Single- and double-row treatments each show advantages for repair of rotator cuff tears
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Surgical procedures for rotator cuff repair can be difficult and time consuming to perform and may be associated with a steep learning curve. According to some shoulder surgeons, the trend today is toward arthroscopic techniques for rotator cuff repair and away from mini-open and open procedures. Despite the approach used, often the surgeon must determine, when indicated, whether repair with a single row or a double row is appropriate for the type of rotator cuff tear being treated.
Emilio Calvo, MD, PhD, MBA, of Madrid, sees the surgical trend in this area moving toward double-row repair, especially for large rotator cuff tears. He said by far the majority of rotator cuff surgeries today are performed arthroscopically, as opposed to when the surgery was first developed in the 1980s.
“Now, I would say 80% of the cases throughout the world are doing this surgery with arthroscopic surgery, and open surgery only for very difficult cases with severe tendon retraction” Calvo told Orthopaedics Today Europe.
According to Calvo, the ideal situation in which arthroscopic rotator cuff repair is performed is when the physician specializes in shoulder surgery or sports medicine.
No difference in the literature
According to the literature, both the single-row and double-row techniques can result in rotator cuff repairs that are done well. However, Calvo said double-row repairs are much more challenging procedures.
“It is an interesting topic and very controversial because double-row repair typically achieves a more robust repair, but is technically more demanding, more expensive and more time consuming. It is important for a patient undergoing surgery. But we know from biomechanical data, the surface [area] in contact between the tendon and the footprint, where the tendon should be put back, is higher if you do a double-row repair compared to the surface in contact with the tendon with a single-row repair,” Calvo said.
A study by Prasathaporn and colleagues in Arthroscopy in 2011 found double-row repair had a significantly higher rate of tendon healing compared to single-row repair, but there was no statistically significant difference in shoulder function, muscle strength, forward flexion, internal rotation, patient satisfaction or return to work following the two procedures.
Several types of tears
The most common rotator cuff tear, according to Calvo, is a posterosuperior tear, which typically involves tears of the supraspinatus or infraspinatus tendons. A much less common rotator cuff tear, however, is that of the subscapularis tendon.
“Subscapularis tears — these are the tears involving the interior part of the tendon. It is a very strong tendon, and it is less common to tear than the supraspinatus and infraspinatus tendons. The data supporting the use of double row in these (subscapularis) tendons are very poor, but I think, again, double-row repair is a good indication for these tears,” Calvo said.
Also, he reported the number of rotator cuff surgeries performed on elderly patients increases nearly every year. This population of patients is staying active longer, Calvo said, and they want to maintain their lifestyle and their shoulder function.
Double-row may be difficult to complete
Zinon T. Kokkalis, MD, PhD, of Athens, told Orthopaedics Today Europe data in the literature support both of these techniques for small to medium rotator cuff tears and they both lead to similar functional outcomes, patient satisfaction and days out of work.
Compared to single-row repairs a double row provides better tendon healing and a better tendon footprint. It also leads to more optimal treatment for rotator cuff tears in which the tendons are retracted more than 3 cm, according to Kokkalis.
“The main disadvantages of double row are they require more anchors — that is to say an increased cost, greater operating time and a demanding learning curve. On the other hand, single row is more simple and can be performed by the average arthroscopic surgeon,” he said. “According to the literature, and my practice, double- and single-row results are quite similar for functional outcomes in small and medium tears, less than 3 cm.”
“There is little evidence to support (better outcomes) between the two techniques, except for tendons retracted by more than 3 cm,” Kokkalis said.
Kokkalis and colleagues published a study in 2014 that showed that GraftJacket human dermal allografts (Wright Medical Technology; Arlington, Tenn., USA) can be used successfully and safely for massive rotator cuff repairs 5 cm in size or greater. The technique is effective when performed with a mini-open procedure, Kokkalis said. Eighteen of 21 patients who underwent the procedure reported they were satisfied or very satisfied with their outcomes and all patients experienced significant pain relief (P = 0.001) and improved range of motion (P = 0.001), according to the study results.
“This is interesting because a repair of the rotator cuff is not only technical, but also has to do with the biology and the anatomic and mechanical properties of the repair,” Kokkalis said.
However, as with any tear, the chance of a re-tear is high. This is due to many factors, including the patient’s age, poor tendon biology, diabetes and a previously failed rotator cuff repair surgery, he said.
Broad spectrum of patients
Most patients being treated for rotator cuff tears are either elderly, between age 50 years and 75 years, or are athletes who participate in overhead sports and have an age range of 18 years to 40 years, according to Klaus Bak, MD. However, overhead athletes rarely require surgery for their cuff tears, he said.
Bak said he uses a single-row procedure in about 90% of the rotator cuff repairs he performs.
“To me, this is more a question of when double row is indicated. It seems today that it is more often recommended for retracted, reducible tears, but I fear that in the case of bad tendon tissue, the risk of failure is higher and revision is much more complicated. A medium retracted 1-cm to 2-cm tendon tear with good tissue in a younger active individual is a good indication for double-row repair,” Bak told Orthopaedics Today Europe.
Bak performs all his rotator cuff tear repairs arthroscopically and has not used a mini-open or open technique in the past 10 years.
“I admit there are very rare cases of three tendon tears where open repair may be easier, but I generally fear the much higher rate of complications in open repair such as infection, deltoid muscle detachment and prolonged morbidity. I am convinced that within 3 years to 4 years, open repair will be banned just as it is with meniscal surgery,” he said.
Although Bak uses a single row the majority of the time, he said “we do not have the correct solution yet” for rotator cuff repair surgeries and a correct biomechanical construct has yet to be developed.
Tissue more problematic than sutures
For the procedures he performs, Bak will use non-absorbable number 2 sutures with metal anchors.
Calvo does the same type of suturing, but said the degeneration of tissue in the rotator cuff is an important consideration in repair of the tendon.
“Now we have excellent materials, highly resistant sutures to make a very stable repair. But we know now it is not the sutures, but the problem can be the tissue quality. Now we have excellent sutures made from highly resistant materials, so there is not much of a concern of the sutures breaking. The weak link of the chain is the tissue,” he said.
Surgeons need to take great care to select anchors that will not pop out of the bone and make sure the interface between the sutures and tendon tissue is secure, according to Calvo, which can be challenging in some types of patients, especially in elderly, osteoporotic women who have poor bone quality.
“New anchors that are more stable and with a lower probability to pop out have been developed, but there is still a possibility the anchor pops out, especially women with osteoporosis or patients with poor tissue quality,” he said.
Imaging can determine technique
W. Jaap Willems, MD, PhD, of Amsterdam, told Orthopaedics Today Europe smaller tears work better with single-row repair, particularly tears of the supraspinatus tendon. Most other tears, he said, should be handled with a double-row repair.
Willems said imaging is also a factor in determining the most appropriate way to repair a rotator cuff tear. CT scans, ultrasound and MRI are all effective in assessing the amount of damage and retraction associated with the injury, he said.
“Ultrasound gives very good information. It shows if there is a full thickness tear, the size of the muscle, but it does not show the quality of the tendon. The CT scan ... gives you some information on the quality of the tissue and the degree of the tendon degeneration,” Willems said. “But plain MRI can give you very accurate information.”
Timing of exercise, rehabilitation
After surgery is completed, it is important to wait until the tendon is properly attached to the bone before exercise can begin, which is typically 6 weeks after the surgery, Willems said. However, passive movement can begin at 3 days to 5 days after the repair surgery, which immediately begins to improve a patient’s range of motion.
This is the same approach used for athletes and non-athletes, he said, as the healing is no different for different types of patients.
“It makes no difference if you immobilize or if you start passive exercise,” Willems said, noting full exercises can usually begin at 6 weeks postoperatively.
Depending on the athlete and the size of the tear, Willems waits 4 months to 6 months before he allows a return to sports.
The rehabilitation after operative repair of a rotator cuff tear is less involved when the patient had a small supraspinatus tendon tear compared to what is done for a larger, more retracted tear, he said.
PRP for rotator cuff repair
There have been recent reports of platelet-rich plasma (PRP) being added during surgery for rotator cuff tears. Willems said the injection of PRP or growth factors has little to no effect on the outcome of a repair procedure or healing and there is no evidence in the literature of this method having an effect on the overall healing or outcome of rotator cuff repair surgery.
Kokkalis, however, uses PRP in selected cases he treats. He agreed with Willems that the evidence in the literature is controversial, but he believes PRP can help with some of the potential complications and re-injuries after rotator cuff surgery.
“I currently use PRP in my practice. I usually use PRP when I do arthroscopic repair for a large tear,” Kokkalis said. “In the literature, there is a controversy if it helps or not, but in my practice I think there is some benefit. But I cannot recommend this for everyone.”
Kokkalis said there is scientific evidence in a study by Jo and colleagues that supports the possibility that PRP injections may decrease the chances of a re-tear compared to the chances of a re-tear in a patient who did not receive PRP treatment intraoperatively. – by Robert Linnehan
- References:
- Jo CH. Am J Sports Med. 2013;doi:10.1177/0363546513497925.
- Kokkalis ZT. Orthopedics. 2014;doi:10.3928/01477447-20141124-59.
- Prasathaporn N. Arthroscopy. 2011;doi:http://dx.doi.org/10.1016/j.arthro.2011.01.014.
- For more information:
- Klaus Bak, MD, can be reached at Teres Hospitalet, Oester Allé 42, 3. sal, DK-2100 Copenhagen, Denmark; email: klaus.bak@teres.dk.
- Emilio Calvo, MD, PhD, MBA, can be reached at the Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Fundación Jiménez Díaz, 2, 28040, Madrid, Spain; email: ecalvo@fjd.es.
- Zinon T. Kokkalis, MD, PhD, can be reached at the First Department of Orthopedics, University of Athens School of Medicine, 75, Mikras Asias St., 11527 Goudi (2nd floor), Athens, Greece; email: kokkaliszinon@yahoo.com.
- W. Jaap Willems, MD, PhD, can be reached at Shoulder Unit, Lairesse Kliniek, Valeriusplein 1, Amsterdam, The Netherlands; email: w.j.willems@xs4all.nl.
Disclosures: Bak, Calvo and Kokkalis report no relevant financial disclosures. Willems is a consultant for Smith & Nephew and Tornier.
Is the number of rotator cuff repair procedures a surgeon performs annually critical to the success of a single-row or double-row repair?
Repetition may result in good habits
The number of repeated surgical procedures in a large series in a year is able to influence the outcome of a given treatment by increasing the percentage of good results in a significant way, but only for certain types of surgery. In particular, the implantation of a prosthetic shoulder seems to give very different results depending on whether the surgeon who implants it is used to performing this type of intervention or only performs such surgery a few times in a year.
This type of change should not occur in the case of single- or double-row repair of the rotator cuff. The reason is mainly due to the fact that first level papers, with randomized controlled trials, found no evidence of differences in the results of the treatment of lesions of the rotator cuff with one or two rows of anchors. For these reasons, a large volume of cuff repairs performed in a year should only better the outcomes of the patients due to the accuracy of indications, based on the knowledge of the natural history of the lesions, the causes of failure and the limits of this surgery. So, the answer to this question should be no, based on the use of double or single row, and the answer should be yes if we consider the habits formed when a determinate procedure is performed repetitively.
Giuseppe Porcellini, MD, heads the Unit of Shoulder and Elbow Surgery at D. Cervesi Hospital, in Cattolica (RN), Italy.
Disclosure: Porcellini reports no relevant financial disclosures.
Increased volume improves outcomes
Rotator cuff tears remain an important source of shoulder disability and health care costs. Their surgical management has proven an effective choice resulting in functional improvement as well as pain relief. Particularly, the last decade has brought enormous advances of knowledge regarding different treatment options. But regardless of the frequency of rotator cuff tears, there is still an on-going controversial debate on their optimal management, specifically considering high rates of re-ruptures. Therefore, a safe and stable regeneration of the tendons’ insertion is still of particular interest to provide better care to our patients.
Nevertheless, different surveys have shown a significant variation in tear management. This is especially since new procedures evolved in the last years, like double-row suture anchor repair techniques.
Indeed, there are numerous patient-related factors like age, comorbidities or inpatient status that have been shown to influence the clinical outcome. However, it is clear that increased surgeon volume is associated with an improved patient outcome. Especially, the use of newer techniques requires a critical discussion when considering the surgeon’s volume. These techniques are more complex and require more surgical time. They need careful suture management and a safe command level, especially for arthroscopic repair. It demands a high level of experience to choose, for example, the right anchor placement, stitch configuration or tendon mobilization so as to not result in impaired tissue healing. To meet this target, a certain number of repair procedures are necessary.
Mike H. Baums, MD, is an assistant professor at the University of Göttingen Medical Center and a consultant orthopaedic surgeon at Aukamm-Klinik, in Wiesbaden, Germany.
Disclosure: Baums reports no relevant financial disclosures.