Sage Journals: Discover world-class research

Abstract

Background:

Rotator cuff tear is a common disease for middle-aged and elderly patients, and relatively good postoperative outcomes have been reported in the literature. The aim of the study was to examine cases that underwent miniopen rotator cuff repair and to clarify their long-term clinical and imaging outcomes.

Methods:

A total of 68 patients who underwent a miniopen repair for small- to medium-sized rotator cuff tears with good cuff integrity and without retear on magnetic resonance imaging (MRI) at 1 year postoperatively were followed up for a minimum of 10 years (mean ± standard deviation: 11.4 ± 1.2 years) and analyzed retrospectively. One-year and 10-year postoperative University of California Los Angeles (UCLA) shoulder scores and radiographs were compared. MRI was used to evaluate cuff integrity and fatty infiltration, and staging at 1 and 10 years was compared.

Results:

The 1-year and 10-year postoperative UCLA scores were 33.1 points and 32.9 points, respectively. There were no significant differences between the two groups. Plain radiography showed that osteoarthritis (OA) staging was significantly worse at 10 years postoperatively compared to 1 year postoperatively. Cuff integrity was maintained at an excellent level at 10 years postoperatively. Fatty infiltration significantly progressed up to 10 years postoperatively.

Conclusions:

At 10 years postoperatively, OA progression and fatty infiltration were observed; however, UCLA scores and cuff integrity remained well preserved.

Keywords

cuff integrity fatty infiltration long-term outcomes miniopen repair osteoarthritis rotator cuff tear

Introduction

Surgical treatment is commonly performed for full-thickness rotator cuff tears that resist conservative treatment, and numerous reports have demonstrated favorable clinical outcomes at 2–9 years after rotator cuff repair.^1
–3 Some articles have presented results with a long-term follow-up of >10 years following the surgical repair of the rotator cuff,^4

–11 but some reports suggest that 80–91% of all cases were rated as good or excellent at >10 years after rotator cuff repair.^4,7,8

However, there are some reports on the association between postoperative clinical outcomes and the preservation of cuff integrity. Some researchers have reported that the size of retear after rotator cuff repair may significantly increase with time, regardless of being able to obtain good clinical results.^12,13 In contrast, others have reported that the preservation of cuff integrity correlated with clinical and functional outcomes at more than 16 years after open rotator cuff repair.¹¹ Thus, it remains unclear whether postoperative clinical outcomes are associated with the preservation of cuff integrity during a long-term follow-up.

The aim of this study was to examine and clarify the relationship between postoperative clinical performance and image findings; therefore, we investigated the long-term clinical and imaging outcomes following cuff repair.

We hypothesized that osteoarthritis (OA) and fatty infiltration were aggravated due to changes over time; in contrast, favorable clinical outcomes and cuff integrity were well preserved after a long-term follow-up.

Materials and methods

Study population

This study included 307 shoulders of 291 patients in whom primary repair was achieved by surgery for rotator cuff tear at our hospital between March 1998 and August 2005 (Figure 1). The mean age at operation was 60.2 years (standard deviation (SD) ±9.1 years). A letter inviting patients to a re-examination was issued to all patients at more than 10 years postoperatively. Responses to the letter were received for 180 shoulders, and no response was received for the remaining 127 shoulders.

Figure 1.

Flow diagram of the study recruitment process.

The following patients were excluded from this study: poor general condition and the need for long-distance travel (23 shoulders), deceased patients (12 shoulders; responses were provided by family members), patients who underwent reoperation within the previous 10 years (3 shoulders), patients who developed shoulder disorder due to cerebral infarction (2 shoulders), and patients who developed shoulder disorder due to trauma such as fracture (2 shoulders). We were able to investigate 138 shoulders in 133 patients. Large (20 shoulders) and massive tears (13 shoulders) according to the DeOrio and Cofield¹⁴ classification were excluded due to the inability to provide sufficient footprint coverage during their repair.

This case series involved 68 shoulders of 68 patients whose primary repair was achieved by miniopen repair of small-to-medium rotator cuff tears. These patients consisted of type 1–3 cases with good cuff integrity (68 shoulders) and without retear (37 shoulders) on magnetic resonance imaging (MRI) at 1 year after surgery under the Sugaya classification system.¹⁵ Patients with 1-year postoperative clinical records and MRI were included. All patients were scanned routinely at 1 year postoperatively using the MRI to investigate the postoperative cuff integrity.

The mean age at operation was 60.1 years (SD ± 7.8 years). The study included 30 male shoulders and 38 female shoulders (46 right shoulders and 22 left shoulders). Preoperative tear size was assessed during open surgery and was classified according to the DeOrio and Cofield classification system.¹⁴ The size of lesions consisted of 18 small tears (<1 cm in length) and 50 medium tears (1–3 cm). The postoperative follow-up period was 11.4 years (SD ±1.2 years).

This is a retrospective study. The study protocol was approved by the Azumi General Hospital Ethics Committee (reference number: 774), and written informed consent was obtained from all patients prior to surgery. The methods were carried out in accordance with the approved guidelines.

Surgical procedure and postoperative rehabilitation

In all patients, surgery was performed with the miniopen deltoid split approach^16,17 by the same shoulder surgeon. A 3-cm skin incision was made from the midpoint of the anterior edge of the acromion toward the axilla. The anterior deltoid muscle was divided longitudinally along the myofibers. The degenerative coracoacromial ligament was resected, and acromioplasty was carried out visually in accordance with the Neer method.¹⁸ The degenerated edge of the cuff tear was resected, and a bony groove was created at the greater tubercle footprint. The torn area was repaired with a transosseous suture while keeping the position at 0° shoulder abduction.

Postoperative therapy was based on the same rehabilitation program in all patients. The operated arm was fixed with an abduction pillow for 2 weeks at 70° abduction and 30° horizontal flexion. Active flexion/extension exercise of the elbow joint, shoulder girdle (trapezius, rhomboideus major and minor, levator scapulae, and serratus anterior) relaxation, and passive shoulder joint range of motion (ROM) training was started at day 1 after surgery. Two weeks after surgery, the pillow was replaced with a small abduction pillow. Three weeks after surgery, active ROM training in the complete hang-down position was started. Two to three months after surgery, muscular strength reinforcement training was started on the extrinsic muscles, and light work was permitted. Heavy labor and sports were permitted without restriction 6 months after surgery.

Clinical evaluation

The same orthopedic surgeon performed clinical measurements of patients at 1 and 10 years postoperatively. Although the examiner was aware of their disease history, measurements were performed without providing the examiner with imaging findings. Shoulder function was evaluated using the University of California Los Angeles (UCLA) shoulder score.¹⁹ The total UCLA score was compared between 1 year and 10 years postoperatively.

Evaluation using radiographs

Radiographs of the shoulders were obtained at 1 and 10 years postoperatively using the same settings and consisted of an anteroposterior exposure with the shoulder in internal rotation, external rotation, and elevation positions. The radiographs were analyzed by an experienced shoulder joint surgeon with no knowledge of the clinical findings of each patient. The degree of OA on the radiograph was compared between the 1-year and the 10-year postoperative time points. We evaluated the degree of OA using the Samilson and Prieto classification system.²⁰ OA was graded into four stages: 0 = normal, 1 = mild (osteophytes < 3 mm on the humeral head), 2 = moderate (osteophytes between 3 mm and 7 mm on the humeral head or the glenoid rim), and 3 = severe (osteophytes > 7 mm with or without articular incongruity).

Evaluation using MRI

Patients were scanned at 1 year and >10 years postoperatively using the same MRI setting using a GP Flex Coil with a 1.0 Tesla unit (Signa Horizon Lx1.0 T, GE Healthcare, Waukesha, Wisconsin, USA).

MR images were analyzed by an experienced shoulder joint surgeon with no knowledge about the clinical findings on each patient using spin echo proton-weighted sequences (repetition time: 3000 ms, echo time: 7.4 ms, matrix: 256 × 192), spin echo T2-weighted sequences (repetition time: 3000 ms, echo time: 90 ms, matrix: 256 × 192), and gradient echo T2*-weighted sequences (repetition time: 440 ms, echo time: 20 ms, flip angle: 30°). Sections were 4 mm thick with a 1-mm gap between sections.

Cuff integrity was classified into five categories using the Sugaya classification system¹⁵: type I, repaired cuff appeared to have sufficient thickness compared with normal cuff with homogenously low intensity on each image; type II, sufficient thickness compared with normal cuff associated with partial high intensity area; type III, insufficient thickness with less than half the thickness when compared with normal cuff, but without discontinuity; type IV, presence of a minor discontinuity in only one or two slices on both oblique coronal and sagittal images; and type V, presence of a major discontinuity observed in more than two slices on both oblique coronal and sagittal images.

The extent of fatty infiltration of subscapularis muscle belly (SSC), supraspinatus muscle belly (SSP), and infraspinatus muscle belly (ISP) was evaluated using the method of Goutallier et al.²¹ This classification, which was initially developed for evaluation by computed tomography, was later modified for MRI.²²

Statistical analysis

Wilcoxon signed rank test was used to compare the UCLA score, degree of OA on radiographs, cuff integrity, the extent of fatty infiltration between the 1-year and the 10-year postoperative time points. Statistical analysis was performed using SPP version 16 software (SPSS, Japan) with the significance level set at 5%.

Results

Clinical evaluation

The total UCLA score at 1 year postoperatively was 33.1 points (SD ±2.6 points). The total UCLA score at 10 years postoperatively was 32.9 points (SD ±3.3 points). There was no significant difference between the two points in time (p = 0.055).

Evaluation using radiographs

None of the patients had severe OA (Samilson and Prieto stage 3) in any category. OA was significantly worse at 10 years postoperatively than at 1 year postoperatively (p < 0.001). With regard to the degree of OA progression, 44% of patients had OA progression (no change, 38 cases; one stage worse, 27 cases; two stages worse, 3 cases) (Table 1).

Table 1.

Comparison of radiographic osteoarthritis classification at 1 year and 10 years postoperatively.

	1 year Postoperatively (n)	10 years Postoperatively (n)	p Value
Osteoarthritis staging (Samilson and Prieto classification)
Stage 0	41	19	<0.001
Stage 1	25	36
Stage 2	2	13

MRI findings: evaluation of cuff integrity

There was no significant difference in cuff integrity between 1 year and >10 years postoperatively (p = 0.18). Type IV and V cases suggestive of retear was 5.9% at >10 years postoperatively. The 1- to 10-year postoperative outcomes were as follows: two-stage improvement, 1 case; one-stage improvement, 13 cases; no change, 37 cases; one-stage worse, 10 cases; two stages worse, 7 cases (Table 2).

Table 2.

Comparison of the cuff integrity on MRI at 1 year and 10 years postoperatively.

	1 year Postoperatively (n)	10 years Postoperatively (n)	p Value
Cuff integrity (Sugaya classification)
Type 1	21	25	0.18
Type 2	31	21
Type 3	16	18
Type 4	0	1
Type 5	0	3

MRI: magnetic resonance imaging.

MRI findings: evaluation of fatty infiltration

There was no significant difference in fatty infiltration of SSC between 1 year and >10 years postoperatively (p = 0.83). The 1- to 10-year postoperative outcomes were as follows: one-stage improvement, 12 cases; no change, 45 cases; and one-stage worse, 11 cases (Table 3).

Table 3.

Comparison of the fatty infiltration on MRI at 1 year and 10 years postoperatively.

	1 year Postoperatively (n)	10 years Postoperatively (n)	p Value
Fatty infiltration of subscapularis muscle belly (Goutallier classification)
Stage 0	14	20	0.83
Stage 1	47	39
Stage 2	6	5
Stage 3	1	4
Stage 4	0	0
Fatty infiltration of supraspinatus muscle belly (Goutallier classification)
Stage 0	0	0	0.0044
Stage 1	19	12
Stage 2	39	36
Stage 3	8	17
Stage 4	2	3
Fatty infiltration of infraspinatus muscle belly (Goutallier classification)
Stage 0	0	0	0.038
Stage 1	40	34
Stage 2	24	22
Stage 3	3	8
Stage 4	1	3

MRI: magnetic resonance imaging.

Fatty infiltration of SSP at >10 years postoperatively showed significantly greater severity than at 1 year postoperatively (p = 0.0044). The 1- to 10-year postoperative outcomes were as follows: one-stage improvement, 9 cases; no change, 34 cases; one-stage worse, 23 cases; and two stages worse, 2 cases (Table 3).

Fatty infiltration of ISP at >10 years postoperatively showed significantly greater severity than at 1 year postoperatively (p = 0.038). The 1- to 10-year postoperative outcomes were as follows: one-stage improvement, 8 cases; no change, 43 cases; one-stage worse, 14 cases; two stages worse, 2 cases; and three stages worse, 1 case (Table 3).

Complications

There were no intraoperative or perioperative complications. No patients had neural injuries or wound infection problems. There were no postoperative stiffness shoulders that required manipulation or capsular release.

Discussion

For full-thickness rotator cuff tears that resist conservative treatment, surgical treatment is commonly performed, and some reports have demonstrated good or excellent results at >10 years after rotator cuff repair.^4,7,8 Some researchers have reported that the size of retear after rotator cuff repair may significantly increase with time regardless of being able to obtain good clinical results.^12,13 In contrast, others have reported that the maintenance of cuff integrity correlated with clinical and functional outcomes at more than 16 years after open rotator cuff repair.¹¹ Thus, it remains unclear whether postoperative clinical outcomes are associated with the preservation of cuff integrity. To our knowledge, none of these studies have assessed the imaging results to determine whether or not the cuff is healed immediately after surgery; thus, these studies include failed cuff repair and retears. In contrast, we limited our cases to those with good cuff integrity at 1 year postoperatively and investigated their clinical and imaging outcomes. In this study, the UCLA scores demonstrated favorable outcomes and showed no significant differences between 1 year postoperatively and >10 years postoperatively.

Regarding the outcome of rotator cuff repair at >10 years postoperatively, some have reported that 80–91% of all patients obtained good or excellent results.^4,7,8 The results in this study are in line with these previous studies. We verified that cuff repair is a procedure that provides good shoulder joint function after 10 years.

In general, the development of OA is believed to be associated with age. Kobayashi et al. reported that the prevalence of shoulder OA in respondents younger than 65 years was 11.1%, whereas those 65 years of age or older was 20.3%.²³ This study showed that OA of the shoulder progressed in significantly more cases over a mean follow-up duration of 11.4 years postoperatively. We have previously compared the progression of OA of the affected and unaffected sides following cuff tears.²⁴ OA of the shoulder progressed on both the affected and unaffected sides but occurred in significantly more cases on the affected side over a mean follow-up duration of 11.1 years postoperatively. Because the unaffected shoulder also showed OA, we confirmed that osteoarthritic changes occurred with age.

Cuff integrity at the supraspinatus tendon was maintained at an excellent level up to >10 years postoperatively, with only a 5.9% incidence of type IV and V cases suggestive of retear. The incidence of retear, however, varies greatly in past reports (13–94%).^6,11,13 Past reports have included many cases, where free tendon grafts were applied to treat massive tears, but all of our cases received a transosseous suture, and excluding cases of possible retear at 1 year after surgery may have resulted in a lower incidence of retear.

Fatty infiltration of SSP and ISP significantly progressed up to >10 years postoperatively. There is a report on short-term outcomes (at 1 year postoperatively) demonstrating alleviation of SSP atrophy due to fatty infiltration in cases showing favorable repair of the rotator cuff.²⁵ However, in another report with a 2-year follow-up in 87 cases, none of the cases showed alleviation of fatty infiltration; moreover, fatty infiltration progressed significantly in cases of retear.²⁶ In terms of fatty infiltration in SSC, there was no significant difference between cases at 1 and 10 years postoperatively. We believe that these results were affected by the small sample size and the size of lesions that consisted of 18 small tears (<1 cm in length) and 50 medium tears (1–3 cm), since small tears do not involve the subscapularis tendon.

Collin et al.²⁷ performed isolated supraspinatus repairs and investigated 288 cases with a minimum of 10-year follow-up. The clinical score improved and the retear rate was 19%, but the fatty infiltration showed progression. Furthermore, because functional or physical need is reduced with aging, UCLA scores tend to be preserved despite aging.⁵ This may explain why UCLA scores were maintained in our cases despite aggravation of OA and fatty infiltration.

This study has several limitations. First, the sample size of patients was small due to the study being performed at a single center. This study only included small- and medium-sized tears to ensure consistency of surgical technique. The exclusion of large tears may have created a selection bias, and patients with large tears could potentially yield different results. Future research may benefit from multicenter studies with a larger sample size. However, because physicians who performed the clinical and imaging evaluations were not involved in the surgery, we believe that objective data were obtained from this blinding process. Secondly, our cases were evaluated using radiographic images, which may lead to poor reproducibility. However, since patients underwent radiographic evaluation using identical settings and positions at the same institution, we believe that objective data were obtained. Thirdly, although we believe that the use of multiple scoring systems such as the constant score and ASES score is ideal for assessing the shoulder function score, we were only able to perform an assessment using the UCLA score. Fourthly, we used the Samilson and Prieto classification that was originally described for use in patients with dislocation arthropathy and did not use the Hamada classification and acromiohumeral interval that is specific to rotator cuff tear arthropathy. Because none of the patients had severe OA in any category, Samilson and Prieto classification enabled us to detect more subtle changes in the progression of OA compared to others.

Conclusion

We evaluated 68 shoulders that underwent miniopen rotator cuff repair achieving good cuff integrity and exhibiting no retears on MRI at 1 year postoperatively with a minimum follow-up of 10 years. OA and fatty infiltration of SSP and ISP were aggravated due to changes over time; in contrast, UCLA scores and cuff integrity were well preserved.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tomoyuki Matsuba

References

Goutallier

Postel

Radier

, et al. Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair. J Shoulder Elbow Surg 2009; 18: 521–528.

Jost

Zumstein

Pfirrmann

, et al. Long-term outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 2006; 88: 472–479.

Lähteenmäki

Virolainen

Hiltunen

, et al. Results of early operative treatment of rotator cuff tears with acute symptoms. J Shoulder Elbow Surg 2006; 15: 148–1453.

Adamson

Tibone

. Ten-year assessment of primary rotator cuff repairs. J Shoulder Elbow Surg 1993; 2: 57–63.

Bell

Lim

Coghlan

. Long-term longitudinal follow-up of mini-open rotator cuff repair. J Bone Joint Surg Am 2013; 95: 151–157.

Borgmästars

Paavola

Remes

, et al. Pain relief, motion, and function after rotator cuff repair or reconstruction may not persist after 16 years. Clin Orthop Relat Res 2010; 468: 2678–2689.

Cofield

Parvizi

Hoffmeyer

, et al. Surgical repair of chronic rotator cuff tears: a prospective long-term study. J Bone Joint Surg Am 2001; 83: 71–77.

Galatz

Griggs

Cameron

, et al. Prospective longitudinal analysis of postoperative shoulder function: a ten year follow-up study of full-thickness rotator cuff tears. J Bone Joint Surg Am 2001; 83: 1052–1056.

Paxton

Teefey

Dahiya

, et al. Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up. J Bone Joint Surg Am 2013; 95: 627–632.

10.

Sperling

Cofield

Schleck

. Rotator cuff repair in patients fifty years of age and younger. J Bone Joint Surg Am 2004; 86: 2212–2215.

11.

Vastamäki

Lohman

Borgmästars

. Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair. Clin Orthop Relat Res 2013; 471: 554–561.

12.

Dodson

Kitay

Verma

, et al. The long-term outcome of recurrent defects after rotator cuff repair. Am J Sports Med 2010; 38: 35–39.

13.

Zumstein

Jost

Hempel

, et al. The clinical and structural long-term results of open repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2008; 90: 2423–2431.

14.

DeOrio

Cofield

. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984; 66: 563–567.

15.

Sugaya

Maeda

Matsuki

, et al. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fixation. Arthroscopy 2005; 21: 1307–1316.

16.

Hata

Saitoh

Murakami

, et al. Atrophy of the deltoid muscle following rotator cuff surgery. J Bone Joint Surg Am 2004; 86: 1414–1419.

17.

Hata

Saitoh

Murakami

, et al. A less invasive surgery for rotator cuff tear: mini-open repair. J Shoulder Elbow Surg 2001; 10(1): 11–16.

18.

Neer

2nd . Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972; 54: 41–50.

19.

Ellman

Hanker

Bayer

Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am 1986; 68(8): 1136–1144.

20.

Samilson

Prieto

. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983; 65: 456–460.

21.

Goutallier

Postel

Bernageau

, et al. Fatty muscle degeneration in cuff ruptures. Clin Orthop 1994; 304: 78–83.

22.

Fuchs

Weishaupt

Zanetti

, et al. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999; 8: 599–605.

23.

Kobayashi

Takagishi

Shitara

, et al. Prevalence of and risk factors for shoulder osteoarthritis in Japanese middle-aged and elderly populations. J Shoulder Elbow Surg. 2014; 23: 613–619.

24.

Matsuba

Hata

Ishigaki

, et al. Osteoarthritis progression of the shoulder: a long-term follow-up after mini-open rotator cuff repair. J Orthop Surg (Hong Kong). 2018; 26(2): 2309499018768106.

25.

Chung

Kim

Tae

, et al.

Is the supraspinatus muscle atrophy truly irreversible after surgical repair of rotator cuff tears?

Clin Orthop Surg 2013; 5: 55–65.

26.

Deniz

Kose

Tugay

, et al.

Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate?

Arch Orthop Trauma Surg 2014; 134: 985–990.

27.

Collin

Kempf

Molé

, et al. Ten-year multicenter clinical and MRI evaluation of isolated supraspinatus repairs. J Bone Joint Surg Am 2017; 99: 1355–1364.

Long-term clinical and imaging outcomes after primary repair of small- to medium-sized rotator cuff tears

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Introduction

Materials and methods

Study population

Surgical procedure and postoperative rehabilitation

Clinical evaluation

Evaluation using radiographs

Evaluation using MRI

Statistical analysis

Results

Clinical evaluation

Evaluation using radiographs

MRI findings: evaluation of cuff integrity

MRI findings: evaluation of fatty infiltration

Complications

Discussion

Conclusion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References