Evaluation of the functional results after rotator cuff arthroscopic repair with the suture bridge technique

Introduction

Surgical treatment of rotator cuff injuries (RCI) has beenincreasingly indicated; recently, arthroscopy became the mostwidespread method1since there is no need to detach the del-toid muscle, allows complete visualization of the shoulderjoint and rotator cuff lesions, evaluation of associated lesions,less cumbersome postoperative recovery, early return to workactivities, and lower rate of postoperative infection.2,3

Since the description of the insertion of the rotator cuff ten-dons by Apreleva et al.,4 the purpose of repair, regardless of thetechnique, became the anatomical restoration of structures.5 Among the variations in the RCI arthroscopic suture technique, the most used are: single row with simple suture,6 double row,7 and the suture bridge (SB) technique.8 The latter presents the advantages of better contact and coaptation ofthe tendon to the bone and promotion of healing9; it provides astronger repair than the double-row technique10and producesa self-reinforcement effect that helps support the structuralintegrity and potentially improve the biology of healing.11

This study aimed to assess the clinical results of patientswho underwent arthroscopic repair of the rotator cuff usingthe transosseous-equivalent suture technique, or SB, and itscomparison with the literature.

Patients and methods

From November 2006 to November 2014, 41 patients withRCI underwent arthroscopic surgical treatment with the SBSB technique, performed by the Shoulder and Elbow Group of theDepartment of Orthopedics and Traumatology of this institu-tion. Inclusion criteria were patients with large and extensiveinjuries according to the classification of Cofield,12 involv-ing tendons of the supraspinatus and infraspinatus muscles,in whom the SB technique was used, and who underwentonly primary surgery and presented a minimum postoperativefollow-up of one year. Thirty-seven patients were reassessed.Four did not fit the inclusion criteria.

The study included 24 male (64.8%) and 13 female patients(35.1%). Mean age was 60 years (range: 45–75 years). The domi-nant limb was affected in 32 cases (86.4%). Among the lesions,18 (48.6%) were due to trauma.Mean range of motion at preoperative evaluation was 123ºof elevation (range: 20ºto 160º).

Mean lateral rotation was58º(range: 20ºto 60º) and mean medial rotation was T11 (range: gluteus to T5). Fatty degeneration was assessed andclassified according to Goutallier et al.13 by magnetic resonance imaging (MRI) in 36 patients. A mean grade of 2.60 wasobserved, ranging from 2 to 4: 23 (63.8%) cases were classified as grade 2, five (13.8%) as grade 3, and eight (22.2%) asgrade 4. The MRI of one patient was not found for evaluation.

All patients underwent surgery on a beach chair posi-tion, under general anesthesia associated with brachial plexusblock. Arthroscopic inspection of the joint was performedprior to repair of the cuff. Subsequently, the subacromial spacewas approached, at this point, bursal debridement, tendonmobilization, and debridement of the greater tubercle of thehumerus bone were performed, followed by cuff repair using the SB technique, which consisted of a medial row of twoanchors in the articular margin associated with the lateral fix-ation without stitches, as described by Park et al.8(Fig. 1A andB). In the medial row, Bio-Corkscrew®anchors were used in allpatients, with Fibertape®in 33 (89.1%) cases and Fiberwire®infour (10.8%). For lateral fixation, two PushLock®anchors wereused in 34 patients (89.18%), and SwiveLocks®were used inthe other four (10.8%).

Resection of the lateral portion of the clavicle was per-formed in 13 patients (35.1%); tenotomy and tenodesis of thelong head of the biceps were performed in 26 (70.2%) and 23(62.1%), respectively. In three patients (8.1%), the long headof the biceps was absent. Acromioplasty was conducted in 36 patients (97.2%). In the patient in whom it was not performed, a severe degenerative lesion of the rotator cuff tendons wasobserved. In six patients (16.2%), a simple tendon–tendonsuture was made for closure of the remaining lesion. High sub-scapular lesion was identified in four patients (10.8%), suturedwith a simple stitch.Mean time of immobilization in the postoperativeperiod, with a functional sling, was seven weeks (range:6–12).

Mean follow-up was 30 months (range: 12–63 months). Patients were evaluated using the criteria proposed by the University of California at Los Angeles (UCLA).14 The range of jointmotion was measured following the criteria of the American Academy of Orthopaedic Surgeons (AAOS).15

This study was duly submitted to and approved by theEthics Committee of the institution and was registered underCAAE No. 45987815.9.0000.5479.

Results

Mean UCLA score14 of the 37 patients was 33.7 points (range16–35). Results were considered excellent in 30 (81%) cases and good in five (13.5%). In one case (2.7%), the result wasfair, as it evolved with adhesive capsulitis in the postoperative period; in another case (2.7%), it was considered poor, sincethe patient presented a new symptomatic rupture, confirmedby MRI (Fig. 3).

Mean range of motion at postoperative evaluation was 148º (range: 120ºto 160º) of elevation, 55º(range: 20ºto 70º) of lateral rotation, and T9 (range: L4–T5) medial rotation, i.e., gainswere observed in all directions of movement, with a meanincrease of 25º of elevation, 3º of lateral rotation, and twovertebral levels of medial rotation.

Discussion

The increase in overall longevity associated with the practiceof physical activity has led to the consideration of surgicalRCI treatment in older patients; the literature indicates thatarthroscopic repair is consistently better.16–20

The study by Hattrup21 established an association betweenlesion size and age of the patient; this was actually observedin the present study, in which the mean age of patients was60 years. It is noteworthy that lesions in elderly patients arenot only large, but also usually have a degenerative character,with atrophied muscles and thin tendons of poor quality forsuture,20 which further complicates the RCI treatment; this isone of the indications for the SB technique.8

As previously mentioned,8 the SB technique was developedin order to increase the contact and coaptation of the tendonto bone, to achieve scarring9 and thereby the healing of theinjury. Furthermore, this technique has been documented bynumerous authors for its efficacy and effectiveness in repairing large and extensive RCIs.22 This was one of the factors thatled to the choice of this technique in the present study. It mustbe emphasized that the present study had large and extensivelesions as an inclusion criterion (Fig. 3).

Regarding the etiology, in 2015 Miyazaki et al.20 demon-strated a significant association between trauma and incidence of large and extensive Cofield lesions,12 as was observedin the present study, in which 48.6% of the injuries had a traumatic origin.

The development of arthroscopic repair techniques hasreduced the incidence of reruptures and revisions for rotatorcuff repair. It is now known that the ideal treatment shouldprovide sufficient strength to maintain the repair of the lesionwith enough shoulder movement and stability to allow healing of the tendon to the bone without the appearance of a newlesion.23

Using the arthroscopic SB technique, excellent and goodresults were obtained in 94.5% of the present cases accord-ing to the UCLA score.14

Using this technique, only two cases(5.4%) presented unsatisfactory results, one case (2.7%) withfair outcome and one case (2.7%), poor, in patients aged 56–71years. These results prove the efficacy of the technique usedin the repair of these lesions.

The increased degree of fatty degeneration led to the recurrence of rotator cuff rupture after arthroscopic repair in 31.8% of the patients in the study by Ozbaydar et al.,24 in 2005, andin 30% of those in the study by Godinho et al.,25 in 2010. Mostcases were asymptomatic, as patients had no pain or functional loss.26 In this service, postoperative routine MRI imageswere not performed; the examination was requested only forthe one symptomatic case in this study, which evidencedsuture dehiscence (Fig. 2). The authors believe that the suturefailure happened because, in addition to not maintaining theimmobilization (sling), as recommended, and not attendingthe postoperative rehabilitation, the patient presented Goutallier et al.13 grade 4 fatty degeneration in the preoperative MRI, above the average of 2.6 in the current study.

Five cases presented signs of a capsular inflamma-tory process that suggested adhesive capsulitis during the arthroscopic joint inspection procedure, but did not require supplementary treatment, whether intra- or postoperatively.

Conclusion

The arthroscopic treatment of RCI using the SB technique ledto 94.5% excellent and good results when assessed by theUCLA functional score.

Conflicts of interest

The authors declare no conflicts of interest.

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