Biomedical Engineering Reference
In-Depth Information
12.5 Surgical Factors Affecting Rotator Cuff Tendon Healing
The surgical factor receiving the greatest attention, and having the greatest effect
on rotator cuff healing, is repair construct. Historically, the distal end of the
rotator cuff tendon has been re-apposed to the bone using a single row of anchors.
However, a “double row” repair was popularized several years ago in response to
the relatively high failure rate of tendon healing after repair [ 41 - 44 ]. The goals of
this repair are to increase the mechanical strength of the repair and to better
recreate the anatomic footprint of the native insertion site. Apreleva et al. were the
first to evaluate the effect of a double row repair on recreation of a normal
footprint after repair in a cadaveric model [ 45 ]. They found that a double row
construct successfully increased the contact area between the repaired tendon and
the bony insertion site.
Several mechanical studies [ 43 , 44 , 46 - 49 ] evaluated the strength of the double
row repair in comparison to a single row repair and found improvement in the
overall strength of the repair. However, these results have not necessarily been
translated into improvements in structural healing or clinical outcomes. Many
studies report excellent results after a single row repair [ 50 ], often in spite of a
high rate of failure of healing. Furthermore, many studies show no difference or
only modest differences in healing between double and single row repair. Duquin
et al . [ 51 ] performed a systematic review of 23 eligible studies and found re-tear
rates significantly lower for double row repairs in tears greater than 1 cm in size.
Similarly, several recent high level studies comparing the two methods showed no
difference in clinical outcome, except in tears
3 cm, where strength was improved
with a double row repair [ 52 , 53 ]. Further investigation is necessary to ultimately
determine the appropriate application of various repair techniques in given patient
populations.
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12.6 Surgical Repair Techniques and Outcomes
12.6.1 Technique
A rotator cuff repair can be accomplished through either open or arthroscopic
techniques. Consistent with the current trend in surgery, there has been a shift
toward arthroscopic or minimally invasive techniques. A variety of devices and
instruments are commercially available to achieve a tendon-to-bone reattachment
in the shoulder.
Access to the joint is achieved via a posterior portal. An anterior portal is
established through the rotator interval (Fig. 12.4 ). A thorough examination of
intraarticular structures allows an accurate diagnosis and assessment for concurrent
pathology. The long head of the biceps arises from the supraglenoid tubercle and is
evaluated for tearing and attenuation. Attritional changes may be seen as the biceps
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