendon retraction, (figure 1) the
tendon still partially covers the head of the humerus and the retraction is at the level of the acromioclavicular joint;
Grade 3: severe tendon retraction, the humeral head
is uncovered and the tendon is retracted to the glenoid;
but the most important element is
• fixity or elasticity of this retraction, we recognize
three stages
Stage 1 : The cuff injury is recent, the tendons are
still healthy and mobile, the muscle retains its function and the joint is stable;
Stage 2 : the injury occurred more than six weeks,
the tendons are hypomobile but recoverable in anatomical site in spite of being already an initial degeneration of the tendon and muscle, the joint has a
dynamic instability;
Stage 3: the lesion is deep-rooted, the retraction of
the tendon is fixed, the muscle and tendon tissue
is gone to meet fatty infiltration, the glenohumeral
joint is unstable, in this case it is not possible to
make a direct repair but you must perform a muscle
transposition.
The quality of the tendon tissue and of the muscle belly
depends on the fatty infiltration, Goutallier 2 in 1996, identifies five stages according to the relationship between the
degenerated muscle volume and the volume of healthy
muscle. Because there is a good result functional muscle
degeneration must not be higher than the second stage
(Figure 2).
Ide3 in agreement with Romeo4 considers that the extension of the lesion, if it exceeds 5 cm, results in clinically
unsatisfactory results, in fact, in our opinion is not the extent of the lesion but its fixity the element that determines
the repairability of the lesion while the functional outcome
depends on the quality of the tendon tissue and of the residue muscle trophism.
Fuchs5 observed that, in the cuff repaired that had a muscular atrophy of tendons involved in the lesion, this condition does not regress, but in case of rupture of the tendon
of the supraspinatus atrophy is stable if the injury heals in
case of involvement of the subscapular tendon, although
healed after repair, not just the atrophy does not regress
but increases also the fatty infiltration of the infraspinatus
tendon that was not involved in the lesion. The authors do
not exclude the possibility of suffering neurological due to
technique of repair.
Figure 1: immagine
RMN che evidenzia
retrazione del
tendine che
parzialmente ancora
ricopre la testa
omerale
Figure 2: immagine
RMN che evidenzia
degenerazione
grassosa di 2 grado
secondo Gouttalier
Object of our study are the lesions that can not be repaired,
the massive tears with severe fatty infiltration of the muscle bellies, in these cases, in patients older than 70 years,
you can perform muscle transfers: if the lesion is posterior superior is necessary that the front wall, represented
mainly by the subscapularis is intact to have a good focus
during the elevation of the limb. If possible it may be useful to anchor the tendon transferred to the tendon of the
subscapularis muscle; if the lesion is superior anterior we
are used to transpose the anterior tendon of the pectoralis
major muscle.
MATERIALS AND METHODS
From 1998 to 2012 142 patients underwent surgical treatment (transfer of large round muscle in superior- posterior
rupture massive irreparable rotator cuff). The median age
was 67.8 years in the female population, 71.4 years in male
population. Males constitute 60 % of the population. At
mean follow-up of 7 years, the constant total score is equal
to 66, the front elevation 158 degrees external rotation in
adduction 41 degrees, 66 degrees external rotation in abduction, and the strength of 2.4 according to the cs.
Patients who have undergone surgical treatment of great
Figure 3a, b: quadro RMN lesione
massiva della cuffia dei rotatori, si
osserva retrazione tendinea alla glena e
degenerazione grassosa di 3 gradi secondo
Gouttalier
A
B
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Vol. 125 - 1-2 Novembre 2014
round transfer had an irreparable rupture of the rotator
cuff tendon of the superior- posterior with subscapularis
intact; were excluded unmotivated patients with moderate
pain and age over 75 years, in addition to patients with
glenohumeral osteoarthritis, retractile capsulitis, or neurological problems.
Surgical treatment was performed in the open surgery with
two skin incisions, postoperative treatment provided by a
sling immobilization for 40 days at 45 degrees of abduction, followed by a re-education for 6 months.
The transfer of the latissimus round requires as a necessary
condition for the integrity of the tendon of the subscapularis muscle. We recently rechecked the 10 patients in our
series and subjected to evaluation as well as clinical, electromyographic and all patients were satisfied with regard
to pain and function even if the recovery of strength was
not equal to the contralateral limb, and in eight of the ten
patients examined, we observed electromyographic activation of the muscle passed during external rotation with
limb adduct the hip (Figg. 3-5).
DISCUSSION
For massive lesions according to Patte and Elman we intend lesions involving two or more tendons.
To choose a proper treatment we must consider several important parameters, such as: type of injury, age and activity
of the patient and the patient’s motivation.
To evaluate the type of lesion should consider the following elements: the location, the extension and the form, the
retraction of musculotendinous and quality of the muscle
tissue.
A retraction of the tendon to the glenoid make it very difficult if not impossible to complete repair of the lesion,
also a muscle fatty degeneration (visible by NMR) of 3°
- 4° degree by Goutallier is a negative prognostic factor.
Therefore, in these conditions a massive lesion can be considered as irreparable.
Different types of treatment for massive lesions have been
described: the conservative treatment, the simple open or
arthroscopic debridement (5. 6), generally associated to an
acromioplasty; partial repairs; tendon allograft and synthetic, and the muscle transfers.
Many patients with chronic massive lesions can be treated
conservatively with success through modification of activities, NSAIDs, physiotherapy and infiltration of corticosteroids in the sub acromial space. Bokor et al6 have noted
an improvement between 50 % and 85 % of patients treated conservatively. Many studies on the other hand showed
a negative correlation between the number of preoperative
infiltration of corticosteroids and the results obtained after
repair of tendon injury.
Rockwood in a 1984 study reported satisfactory results in
the treatment of full-thickness lesions with debridement
and subacromial decompression in the open air7. Always
Rokwood in 19958 demonstrated that the simple debridement and acromioplasty in massive lesions irreparable
gave satisfactory results, but at a distance of time, follow
up > 5 years, tended to deteriorate. Several authors have
obtained similar results using a similar technique but al-
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Vol. 125 - 1-2 Novembre 2014
Figure 4a, b: riscontro
intraoperatorio della lesione
massiva della cuffia dei
rotatori, la testa è scoperta il
tendone retratto, sutura del
tendine trasposto
A
ways without arthroscopic repair of the lesion5.
In contrast to other authors have described unsatisfactory
results in the long term with the only decompression and
debridement9-12. A study of Melillo et all, 199713 showed
that in a group of 52 patients, 27 treated by repair of tendon injury and 25 with debridement and decompression,
only 8% of patients treated with the latter procedure was
satisfied, compared to 87 % of patients who underwent
cuff repair.
This type of treatment can be taken into consideration for
elderly patients with few requirements, in which the test
Neer with subacromial injection of anesthetic is able to
resolve the pain with improved function. You can also perform the resection and tenodesis of the long head of the
biceps, thereby eliminating the biological causes of pain
(inflammatory synovial tendon reaction) and the mechanical action of the medial displacement of the clb against the
tendon of the subscapularis (Burkart 1996)10.
To achieve good results in the treatment of massive injuries, tendon repair should be respected by prognostic factors set out above. In a study conducted by Wolf et all. in
2000 14, we wanted to demonstrate just that the quality of
the results is directly proportional to the respect of preoperative prognostic factors. To this were included in the
study patients with a tendon degeneration not exceeding at
stage 2 of Goutallier, absence of pseudoparalysis, absence
of anterior-superior subluxation of the humeral head. The
results were positive, with a mean postoperative Constant
score of 85.5.
The results obtained by different authors who have not
taken account of prognostic factors have not been up to
expectations .
Lately in elderly patients with irreparable lesions with involvement of the subscapularis and cuff tear arthropathy
space is treated with reverse prosthesis. While, in irreparable injury posterior superior muscle transfers represent a
B
true palliative treatment, as they use muscles of the shoulder joint in order to recover the functions of stability and
movement of his cuff muscles degenerate irreversibly.
The indication to muscle transfers occurs in the presence
of massive lesions or relapsed chronic pain in patients with
active and severe functional deficit highly motivated to
functional recovery.
By contrast, in the presence of joint stiffness, severe bone
and joint abnormalities of the glenohumeral joint, insufficiency of the deltoid muscle and nerve damage, muscle
transfers are contraindicated.
Transfers muscle can be divided into local and regional.
The first uses the remaining tendon tissue by rotating to
cover the head using subscapularis. (Cofield 1982)15 or the
small round (Paavolainen 1988)16. With this type of treatment, there is the risk of clinical worsening (loss of elevation of the limb) if the tendon insertion in the new location
does not heal.
Debeyre, Patte, Goutallier 17 suggest a muscle-tendon advancement of the elements of the rotator cuff.
The reinsertion of tendon after lateral movements of the
muscle bellies of the supra and infraspinatus, creates a
technique that restores the ‘ anatomy as close to normal
as possible.
The results of this method are questionable and there are
conflicting opinions in the literature. Patte 1 reported good
results in 41% of patients, 11 % Walch (1992)18 and Patte
Goutallier 17 36%.
The best results are obtained when the humeral head is
centered with moderate muscle degeneration.
Experimental studies on cadavers carried out by Warner
and Gerber (1992)19 show that this technique allows a limited traverse and risk to damage the neuro-muscular structures. Combes and Mansat 20 think that this treatment is illogical because it uses muscles retracted and not working.
We agree, in fact the fibrous structure - muscle, in the case
Figure 5a, b:
clinica pre e post operatoria
A
B
of chronic injury, is retracted and little expandable and the
possible muscle fatty degeneration makes this technique
useless.
In the case in which the trophism is good it is supposed
that the lesion is recent and the mobilization of the muscletendon is possible with a capsular release.
The regional transfers can use a deltoid flap (AugereauApoil 198521, Takagishi 22, Vandenbussche (2004)23, the
trapezius (Mikasa)24, the muscle angle of the scapula (Celli
1986) pro supraspinatus. The big round (Combes - Mansat
1993)20 and the latissimus dorsi (Gerber 1987) 25,27 can be
used to vicariare the infraspinatus.
The pectoralis can be used in the rare, but serious degeneration of the subscapularis (Chaffaï - Mansat 1988)26.
DISCUSSION
The rupture of the rotator cuff is a common disease in the
aging population, repair techniques and the means available are varied but relapses are equally present. Factors
that should be considered to address the repair of the rotator
cuff of the shoulder, such as age, pain, patient motivation,
muscle trophism, the status of the long head of the biceps,
make it difficult to systematize this disease. Not all broken
rotator cuff must be treated surgically. MRI has allowed us
to assess not only the size of the lesion but also the trophic
muscle, which together with the pain and the functional
needs of the patient allows us to give an indication to the
appropriate treatment for the individual patient.
Mc Laughlin 28 in 1944 describes a technique in repair of
tendon injuries of the shoulder by means of sutures transosse tendon to the greater tuberosity, several authors subsequently studied various fixation techniques to achieve a
better seal to the bone, but the method of McLaughlin and
subacromial decompression is still the most widely adopted with excellent or satisfactory in 80% of cases according
to Cofield 29.
REFERENCES
1. Patte D Classification of rotator cuff lesions. Clin Orthop Rel Res
1990; 254:81-6
2. Goutallier D, Postel JM, Boudon R et al. A study of the neurologic risk in tendino-muscular advancement of supra-spinatus
and infra-spinatus in the repair of large rotator cuff rupture. Rev
Chir Orthop Reparatrice Appar Mot. 1996; 82:299-305
3. Ide J, Maeda S, Katsumasa T. A comparison of arthroscopic and
open rotator cuff repair. Arthroscopy 2005; 21:1090-1098
4. Romeo AA, Hang DW, Bach BR, Shott S. Repair of full thikness
rotator cuff tears. Clin Orthop 1999; 367: 243-255
5. Fuchs B, Gilbart MK, Hodler J, Gerber C. Clinical and structural
results of open repair of an isolated one tenson tear of the rotator cuff J Bone Joint Surg 2006; 88:309-316
6. Bokor DJ, Hawkins RJ, Huckell GH et al. Results of nonoperative
management of full-thickness tears of the rotator cuff. Clin Orthop Rel Res1993; 294:103-110
7. Szalay EA, Rockwood CA. Injuries of the shoulder and arm.
Emerg Med Clin North Am. 1984; 2:279-294
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8. Rockwood CA, Williams GR, Burkhead WZ. Débridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint
Surg 1995; 77:857-866
9. Baleani M, Schrader S, Veronesi CA et al. Surgical repair of the
rotator cuff: a biomechanical evaluation of different tendon
grasping and bone suture fixation techniques. Clin Biomech
2003; 18:721-729
10. Burkhart SS, Athanasiou KA, Wirth MA Margin convergence: a
method of reducing strain in massive rotator cuff tears. Arthroscopy 1996; 12:335-338
11.Accousti KJ, Flatow EL, Technical pearls on how to maximize
healing of the rotator cuff. Instr Course Lect 2007; 56:3-12
12. Baring T., Emery R, Reilly P Management of rotator cuff disease:
specific treatment for specific disorders. Best Practice and Research. Clin Rheumatol 2007; 21: 279-294
13. Melillo AS, Savoie FH, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am 1997; 28:117-124
14. Wolf BR, Bries AD, Nepola JV Greater tuberosity osteotomy and
teres minor transfer for irreparable superior rotator cuff tears.
Iowa Orthop J 2007; 27:65-70
15. Cofield RH. Subscapular muscle transposition for repair of chronic
rotator cuff tears. Surg Gynecol Obstet 1982; 154:667-672
16. Björkenheim JM, Paavolainen P, Ahovuo J, Slätis P Surgical repair
of the rotator cuff and surrounding tissues. Factors influencing
the results. Clin Orthop Rel Res 1988; 236:148-53
17. Patte D, Goutallier D, Debeyre J Ruptures of the rotator cuff.
Results and perspectives of the retrostructure. Orthopade 1981;
10:206-215
18. Walch G, Maréchal E, Maupas J, Liotard JP Surgical treatment of
rotator cuff rupture. Prognostic factors. Rev Chir Orthop Reparatrice Appar Mot 1992;78:379-388
19. Warner JP, Krushell RJ, Masquelet A, Gerber C Anatomy and relationships of the suprascapular nerve: anatomical constraints
to mobilization of the supraspinatus and infraspinatus muscles
in the management of massive rotator-cuff tears. J Bone Joint
Surg 1992; 74:36-45
20. Bonnevialle P, Savorit L, Combes JM et al. Value of intramedullary locked nailing in distal fractures of the tibia. Rev Chir Orthop
Reparatrice Appar Mot 1996; 82:428-436
21.Apoil A, Augereau B Deltoid flap repair of large losses of substance of the shoulder rotator cuff. Chirurgie 1985; 111:287290
22.Takagishi K, Kaibara N, Hotokebuchi T et al. Serum transfer of
collagen arthritis in congenitally athymic nude rats. J Immunol
1985; 134:3864-3867
23. Vandenbussche E, Bensaïda M, Mutschler C et al. Massive tears
of the rotator cuff treated with a deltoid flap. Int Orthop 2004;
28:226-230
24. Hamada K., Fukuda H., Mikasa M., Kobayashi Y.Roentgenographic
findings in massive rotator cuff tears. A long-term observation.
Clin Orthop Rel Res 1990; 254:92-96
25. Gerber C, Ganz R, Vinh TS Glenoplasty for recurrent posterior
shoulder instability. An anatomic reappraisal. Clin Orthop Rel
Res1987; 216:70-79
26. Chaffaï MA, Mansat M Anatomic basis for the construction of a
musculotendinous flap derived from the pectoralis major muscle. Surg Radiol Anat 1988; 10:273-282
27. Jost B, Zumstein M, Pfirrman CWA, Gerber C. Long term out
come after structural failure of rotator cuff repairs. J Bone J Joint
Surg 2006; 88:472-479
28. McLaughlin, HL, Lesion of the muscolotendinous cuff of the
shoulder. The exposure and treatment of tears with retraction. J
Bone Joint Surg 1944; 26:31-51
29. Cofield HR, Parvizi J, Hoffmeyer PJ et al. Surgical repair of chronic rotator cuff tears. J Bone Joint Surg 2001; 83:71-77
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Reverse shoulder arthroplasty with and without tendon
transfer for arthropathy with massive rotator cuff tear:
personal experience and critical analysis of the literature
Nicola Ivaldo, Giovanni Caione, Mario Rossoni, Tony Mangano*
GSL - Gruppo Sanitario Ligure, Ospedale S.M. di Misericordia, Albenga
*Clinica Ortopedica e Traumatologica, IRCCS S. Martino - IST, Genova
Indications and rationale for reverse
shoulder arthroplasty in CTA
The first cases of glenohumeral arthritis occurring with
tears of the rotator cuff were described by Adams and
Smith in the 1850s1. In 1983 Neer defined this condition
“cuff tear arthropathy” and described it as a massive rotator cuff tear with superior humeral migration and diminished acromionhumeral distance, erosion of the great tuberosity (“femoralization”) and other arthritic changes in
the glenohumeral joint2.
Goal of the reconstructive surgery should be to repair the
rotator cuff, restoring a balanced shoulder in which the rotator cuff tendons keep the humeral head within the center of the glenoid during arm elevation, allowing motion
while maintaining joint stability. Unfortunately, in severe
massive RCT tendons retraction often makes repair impossible. Sometimes, despite a moderate retraction and
technically possible repair, tendons degeneration makes
the repair biomechanically useless. If the anterosuperior
or posterosuperior cuff is compromised, dynamic and/or
static superior humeral subluxation may occur, and this
ultimately lead to an unbalanced shoulder, with decreased
acromionhumeral distance and function impairment. In
this condition indeed, when deltoid muscle fibers contract
the humeral head will migrate superiorly, instead of allowing arm elevation, leading to painful acromial erosions and
glenohumeral arthritis. If a balanced shoulder cannot be
restored through a standard RC repair, alternative treatment options should be considered in order to improve
symptoms3,4. However, when pseudoparalysis develops,
RTSA may be the sole treatment option able in restoring
the glenohumeral joint function, recreating a stable joint
fulcrum on which the deltoid can lever and raise the arm5.
Patients must be made aware, however, that full range of
motion may not be obtained, with good anterior elevation
and abduction recovery, but limited and not predictable
gain in internal and external rotation. Despite shoulder
motion may be improved compared with preoperative levels, it may not be completely restored.
Alternative treatment solutions and
RTSA: where is it the boundary?
A potential error is to implant an RTSA in a patient with
a painful massive irreparable RCT with good function
and without arthritis. If the patient has nearly normal active elevation, then the shoulder is still balanced and the
RTSA would be an overtreatment. Nonoperative modali-
INTRODUCTION
Prof. Grammont’s reverse total shoulder arthroplasty (RTSA) reliably reduces pain and improves shoulder function by increasing
active abduction and forward elevation in patients with massive
rotator cuff tears (RCT) and cuff tear arthropathy (CTA). Several
works have been published in the last years, mirroring the increasing interest this kind of prosthesis received after FDA approval in
2003. Since that year, popularity of RTSA grew up among the initially skeptic surgeons in USA and furtherly increased in Europe
and other countries as well. We can actually identify more than
400 works, when looking for shoulder reverse arthroplasty in the
PubMed engine, most of which are reviews of the literature. We
aimed at focusing our work mainly on the controversial aspects
about RTSA. Sharing our own 13 years experience, we tried and
carry out a fruible critical reading of the available literature, and
some practical advices too, for surgeons approaching this fascinating surgery.
ties should be considered first, as subacromial steroid injections coupled with stretching exercices and, after pain
resolution, strenghtening excercices. In refractory cases,
the arthroscopic joint débridement is indicated and, if the
biceps is still in place, biceps (LHB) tenotomy3,4. Despite
good results are published, several factors may lead to a
negative outcome after débridement with or without LHB
tenotomy: preoperative superior migration of the humeral
head, presence of a subscapularis tear, presence of glenohumeral arthritis and decreased range of motion6,7.
We did not find research works specifically addressed at
simple débridement in presence of a spontaneously ruptured biceps tendon. Klinger et al. compared the outcome
of simple débridement with and without LHB tenotomy,
and reported similar results8. After considering the safety
of the procedure and the low risk of (solely) cosmetic damage, we actually proceed with tenotomy in our practice.
Sometimes, patients show a complete active elevation but
are unable to lift even low weights. In this situation, we
always suggest an initial physiotherapic approach but, in
case of failure, an RTSA could be considered for functional recovery, even if pain is not prominent9.
RTSA in umbalanced massive cuff tears
without arthritis
In the recent past, surgeons were reluctant to implant
RTSA in case of pseudoparalysis without clear degenerative arthropathy. Actually, several works report about this
subgroup of patients10. In particular Hyun et al. warned
about possible errors in indication, when a cause for functional impairment different from the RC tear is underestimated (e.g. neurological lesion), and in case the functional
recovery possibilities are overestimated, in patients with
preoperative preserved active forward elevation greater
than 90°. Both of these conditions are unlikely to benefit
from RTSA11.
What can we do when medical therapies
and conservative surgery fail?
The role of the latissimus dorsi (LD) transfer in massive
RCT has been extensively cleared by Gerber, who also
identified limits for this procedure. In particular, a not
reparable subscapularis tear and a Goutallier grade II or
more fatty degeneration of the teres minor represent independent negative prognostic factors. On the other hand,
we should consider that when these muscles are not compromised, most of shoulders show an acceptable function,
which excludes them from substitution with RTSA.
Weening and Willems reported about 16 patients treated
with LD transfer, where they found a 26° mean recovery
in active elevation (from 79° to 105°) and did not observed
the humeral head recentering in most of cases. Mean functional results in this series are worse than those obtained
with RTSA in similar cases12-14.
In our practice, we gradually limited the isolated LD transfer,
considering the correct indication still unclear. We reserve the
combined transfer of LD and teres major (TM) to patients in
which, due to massive posterosuperior RCT and teres minor
impairment, preserved active elevation and abolished external rotation are shown. Furthermore, we use the same transfer procedure in association with RTSA in cases of combined
forward elevation and external rotation deficits.
Recently, Savarese and Romeo reported a technical note
about using a biodegradable subacromial spacer able in
re-centering the humeral head at the glenoid. This device
could represent a possible new and original solution, and
we wait for clinical results15.
Table 1
Study
Mean FU
(months)
Revision
rate
Function Scores
Sirveaux et al.20
44.5
4%
67 (Constant-Murley)
Werner et al.23
38
18%
72% (Relative
Constant-Murley)
Frankle et al.19
33
13%
68.2 (ASES)
Favard et al.18
91
5%
61 (Constant-Murley)
Nolan et al.24
24
0%
62 (Constant-Murley),
76 (ASES)
Functional results and revision rate in published series of RTSA for massive
RCT with or without glenohumeral arthritis.
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RTSA for young patients
Despite not frequently, it is possible to find out a massive
RCT with severe function impairment in patients aging the
V or VI decade of life. Most of works state RTSA should
be reserved for patients aged 70 years or more, because
of the risk of components wear. Our personal choice is to
consider the possibility of a RTSA implantation together
with younger patients, clearly presenting them the eventual doubts concerning components wear due to strenuous
activities, and the need for frequent radiographic followup evaluations. It is not unfrequent that after extensive
explanations these patients accept the proposed solution.
Two recently published works seem to support this behaviour. Sershon et al.16 report a short term success rate
of 75% in a series of patients, most of which treated for
post-traumatic arthropathy or revision surgery, indication
subgroups known to have a worse prognosis than CTA and
massive RCT. Neukom et al. describe good results in the
long term follow-up, despite evidencing an high complication rate17. Of note, most of the complications described
have been treated successfully without compromise to
clinical outcome.
Results of RTSA in Cuff Tear Arthropathy
and Massive Rotator Cuff Tears
Favard et al.18 recently published the largest series (464
patients with a 7.5 years mean follow-up) of RTSA implanted for CTA. Reported mean active anterior elevation
(AAE) improved from 69.3° to 128.6°, active external rotation (AER) with the abducted arm improved from 23.5°
to 42.1°, while AER with the arm at the side showed little
improvement, from 4.9° to 10.6°. Survivorship free of revision was 89% at 10 years with a marked break occurring at 2 and 9 years. Survivorship to a Constant-Murley
score of less than 30 points was 72% at 10 years, with
a marked break observed at 8 years. They observed progressive radiographic changes after 5 years and increasing frequency of large notches with long-term follow-up.
Of note, most of the surgeons were at the beginning of
their experience with RTSA, then data could suffer from
the learning curve. Frankle et al.19 reported results of sixty
patients with a rotator cuff deficiency and glenohumeral
arthritis, with a mean follow-up of 33 months. The mean
total score on the American Shoulder and Elbow Surgeons
score improved from 34.3 to 68.2. The score for function
on the visual analog scale (VAS) improved from 2.7 to 6,
and the VAS score for pain improved from 6.3 to 2.2. AAE
increased from 55° to 105.1°, and 41 of the sixty patients
(67.2%) rated the outcome as good or excellent. Sirveaux
et al.20 reviewed 80 shoulders with a mean follow-up of 44
months. Three implants had failed and had been revised.
Mean Constant-Murley score increased from 22.6 points
pre-operatively to 65.6 points at review. In 96% of these
shoulders there was no or only minimal pain. Mean AAE
increased from 73° to 138° (table 1).
Studying a series of patients treated with RTSA, Wall et al.
demonstrated that patients with primary CTA or massive
RCT had better clinical outcomes than other diagnosis21.
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Vol. 125 - 1-2 Novembre 2014
Figure 1.
a) High degree scapular
notching at 8 years
follow-up.
b) Delta III RTSA with
upwards directed inferior
screw: no sign of notching
at 7 years follow-up.
The same conclusion can be found in a precedent work
from Boileau et al.22
Furthermore, comparing results on two series of patients
treated for primary or revision surgery, Werner et al. stated
that patients in the two groups showed similar amounts of
improvement. However, this observation should be taken
with caution, because authors included in the “primary surgery” group also previously operated post-traumatic cases,
probably biasing final results. In our experience, cases
with sequelae from previous reduction and synthesis surgeries are more consistently comparable to revisions, with
respect to technical difficulties and outcome results23.
Radiological results: focus on
scapular notching
RTSA ��
is associated with higher complication rates than anatomic shoulder arthroplasties. Most common complications
include baseplate failure, instability, infection, nerve lesion,
surgical site haematoma and scapular fracture. Despite a
systematic treating is out of the purpose of this work (for
review, see ref. 25) we agree with other authors in that we
have only very limited series relating to RTSA in specific
indications and we need to know how likely each complication is in a specific patient and not in completely different
circumstances. Behind this consideration, we would tribute
particular attention to the almost constantly reported radiographic complication of scapular notching.
Infraglenoidal scapular notching in RTSA is a frequent finding related to mechanical impingement by the medial rim
of the humeral cup against the scapular neck in adduction
and internal-external rotation (Fig. 1a). This complication
typically occurs within the first few months after RTSA24
and the reported incidence ranges from 44% to 96%. The influence of infraglenoidal scapular notching on clinical outcome has not been fully delineated yet and is still controversial in the current literature. Sirveaux20 showed a negative
effect of scapular notching on the Constant-Murley score.
On the contrary, Lévigne et al.26 do not report a correlation
of scapular notching with clinical findings. Recent series
with longer follow-up have demonstrated notching can be
progressive and associated with reduced shoulder ROM,
strength, decreased subjective shoulder scores and relative
Constant-Murley score, and increased polyethylene wear
and potential for implant loosening27. Most of high-grade
scapular notching cases is found between patients with longer follow-up18,27. This could reflect not only the progression
of notching itself, but also technical changes that took place
in the years, with actual trend towards a lowered and tilted
positioning of the glenoid metal back.
Whatever its final involvement be in implant stability and
survival, attention should be paid, in our opinion, in order
to minimize the occurrence of scapular notching. An inferior tilt of the metal back (10-15°) is auspicated. Just a little
trick: the inferior screw fixating the metal back should be
parallel to the central peg, and not inferiorly directed (Fig.
1b). When correctly placing the metal back in the lower part
of the glenoid, this will avoid the inferior screw to pierce the
cortical bone and, in case of notching, the polyethylene liner
to take contact with the screw itself (with foreseeable consequences in terms of components wear). At this moment, it
is not clearly defined how much the incidence of notching
could be limited by using an inverted tribology (i.e. glenosphere in PE, metallic liner), while it is bona fide accepted
that major diameter glenosphere could carry some advantages. Furthermore, some authors recently demonstrated
good results in terms of limited notching incidence by using
a glenosphere with eccentric design28.
RTSA combined with muscle transfer
for combined pseudoparalysis
Some patients show a combined deficit of active anterior elevation (AAE) and external rotation (AER), also referred to as
combined pseudoparalysis. This condition generally relates
to a massive posterosuperior tear of the rotator cuff, involving a ruptured or, more frequently, ipotrophic teres minor,
with Goutallier grade III-IV fatty degeneration and positive
hornblower’s and dropping signs. Both a massive RCT and
CTA could underlie this pathology, and patient’s quality of
life is often blunted. Activities of daily living such as eating,
holding a phone or combing hair become difficult or impossible, since the patient cannot control the spatial positioning
of his upper limb while raising an object with the hand30,31.
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Vol. 125 - 1-2 Novembre 2014
Figure 2.
a) Missing postoperative
AER recovery after RTSA in a
patient devoid of
a functional teres
minor muscle.
b) T1-weighted MRI cut
showing severe fatty
degeneration of the
posterior muscle of the
rotator cuff (teres minor
is highlighted).
RTSA allows the restoration of active overhead elevation in
patients with a massive rotator cuff tear and pseudoparalysis of elevation. However, it does not restore active external
rotation, the lack of which can substantially compromise the
functional outcome.
The teres minor muscle contributes to AER, and its deficiency may impair the clinical outcome after RTSA (Fig. 2).
Simovitch et al.32 published results of 42 RTSA and correlated results to teres minor integrity and fatty degeneration.
Shoulders with stage 0, I or II fatty infiltration of the teres
minor muscle (group 1) had a significantly better ConstantMurley score and subjective shoulder value, than shoulders
with stage III or IV (group 2). Group 1 had a net gain of 9°
of external rotation with the arm at the side compared with
an average loss of 7° in group 2. Authors therefore concluded that teres minor stage III or IV fatty infiltration compromises the clinical outcome of RTSA for massive RCT.
Although AER deficit can be treated with a tendon transfer
surgery, this technique alone may be inadequate to power
external rotation and elevation with such global dysfunction, and is contraindicated when arthritic changes are
present32-36.
In our early experience with RTSA (without tendon transfer) we observed some patients functionally disabled after
surgery. This was probably due to the absence of external
rotator cuff muscles (infraspinatus and teres minor) with
consequent no counterbalance for the strong functional internal rotators (pectoralis major, latissimus dorsi, teres major and subscapularis).
Several surgeons, and we too, tried and find a solution by
mean of a tendon transfer combined with the RTSA procedure. Gerber chose a double approach solution with transfer
of the latissimus dorsi (LD) alone37. On the contrary, Boileau
chose a combined transfer of LD and teres major (TM) by
mean of a single deltopectoral approach, inspired by the old
technique Merle D’Aubigné used for the treatment of obstetric paralysis (also referred to as modified L’Episcopo)38.
And this was our first orientation. With this technique we
obtained good results in recovering AER, with a significant
loose in active internal rotation (AIR). Therefore, we hypothesized a single LD transfer where the tendon was passed
through a split TM, by mean of a deltopectoral approach,
but results were unsatisfactory again due to great variability.
Because of this, we finally came back and aligned with Boileau’s idea, accepting the residual AIR deficit39.
Candidates for the combined procedure (RTSA & tendon
transfer) are those patients showing severe active anterior
elevation deficit with impossibility in keeping shoulder external rotation with the arm adducted, independently from
the X-ray status of the joint. In most of these patients, the
hornblower’s sign can’t be evidenced because of pain, limited elevation or joint stiffness, and the quantitative evaluation of ER with 90° arm abduction is sometimes not possible. This parameter would be of great interest when looking
for functional results after transfer surgery but, because of
the aforementioned reasons, few published series reported
it37,38. In our practice, we evaluate the preoperative AER at
maximum abduction, with the examinator sustaining the patient’s elbow. In the postoperative follow up visit the same
evaluation is taken, at the same degrees of abduction, in order to obtain comparable measures.
The indication for a combined procedure should be corroborated by imaging studies like CT or MRI, with axial and
oblique-sagittal cuts directed to teres minor evaluation.
In some cases, the indication is considered in the operative
setting, after direct evaluation of the low quality of the teres
minor and the high quality of muscles to be transferred.
This is not an obvious find, because LD and TM could be
damaged by rheumatoid pathologies, steroid therapies and
previous surgeries as well, particularly at their humeral insertion. Some advantages are foreseeable, in such cases, for
the single approach procedure with respect to Gerber’s technique, in which the preparation of the LD tendon precedes
the prosthesis implantation and takes place through a different access.
RTSA with LD/TM transfer through
deltopectoral approach: surgical
technique
With the patient in a beach-chair position, we use a classical deltopectoral approach, with distal extension to pectoralis major humeral insertion. This is cut 1,5 cm from
the lateral margin of the biceps groove, allowing final reinsertion. Both the anterior axillary vessels and the axil-
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Vol. 125 - 1-2 Novembre 2014
Figure 3.
a) LD/TM tendon transfer
showed in a cadaver
specimen before reinsertion.
b) Transferred LD and TM
tendons after insertion
at the teres minor
insertion site.
lary nerve should be identified at the inferior border of the
subscapularis. In these patients the subscapularis tendon
is generally conserved, and it should be accurately detached form the lesser tuberosity and tagged40. The LHB is
identified in its groove and it is cut or tenodesed, and the
intra-articular portion resected. The humeral head is dislocated anteriorly allowing the RTSA to follow a standard
technique. Medial reflection of the pectoralis major then
exposes the combined insertions of the LD/TM. With the
arm in internal rotation, these tendons are detached from
the humerus. Heavy, nonabsorbable sutures are placed in
the free ends of the combined tendons in a baseball stitch
fashion. Both tendons are released to gain length, with attention in avoiding damage to the neurovascular pedicles.
Adhesions are released with bluntly dissection when it is
pushed medially, and always with the arm in adduction
and flexion to relax the brachial plexus. Dissection should
not venture beyond 6 cm medial to the tendon insertions,
as anatomic studies identified the neurovascular pedicles
of LD and TM at a minimum distance of 7.4 cm proximal
to the humeral insertions41. When sufficient length is obtained (approximately 3–5 cm), the humerus is dislocated
anteriorly and the tendons are transferred around its posterolateral aspect. The transferred tendons are fixed at the
level of teres minor insertion, using transosseous sutures
(Fig. 3). The sutures are placed before implantation and
cementation of the definitive humeral prosthesis, reinforcing the construct by passing them around the prosthetic
neck. When the tendon transfer is completed the prosthesis
is reduced, and the subscapularis tendon reattached to the
lesser tuberosity with transosseous sutures passed through
the bone at the bicipital groove level (also placed before
cementation of the final implant). The pectoralis major is
repaired then, and the wound closed under suction drainage. After surgery, the arm is placed in a sling in slight
abduction and neutral rotation that is maintained for five
weeks.
Results and discussion
Boileau reported on seventeen consecutive patients who
underwent the modified L’Episcopo procedure through
a single deltopectoral approach and were followed for at
least 12 months. Mean AAE increased from 74° preoperatively to 149° postoperatively, and AER increased from
-21° to 13°42.
In our experience, we followed 17 patients for an average of 30 months, basically managed with the same procedure proposed by Boileau. We prefer to call it Merle
D’Aubigné procedure since he described in 1947 LD/TMtransfer through a single deltopectoral approach, suturing
the transferred muscles on the pectoralis major stump, for
treatment of birth brachial plexus palsy43. Our results were
presented in Lyon Secec Meeting on September 2011 but
are unpublished so far.
In our series mean Constant-Murley score improved of
31 points (from 34 to 65), SSV 45% (from 29% to 74%),
mean AER with the arm at the side improved 17° (from
-12° to +5°). We also evaluated external rotation in ab-
Table 2
Sirveaux
et al.20
Boileau
et al.29
Werner
et al.23
Simovitch
et al.27
Nolan
et al.24
Lévigne
et al.26
Wall
et al.21
Mizuno
et al.28
80
45
58
77
71
337
152
47
Follow-up (months)
44,5
40
38
44
24
47
40
30.4
Notching
64 %
36 %
74 %
26 %
68 %
32 %
82 %
18 %
96 %
4 %
54 %
46 %
44 %
56 %
59 %
41 %
49 %
51 %
76 %
24 %
62 %
38 %
66 %
34 %
51 %
49 %
63 %
37 %
40 %
60 %
95 %
5 %
N of prosthesis
No notching
Grades 1 & 2
Grades 3 & 4
Incidence of scapular notching in the main published series is summarized.
duction, with the aforementioned technique, and gain was
32° (from 8° to 40°). Functional external rotation gain was
excellent: 4.1 points (from 3.5 to 7.6), reflecting improvement of both elevation and external rotation. Patients were
able to use the arm over the head level postoperatively,
while they used it at the level of the sternum in the preoperative setting. Internal rotation significantly worsened:
from a preoperative level of L1-L2 to buttock at follow-up.
This worsening reflects what we call the “short blanket effect“: we explain to our patients that the price to pay to improve external rotation is to loose the opposite movement.
This should be clearly discussed with the patient when the
indication is given, taking into account internal rotation in
the opposite limb: in presence of a bilateral deficit of internal rotation, to avoid a serious handicap in activities that
involve such a movement (e.g. hygiene care), we believe
the transfer procedure inadvisable.
Boughebri et al.44 published results about 14 patients managed with the combined procedure through single deltopectoral approach. At an average 33.2 months follow-up,
mean AAE and AER with the arm at the side improved significantly, from 64° to 126°, and from -9° to 27° (gain 36°)
respectively. In their series, contrary to all the published
ones and ours too, authors did not evidence a worsening of
active internal rotation.
Ortmaier et al.45 reported on 13 patients treated with RTSA
in combination with latissimus dorsi transfer with a modified technique, harvesting the LD with a small piece of
bone. At a mean 6 years follow-up, mean AAE improved
from 55° to 138° and mean AER improved from -16° to
21° (gain 37°). They conclude that the modified technique
leads to good tendon integrity, low rupture rates and good
clinical outcome.
Recently, Puskas et al.46 published results about 32 cases followed up for an average of 53 months after RTSA
with LD transfer through a double approach technique.
The age-related mean Constant-Murley score significantly
increased from a preoperative value of 45% to 89%. The
mean SSV increased from 33% to 75%. AER significantly
improved from a mean of 4° to 27° (gain 23°). A preoperative external rotation lag sign could be corrected in 25 of
the 32 shoulders. In their series, authors described a worsening of AIR, despite at a lower extent with respect to the
AIR loss Boileau and we observed.
Conclusions
Reverse total shoulder arthroplasty represents a useful solution in case of cuff tear arthropathy or massive rotator
cauff tear with function impairment. Due to its inherent
design, this kind of implant is able in recovering active
anterior elevation at the overhead level in most of patients,
despite lower results could be expected for active external
and internal rotation.
In presence of severe loss of active elevation and external
rotation, combined latissimus dorsi transfer and reverse total shoulder arthroplasty can restore both AAE and AER.
In our experience, the overall functional improvement in
these patients is excellent: AER with the arm at the side
improves of relatively few degrees, but AER in abduction
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Vol. 125 - 1-2 Novembre 2014
improves of more than 30 degrees. Active internal rotation
clearly worsen and it requires a thoughtful and eclectic behavior in presence of bilateral disease, for consequences
inherent the activities of daily living.
In some patients, tendons that should be transposed show a
poor tissue quality due to prolonged corticosteroid therapy
or iatrogenic lesions. In these cases, the decision about
executing the transfer procedure should be considered in
the operative setting, according to directly verified tendon
quality.
Surgery through a single deltopectoral approach is easier
and faster compared to the dual access technique. Furthermore, according to our experience, it is also burdened by a
lower complication rate.
In our practice, we observed some cases in which RTSA
without muscle transfer in patients completely devoid of
the posterior cuff finally resulted in a sensible recovery of
AER. The role the posterior deltoid muscle could lead in
these situations and, more generally, in recovering AER
has not been clearly defined yet.
Finally, when considering indication for adding a tendon
transfer, surgeons must keep in mind that most of expert
authors indicate it in no more than 10-15% of their patients
requiring RTSA for cuff tear arthropathy or massive rotator cuff tear.
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26. Lévigne C, Boileau P, Favard L et al. Scapular notching in reverse
shoulder arthroplasty In: Walch G, Boileau P, Molé D, Favard L,
Lévigne C, Sirveaux F: Reverse shoulder arthroplasty: Clinical
results, Complications, Revisions. Ed. Sauramps Médical, Montpellier, France 2006, pp. 353-72
27. Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scapular notching in patients managed with the Delta III
reverse total shoulder replacement. J Bone Joint Surg Am. 2007;
89: 588-600
28. Mizuno N, Denard PJ, Raiss P, Walch G. The clinical and radiographical results of reverse total shoulder arthroplasty with eccentric glenosphere. Int Orthop. 2012; 36(8): 1647-53
29. Boileau P, Watkinson D, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale and biomechanics. J Shoulder
Elbow Surg. 2005; 14: 147S–51S
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30. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty
muscle degeneration in cuff ruptures. Clin Orthop Relat Res.
1994; 304: 78-83
31. Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’
and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J
Bone Joint Surg Br. 1998; 80: 624-8
32. Simovitch RW, Helmy N, Zumstein MA, Gerber C. Impact of fatty
infiltration of the teres minor muscle on the outcome of reverse
total shoulder arthroplasty. J Bone Joint Surg Am. 2007; 89:
934-9
33. Covey DC, Riordan DC, Milstead ME, Albright JA. Modification of
the l’Episcopo procedure for brachial plexus birth palsy. J Bone
Joint Surg Br. 1992; 74: 897-901
34.Edwards TB, Baghian S, Faust D, Willis RB. Results of latissimus
dorsi and teres major transfer to the rotator cuff in the treatment of Erb’s palsy. J Pediatr Orthop. 2000; 20: 375-9
35. Freund RK, Terzis JK, Jordan L, Taylor G. Modified latissimus
dorsi and teres major transfer for external rotation deficit of the
shoulder. Orthopedics. 1986; 9: 505-6
36. Gerber C, Maqueira G, Espinoza N. Latissimus dorsi transfer for
the irreparable rotator cuff tears. J Bone Joint Surg Am. 2006;
88: 113-20
37. Gerber C, Pennington SD, Lingenfelter EJ, Sukthankar A. Reverse
Delta-III total shoulder replacement combined with latissimus
dorsi transfer. A preliminary report. J Bone Joint Surg Am. 2007;
89: 940-7
38. Boileau P, Chuinard C, Roussanne Y, Bicknell RT, Rochet N, Trojani C. Reverse shoulder arthroplasty combined with a modified
latissimus dorsi and teres major tendon transfer for shoulder
pseudoparalysis associated with dropping arm. Clin Orthop
Relat Res. 2008; 466: 584-93
39. Ivaldo N, Rossoni M, Caione G, Franzi P. Latissimus dorsi transfer
associated to Grammont reversed shoulder prosthesis: results
at 22 months of follow up. Minerva Ortop Traumatol. 2006; 57:
329-36
40. Boileau P, Chuinard C, Roussanne Y, Neyton L, Trojani C. Modified
latissimus dorsi and teres major transfer through a single deltopectoral approach for external rotation deficit of the shoulder:
as an isolated procedure or with a reverse arthroplasty. J Shoulder Elbow Surg. 2007; 16: 671-82
41. Bartlet SP, May JW, Yarenchuk MJ. The latissimus dorsi muscle: a
fresh cadaver study of the primary neurovascular pedicle. Plast
Reconstr Surg. 1981; 67: 631-6
42. Boileau P, Rumian AP, Zumstein MA. Reversed shoulder arthroplasty with modified L’Episcopo for combined loss of active elevation and external rotation. J Shoulder Elbow Surg. 2010; 19:
20-30
43. Merle D’Aubigné R. Paralysie obstétricale du plexus brachial traitée par transposition des tendons du grand rond et du grand
dorsal. Mémoire Académie de Chirurgie 1947; 73: 561
44. Boughebri O, Kilinc A, Valenti P. Reverse shoulder arthroplasty
combined with a latissimus dorsi and teres major transfer for a
deficit of both active elevation and external rotation. Results of
15 cases with a minimum of 2-year follow-up. Orthop Traumatol
Surg Res. 2013; 99: 131-7
45. Ortmaier R, Resch H, Hitzl W, Mayer M, Blocher M, Vasvary I,
Mattiassich G, Stundner O, Tauber M. Reverse shoulder arthroplasty combined with latissimus dorsi transfer using the bonechip technique. Int Orthop. 2014; 38:553-559
46. Puskas GJ, Catanzaro S, Gerber C. Clinical outcome of reverse
total shoulder arthroplasty combined with latissimus dorsi
transfer for the treatment of chronic combined pseudoparesis
of elevation and external rotation of the shoulder. J Shoulder
Elbow Surg. 2014; 23: 49-57
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Shoulder arthroplasty’s rehabilitation
Rossella Costantino, Lorenzo Panella, Elisa Prisco
U.O.C. Medicina fisica e riabilitazione, Istituto Ortopedico G. Pini, Milano
Introduction
The shoulder joint is often subject to different kinds of traumatic
events or various degenerative diseases which may become disabling in course of time. The most common reasons that cause
imbalances in the shoulder are injuries to the soft tissues (rotator
cuff), osteoarthritis, arthritis, avascular necrosis and fracture of
the proximal humerus.
For the rehabilitation therapist is necessary to know the pathology of disease accurately, the choices and the modus operandi
of the surgeon who performed the prosthesis surgery, in order to
draw up a careful rehabilitation program that bears the patient’s
peculiarities in mind.
The rehabilitation program is applied following a temporal sequence. This allows the tissues healing, the joint mobilization
and, finally, the strengthening muscle and the functional recovery1. Mobility, strength and stability are the three functional elements of the shoulder that can be compromised by an acute or
chronic injury and they must be restored.
The physiotherapist has to inform the patient about the possibility
to run into functional limitations and must instruct him the strategies to be able to carry out everyday activities using better the
potentialities of the “new” articulation2.
However, we must always remember that while the therapist
evaluation parameters can and must be others as well, for the patient one of the main valutation measures of the operation and of
rehabilitation success will be the disappearance of pain3.
Rehabilitation treatment
Rehabilitation begins immediately after surgery. The rehabilitation program has the following purposes (Brotzman
SB, Wilk KE)1: passive amplitudes recovery; active motion
recovery; muscular strengthening and returning to normal
activities of daily living. This protocol takes long time and
a few months pass between the first passive movements and
the complete recovery of motion and strength.
The phases of rehabilitation following a logical sequence
that must be respected carefully. The time that is dedicated
to each stage in order to move to the next one is not constant, but extremely variable from one patient to another.
It also depends on the goals he intends to reach, his overall
physical conditions which are often related to age and status
of the periarticular structures before the surgery.
For this reason it is not possible to determine fixed deadlines
between one phase and the other of the rehabilitation program, but only general indicative lines on the timing which
is normally required to reach a certain goal.
Therefore, through exercise, the rehabilitator must assign
to the patient some tasks, which must have as purpose the
specific activation request to local strategies compromised
and not to the attainment of the final result or to the muscle
strengthening. Thus it must be activated the capacity deriving from the ability to connect central and peripheral mechanisms in a variable dynamic way.
The exercises, that are gradually included, before passive
then active assisted and active lastly, do not replace each
other, but they are added to those already acquired previously. In the end they allow an overall recovery of motility
(clearly dictated by individual variables).
Generally a series of rehabilitation programs are applied because of the compliance with the various biological phases
of traumatized tissues repair by careful exercises of passive,
segmental and global motility, isotonic exercises in a particular joint range and isometric exercises. It also provides a
strengthening of the insufficient musculature through exercises in a closed kinetic chain, exercises against increasing
resistance, isokinetic and proprioceptive exercises.
The passive mobilization is the first physiotherapic operation implemented in all types of shoulder pathology. It is
performed by the therapist, but also through practices of
gravitational and self-assisted mobility. Traditional exercises are usually preferred. Permforming them you must check
that the mobilization takes place in the scapular plane. Actually, the exercises executed on this level guarantee a correct
biomechanical alignment.
The first few weeks of treatment are usually set up with caution because of the pain4. In this first phase, the scar treatment is important to encourage the flow of the underlying
tissues and to soothe the pain of the pulled cutis. Generally,
at the beginning of the session, we prefer to start with the
treatment of relaxation of the trapezius and paravertebral
through cervical pompages and the help of deep breathing5.
It continues with a cautious passive motility of the elbow to
retrieve the extension, also using postures of relaxation in
extension. The patient is educated on the movements he has
to avoid when he practices them at home because they might
endanger the stability of the prosthesis and self-mobilization
exercises of hand, wrist and elbow6.
Through the exercises defined commuters, proposed by
Codman, we try to get mobilization by the force of gravity,
making a pendulum movement to be performed first in the
frontal, then sagittal and finally, in a circular, clockwise and
counterclockwise way.
After the first stage of passive exercises, we will switch to
an active phase, in which we distinguish an initial segmental treatment following by another defined global. The first
step is dedicated to the recovery of motility, maintaining,
initially, a free range from pain, using the scapular plane
and having the foresight to support the arm and then extend
more and more the motility range. The initial movements,
which are performed in the supine position trying to avoid
as much as possible any compensations, are aimed at the
recovery of flexion and extension .
In addition, you can begin the passive motility of the shoulder blade sliding it slowly on the chest wall, in the directions
physiological scapulars, trying to restrict acromion movements in the lateral decubitus position on the healthy side.
Afterwards abduction and adduction movements will be
introduced always in a supine position. At a later time, you
can devote to the strengthening of the individual muscles.
Currently, for the shoulder pathology, strengthening exercises aimed at the individual muscle are suggested, performing
them either against the resistance offered by the therapist, or
against the resistance made by the patient himself or with
his help. Beside exercises which require the voluntary contraction of individual muscles, defined segmental, at a later
stage of treatment, the use of global type exercises in which
the activation of a large number of muscles is requested is
raccomanded.
In later stages, rotational movements, both internal and external, are added.
When you plan the exercises you will need: to identify the
function which is involved in the ability of the shoulder to
participate in organizational processes (for instance, function of indication, tracking, achievement, pressure and boost,
etc.); to identify which contribution the shoulder gives to the
retrieval object function; to identify through which ways the
shoulder is able to cope with the need to allow the relationships among the various body segments in relation to different functions.
The exercise must be a cognitive problem to be solved by
the selection and splitting of some body segments and,
therefore, it will be based on the development and testing of
perceptual hypotheses aimed at solving the problem.
Proprioceptive exercises
Starting from this premise, we propose a initial group of exercises directed specifically to enable local strategies which
affect the relationship among the sternum, clavicle and
scapula in order to ask the patient the building of a correct
relationships. The patient suffering from shoulder disorders,
hardly presents a perfect symmetry of body towards the
midline. Problems posed by this situation can be controlled
through the application of touch operations, evoked through
the request for the recognition of sponges of different texture
in a sitting position2. The exercise proposed to recognize
contact-pressure information, through the use of sponges of
different consistency. Therapists place these sponges significantly, in correspondence of the scapula, in the direction of
the movement of the rear position of the track, in correspondence of the clavicle, in relation to the direction of elevation
movement of shoulder and in correspondence of the front
part of the track for anteposition movements.
With this type of information you are able to reconstruct
more accurate reports of fragmentation among different
joints, through proper use of muscle systems. In this way
an evolution of the scapula motility occurs. From an initial
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Vol. 125 - 1-2 Novembre 2014
static breakaway, i.e. to not relations with the trunk, it starts
to build more meaningful relationships, also of dynamic
type, which enable the movements for the proper maintenance of the correct position of upper limb. From this first
step an improvement in pain symptoms may also derives. Its
genesis is to be found both in the antalgic contracture, and
in a sort of deafferentation, but also in a reduced ability to
perceive correctly the somesthetic information.
In the third group of exercises the requests made to the patient
are designed to require the activation of spatial operations,
characterized by a broader hike and more attention is given
to the mobility of the glenohumeral joint, whose movements
and informative activities are interested in solution of spatial
type tasks. In this group of exercises, the preference is given
to the pursuit and achievement of trajectories, among which
you should preferred circular paths as there are substantial
evidences which support some hypothesis that the upper
limb movements occur within strategies related to movements with conical apex at the level of the glenoid and they
allow full activation of all muscle components of the joint.
The solution of the problem posed by this exercise to the
patient requires the construction of a correct rotational orientation of the humeral head with the glenoid; the exercise
evolution allows the hand the reacquisition of freedom to
move properly in a broader space.
Idrokinesitherapy
For nearly a century, both in orthopedics and traumatology,
and in neurological field, we tried to use water as a rehabilitative means exploiting its inherent characteristics. For the
last thirty years, however, this branch of rehabilitative medicine has taken on its own identity. It has been the subject of
scientific studies and critical evaluation in order to define
precise clinical indications and protocols to be followed in
every single diseases.
Rehabilitation in water can be active and passive, instrumental or it can be consisted on physical exercises performed in
water, not necessarily of swimming type. In any case, we
use the water capacities, from the principles of hydrodynamics to the ludic effect7. Inherent properties of water play
an important role in the therapeutic targets, and they can
be amplified through appropriate techniques enriching the
therapeutic possibilities.
It also important to point as the motor activity, carried out in
water, offers the possibility of a recovery of “schemes and
images” motility which, although partially summoned after the trauma or disease are been “lost”, forgotten, because
they have been exercised no more. Moreover, the use of water can lead significant changes to the components of motor
deficit hindering functional recovery and finally it integrates
itself with the other rehabilitative strategies.
Therefore, the intervention must seek the best conditions
for the patient to move in everyday life, through a process
of adaptation to a situation of dipping, or confronting the
physical properties of water and the constraints that follow.
In other words, he can use the facilities and difficulties, that
exercising in the water offers, for progressively recover the
best motor conditions on earth.
Rehabilitation in water is a strong tool for a rehabilitation treat-
ment because the practice of this activity takes as the meaning
of a complement to the rehabilitation program implemented
in the gym and it agrees with the therapeutic goals.
There are many parameters that should be taken into consideration for a good personalization of a therapeutic program. Everything can undergo same changes, from the time
of application to the number of sessions, its approach may
change and, not least, the patient’s intrinsic aquatic ability
affects the treatment.
In conclusion, the progress of stages and phases of the patient should illuminate the rehabilitation process. Some objectives are often longer than expected, but in the other side,
other objectives amaze for the simplicity and speed in their
implementation7.
Thanks to the properties of water it is possible to earn both
objectively a wider and fluid range of motility and give the
possibility of muscular strengthening, and subjectively it
gives a positive psychological feedback to patients.
It will be illustrated below rehabilitation programs for two
common situations, in which greatly vary rehabilitation
time and manners2:
1. Shoulder prosthesis with anatomic rotator cuff valid;
2. Reverse shoulder replacement with rotator cuff invalid.
1. Shoulder prosthesis with anatomic
rotator cuff valid
Phase - I ( 1st -5th week)
1st week: after the surgery is packaged in a brace abduction
of 10 °, to be maintained for 15-20 days. We Use removable
brace, to allow personal hygiene and mobilization of the elbow of the hand.
2nd-3rd week: the brace is removed to perform physical
therapy. It is possible passive mobilization of the shoulder,
without reaching painful amplitudes. It is permitted up to
90° flexion and 45° abduction.
Passive mechanical immobilizers (CPM) appear useful at
this stage, with a programming of the arc allowable movements type.
The patient should perform independently the commuters
Codman exercises and the passive motility in flexion with
the help of the other arm.
4th Week: the use of the brace is limited at night and a few
hours a day.
5th week: patient leaves the brace and the assisted exercises
in flexion-extension and abduction are allowed. The patient
can begin rehabilitation in water.
Phase II (6th -12th week)
6th week: we switch to active physiotherapy in flexion-extension and larger movement arc. Rotation are begun. Some
stretching movements are useful to counteract the tendency
of the capsule to stiffen, especially in his back. When patient
has reached a good range of motility, we start with muscular
strengthening. In the end of the period, patient starts the receptive exercises for restoring efficiency and speed in automatic gestures.
Phase III (13th -16th week)
13th week: we continue with the muscular strengthening and
training of perception; the other muscular chains are involved
in a more intensive way, in order to re- inscribe the shoulder in
its natural context of “pivot” between the creative gestures of
upper arts and the task of supporting his own lower limbs2,8.
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Vol. 125 - 1-2 Novembre 2014
2. Reverse shoulder replacement with
rotator cuff invalid
The rehabilitation of the reverse prosthesis requires from
the rehabilitator the knowledge of the peculiarities of the
plant. In addition, as this is often used in absence of the
rotator cuff, it is important to know the conditions of the
pre-operative group of the deltoid muscle, even if the validity of deltoid typically has already been established by the
surgeon in pre-operative phase, because this is essential for
the prosthesis function.
Generally, the plant input allows the recovery of the abduction bending within acceptable limits for a discreet personal
autonomy, as these movements are simplified by the positioning of the center of rotation in a lower and laterally
way with respect to the norm. The achievement of an active
elevation between 100-150 ° is a frequent result. Rotations
are limited, but still possible, due to the preservation of the
front cuff (subscapularis) and rear (small round and remaining portion of the infraspinatus)9.
The reverse prosthesis often represents the final attempt to
rescue a situation that is already compromised. Therefore,
the main objectives of rehabilitation should be the pain reduction for the patient and a decent autonomy. An exaggerated quest for an unlikely extension of the joint range may
expose the patient to risks that are not relatable to the hypothetical advantages.
This kind of prosthesis allows a rehabilitation more or less
earlier than the endo and arthroplasty in sliding2 .
Phase - I ( 1th -3th week)
1st week: after surgery, the shoulder is immobilized with a
brace in slight abduction and neutral rotation for 15-20 days;
elbow and hand are free and must be mobilized early.
2nd week: if the absence of the headset is complete and it has
not been made any reconstruction of the subscapularis, after
about seven days, the limb can be temporarily released from
the brace and mobilized passively in flexion and abduction,
from 45° to 60°, taking care to respect the limits obtained by
intraoperative measurements. Commuters exercises can be
carried on for a few minutes, several times a day.
3rd week: you can begin the assisted mobilization. At the
same time, you can start a rehabilitation cycle in pool.
Phase II (4th - 5th week)
4th week : we allow the use of discontinuous brace, which
is left at night for a few hours. Then, we begin the kinesitherapy.
5th week: the brace is removed. We seek the muscular compensation, if the amplitude of joint allows it. We will assist
the patient in the realization of possible movements, inserting them in the functional diagrams, and most common and
useful for him.
Measures in the rehabilitation of shoulder replacement in
fracture.
Functional recovery after shoulder replacement surgery in
fracture is more delicate than prosthetic interventions performed with other indications such as osteoarthritis and
rheumatoid arthritis.
This functional recovery is based on the opposite need to
mobilize early the patient to avoid the formation of adhesions that can limit the range of joint motility and to protect
the tuberosity osteosutured carefully by the surgeon.
This seemingly irreconcilable requirement finds its manifes-
tation identifying the type of patient to be treated and dedicating a physiotherapist for each patient in the early stages
of immobilization of replaced joint .
The identification of the patient is based, first, on the “report” provided by the surgeon who will indicate with
“good”, “satisfactory” or “poor “ the mechanical quality of
tuberosity osteosuture; on the other hand, it will be based on
the study of the patient performed by the physiatrist .
Physiatrists must investigate the following parameters for
each patient candidated for a rehabilitation of prosthesis on
fracture: the resilience of motor pattern; the ability to follow
directions provided by the therapist in the delicate phase of
passive mobilization; the quality of bone, muscle and tendon tissues; personal response to pain, possibly basing on a
carefulness collection of the history of previous works carried out by the patient; personal motivations for a maximum
recovery.
At this point, we identify two kinds of patients to who will
be devoted as many types of customized rehabilitation
programs, always aiming to minimize the immobilization
time10.
1) The normal rehabilitation program.
It is dedicated to patients whose osteosuture quality was
judged sufficient, and in which there is inability to perform a true passive mobilization.
The patient protection will be total for 16-18 days. Then,
we will begin with an elevation passive which should get
to 90° after 25-30 days. Rotations will be protected for
about four weeks, and then gradually increase the range
of motility in a selective manner, while we enhance the
elevation.
2) Deleyed rehabilitation program.
It is dedicated to patients whose osteosuture quality
was judged poor and in who there is a poor tolerability
to pain, resulting an inability to perform a true passive
mobilization. It is recommended maximum protection for
four weeks. Passive elevation recovery begins after four
weeks, expecting to reach 90° in a few weeks. Rotation recovery starts after about 50-60 days from the surgery with
extreme caution. In this category of patients, introducing
hydrokinetic may be useful after four weeks post-surgery
in order to reduce joint stiffness that always accompanies
long periods of immobilization.
Conclusions
The results obtained after surgery of the shoulder prosthesis
are closely related to a careful study of pre-operative of patient for a correct direction, the proper positioning of prosthesis and a personalized program of functional rehabilitation. Actually, it is noted as the rehabilitation program will
vary, sometimes considerably, depending on the disease and
the type of surgery performed1.
Therefore, it is necessary for the rehabilitation therapist a
deep understanding of the disease pathology and the surgical technique used, in order to make a precise and timely
rehabilitation daily program, taking care the peculiarities of
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Vol. 125 - 1-2 Novembre 2014
the patient, and that lasts up to several months after intervention.
However, in literature, the results obtained appear to be the
best in terms of articulation, functionality and disappearance
of pain in those patients who have had the opportunity to access treatments hydrokinetic in the course of rehabilitation.
In fact, hydrokinetic becomes essential in the shoulder
treatment because: the articulation gradually returns without stressing the articular heads; it allows the execution of
movements ever wider, respecting the recovery times; it
allows to perform exercises in a tridimensional space and
to change positions easily and without effort; it limits pain,
reduces recovery times and forces to postural symmetry, reducing fees11.
In addition, results improve significantly in those patients
who, despite having completed the cycle of re-education,
performed regularly recalls with a rehabilitation therapist or
independently. In fact, these calls allow to avoid complications and, above all, to preserve over time the results obtained in the months following the intervention.
In conclusion, we feel in any case to support the importance
of a rehabilitation program also taken up to several months
after surgery, focusing on respect for the physiological time
of tissue healing, a careful and conscious articulation motility, and finally, a muscular strengthening and functional recovery which uses the physical characteristics of the aquatic
environment as a rehabilitation setting preferred in diseases
of the upper track.
REFERENCES
1. Brotzman SB, Wilk KE La riabilitazione in ortopedia. II ed., Excerpta Medica, Milano 2004
2. Valobra GN, Gatto R, Monticone M Medicina fisica e riabilitazione. Utet 2008: cap. 55-56-108-112
3. Di Domenica F, Galletti R, Leo R Riabilitazione dopo intervento di
osteosintesi o protesi di spalla in frattura. Arch Ortop e Reumatol
2011; 122: 31-3
4. Marinko LN, Chacko JM, Dalton D, Chacko CC The effectiveness
of therapeutic exercise for painful shoulder conditions: a metaanalysis. J Shoulder Elbow Surg 2011; 20(8): 1351-9
5. Gleyze P, Flurin PH, Laprelle E, et al. ��
Pain management in the rehabilitation of stiff shoulder: prospective multicenter comparative
study of 193 cases. OTSR 2011; 97: S195-203
6. Gleyze P, Georges T, Flurin PH, et al. Comparison and critical evaluation of rehabilitation and home-based exercises for treating
shoulder stiffness: prospective, multicenter study with 148 cases.
Orthopaedics & traumatologi, surgery and research: OTSR 2011;
97: S182-94
7. Becker BE Aquatic Therapy: Scientific Foundations and Clinical
Rehabilitation Applications. Bruce American Academy of Physical
Medicine and Rehabilitation. PM&R 2009; 1:859-872
8. Seitz WH, Michaud EJ Rehabilitation after shoulder replacement:
be all you can be! Semin Arthr 2012; 23: 106-113
9. Marrero L, Garcia G, Pacheco I Early outcomes of reverse total
shoulder arthroplasty. Boletín de la Asociación Médica de Puerto
Rico 2009; 101:34-7
10. Inglese F, Creta D, Biondi M Fratture dell’estremo prossimale
dell’omero e protesi di spalla: trattamento riabilitativo. Lo Scalpello 2009; 23:70-4
11. Castillo-Lozano R, Cuesta-Vargas A, Gabel CP Analysis of arm elevation muscle activity through different movement planes and
speeds during in-water and dry-land exercise. J Shoulder Elbow
Surg 2013; 23:159-65
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