To secure a first body tissue with a second body tissue, a first anchor is moved along a first path through the first body tissue into the second body tissue. A second anchor is moved along a second path through the first body tissue into the second body tissue. A suture extending between the anchors may be tightened by moving the second anchor along a path which extends transverse to the path of the first anchor. The suture which extends between the anchors may have free ends which are connected with a suture retainer. The free ends of the suture may be interconnected either before or after the anchors are moved along the first and second paths. Alternatively, the suture may be a continuous loop which extends between the two anchors. A guide assembly may be provided to guide movement of the anchors along the two paths. The paths along which the anchors move may intersect so that the anchors may be interconnected at the intersection between the two paths.

Method of securing body tissue

Background:Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.Purpose:To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.Study Design:Systematic review and meta-analysis of articles with evidence levels 1-4.Methods:A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.Results:While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic re...

Rotator Cuff Repair: Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome

Purpose: To prospectively evaluate the safety and effectiveness of arthroscopic acellular human dermal matrix augmentation of large rotator cuff tear repairs. Methods: A prospective, institutional review board–approved, multicenter series of patients undergoing arthroscopic repair of 2-tendon rotator cuff tears measuring greater than 3 cm were randomized by sealed envelopes opened at the time of surgery to arthroscopic single-row rotator cuff repair with GraftJacket acellular human dermal matrix (Wright Medical Technology, Arlington, TN) augmentation (group 1) or without augmentation (group 2). Preoperative and postoperative functional outcome assessments were obtained by use of the American Shoulder and Elbow Surgeons (ASES), Constant, and University of California, Los Angeles scales. Gadoliniumenhanced magnetic resonance imaging (MRI) evaluation of these repairs was obtained at a mean of 14.5 months (range, 12 to 24 months). Adverse events were recorded. Results: There were 22 patients in group 1 and 20 in group 2 with a mean age of 56 years. The mean follow-up was 24 months (range, 12 to 38 months). The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. The scores in group 1 were statistically better than those in group 2 (P .035). The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. The scores in group 1 were statistically better than those in group 2 (P .008). The University of California, Los Angeles score improved from 13.3 to 28.2 in group 1 and from 15.9 to 28.3 in group 2 (P .43). Gadolinium-enhanced MRI scans showed intact cuffs in 85% of repairs in group 1 and 40% in group 2 (P .01). No adverse events were attributed to the presence of the matrix grafts. Conclusions: Acellular human dermal matrix augmentation of large (3 cm) cuff tears involving 2 tendons showed better ASES and Constant scores and more frequent intact cuffs as determined by gadolinium-enhanced MRI. Intact repairs were found in 85% of the augmented group and 40% of the nonaugmented group (P .01). No adverse events related to the acellular human dermal matrix were observed. Level of Evidence: Level II, lesser-quality randomized controlled trial.

A Prospective, Randomized Evaluation of Acellular Human Dermal Matrix Augmentation for Arthroscopic Rotator Cuff Repair

The rotator cuff performs multiple functions during shoulder exercises, including glenohumeral abduction, external rotation (ER) and internal rotation (IR). The rotator cuff also stabilizes the glenohumeral joint and controls humeral head translations. The infraspinatus and subscapularis have significant roles in scapular plane abduction (scaption), generating forces that are two to three times greater than supraspinatus force. However, the supraspinatus still remains a more effective shoulder abductor because of its more effective moment arm. Both the deltoids and rotator cuff provide significant abduction torque, with an estimated contribution up to 35–65% by the middle deltoid, 30% by the subscapularis, 25% by the supraspinatus, 10% by the infraspinatus and 2% by the anterior deltoid. During abduction, middle deltoid force has been estimated to be 434 N, followed by 323 N from the anterior deltoid, 283 N from the subscapularis, 205 N from the infraspinatus, and 117 N from the supraspinatus. These forces are generated not only to abduct the shoulder but also to stabilize the joint and neutralize the antagonistic effects of undesirable actions. Relatively high force from the rotator cuff not only helps abduct the shoulder but also neutralizes the superior directed force generated by the deltoids at lower abduction angles. Even though anterior deltoid force is REVIEW ARTICLE

This material is the copyright of the original publisher. Unauthorised copying and distribution is prohibited. Shoulder Muscle Activity and Function in Common Shoulder Rehabilitation Exercises

BackgroundThe purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery.HypothesesWe hypothesized that (1) the rotator cuff repair method will not affect retear rate, and (2) the surgical approach will not affect the retear rate for a given repair method.Study DesignSystematic review of the literature.MethodsThe literature was systematically searched to find articles reporting imaging study assessment of structural healing rates after rotator cuff repair, with data stratified according to tear size. Retear rates were compared for transosseous (TO), single-row suture anchor (SA), double-row suture anchor (DA), and suture bridg...

Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing? A Systematic Review

Background: The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique.

Methods: Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff.

Results: The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores.

Conclusions: Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Arthroscopic rotator cuff repair with double-row fixation

https://www.onlinelibrary.wiley.com/doi/pdf/10.1016/j.orthres.2004.03.010

Shoulder prostheses treating cuff tear arthropathy: a comparative biomechanical study.

The morphology of the glenoid cavity is highly variable, and no consensus exists regarding how to classify the different forms. We examined 98 dry scapulae to identify a common morphological entity and to define reproducible bony references of the glenoid cavity. The glenoid cavities were photographed perpendicularly in a standardized fashion. The bony peripheral rim was studied on these two-dimensional images, defined by randomly chosen points in order to define one or more circles. This study showed that only the peripheral rim of the inferior quadrants of the articular surface was found to be located on a circle (P=0.926) with a radius of 12.8 mm (SD 1.3 mm). Defining the center of this circle appeared to be more reliable (ICC 0.98) than determining the middle point of the longitudinal axis (0,0) between the most cranial and most caudal points, defined as Saller's line (ICC 0.89). The distance of the center of this projected circle to the middle point of Saller's line had a unimodal distribution, suggesting the existence of only one glenoid cavity morphotype. We then investigated the relationship between the center of the circle and the area of subchondral bone thickening under the bare spot, the so-called tubercle of Assaki. Ten phenolized cadaveric glenoid cavities were examined with computed tomography. A circle was projected on the first image showing the bony peripheral rim, and this circle was copied on the consecutive slices until the tubercle of Assaki came across. The center of the circle was located within the area of the tubercle of Assaki, in all but one specimen. To investigate the clinical implications of this finding, the cadaver specimens were used to compare the position of the center of the circle with the postulated center of implantation according to the literature, and to the reference guide for a commonly used total shoulder prosthesis. The center of the circle was consistently situated more distal than the postulated center of the guide (mean 5.5 mm, range 4–8 mm) and the middle point of the glenoid cavity (mean 2 mm, range 1–3 mm). These findings could offer a reproducible point of reference for the glenoid cavity in osseous anthropometry and a valuable reference in shoulder replacement surgery, and might help in the definition of osseous glenohumeral instability.

About the variability of the shape of the glenoid cavity

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.

Bart Berghs

Papers

Arthroscopic rotator cuff repair with double-row fixation

Shoulder prostheses treating cuff tear arthropathy: a comparative biomechanical study.

About the variability of the shape of the glenoid cavity

One-stage revision for patients with a chronically infected reverse total shoulder replacement

Arthroscopic release of adhesive capsulitis.