What percentage of rotator cuff surgeries are successful?

What percentage of rotator cuff surgeries are successful?

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Rotator Cuff Tear and the Effectiveness of Surgical Repair
Rotator cuff tears are a common source of debilitating shoulder pain, reduced strength, weakness, and more than 400,000 rotator cuff surgical procedures are performed annually in the US [1]. Although the surgery can relieve pain for most people and rehabilitation can restore functional range of motion, re-tear of the repair is a relatively frequent occurrence [see Tables 1, 2, 3]. There is a recognized need to improve the clinical and functional outcome of rotator cuff surgery.

• Large (3 — 5 cm) or massive (>5 cm, two tendon) tear (see below)
• Previous failed rotator cuff surgery at that site
• Chronic tear

X-Repair is designed to reinforce the surgical repair site and protect it from receiving excess load that may result in a re-tear of the rotator cuff tendons, and allow the natural repair process to occur.

Clinical Problem
A review of reports describing outcome of rotator cuff repair assessed using imaging (MRI or ultrasound) shows a range of successful outcomes, between 5% and 90% (Tables 1-3), depending in part on the size of the original tear. A major variable in the outcome of rotator cuff repair is reported to be tear size, and so the summaries are separated into results for massive tears (Table 1), large tears (Table 2), and small to medium tears (Table 3). Results were not included from reports when a confident assessment of the size of the original tears could be made. Table 1 indicates the success in structural restoration of massive tears is modest, ranging from 24% — 63% (average is 40%). Table 2 summarizes results of repair for large tears and shows a success rate by imaging of 52% (range of 5% — 90%), and a level of successful repair of 62% when the data of Galatz et al [2], (5% success) is regarded as an outlier and is not included. Similarly a review of the literature for repair of small to medium tears (1 — 3 cm) where repair was assessed using imaging showed a success rate range of 60 — 79%, with an average of 74%. Overall the data indicates a modest success rate in structural restoration of the rotator cuff by surgery.

Tables 1 — 3: Summaries of published data on repair of rotator cuff tears assessed by imaging, and has been used to provide the data for power analyses to calculate group sizes in the planned clinical studies.

Studies have correlated rotator cuff integrity as assessed by postoperative imaging with outcome and have shown cuff integrity to be an important factor in patient clinical outcomes [3, 13-15]. Studies have also shown that better function and pain relief can be obtained if the cuff is intact postoperatively [3-6, 8, 9, 16]. Nevertheless, there is substantial improvement in clinical scores and patient satisfaction after rotator cuff repair [10, 15, 17-20], particularly those with small to medium tears.

1. PearlDiver. Available from: http://www.pearldiverinc.com
2. Galatz, L.M., et al., The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am, 2004. 86-A(2): p. 219-24.
3. Harryman, D.T., 2nd, et al., Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am, 1991. 73(7): p. 982-9.
4. Thomazeau, H., et al., Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop Relat Res, 1997(344): p. 275-83.
5. Gerber, C., B. Fuchs, and J. Hodler, The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am, 2000. 82(4): p. 505-15.
6. Iannotti, J.P., et al., Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. A randomized, controlled trial. J Bone Joint Surg Am, 2006. 88(6): p. 1238-44.
7. Nho, S.J., et al., Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome. J Shoulder Elbow Surg, 2009. 18(1): p. 13-20.
8. Klepps, S., et al., Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med, 2004. 32(7): p. 1716-22.
9. Bishop, J., et al., Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg, 2006. 15(3): p. 290-9.
10. Boileau, P., et al., Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am, 2005. 87(6): p. 1229-40.
11. DeFranco, M.J., et al., Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Shoulder Elbow Surg, 2007. 16(6): p. 759-65.
12. Ko, S.H., et al., Arthroscopic single-row supraspinatus tendon repair with a modified mattress locking stitch: a prospective, randomized controlled comparison with a simple stitch. Arthroscopy, 2008. 24(9): p. 1005-12.
13. Calvert, P.T., et al., Arthrography of the shoulder after operative repair of the torn rotator cuff. J Bone Joint Surg Br, 1986. 68(1): p. 147-50.
14. Goutallier, D., et al., Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res, 1994(304): p. 78-83.
15. Jost, B., et al., Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am, 2000. 82(3): p. 304-14.
16. Gazielly, D.F., P. Gleyze, and C. Montagnon, Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res, 1994(304): p. 43-53.
17. Ellman, H., S.P. Kay, and M. Wirth, Arthroscopic treatment of full-thickness rotator cuff tears: 2- to 7-year follow-up study. Arthroscopy, 1993. 9(2): p. 195-200.
18. Fuchs, B., et al., Clinical and structural results of open repair of an isolated one-tendon tear of the rotator cuff. J Bone Joint Surg Am, 2006. 88(2): p. 309-16.
19. Gartsman, G.M. and S.M. Hammerman, Full-thickness tears: arthroscopic repair. Orthop Clin North Am, 1997. 28(1): p. 83-98.
20. Iannotti, J.P., et al., Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am, 2005. 87(6): p. 1305-11.

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Many rotator cuff shoulder surgeries fail. Understanding the tendon better could help.

Dianne Little
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WEST LAFAYETTE, Ind. — A few years ago, when Dianne Little was leading a horse around the corner of a barn, she was suddenly met by a piece of construction equipment with a tarp flapping heavily in the wind. The horse spooked, rearing up on its hind legs, and tried to head for the hills. Little held tight, refusing to lose control of the horse, but she left the barn that day with a partially dislocated shoulder and a torn rotator cuff.

Rotator cuff tears can happen in a split second, like Little’s did, or they can be caused by prolonged stress and degeneration over years or even decades, finally reaching a point of no return. It’s estimated that up to 2 million people in the United States visit their doctors with a torn rotator cuff each year, with athletes and older active adults especially vulnerable.

Little , an assistant professor of basic medical sciences at Purdue University, has been studying rotator cuff tears and how to repair them for several years.

“Rotator cuff tears are a really debilitating injury because you can no longer do simple things like brush your hair or put your seat belt on,” she said. “Once it gets to that point, many tears need to be repaired surgically. But the problem is, there’s no way to do it that has guaranteed results. Depending on the patient population and on the size of the tear, up to 90 percent of tears repaired surgically fail, so there’s a big push to try and find better solutions.”

Current methods to repair rotator cuff tears involve stitching the torn tendon back to the bone, using a biomaterial made from human or animal tissue or doing a transfer using tendon from nearby to replace rotator cuff function. In some cases, a joint replacement may be necessary. But due to the high physical demands on rotator cuffs and the complex anatomy of tendon, re-tears after surgery are common.

Little wants to engineer tendon that would match the patient’s own rotator cuff. If surgeons were able to use tendon that matched that of the healthy tendon to repair it, they might be able to stimulate early regeneration, rather than scarring and fibrosis.

But there’s one big hurdle in the way of tendon engineering: researchers don’t fully understand what tendon is.

“We know what tendon looks like and how it behaves, but we don’t really know what it is. There’s no marker that tells you, ‘This is tendon.’ There are certain markers for bone and cartilage, so when you see them, you know that’s what you’re looking at. But that’s not true for tendon because we don’t know enough about what tendon is,” Little said. “If you’re trying to grow new tendon, you need to know what it is before you know whether or not you’ve recreated it.”

A $2.5 million grant from the National Institutes of Health could help her toward a breakthrough in the field. For the next five years, Little will be trying to figure out what the rotator cuff tendon looks like at every level – from the proteins, fats and metabolites, to the genetic code that makes tissue turn into tendon.

For her study, she’ll use human tissue and stem cells from fat that aren’t suitable for transplantation to create new tendon. Then she’ll sequence all these levels and genetic factors of the engineered tendon and naturally occurring tendon to see how those profiles change.

“We’ll be able to see if the new tendon ends up being the same as the existing tendon or if it’s different, and if so, how we could push it to become better tendon,” Little said.

This research aligns with Purdue’s Giant Leaps celebration, acknowledging the university’s global advancements made in health and longevity as part of Purdue’s 150th anniversary. This is one of the four themes of the yearlong celebration’s Ideas Festival , designed to showcase Purdue as an intellectual center solving real-world issues.

The project is supported by award 1R01AR073882-01A1 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Little will collaborate with Sarah Calve, assistant professor of biomedical engineering at Purdue; Marxa Figueiredo, associate professor of basic medical sciences at Purdue; Uma Aryal and Jyothi Thimmapurum, researchers in Purdue’s Bindley Bioscience Center; and Dr. Grant Garrigues, of Midwest Orthopedics at Rush.

Writer: Kayla Zacharias, 765-494-9318, kzachar@purdue.edu

Source: Dianne Little, 765-494-9307, little33@purdue.edu

An Alternative Surgical Option for Severe Rotator Cuff Tears

If you have a severe rotator cuff tear that can’t be mended, or if a previous repair didn’t bring relief, superior capsule reconstruction may help.

About Rotator Cuff Tears and Repairs

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Your shoulder is a ball-and-socket joint. The rotator cuff is a group of tendons and muscles that helps keep the ball at the top of your upper arm bone centered in your shoulder socket. It also helps you lift and rotate your arm.

When your rotator cuff tears — either from a sudden injury or long-term wear and tear — the pain and weakness can make it difficult to do simple tasks that involve reaching overhead, like washing your hair or putting away dishes. If nonsurgical treatments like medication and physical therapy don’t help, doctors can repair moderate tears surgically. Until recently, though, there were few options for repairing more severe rotator cuff tears. One option, called reverse shoulder replacement surgery, still requires you to limit your activities after surgery and may not last more than 15 years. As a result, orthopaedic surgeons typically reserve this option for patients older than 70 who are relatively inactive.

Superior Capsule Reconstruction — An Alternative

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In recent years, Duke shoulder specialists have begun offering a newer technique, called superior capsule reconstruction, to repair severe rotator cuff tears. In this approach, the surgeon inserts a human tissue graft, attaching one end to your upper arm bone and the other end to your shoulder socket. The graft doesn’t replace your rotator cuff tendon, but it performs a similar function: keeping the ball of your arm bone centered in your shoulder socket and helping you raise your arm.

Doctors perform the surgery arthroscopically, by inserting a telescope-like camera and surgical instruments through small incisions about the width of a finger. It’s done under regional anesthesia combined with sedation, and most patients go home the same day.

Jocelyn Wittstein, MD, one of a few Duke orthopaedic surgeons who performs the technically demanding technique, said most patients do well with it. “They have an immediate reduction in pain,” she said, “and they’re very happy with their increase in range of motion. Relief of night pain is the most predictable benefit of this surgery.”

Tally Lassiter, MD, MHA, another Duke orthopedic surgeon who performs the procedure, added, “We have been doing superior capsule reconstructions in this country for over four years now, and the short-term results are good-to-excellent in about 75% of patients, particularly in relation to pain relief.”

Recovering from Superior Capsule Reconstruction

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Dr. Wittstein notes that people who have superior capsule reconstruction generally have less pain right after surgery than if they’d had a typical rotator cuff repair. However, the timeline for physical therapy and returning to normal activities is longer and more gradual. That’s because the graft needs time to incorporate with the rest of the shoulder joint. “We protect it from really heavy lifting until about six months after surgery, to let the graft heal in,” said Dr. Wittstein.

Over time, most patients are able to raise their arm again. Dr. Wittstein cautions that not everyone will regain full range of motion, but the improvement is usually significant.

Who Is a Candidate for Superior Capsule Reconstruction?

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This option can restore motion and relieve pain for those who may have been told that their rotator cuff tear is so severe that it can’t be repaired. You may also be a candidate if you had rotator cuff repair surgery and it didn’t heal properly. However, Dr. Wittstein noted that superior capsule reconstruction won’t help if you also have significant arthritis in your shoulder. Instead, reverse shoulder replacement may be recommended. That’s just what it sounds like: a form of shoulder replacement where the joint is reversed. A ball is attached where your shoulder socket normally sits, and a socket is fitted to the top of your upper-arm bone. This allows you to use different muscles, instead of the ones in the rotator cuff, to move and rotate your arm.

“Reverse shoulder replacements are a good option for patients over 70 years of age with large tears and significant arthritis who do not have daily activities that require lifting of greater than 25 pounds overhead,” said Dr. Lassiter. “For younger or more active patients without arthritis, superior capsule reconstruction is a good option.”

In many cases, Dr. Wittstein said, she’ll begin surgery by attempting to repair the torn rotator cuff tendon, with superior capsule reconstruction as an agreed-upon backup option for the patient. “If the tendon is surprisingly flexible and more mobile than pre‐op imaging suggested, we can still do a primary repair,” she said. “So, we have a plan for what we expect, but in borderline cases we can make the decision after surgery begins.”

Technique Offers Long-Term Benefits

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In addition to easing pain and improving mobility, superior capsule reconstruction can also prevent shoulder problems from getting worse. When a rotator cuff tear goes unrepaired, the ball part of the joint tends to drift higher in socket, causing arthritis over time. Superior capsule reconstruction restores the alignment of the shoulder joint and normalizes its mechanics, which may slow progression of the condition.