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Vol. 125 - 1-2 Novembre 2014

The oldest journal on orthopaedic and traumatology topics

Archivio diOrtopedia e Reumatologia

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Comitato di Redazione G. Bernabè, Milano M. Berruto, Milano S. Brambilla, Milano C. Corradini, Milano U. Dacatra, Milano U. De Bellis, Milano A. D’Aloia, Milano S. Failoni, Milano M. Franceschini, Milano L. Galdi, Milano A. Marchesoni, Milano E. Mazza, Milano V. Pedrini, Milano A. Pellegrini, Milano D. Peroni, Milano L. Pierannunzi, Milano A. Ventura, Milano, F. Tramontana, Milano M. Varenna, Milano E. Vignali, Milano S. Zeni, Milano A. Wolf, Milano

Commissione ECM G. V. Mineo, Milano P. Meroni, Milano B. M. Marelli, Milano G. M. Calori, Milano

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BOARD SCIENTIFICO

The aRCHIVIO DI ORtOPeDIa e ReUMatOLOGIa is an historic scientific magazine that for our Institute has

always had a major role in helping to spread experiences and knowledges in the fields of orthopaedics and reumathology.this first issue after a lack of pubblications due to a change of editor, is presented in a graphic totally renewed, more usable and now similar to the most famous scientific international publications.this issue, first with the new format, is totally dedicated to degenerative shoulder that is represented by all shoulder diseases that slowly appear after 40yo and then evolve after 50yo and especially after 60yo.the index of the present issue follows the stages of a conference held two years ago in Milan for which I worked in co-operation with Pierluigi Gambrioli and alessandro Castagna, two friends of mine and celebrated shoulder surgeons. the former idea was to build the congress following a theoretical evolution of the degenerative shoulder disease in which the anatomical damage becomes gradually more and more serious.then we will start from basic science and biology, trying to understand how and why rotator cuff tendinopathy begins. at the same time we will discuss two particular shoulder diseases that not infrequently affect the shoulder like adhesive capsulitis and calcifying tendinopathy. after the beginning of a real tendinopathy, tendon fibers deteriorate and torn leading to a partial tear or, in some case of no-treatment, to a full thickness tendon tear.a lot of papers will be focused on rotator cuff tear talking from modern suture techniques to the possibilities that modern biological science offer in order to improve rotator cuff healing after surgical repair. We will also discover that not all kind of ruptures can be treated arthroscopically, like a complete full thickness subscapular tear, that requires open surgery, or like massive irreparable cuff tear requiring latissimus dorsi or teres major tendon transfer that should be isolated via open surgery.another kind of degenerative shoulder disease affects cartilage layer. In this case we recognise a shoulder arthropathy that can be primitive or secondary to a fracture or to a serious rotator cuff tear that have been never treated before. When degenerative disease lead to an arthropathy the treatment can be a modern shoulder prosthesis that is generally widely adaptable to the anatomy of the patient and to the pathology.Last but not least an adequate space has been left to rehabilitation even in the field of tendinopathy than in shoulder prosthesis field.In this issue the reader will find a reference in modern approaches to surgical treatment and in rehabilitation of degenerative shoulder.

Roberto LEO

n

EDITORIALE

Vol. 125 - 1-2 Novembre 2014Archivio di Ortopedia e Reumatologia

Archivio di Ortopedia e Reumatologia Vol. 125 - 1-2 novembre 20144

SOMMARIO

2 Editoriale Roberto Leo

5 Tendon disease and rotator cuff tears A. Castagna, V. Fogliata, R. Garofalo

8 Calcific tendinitis of the shoulder P. Randelli, V. Ragone, R. D’Ambrosi, F. Randelli,

P. Cabitza

13 Adhesive capsulitis: clinical aspects and treatment

R. Leo, PL. Gambrioli

16 Biological enhancement in rotator cuff repairs A. Castagna, V. Fogliata, R. Garofalo, E. Cesari

23 Partial-thickness rotator cuff tear. Surgery: when and how

M. Rebuzzi, P. Baudi, M. Gialdini, C. Rovesta, F. Catani

29 Rotator cuff rehabilitation M. Conti, R. Garofalo

35 Modern technique of arthroscopic suture in reparable rotator cuff tears. Actual standards and limitations

R. Leo, V. Fogliata, A.M. Querenghi, M. Pivetta, B.M. Marelli

43 Subscapularis tendon tear. Modern surgical approach

D. Petriccioli, G. Marchi, C. Bertone

47 Painful shoulder: the Rheumatologist’s point of view

L. Sinigaglia, F. Zucchi, M. Varenna

53 Platelet Rich Plasma in Arthroscopic Rotator Cuff Repair: State of the Art

P. Randelli, V. Ragone, A. Menon, R. D’Ambrosi, F. Randelli, P. Cabitza

58 Platelet rich plasma in rotator cuff disease U.G. Longo, A. Berton, G. Rizzello, G. Salvatore,

V. Denaro

61 Biology of rotator cuff tendinopathy A. Murgo, O. De Lucia, C. Crotti, PL. Meroni

64 Scaffold augmentation in rotator cuff tears repairs

R. Rotini, A. Marinelli, E. Guerra, G. Bettelli, M. Cavaciocchi, L. Zaccarelli, M. Fini, E. Bondioli

72 Rational approach to the irreparable cuff tears - from “functional” repair to muscle transfer

F. Campi, P. Paladini, C. Buononato, A. Tartarone, G. Merolla, G. Porcellini

76 Arthroscopically-assisted latissimus dorsi transfer

E. Gervasi, A. Spicuzza

81 The rotator cuff irreparable tears: latissimus round muscle transfer

F. Odella, S. Odella

85 Reverse shoulder arthroplasty with and without tendon transfer for arthropathy with massive rotator cuff tear: personal experience and critical analysis of the literature

N. Ivaldo, G. Caione, M. Rossoni

92 Shoulder arthroplasty’s rehabilitation R. Costantino, L. Panella, E. Prisco

4


Tendon disease and rotator cuff tearsalessandro Castagna, Valentina Fogliata*, Raffaele Garofalo**Unità di chirurgia della spalla e gomito, IRCCS Istituto Humanitas, Milano * Dipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,

Struttura Semplice Dipartimentale Chirurgia Spalla e Gomito, Istituto Ortopedico G. Pini, Milano**Servizio Chirurgia della spalla Ospedale F. Miulli, Acquaviva delle Fonti, Bari

INTRODUCTION

In 1972, Neer coined the term of subacromial impinge-ment to indicate a pathologic condition characterized by an extrinsic compression of the supraspinatus tendon in particular by the anterior margin of the acromion, the cora-coacromial ligament, and also by acromioclavicular joint osteophytes 1. This chronic, compression associated with microtrauma, firstly implied an inflammatory-reactive framework and therefore a progressive degeneration un-til the rupture of the tendon itself, with consequent pain syndrome and shoulder functional impotence. However, in 1922 Meyer had already suggested that capsular and tendinous shoulder injuries were the result of the contact between the greater tuberosity and the acromion2. In sup-port of this theory Bigliani had described 3 different ac-romion morphologies: type I (flat), type II (curved), and type III (hooked acromion). This author suggested that 70% of rotator cuff lesions were associated with a type III acromion 3. Later, Nyffeler has shown how not only the acromion shape but also its lateral extension could be re-sponsible for an impingement subacromial syndrome and a consequent lesion of the rotator cuff 4.In recent years, however, there has been a considerable in-centive to the study of the rotator cuff pathology basis. In particular, these studies have revealed that the injury of the cuff tendons is the result of a tendon desease that is associated with specific extrinsic situations (impingement) and microtrauma. This paper aims to analyze the literature for intrinsic aspects that could contribute in causing rotator cuff injuries.

ROTATOR CUFF TENDONS STRUCTURE

The rotator cuff is represented by 4 tendons that are the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Each of these tendons is inserted at the level of the proximal humerus. In particular, the subscapularis inserts on throchine (lesser tuberosity) and the other three tendons are inserted on the throchite (greater tuberosity). Of these tendons, supraspinatus is the most vulnerable; the cause of this condition is attributed to the fact that this tendon is located below the coracoacromial arch and also to the fact that it presents an abnormal vascularization. The type I collagen accounts for about 85% of the dry weight of the rotator cuff tendons. In supraspinatus there is a significant proportion of type III collagen and a rela-tively high content of glycosaminoglycans (GAGs). The supraspinatus undergoes significant compression because

of its location and biomechanics, and expressed proteins of the extracellular matrix (ECM) that are often found in the cartilage (decorin, biglycan and aggrecan). Since the most anterior region of the supraspinatus is that which most frequently undergoes breakage, it is easy under-stand how the concentration of proteoglycans at the level of this region is important. At tendon to bone interface (entheses) there is an interdigitation of several layers of longitudinally oriented fibers of type I collagen which are inserted in a gradual manner on the humerus5. The number of vessels and their size gradually decrease getting closer to the bone5. At the level of this junction 4 zones are distinguished: tendon, non-mineralized fi-brocartilage, mineralized fibrocartilage, and bone. Type I collagen predominates in zones 1 and 4, while zones 2 and 3 contain mainly collagen I, II and X, as well as ECM with proteoglycans. With the aging process, the level of vascularization in this area tends to decrease pro-gressively, altering the intrinsic structure of the tendon to bone interface. ECM is constantly being reshaped itself and this is pos-sible thanks to the delicate balance between collagenase and collagenase inhibitors themselves. This balance is influenced by genetic factors, functional overload and extrinsic factors that can influence the activity of these enzymes. Many studies have emphasized the importance of ECM in connective tissue homeostasis. Physiological and pathological ECM changes appear to be involved in tendinopathy and tendon lesions. From the biomechanical point of view the articular por-tion of the supraspinatus is the one that has the highest modulus of elasticity. Tendon longitudinal bursal bundles

ABSTRACT

Shoulder impingement syndrome was originally introduced by Neer in 1972, when he described the compression of the supraspi-natus tendon against the anterior edge of the acromion, the cora-coacromial arch and the acromioclavicular joint. As a result, for long rotator cuff tendons lesions were believed to be caused by extrinsic factors and in particular by subacromial impingement. Recent studies on rotator cuff pathology reveal that, actually, most of these injuries result from a multifactorial process in which the intrinsic factors play a key role. The recognition of these different factors is very important in order to improve the approach to this disease. The hope is that, in the future, prevention and treatment of rotator cuff diseases could be optimized even with pharmaco-logical interventions.


are better able to disperse the tensile loads than the thin-ner fibers present at the level of the articular portion. This effect is most noticeable during abduction of the arm. Mathematical models confirm these data and show that the concentration of stress is greater in articular insertional area and increases with abduction.

TENDON DISEASE AND ROTATOR CUFF TEARS

Recent scientific evidence shows that the majority of rota-tor cuff tears (RCTs) are caused by a degenerative disease intrinsic in the tendon.

VASCULAR THEORY

One of the causes of this degeneration would be repre-sented by the particular vasculature of certain tendons, especially the supraspinatus tendon. In particular, an hy-poperfusion area was described at about 10-15 mm from the insertion of the supraspinatus tendon. However it is not clear whether the hypoperfusion could really contrib-ute to the tendon degeneration. Furthermore some authors have studied the capillaries distribution in cadaver cuff samples, and have concluded that hypovascularization area does not exist 6. Other au-thors have revealed that at the cuff tendon rupture margin there is not an hypovascular reaction but an hyperemic response. Goodmurphy says that the reduced vascularity that can be seen at the criticism zone may be an artifact of the technique used7. Taking account of the above, the etiopathogenetic vascular hypothesis is currently in steep decline.

DEGENERATIVE THEORY

In the 30s, Codman had already suggested the degenera-tive theory as an RCTs cause 8. This theory was recently confirmed by a series of pathological studies performed on the edge of the tendinous lesion. These studies, in fact, confirm the presence of thinning of the tendon, disruption of the collagen fibers, myxoid degeneration, hyaline de-generation, chondroid metaplasia, calcification, angiogen-esis and fatty infiltration at the margin of the injured ten-don 9. Other authors have also shown how the degenerative process involves not only the edge of breakage, but also a medial part of the tendon (1 cm) which apparently shows to be healthy. This data is very important in consideration of the cuff tendon repair 10. The degeneration of the tendon appears to be closely cor-related with the age of the patient. Yamaguchi et al. in a retrospective study showed a difference of about 10 years among patients without rotator cuff lesion (48.7 years) in comparison with those with partial lesion (58.7 years), and patients with full-thickness lesion (67.8 years). Also in this study is shown that 35.5% of patients with a symptomatic rotator cuff lesion had a non-symptomatic lesion in the contralateral limb11.

ECM and metalloproteaseTenocytes taken from a tendon inveterate tear are not ca-pable of synthesizing a normal ECM. ECM is the substrate on which the cells adhere, migrate and differentiate. An alteration of the ECM seems to be one of the most im-portant factors involved in tendinopathy and tendon tears. The ECM turnover in a normal tendon is mediated by ma-trix metalloproteinases (MMPs) 12. In particular, MMP-1, MMP-2 and MMP-3 seem to be the most involved. An increase in the activity of MMP-1 leads to a degradation of the network of collagen fibrils with a consequent weak-ening of the tendon matrix. The tendon in this manner be-comes less stable from a mechanical point of view and this can contribute to the rupture of the tendon itself. Some authors have shown that at the level of the edge of a damaged tendon there is an increased activity of MMPs (MMP 1,2,3) and a decreased activity of their inhibitors. Moreover, since even more interesting, this alteration even manifested itself in the most medial portion of the tendon that appeared to be intact13. This data shows how likely the biological degradation processes precede macroscopic morphostructural alterations and are not a consequence.

ApoptosisYuan et al. were the first authors to recognize a role of apoptosis in rotator cuff pathology14. Apoptosis is a physi-ological process that leads to a mechanism of programmed cellular suicide. This process is regulated by a family of proteases, in particular by caspases. The role of apoptosis in determining an RCT is not yet completely clear. How-ever, what is certain is that an increase in apoptosis at the level of the tendon tissue can result in a reduction of the cell population, the collagen synthesis and in a progression to tendon degeneration. It is interesting to note that caspases can also be activated by oxidative stress derived from overuse and from reduced vascularity of the tendon itself. The same caspases alter the ECM composition, weakening the tendon and there is a stimulus to the increase of MMPs activity, which (in turn) weakens the tendon itself. In this manner a sort of vicious circle that leads to the tendon tear is created. Recently some authors have shown that, in the case of tendon rupture, the caspases activity is not increased only at the level of the broken margin of the tendon, but also 1 cm medial to the break15. This is important not only to understand the tendon degenerative disease, but also for the considerations that follow for the surgical treatment of lesions.

Metabolic disorders and RCTSymptomatic lesions of the rotator cuff have been more commonly observed in patients with type I and II diabetes and in patients with glucose intolerance16. In asymptom-atic diabetic patients, there were an increased thickness of the supraspinatus tendon and the long-head biceps tendon and a higher prevalence of RCT. Recently, Abboud et al. have found a correlation between hypercholesterolemia and RCT. In particular it has been found that the levels of total cholesterol, triglycerides and LDL, were higher in patients with RCT17. It is unclear, however, whether this represents an indepen-


dent risk factor for rotator cuff injury or whether it repre-sents an aspect of concomitant disease related to aging of the patient.

CONCLUSIONS

In light of recent studies it appears that the majority of RCT are the result of a multifactorial process, where there is probably not a single cause capable of determining the wear, and then the rupture of the tendon. Both the patient’s age and the degenerative tendinous intrinsic process asso-ciated with it, are certainly the basis on which may contrib-ute also external factors such as overuse and impingement, as well as the responsible lifestyle for metabolic diseases. In choosing the appropriate plan of treatment of this dis-ease, the clinician must be very careful to specifically as-sess the various factors that contribute to the pathology of the patient. It is to be hoped that, in the future, a prevention and treatment of RCT can be optimized with pharmalogi-cal treatments that can avoid surgery or improve the results of the latter.

REFERENCES

1. neer CS II anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg 1972; 54-a:41-50

2. Meyer aW Further observations on use-destruction in joints. J Bone Joint Surg. 1922; 4:491–511

3. Bigliani LU, Morris DS, april eW the morphology of the acromi-on and its relationship to rotator cuff tears. Orthop trans 1986; 10:216

4. nyffeler RW, Werner CM, Sukthankar a et al. association of a

large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg am 2008; 88:800-5

5. Uhthoff HK, Seki M, Backman DS et al. tensile strength of the su-praspinatus after reimplantation into a bony trough: an experi-mental study in rabbits. J Shoulder elbow Surg 2002; 11:504–509

6. Moseley HF, Goldie I the arterial patterns of the rotator cuff of the shoulder. J Bone Joint Surg Br 1963; 45:780-89

7. Goodmurphy CW, Osborn J, akesson eJ et al. an Immunocy-tochemical analysis of torn rotator cuff tendon taken at the time of repair. J Shoulder elbow Surg 2003; 12:368-374

8. Codman ea the shoulder. Rupture of the supraspinatus tendon, Boston, thomas todd, 1934: 123-177

9. Chillemi C, Petrozza V, Garro L et al. Rotator cuff re-tear or non-healing: histopathological aspects and predictive factors. Knee Surg Sports traumatol arthrosc 2011; 19:1588-96

10. Longo UG, Franceschi F, Ruzzini L et al. Histopathology of the su-praspinatus tendon in rotator cuff tears. am J Sports Med 2008; 36:533-8

11. Yamaguchi K, Ditsios K, Middleton WD et al. the demographic and morphological features of rotator cuff disease. a compari-son of asymptomatic and symptomatic shoulders. J Bone Joint Surg am 2006; 88:1699-1704

12. Garofalo R, Cesari e, Vinci e, Castagna a. Role of metalloproteasi in rotator cuff tear. Sports Med arthrosc 2011; 19:207-12

13. Castagna a, Cesari e, Garofalo R et al. Matrix metalloproteases and their inhibitors are altered in torn rotator cuff tendons, but also in the macroscopically and histologically intact portion of those tendons. Muscles Ligaments tendons J 2013; 3:132-8

14. Yuan J, Murrell Ga, Wei aQ, Wang MX apoptosis in rotator cuff tendinopathy. J Orthop Res 2002; 20:1372–1379

15. Lee HJ, Kim YS, OK JH, Song HJ. apoptosis occurs throughout the diseased rotator cuff. am J Sports Med 2013; 41: 2249-2255

16. Longo UG, Franceschi F, Ruzzini L et al. Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears. Br J Sports Med 2009; 43:284–7

17. abboud Ja, Kim JS. the effect of hypercholesterolemia on rota-tor cuff disease. Clin Orthop Relat Res 2010; 468:1493-97

TORNIER. WE EXPECT MORE THAN OTHERS THINK IS POSSIBLE.www.tornier.com

PRESERVATION.

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CONVERSION.

PERFORMANCE.


INTRODUCTION

Calcium deposits within the tendons of the rotator cuff are a com-mon shoulder disorder 1. The incidence in the healthy popula-tion is 2.7%, rising to 6.8% in patients with shoulder pain 2. The predominant age is 30–60 years and women are affected slightly more often than men. Bilateral involvement is not uncommon (in 10% to 25% of patients). Calcifications occur commonly in the supraspinatus tendon (51%–90%) and least commonly in the sub-scapularis tendon (3%) 3. Up to 50% of cases are asymptomatic and run a self-limiting course 4-5.Two different etiological processes have been proposed. The first is degenerative calcification, in which Codman6 proposed that de-generation within the tendon fibers precedes calcification. This was later adopted by Moseley and Goldie, 7 who defined the ten-don-bone insertion area as the ‘‘critical zone’’. The second cause proposed is reactive calcification within a healthy tendon 8. Other theories have been introduced in recent years involving chemical factors causing the deposit of calcium, cell proliferation and production of inflammatory agents, metabolic factors and ge-netic predisposition to the formation of calcific deposits.

Calcific tendinitis of the shoulderPietro Randelli, Vincenza Ragone, Riccardo D’ambrosi, Filippo Randelli, Paolo CabitzaDipartimento di Scienze Medico-Chirurgiche, Università degli Studi di Milano, IRCCS, Policlinico San Donato, Milano

CLASSIFICATION

There are numerous classifications that have been pro-posed by various authors.Anatomical9: small (< 0.5 cm), medium (from 0.5 to 1.5 cm) and large (>1.5 cm). Patte and Goutallier10 have dis-tinguished calcifications in localized and diffuse. Clinical: depending on the symptomatology can be divided into acute, subacute and chronic.Pathological: Uhthoff 8 proposes that the evolution of the disease can be divided into three distinct stages: 1) precalcific, 2) calcific, and 3) postcalcific.

1) Precalcific stage: fibrocartilaginous transformation be-gins within the tendon at the site of predilection for cal-cification. This metaplasia of tenocytes into chondrocytes is accompanied by metachromasia, indicating the elabora-tion of proteoglycan.

2) Calcific stage that follows is subdivided into three phas-es 11: a) formative, b) resting, and c) resorptive.

a) Formative phase: separated by chondrocytes and fibrocartilaginous tissue septae, calcium crystals are deposited primarily in matrix vesicles that co-alesce to form large foci of calcification. In this

formative phase, the deposits exhibit a chalk-like consistency.

b) Resting phase: occurs when fibrocollagenous tissue borders the foci of calcification without evidence of inflammation, thereby indicating termination of deposition.

c) Resorptive phase: is marked by the appearance of thin-walled vascular channels at the periphery of the deposit. Macrophages and multinucleated giant cells then surround the deposit and phagocytose de-bris with calcium removal. In this phase the deposit exhibits a thick, creamy, or tooth- paste-like mate-rial that is often under pressure.

3) Postcalcific stage: as the tissue undergoes healing during the post-calcific stage, new vascular channels promote fi-bro- blasts to form type III collagen that becomes replaced by type I collagen. The tendon is healed subsequently with fiber realignment and resolution of the calcium deposit.

CLINICAL pRESENTATION

The onset of symptoms is chronic, with very low noise and discomfort content. The initial state of formation of the deposits has no vascular neo-formation, cellular reaction and there is no change in tension of the tendon tissue. The clinical presentation becomes very painful, however, in the phase of resorption because the vascular neoformation, together with the exudative state, can bring a substantial increase in the volume of tissue with consequent increase of intratendinous pressure. The pain typically exacerbates overnight, radiates to the outside face of the ipsilateral arm, with the forearm extension. In some cases, this is also reflected radiation to the cervical region. Symptoms are accompanied by functional impotence of variable degree in relation to pain. Three symptomatic phases can be distinguished:

1. The acute phase may occur in 1 to 5-6 weeks. In this phase an intense pain causes important discom-fort and loss of function.

2. The chronic phase can occur for many months with a continuous, dull and of fixed intensity pain. This pain is significantly lower than the acute form.

3. Persistent chronic phase characterized by periods of pain and periods of complete well-being. Its mini-mum duration of 1-2 months can extend for more than 6 months.


Figure 2: Arthroscopic image.

Removal of calcification of the supraspinatus tendon.

Figure 1: Rx anterior-posterior left shoulder.

Clearly visible calcification in the context of the supraspinatus tendon.

Several methods of treatment are listed in the literature. Among the most known are Shockwaves, US lavage, Nee-dling and Arthroscopy (Figure 2).

Extracorporeal shock wave therapyIn the last two decades, several studies have demonstrated the effectiveness of extracorporeal shockwave therapy (ESWT) in treatment of calcifying tendinitis of the rota-tor cuff15-18. One study even stated that ESWT should be preferred to arthroscopy due to its non-invasiveness at equivalent outcome. A single high-level middle-energetic ESWT was found as effective as two applications of a low-er-dosed middle-energetic ESWT for calcifying tendinitis of the rotator cuff after failure of other conservative treat-ment options (physiotherapy, infiltrations or NSAIDS)19. A literature review20 suggests that ESWT is moderately effective in reducing pain and improving function in indi-viduals with chronic shoulder calcific tendinitis, for up to a year after its application. Although satisfaction results are been associated to this treatment there is no clear evidence regarding the optimal dosage in energy level, intervals be-tween sessions, and number of sessions required for opti-mal recovery from the condition. Clinicians should also record the intervention parameters because these provide important clinical audit information for future investiga-tions. Future studies of level 1 of evidence are needed to dry definitive conclusions on ESWT treatment for shoul-der calcific tendinitis.

NeedlingNeedle lavage has been described as an effective treatment that can be performed either in the operating room or in the radiology suite. This technique is best used in patients

IMAGING

Calcium deposits can be seen on plain radiographs with a full series of shoulder films that include AP, (Figure 1), internal and external rotation, scapular Y, and axillary lat-eral views. These views help to localize the deposit to a specific tendon and show signs of possible impingement. For the recognition of calcifications is also very useful ul-trasound examination.Hartig and Huth12 have shown that ultrasound allows to detect the totality of calcifications while radiography per-mits only in 90% of cases. Magnetic resonance imaging (MRI) evaluation can lead to diagnostic errors and it is not indicated routinely.

TREATMENT

The choice of treatment should be evaluated and placed in relation to each other the medical history, symptoms and radiographic findings. In some cases, calcifications will resorb during the natural progression of disease. Gärtner13 followed the natural evo-lution of calcific deposits, finding that radiologically dense deposits disappeared in 33% compared with 85% of fluffy deposits over 3 year.

Unfortunately it’s known that up to 38% of the calcifica-tion do not disappear with time5.In particular medial and anterior localization of the calcifi-cation is a negative prognostic factor for self reabsorption of the deposit14.The persistence of the calcification is detrimental to the tendon biology and resistance.Thus is mandatory to follow-up the calcification and to treat it in case it would not reabsorb spontaneously.


with an acutely painful shoulder in the resorptive phase, and it can help decrease the intratendinous pressure. Clini-cal studies that have analyzed the US-guided percutane-ous treatment of calcific tendonitis have reported generally satisfactory results. Serafini et al.21 compare short and long term outcomes of patients with rotator cuff calcific ten-donitis who did and did not undergo ultrasonographically (US)-guided percutaneous treatment. Of 219 patients re-ferred for US-guided treatment of rotator cuff calcific ten-donitis, 68 patients refused treatment and served as control subjects. Compared with control group, treated patients reported a significant decrease in symptoms at 1 month, 3 months and 1 year. Clinical scores were not significantly different between the two groups at 5 years and 10 years. The authors conclude that US-guided percutaneous treat-ment facilitated prompt shoulder function recovery and pain relief. Another study22 compares 2 regularly applied calcific rota-tor cuff treatments: ultrasound (US)–guided needling and lavage combined with a US-guided corticosteroid injection in the subacromial bursa (barbotage group) versus an iso-lated subacromial bursa injection (control group). Patients were randomly assigned to the 2 groups. Shoulder function was assessed before treatment and at regular follow-up in-tervals (6 weeks and 3, 6, and 12 months). Additionally, calcification location, size, and Gärtner classification were assessed on radiographs. On average, there was improve-ment at 1-year follow-up in both treatment groups, but clinical and radiographic results were significantly better in the barbotage group. Furthermore ultrasound-guided needling in combination with high-energy shock-wave therapy (treatment group) was found more effective than shock-wave therapy alone (control group) in patients with symptomatic calcific ten-donitis23. A higher rate of elimination of the calcium de-posits was seen in treatment group (60%) than in control group 2 (32.5%) (p < 0.05). Arthroscopic removal of the deposit was avoided in 32 patients of treatment group and in 22 of control group (p < 0.05) .

Platelet-rich plasma therapyPlatelet-rich plasma therapy (PRPT) has been advocated for the treatment of muscle, tendon as well as joint pa-thologies24. Seijas et al.25 reported the use of PRPT in a 44-year-old female with chronic calcific tendinopathy of the supraspinatus that was nonresponsive to traditional con-servative therapy. The patient received three treatments at 2-week intervals. After 6 weeks, the patient was reportedly asymptomatic. Follow-up at 1 year confirmed the patient remained pain-free and was able to return to unrestricted activities. This isolated case study (level V) suggests PRPT may be of value for intractable cases of calcific tendinopa-thy. However evidence from clinical studies of Level 1 are required.

SurgerySurgery is indicated for patients who have progression of their symptoms, constant pain that interferes with activities of daily living, and absence of improvement after conser-vative therapy. Surgical treatment is helpful for the chronic formative phase patients (radiological dense calcification

and sharp edges) and especially those with impingement symptoms. Harrington and Codman performed the first operative procedure for removal of calcific deposit in 1902 6. Since the 1930s many investigators have supported this proce-dure 26--28. Rochwerger et al.29 reported on 22 patients who underwent open removal of a calcific deposit and acromionplasty and found the Constant-Murley assessment score was in-creased 23 months after the treatment. They concluded that the most favorable results are obtained in patients with the longest interval between onset of the disease and interven-tion (more than 1 year) and with a progressive course of the disease. Arthroscopic treatment has been shown to have outcomes that are equivalent to those of open procedures, and it has the added benefits of improved cosmesis and possibly a shorter hospital stay, which leads to decreased cost (Fig-ure 2). Rehabilitation consists of a simple home exercise program to regain muscle tone and to prevent adhesive capsulitis. In 1987 Ellman30 first described his arthroscopic technique, involving blind needle aspiration to locate the deposit, fol-lowed by excision, and the acromionplasty. Jerosch et al.31 evaluated 48 patients treated arthoscopi-cally with deposit removal, resection of the coracoacro-mial ligament and acromionplasty. Results showed patients with post-operative radiographic elimina-tion or reduction of the deposits had significantly bet-ter outcomes than those without radiographic change and that acromionplasty did not improve the results. Even more recent studies support the arthroscopic tech-nique in patients with persistence or progression of symp-toms and constant pain. Seil et al.32 have analyzed the outcome of arthroscopic re-moval of calcifying tendinitis of the rotator cuff on 58 pa-tients. Every patient was evaluated by using the Constant score, pre and post-operative radiographs and ultrasonoog-raphy to assess integrity of rotator cuff. Shoulder function improved according to Constant score, and ultrasonogra-phy revealed minor structural changes of the supraspinatus in 66% patients. 92% of the patients were very satisfied. The study confirmed previously reported successful re-sults of arthroscopic treatment of calcifying tendinitis of the rotator cuff. El Shewy33 studied the results of arthroscopic removal of the calcium deposits within the rotator cuff, without rota-tor cuff repair after a minimum follow-up of 7 years. On 56 patients everyone improved their shoulder’s activity (measured by ASES, UCLA and Costant). Only 3.7% of cases developed rotator cuff tears over the period of fol-low-up. The author concludes that arthroscopic removal of as much as possible of symptomatic calcium deposits of the rotator cuff is a safe and effective treatment when nonoperative methods fail. Yoo et al.34 also substained that complete removal of cal-cium deposits in tendon cuff provides good clinical results and earlier pain relief when it was compared to previous literature of minimal removal technique.Porcellini et al.35 demonstrated results of arthroscopic re-moval of calcifications and an acromioplasty only when


the coracoacromial ligament was rough and the acromion was exposed. They concluded that a successful outcome seemed strongly related only to the absence of calcium de-posits in the tendon cuff.Other studies have advocated the surgical removal of de-posits, either by an open or artrhoscopic procedure. Balke et al.36 reported the results on 70 shoulders of 62 patients with a mean age of 54 years, after arthroscopic re-moval of calcium deposits of the supraspinatus tendon. In 44 shoulders, additional subacromial decompression was performed. After a mean follow-up of 6 years, patients were clinically investigated, and function was statistically evaluated using Constant and ASES scores. Affected and contralateral shoulders were examined by ultrasound in 48 shoulders, and rotator cuff tears were documented. The mean Constant scores of the operated shoulders were sig-nificantly lower than those of the healthy shoulders. The ASES scores significantly increased after surgery but were still lower than the ASES scores of the healthy shoulders. Pain was found significantly better in patients with the subacromial decompression. Ultrasound examination at last follow-up showed a partial supraspinatus tendon tear in 11 operated and 3 contralateral shoulders. The results of this study indicate that although the good clinical results after arthroscopic treatment of calcifying tendinitis of the shoulder persist midterm, the affected shoulders present significantly lower clinical scores than healthy shoulders. The rate of partial supraspinatus tendon tears seems to be higher after calcium removal. Additional subacromial de-compression seems to reduce postoperative pain. Tilland-er and Norlin37 compared two groups with an impingement syndrome, one group showing deposits in the rotator cuff and the other not showing such deposits. Both groups per-formed arthroscopic acromioplasty, with no difference in results or calcification dissolution. They suggested that calcifications may not cause pain and are an insignificant observation on radiographic evaluation regarding treat-ment indication.Hofstee and collagues38 evaluated two groups of patients after 3 years. The first group treated with acromioplasty and removal of calcification, the second only with acro-mioplasty. There was no difference in clinical outcomes between surgical subacromial decompression with or without removal of the calcifications.

TREATMENT ALGORITHM

Calcific Tendinitis represent a treatment challenge since there is no consensus on its treatment.Most studies concerning treatment of rotator cuff calci-fications are uncontrolled. Moreover, most studies focus on symptom disappearance, more than calcification disap-pearance, after conservative or operative therapy. There-fore, although symptoms may improve, the pathology (in-tratendinous degeneration and calcification) remains.

Patients compliance is the key in the treatment algorithm for this disease. As a matter of fact shockwaves are not well tolerated by patients, as like as the surgical treatment is not well perceived. Recently US guided lavage offers

an easy way of treatment of the tendinitis, washing out the entire deposit. Unfortunately US lavage is suitable only in acute calcific tendinitis when the deposit is pretty fluid. On the other hand the arthroscopic treatment allows to repair a cuff tear related to a chronic calcific tendinitis.

A practical Treatment Algorithm has been developed fol-lowing the main concepts of: 1) reduce the pain, 2) treat the tendon avoiding a subsequent cuff tear.

1. In case of acute onset of calcific tendonitis diag-nosed by X-Rays, the patients are sent to the radiol-ogy dept for US lavage. The lavage is performed in local anesthesia and in an outpatient way.

2. Two days after the treatment the patients start phys-ical therapy, for passive range of motion (ROM) exercises, with a full ROM recovery at 7 days after treatment. Active ROM exercises will start only 15-20 days after treatment depending on the residual pain.

3. The patients will repeat an X-rays at 2 months after treatment plus an MRI in case of persistent pain. If the tendon is torn the patients are scheduled for sur-gery, if not they continue follow-up surveillance.

4. In case of Chronic calcific tendonitis we suggest an arthroscopic treatment with/out rotator cuff repair.

CONCLUSIONS

The calcific tendonitis is a cell-mediated pathology, multi-phasic, which creates a calcium deposit particularly in the supraspinatus tendon, or subacromial bursa, and a subse-quent resorption. Most cases resolve spontaneously. In the literature, sev-eral conservative treatments have been reported with vary-ing levels of evidence on their effectiveness. A very well accepted and successful technique is the US lavage. The arthroscopic surgery is the last option available to the or-thopedic specialist; should be noted that the post-surgical pain may be present for several weeks after surgery. Ar-throscopic treatment should be reserved for chronic cases or for cuff ruptures due to the deposit.

REFERENCES

1) Lippmann RK. Observations concerning the calcific cuff deposit. Clin Orthop 1961; 20:49-60

2) Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis; a survey of 12122 shoulders. JaMa 1941; 116:2477–82

3) editorial. Calcific tendonitis of the shoulder. new engl J Med 1999; 340:1582–4

4) Hedtmann a, Fett H. So-called humero-scapular periarthropa-thy: classification and analysis based on 1,266 cases. Z Orthop Ihre Grenzgeb. 1989; 127:643-649

5) Uhthoff HK, Loehr JF. Calcifying tendinitis. In: Rockwood Ca, Matsen Fa, eds. the Shoulder. Philadelphia: Saunders; 1998:989-1008

6) Codman ea. On stiff and painful shoulders. Boston Med Surg J. 1906; 154:613-620


7) Moseley HF, Goldie I. the arterial pattern of the rotator cuff of the shoulder. J Bone Joint Surg Br. 1963; 45:780-789

8) Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff. J am acad Orthop Surg. 1997; 5:183-191

9) Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survay of 12122 shoulders JaMa 1941; 116: 2477-2482

10) Patte and Goutalier D. Calcifications. Rev Chir Orthop 1988; 74: 277-278

11) Gosens t, Hofstee DJ. Calcifying tendinitis of the shoulder: ad-vances in imaging and management. Curr Rheumatol Rep. 2009; 11:129-34

12) Hartig a and Huth F. neue aspekte zur Morphologie und thera-pie der tendinosis calcarea der Schultergelenke. artroskopie 1995; 8: 117-122

13) Gärtner J. Is tendinosis calcarea associated with HLa-a1? Z Or-thop Ihre Grenzgeb 1993; 31:461–469

14) Ogon P, Suedkamp nP, Jaeger M, Izadpanah K, Koestler W, Maier D. Prognostic factors in nonoperative therapy for chronic symp-tomatic calcific tendinitis of the shoulder. arthritis Rheum 2009; 60:2978–2984

15) Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendi-nitis of the shoulder. J Bone Joint Surg Br 1999; 81:863–867

16) Gerdesmeyer L, Wagenpfeil S, HaakeM MM, Loew M, Wörtler K, Lampe R, Seil R et al. extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff. JaMa 2003; 290:2573–2580

17) Ogden Ja, toth-Kischkat a, Schultheiss R. Principles of shock wave therapy. Clin Orthop Relat Res 2001; 387:8–17

18) Speed Ca, Richards C, nichols D, Burnet S, Weiss Jt, Humphreys H, Hazleman BL () extracorporeal shock wave therapy for ten-donitis of rotator cuff. J Bone Joint Surg Br 2002; 84-B:509–512

19) Farr S, Sevelda F, Mader P, Graf a, Petje G, Sabeti-aschraf M. extracorporeal shockwave therapy in calcifying tendinitis of the shoulder. Knee Surg Sports traumatol arthrosc 2011; 19:2085-9

20) Lee SY, Cheng B, Grimmer-Somers K. the midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. J Shoulder elbow Surg 2011; 20:845-54

21) Serafini G, Sconfienza LM, Lacelli F, Silvestri e, aliprandi a, Sarda- nelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle US-guided percutaneous treatment. nonrandomized controlled trial. Radiology 2009; 252:157-164

22) de Witte PB, Selten JW, navas a, nagels J, Visser CP, nelissen RG, Reijnierse M. Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids. am J Sports Med 2013; 41:1665-73

23) Krasny C, enenkel M, aigner n, Wlk M, Landsiedl F. Ultra-

sound guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. J Bone Joint Surg Br. 2005; 87:501-7

24) Podd D. Platelet-rich plasma therapy: origins and applications investigated. JaaPa 2012; 25:44-49

25) Seijas R, ares O, alvarez P, et al. Platelet-rich plasma for calcific tendinitis of the shoulder: a case report. J Orthop Surg 2012; 20:126-130

26) Bosworth BM. examination of the shoulder for calcium depos-its. technique of fluoroscopy and spot film roentgenography. J Bone Joint Surg 1941; 23:567-77

27) Harmon PH. Methods and results in the treatment of 2580 pain-ful shoulders with special reference to calcific tendinitis and the frozen shoulder. am J Surg 1958; 95:527-44

28) McLaughlin HL. the selection of calcium deposits for opera-tion: the technique and resultant operations. Surg Clin n am 1963;43:1501-4

29) Rochwerger a, Franceschi JP, Viton JM, Roux H, Mat- tei JP. Surgi-cal management of calcific tendinitis of the shoulder: an analy-sis of 26 cases. Clin Rheumatol 1999; 18:313-6

30) ellman H. arthroscopic subacromial decompression. analysis of one- to three-year results. arthroscopy 1987; 3:173-81.

31) Jerosch J, Strauss JM, Schmiel S. arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder elbow Surg 1998; 7:30-7

32) Seil R, Litzenburger H, Kohn D, Rupp S.arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. arthroscopy 2006; 22:521-7

33) el Shewy MT. arthroscopic removal of calcium deposits of the rotator cuff: a 7-year follow-up. am J Sports Med 2011; 39:1302-5

34) Yoo JC, Park WH, Koh KH, Kim SM. arthroscopic treatment of chronic calcific tendinitis with complete removal and rotator cuff tendon repair. Knee Surg Sports traumatol arthrosc. 2010; 18:1694-9

35) Porcellini G, Paladini P, Campi F, Paganelli M: arthroscopic treat-ment of calcifying tendonitis of the shoulder: clinical and ultra-sonographic follow-up findings at two to five years. J Shoulder elbow Surg 2004; 13:503-508

36) Balke M, Bielefeld R, Schmidt C, Dedy n, Liem D. Calcifying ten-dinitis of the shoulder: midterm results after arthroscopic treat-ment. am J Sports Med 2012; 40:657-61

37) tillander BM, norlin RO. Change of calcifications after ar-throscopic subacromial decompression. J Shoulder elbow Surg 1998; 7:213–217

38) Hofstee DJ, Gosens t, Bonnet M, De Waal Malefijt J. Calcifi-cations in the cuff: take it or leave it? Br J Sports Med. 2007; 41:832-5

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Adhesive capsulitis: clinical aspects and treatmentRoberto Leo, PierLuigi GambrioliS.S. Dipartimentale Diagnosi e Chirurgia Patologia Spalla e Gomito, Istituto Ortopedico Gaetano Pini, Milano

DEFINITION

Adhesive capsulitis, also called frozen shoulder (in Italian literature “capsulite retrattile”, a definition that suggests inflammatory capsular contracture responsible of pain and stiffness) is a self-limiting syndrome of unknown etiol-ogy that produces progressive shoulder pain and mobility deficits for a period of about six months followed, in most of cases, by a pain resolution and mobility recovery in about four-six months, which is the average healing time. However, it is not infrequent to observe healing over a lon-ger period of time, one–two years, with variable residual shoulder stiffness.

INCIDENCE

Adhesive capsulitis occurs in 2% to 5% of the population, but prevalence and incidence figures seems to be increas-ing, the majority of patients are female ranging in age from 40 to 60 years old 1. The non dominant hand is more frequently involved. In 20% to 30% of cases the pathol-ogy will also affect the opposite shoulder after a variable period of one or more years. In our experience, concur-rent involvement of both shoulders is extremely rare. At present, this pathology is considered not recurrent in the same joint.

ETIOLOGY AND ANATOMO-PATHOLOGICAL ASpECTS

The etiology for primary frozen shoulder remains un-known. The onset of adhesive capsulitis is usually sponta-neous, without any relevant trauma. About 30% of patient reports a doubtful history of minor trauma, without immediate consequences. Bunker et al 2 considered adhesive capsulitis a Dupuytren like disease because this condition can be associated with shoulder capsulitis in some patients. In histological studies of adhesive capsulitis, capsule and synovial membrane showed a matrix of type I and type III collagen populated by fibroblasts and myofibroblasts in capsular tissue, with no significant inflammation. Rodeo et al 3, from a biological point of view found the presence of inflammatory cytokines and their receptors in capsular tissue with involvement of growth factors and TGF- beta but inflammatory test and HLA-B27 were negative. Intercellular adhesion molecule-1 (ICAM-1, CD54), which

are more abundant in diabetes mellitus, are also present in capsular tissue of patients with adhesive capsulitis 4 and this association seems to explain the frequent association between diabetes and adhesive capsulitis. According to Hagiwara et al 5 the number of chondrogen-ic cells and gene expressions related to fibrosis, inflam-mation, and chondrogenesis was significantly higher and the capsular tissue was significantly stiffer in idiopathic frozen shoulders compared with shoulders with rotator cuff tears.

CLINICAL ASpECTS AND pATHOLOGICAL ASSOCIATIONS

In shoulder surgery, adhesive capsulitis may complicate the outcome of minor interventions such as arthroscopic treatment of small or partial supraspinatus tears and ar-throscopic removal of tendon calcium deposits. In these cases is difficult to understand if the pain leading to the operation was related to the pre-existence of an undiag-

ABSTRACT

Adhesive capsulitis is a complex shoulder pathology character-ized by increasing pain related to synovial inflammatory reac-tion and loss of passive mobility due to a fibrosis and contrac-ture of the articular capsule. The etiology is unknown and this particularity is the main obstacle to the identification of an ef-fective treatment. Adhesive capsulitis is a self-limiting condition, which typically has three stages and ends in resolution in a variable period of about one year, but can also last longer. The duration of symp-toms and the level of pain and stiffness are variable for every patient. The etiologic knowledge of this pathology is limited. Conse-quently also the treatment is controversial and, at present, no treatment can stop the evolution of the pathology at the begin-ning or to significantly shorten the period of pain and stiffness. Over the years, many types of treatments have been proposed. Many of these have been abandoned and today the preferred options are non-operative treatments including analgesia, phys-iotherapy, oral or intra-articular corticosteroids, and intra-artic-ular distension injections, mainly performed in early stages of the pathology. Operative options, including manipulation under anaesthesia and arthroscopic release, are generally reserved for refractory cases, with severe residual stiffness at the end of in-flammatory stages.

PL. GAmbrioLi


nosed early stage of adhesive capsulitis without stiffness or the capsulitis has been declenched by the trauma related to the surgery. In these patients, to avoid a complicated and long post-operative convalescence it is wise to evalu-ate the passive mobility of the shoulder and if the joint is painful and stiff; one or two months of physical therapy al-lows physician to decide if the symptomatology is related to an adhesive capsulitis or not. Adhesive capsulitis is frequently associated with other systemic conditions, most commonly diabetes mellitus, thyroid dysfunction or epilepsy in treatment, but also with immobilization e.g. stroke disease, Dupuytrens and Led-dherose pathologies, autoimmune diseases and treatment of breast or pulmonary cancer. The risk of developing shoulder adhesive capsulitis in diabetes mellitus in a large longitudinal population-based follow-up study was 1,2% in diabetics and 0,95% in non diabetic subjects 6.

Clinical evolution Adhesive capsulitis progresses through three stages char-acterized by clinical aspects and related with anatomo-pathological articular changes, as demonstrated by ar-throscopic examination.Stage 1, painful stage, is characterized by a gradual on-set of shoulder pain, which can worsen rapidly or evolve slightly for weeks or months. In this Stage, the pathog-nomonic symptom of adhesive capsulitis i.e. the limita-tion of movement by capsular contracture is not clearly present. The early loss of external rotation is the clinical hallmark of adhesive capsulitis. At this Stage, the low level of pain-ful stiffness limits the possibility of a clinical diagnosis and makes the choice of the treatment uncertain. Arthroscopi-cally, at Stage 1, only a fibrinous synovial inflammatory reaction without capsular adhesion or contracture has been observed. Stage 2 is characterized by acute synovitis and progressive capsular contracture. The pain is present also at night and in many patients is particularly severe, not influenced by analgesic or non steroidal anti-inflammatory drugs. Only oral or intra-articular steroid therapy has some efficacy for the severe pain. The loss of motion is correlated to con-tracture of the axillary capsular pouch, fibrous metaplasia of the capsule and hypertrophic synovitis. This is the stage of “freezing” of the shoulder that reach the highest level of stiffness. Stage 3 is sometimes divided in “frozen”, or in its late phase, “thawing” stage because the principal complaint is stiffness and nocturnal pain and severe pain during the normal activities is decreased or disappeared, and, in the late period of this stage, the absence of pain favours more aggressive rehabilitation with minimal pain. Arthroscopy shows mature adhesion of articular structures, with a tick fibrous capsule but a minimal synovitis. The gradual re-covery of the movement allows better use of the arm and frequently patients stop the assisted physical therapy when they reach the minimum of mobility required for the nor-mal day life activities and, consequently are satisfied even if at clinical examination a variable amount of stiffness is still present.

Clinical and instrumental diagnosisThe diagnosis of frozen shoulder can be difficult at the ini-tial stage, before the onset of the capsular retraction and the stiffness. When stiffness is clinically evident the diag-nosis is easily established and does not require particular instrumental investigations. Patient’s history and clinical exams are sufficient for a reliable diagnosis of adhesive capsulitis in Stage 2 and usually an x-ray of the shoulder is required to detect the presence of calcifying tendinitis, gle-no-humeral arthritis or other osteo-cartilagineous patholo-gies that could cause both pain and stiffness. The recent interest in treatment with intra-articular cortisonic injec-tion in the Stage 1, before the capsular contracture, to stop inflammatory process of synovial tissue, has increased the use of contrast-enhanced MRI for early recognition of cap-sular damage.Arthro-MRI with gadolinium is useful to detect reduced joint capsule volume of the axillary recess. Also a simple MRI in T2 outlines the fibrous capsular thickening and offers a valuable imaging for the diagnosis of adhesive capsulitis 7, but, in current practice MRI-arthrography is utilized only when clinical aspects are confused by the presence of an associated cuff pathology.

TREATMENT

The traditional treatment based on mobilization under an-esthesia has been substituted by a more conservative ap-proach with treatments including analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections, mainly performed in early pathology stages. Surgical options, including manipulation under an-aesthesia associated to arthroscopic release, are generally reserved for refractory cases, with severe residual stiffness at the end of inflammatory stages.

Physiotherapy is a conservative treatment usually based on early and prolonged physical therapy. Treatment must be adapted to the patient’s symptoms, stage of the condi-tion, and recognition of different patterns of motion loss, avoiding painful or forced mobilization during the painful Stages 1 and 2. Forced mobilization of a stiff shoulder can be too painful and potentially harmful to the glenohumeral joint. Physiotherapeutic interventions can reduce pain and/or increasing mobility, but there is little evidence that the disease prognosis and evolution is affected. A prolonged therapy and the use of a static progressive stretching device at home in combination with traditional therapy seems to improve long-term range of motion.

Non steroidal anti-inflammatory drugs (NSAID) are large-ly used to decrease the level of pain. The efficacy is very limited and indipendent from the different type of NSAIDs and the treatment doses. Usually patients report a mild and temporary reduction of pain but no significant reduction of stiffness and of time of evolution of the pathology is recog-nizable for these treatments.

Oral steroid treatment has shown a great efficacy on pain relief and a beneficial effect also in mobility of the shoul-


der but this improvement ceased after the suspension of the therapy and the course of the pathology is the same of patients treated only with physical therapy and NSAIDs. Oral steroid treatment can be proposed to patients that need some temporary relief from acute pain but the well-known side effects of a prolonged steroid therapy are an important concern to be seriously evaluated.

Intra-articular steroid injections: is the therapy most fre-quently practised and reported in literature. This treatment offers good results both for the pain and mobility improve-ment, but only if is started in Stage 1 or early Stage 2 of the pathology, before the capsular contracture. Usually, the injection in the glenohumeral joint is conducted blindly. If the surgeon is not accustomed to shoulder arthroscopic techniques an ultrasound-guided technique may be useful. Although ultrasound guidance may improve the accuracy of the injection to the site of the pathology in the shoulder, it is not clear that this technique improves its efficacy. Patients treated with a single corticosteroid injection in different locations of the shoulder showed that the efficacy of a single corticosteroid injection was not related to the site of injection 8. Yoon SH et al 9 reported that there was no significant dif-ference between patients treated with high- or low-dose corticosteroid injection, indicating the preferred use of a low dose in the initial stage.

Manipulation under anesthesia and arthroscopic release: even if is still utilized in refractory stiffness in Stage 3, iso-lated manipulation under anaesthesia has been substituted by the arthroscopic release. Arthroscopic capsulotomy, more or less complete, circumferential or limited to the an-terior part and axillary pouch of the capsule, is less prone than closed manipulation to complications such humeral or glenoid anterior rim fractures, subscapularis or long bi-ceps ruptures and allows a controlled final mobilization at the end of arthroscopic procedure 1.

CONCLUSIONS

The published literature about adhesive capsulitis is at the same time increasingly abundant and controversial. In this situation we can only conclude with some suggestions of treatments based on our experience, waiting for better

etiologic knowledge of the biological mechanism of this pathology. The clinical stages of adhesive capsulitis reflects different pathological aspects of this disease.In Stage 1 or at beginning of the Stage 2, the problems are related to synovial and capsular inflammation. The ratio-nale treatment is based on intra-articular corticosteroids, analgesic or NSAIDs for controlling the pain and gentle mobilization of the shoulder within the pain free zone to lessen the capsular contracture. In late Stage 2 oral or in-tra-articular steroids are of limited efficacy and the objec-tives are the analgesic control of the pain and the assisted mobilization of the shoulder. In Stage 3, in our experience, it is rarely necessary to face stiffness that severely lim-its daily activities. In patients with severe limitations, ar-throscopic release provides good benefits with less risk of complications compared to the closed manipulation under anaesthesia.

REFERENCES

1. neviaser aS, Hannafin Ja. adhesive Capsulitis. a Review of Cur-rent treatment. am J Sports Med. 2010; 38:2346-2356

2. Bunker tD, anthony PP. the pathology of frozen shoulder: a Dupuytren-like disease. J Bone Joint Surg Br. 1995; 77:677–680

3. Rodeo Sa, Hannafin Ja, Warren RF, Wickiewicz tL. Immunolocal-ization of cytokines and their receptors in adhesive capsulitis of the shoulder. J Orthop. Res. 1997; 15: 427-436

4. Kim YS, Kim JM, Lee YG et al. Intercellular adhesion molecule-1 (ICaM-1, CD54) is increased in adhesive capsulitis. J Bone Joint Surg am. 2013; 95:181-188

5. Hagiwara Y, ando a, Onoda Y, takemura t et al. Coexistence of fibrotic and chondrogenic process in the capsule of idiopathic fro-zen shoulders. Osteoarthritis and Cartilage. 2012; 20:241-249

6. Huang YP, Fann CY, Chiu YH, Yen MF et al. association of diabe-tes mellitus with the risk of developing adhesive capsulitis of the shoulder: a longitudinal population-based follow-up study. arthritis Care Res. 2013; 65:1197-1202

7. Gondim teixeira Pa, Balaj C, Chanson a et al. adhesive capsulitis of the shoulder: value of inferior glenohumeral ligament signal changes on t2-weighted fat-saturated images. aJR am J Roent-genol. 2012; 198:589-596

8. Shin SJ, Lee SY. efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder elbow Surg. 2013; 22:521-527

9. Yoon SH, Lee HY, Lee HJ, Kwack KS. Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. am J Sports Med. 2013; 41:1133-1139


Biological enhancement in rotator cuff repairsalessandro Castagna, Valentina Fogliata*, Raffaele Garofalo**, eugenio CesariUnità di chirurgia della spalla e gomito, IRCCS Istituto Humanitas, Milano * Dipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,

Struttura Semplice Dipartimentale Chirurgia Spalla e Gomito, Istituto Ortopedico G. Pini, Milano**Servizio Chirurgia della spalla, Ospedale F. Miulli, Acquaviva delle Fonti, Bari

INTRODUCTION

Rotator cuff injuries are a common source of pain and imply an important decrease in patient’s life quality.The incidence of this pathology tends to increase with age, however, symptomatic rotator cuff lesions could also be found in young subjects above 30 years. Cadaver studies have shown that the incidence of full-thickness tears of the rotator cuff is equal to 40% in people older than 60 years1.Many patients undergo surgery to repair these lesions, in order to improve symptomatology and function. Howev-er, despite the continuous development of suture materi-als and repair techniques (use of titanium and absorbable anchors, “tension band”, “single-row”, “double row”, “transosseous equivalent repair”), recurrence of tendon rupture is not uncommon, regardless of the technique (open or arthroscopic) or the type of material used. The rate of recurrence or non-healing has been reported in a percentage varying from 20% to 94%, and is a mul-tifactorial process2. The causes of this failure are various and depend on the characteristics of the lesion (size, shape), the degree of degeneration of the muscle-tendon system, the character-istics and the lifestyle of the patient2. Although some studies showed a correlation between

functional outcome and tendon healing, but recent me-ta-analysis demonstrate that there are no differences in terms of pain or functional score between patients whose tendon is healed than those where the tendon has not been healed3. However, patients with a complete tendon-healing show a significant improvement of the strength during follow-up examination3-4. The weakest link in repair system of the rotator cuff is to be found at the level of the biology of tendon-bone healing process and therefore, current ef-forts are also directed to the study of the biological mech-anisms of tendineous tissue healing and the possibility to improve healing of the tendon-bone system. However, when the biology of the repair of the rotator cuff is con-sidered, the etiology of the rupture itself must be kept in mind, as this lies in a degeneration of tendon and tendon-bone junction5 in most cases. The purpose of this manuscript is to draft a literature re-view of healing processes of the rotator cuff tendons and point out, in light of recent discoveries, if there are bio-logical possibilities to influence in a positive way these processes.

THE BONE-TENDON JUNCTION (ENTHESIS)

The physiological tendon-bone interface consists of an inter-digitation of several layers of longitudinally ori-ented fibers of type I collagen which are inserted in a gradual manner on the humerus6. The vascularization is also organized within the tendon; the number of vessels and their size gradually decrease as they get closer to the bone6. At the level of this junction there is a gradual tran-sition from tendon to bone and stand 4 zones: tendon, non-mineralized fibrocartilage, mineralized fibrocarti-lage and bone. Type I collagen predominates in zones 1 and 4, while zones 2 and 3 contain mainly collagen I, II and X, as well as extracellular matrix with proteoglycans. With the aging process, the level of vascularization in this area tends to decrease progressively, altering the in-trinsic structure of the tendon-bone interface.The healing process of the tendon is very complex. Ex-perimental studies have shown that the healing process is initiated mainly by mesenchymal cells that originate from the bone footprint and the subacromial bursa7. How-ever, the terminal structure of the tendon-bone junction is quite different from the native insertion. In fact, instead of the four distinct areas, bone and tendon are linked by a layer of fibrovascular tissue predominated by collagen type III6. It is therefore a non-regenerative but reparative

ABSTRACT

Rotator cuff injuries are a common source of pain and imply an important decrease in patient’s life quality. It is estimated that 40% of individuals over the age of 60 years experience rotator cuff injuries. Despite surgical techniques advances, after surgical repair there is a high rate of recurrent tears (up to 96% for mas-sive and large tear). Tendons healing process make inferior qual-ity tissue at the level of the tendon-bone unit and this is related to the fact that the healing process is a reparative process and not a regenerative process. Due to the frequency of these injuries, as well as the rate of re-tear, it is not surprising that biological strate-gies have become more appealing. There are different biological means like creation of bone marrow vent, microfracture or other strategies using tissue engineering. Tissue-Engineering strategies involve the use of PRP, mesenchymal stem cells, use of protease inhibitor, biomimetic or biological scaffolds, to promote tendon regeneration via natural process. The present paper reviews the current state of knowledge regard-ing the biological enhancement strategies to improve the rotator cuff healing after repair.


process which resulted in a bone-tendon junction that is sub-optimal from a physiological point of view. This dif-ference is substantial. Immediately after injury, the gap is bridged by a blood clot that acts as a scaffold for re-pair and release a variety of chemotactic and mitogenic growth factors (haemorrhagic phase). Cytokines released within the clot activate polymorphonuclear leukocytes and lymphocytes that reach the site of the lesion within a few hours. These cells respond to autocrine and paracrine signals expanding the inflammatory response and recruit-ing other types of cells. The macrophages reach the site of the lesion within 48 hours and predominate for several days (inflammatory phase). They are responsible for the phagocytosis of necrotic tissue and with epitenon and en-dotenon cells (intrinsic cells) they secrete various growth factors, especially Transforming Growth Factor-ß1 (TGF ß1) that increase the activity of protein kinases and the collagen formation. After three days, at the site of the le-sion will be present platelets, macrophages, polymorpho-nuclear leukocytes, lymphocytes, and multipotent mes-enchymal stem cells. Platelets release Platelet-Derived Growth Factor (PDGF), TGF-β and Epidermal Growth Factor (EGF); instead macrophages release PDGF, Trans-forming Growth Factor-α (TGF-α), TGF-β, and Basic Fibroblast Growth Factor (bFGF). These factors are not only chemotactic for fibroblasts and other cells but also stimulate the fibroblasts proliferation and the synthesis of collagen type I, III and V and non-collagenous proteins. The last to arrive are fibroblasts that are recruited from surrounding tissues and systemic circulation (prolifera-tive phase). Fibroblasts begin to produce collagen and other matrix proteins within one week from the injury.Although the reparative phenomena begin at the end of the first week, Randelli et al. have noted that some of these cytokines may appear immediately after the surgi-cal repair of the rotator cuff if associated acromioplasty8. In this study the author noted that by taking a sample of 3 ml of the fluid of the shoulder 15 minutes after the end of the surgery, PDGF-β, TGF-1, and bFGF levels were significantly higher than in venous blood of the same patient. These observations indicate that growth factors may be important at the beginning and at the end of the tendon healing process. After two weeks, the blood clot is more organized and begin to shape the first capillaries. The total content of collagen is greater than that of a nor-mal tendon, but the density is lower and the extracellular matrix is disorganized. The last phase is characterized by the reduction of cel-lularity and by increase in collagen density (remodeling phase). Biochemical and biomechanical signals regu-late the expression of structural and enzymatic proteins, including collagenase, activation of plasminogen and stromelysin. The healing process continues for several months, and the maturation of the tendon will be com-pleted only one year after. Despite the remodeling phase, the healed tendon does not reach mechanical properties and morphological characteristics of a normal tendon. The tension force remains lower than 30% compared to a normal tendon even after several months or years9. The reduction of the mechanical properties is associated with a lower diameter of collagen fibers and with an alteration

of the proteoglycans profile in the matrix. This reduction of the mechanical properties of the tendon will make the tissue weaker and more susceptible to recurrence of le-sions10.

GROWTH FACTORS

Growth factors are proteins used for communication among cells of an organism and they are able to stimu-late cell migration, proliferation and synthesis of proteins. Their action depends on the bond of specific membrane receptors. Once activated, receptors trigger a cascade of chemical reactions in the cytoplasm that cause the activa-tion of genes in the nucleus and thus the DNA synthesis. Growth factors are synthesized and secreted by a wide va-riety of inflammatory cells, platelets, fibroblasts, epithe-lial cells and vascular endothelial cells. They can activate neighboring cells (paracrine action) or the same cells that released them (autocrine action). Numerous studies have shown that growth factors (basic fibroblast growth fac-tor (bFGF), Insulin-Like Growth Factor (IGF-1), PDGF, TGF-1, Vascular Endothelial Growth Factor (VEGF), Epi-dermal Growth Factor (EGF)) may be involved in tendi-nous and ligamentous tissue repair. TGF-β exists in three isoforms (TGF-1, TGF-2, TGF-3). It is a cytokine secreted by most cells involved in healing process. Together with IGF, TGF-β1 is rapidly released at the site of the lesion, during the inflammatory phase. TGF-β3 plays a decisive role in fetal healing process that occurs without scar and is regulated by mechanisms of regenerative type. However it is not found in adult typical cicatricial healing processes, where TGF-β1 is present6. IGF-1 (somatomedin C) is secreted by osteoblasts and fibroblasts. This growth factor too is secreted immediately after injury, but reaches its peak after 3 weeks and it is important in inflammation, proliferation and remodeling processes7. It inhibits the migration of inflammatory cells during the inflammatory phase exerting a mechanism of modulation of the inflam-mation itself.PDGF is secreted not only by platelets, but also from mac-rophages and other cells. This protein stimulates and regu-lates the synthesis of other growth factors and stimulates the synthesis of type I collagen and non-collagenous pro-teins. Its peak of expression is reached during the forma-tion phase as well as for bFGF: the latter stimulates the production of collagen type III. VEGF stimulates angio-genesis and vasculogenesis. There are no studies to date that have evaluated the efficacy of this growth factor in rotator cuff repair.Other important proteins involved in tendon-to-bone heal-ing processes are the BMP (bone morphogenetic pro-teins). These proteins, in particular BMP 2,7,12,13,14, are a group of factors that belong to the TGF-β superfamily and stimulate bone formation, but also tendinous cells mitogenesis and healing. Although it is clear that BMPs stimulate tendon healing, the mechanism remains unclear. Animal studies have revealed that recombinant BMP 12 accelerates healing of the cuff tendons and, more impor-tantly, improves the formation of fibrocartilage at tendon-bone junction10. In addition, BMP 2, 7 and 12 are together


involved in improving the tendon to bone healing, en-hancing insertion resistance itself.Ultimately different growth factors work in concert ap-pearing with different concentration at different times in order to create an appropriate interface for tendon-to-bone healing.For this reason there is a great deal of attention to the use of growth factors in tendon pathology, especially in rotator cuff diseases. Platelets concentrate and prepara-tions rich in growth factors are obtained by centrifuga-tion of autologous blood. The term of PRP (Platelet Rich Plasma) could be used for every fraction of autologous blood showing a platelets concentration above basic lev-el. The centrifugation process removes from the serum red blood cells that do not bring any benefit to the healing process. However, this simple definition does not accu-rately reflect the different possible formulations of PRP. There are in fact different PRP (6 categories available for sale) that vary according to the presence or absence of leukocytes, the need for exogenous activation of platelets with thrombin or calcium chloride and the presence or absence of fibrin. The presence of leukocytes also means having cells that stimulate inflammatory cytokines and metalloproteases. Platelets are very important as they are the first cells to arrive at the site of injury where they release growth factors that are stored in cytoplasmic or-ganelles (α-granules). Growth factors released include PDGF, TGF-β, bFGF, Epidermal Growth Factor, VEGF. It is believed that approximately 70% of growth factors is released in the first 10 minutes and almost 100% within 1 hour. In this regard the presence of a fibrin matrix can serve to trap the platelets allowing a more gradual growth factors release (5-7 days). In a study with 14 patients who underwent arthroscopic repair of the rotator cuff who re-ceived locally, immediately after surgical repair, a solu-tion of PRP in combination with autologous thrombin, the authors concluded that the use of PRP in arthroscopic repair of rotator cuff is safe and effective, with no side ef-fects, but have not been proven improvements in healing tendon11. Other prospective studies do not support the use of PRP in small and medium size cuff tears. Moreover, the problem is to control the expression of growth factors in some phases of healing12.Interesting results have been obtained in an animal model study, in which a mixture of growth factors (BMP 2.7, TGF and FGF) within a collagen scaffolds have been used at the tendon-to-bone junction, causing an increase of the tensile strength13.Current doubts concerning the use of PRP in rotator cuff surgery, as well as the lack of effectiveness shown by re-cent studies, are related to the fact that different types of PRP could be found for sale, and indications vary in rela-tion to the age of the patient, the site and the manner of inoculation, the decay kinetics, the use of various growth factors which in practice are administered all at time zero.

METALLOpROTEASES AND THEIR INHIBITORS

Besides growth factors, there is a great interest for the role of metalloproteases in repair rotator cuff tears.

MMPs are proteases that regulate extracellular matrix and connective tissue homeostasis, through the degrada-tion of collagen and elastin. MMPs are regulated by in-hibitors proteins (TIMP). Some authors have shown that some of these MMPs, especially MMP-2, are activated during the healing process of the supraspinatus tendon; moreover MMPs 1, 2 and 3 and their inhibitors are al-tered in patients with rotator cuff tears. This element was also found in an interesting manner in tendons apparently intact, showing that biological processes that lead to ten-don rupture precede structural alterations14. MMPs inhib-itors are 4 and in particular TIMP 2 and 4 appear reduced in rotator cuff lesions with a consequent increase of the MMPs activities that would be responsible for tendon de-generation and rupture, by altering the extracellular ma-trix. Some experimental studies about pharmacological MMPs inhibitors, such as Doxycycline, show some po-tential in improving the structural aspect of the repaired tendons; however there are at present time few clinical data that could support the use of these substances.

MESENCHYMAL CELLS

Mesenchymal stem cells (MSCs) are multipotent cells that differentiate into cell lines capable of forming tissue such as osteoblasts, adipocytes, chondrocytes, tenocytes and myocytes. MSCs can be isolated from bone marrow and the fact that some authors have recently demonstrated the possibility to isolate them from proximal humerus dur-ing rotator cuff repair and bring them to differentiate into tenocytes if treated with insulin, makes this therapeutic option extremely fascinating15. This could be considered as a crucial finding in our opinion because the first experi-mental study carried out on the use of MSCs showed no differences in bone-tendon junction when the use of MSCs was compared to control cases. This phenomenon was ex-plained by the fact that MSCs require signals in order to be able to better differentiate to create an enthesis with simi-lar characteristics to the normal one. Even those works that implied micro-fractures at the level of the greater tuberos-ity in order to improve tendon healing, provided conflict-ing results16-17; this data too may be related to the fact that MSCs coming from the greater tuberosity need not only to be isolated but also need some differentiation signals. Previously, other authors had published preliminary data on cuff repair with the same concept using the “crimson duvet.” This technique consisted in performing a series of lateral drilling to what would have been the insertion of the repaired tendon (Fig 1). In this way a sort of a big clot is generated containing MSCs and growth factors that together with the vascular channels created by the perforations (bone marrow vent) give their contribution to the tendon healing18. Many other authors have also recently demonstrated that MSCs can be isolated from the subacromial bursa19 or from rotator cuff tendons or the long head of the biceps20. Other stud-ies, however, are necessary in order to study the complex mechanisms of cellular signals that regulate MSC differ-entiation and biological substrates that must be used to convey this kind of cells.


Figure 1B: upper cuff repair with 2 double suture anchors and

“Crimson Duvet” laterally (Courtesy of Dr. SJ Snyder)

Figure 1A: Before the tendon repair, laterally to the region where it will be reinserted (lateral footprint), a

series of small medullary canals are performed with perforations in order

to create a bed of bleeding (Crimson Duvet).

BIOMIMETIC SCAFFOLDS

Different bio-engineering studies enabled the develop-ment of biomimetic scaffolds, that have the potential to achieve functional integration with the host tissue. Re-cent research focus on biphasic scaffolds compounds of nanofibers of polylactic-glycolic acid (PLGA) and a composite of PLGA and nanoparticles of hydroxyapa-tite21. The purpose of this type of biphasic formation is to promote the regeneration, after the repair of the ten-

don, of the region of mineralized and non-mineralized enthesis fibrocartilage. Studies on animals have shown that the use of these type of scaffolds stimulates the formation of a non-calcified and calcified matrix in a continuum at enthesis level, un-like the fibrovascular tissue that was observed in the con-trol group. The use of these scaffolds, however, is still very experimental.

BIOLOGICAL SCAFFOLDS

The use of extracellular matrices (ECM) is the most com-mon method to improve the healing biology of the ro-tator cuff tendons. An ECM is a complex structure that consists of structural proteins (collagen type I), special-ized proteins (fibrillin and fibronectin) and a variety of proteoglycans. The purpose of using these matrices is to improve the mechanical properties of the repaired tendon at time zero and the biological quality of the repair per-formed. Furthermore, since the ECM is very similar to the one which is present in the human body, for chemical and structural characteristics, it can works as a biological “scaffold” and can stimulate tenocytes to multiply and improve the quality of the repair. Into the past some authors tried to use autologous tis-sue taken from the fascia lata as a biological scaffold and quite recently from the long head of the biceps tendon.The basic science studies on the use of scaffolds to repair rotator cuff include the evaluation of host response, char-acteristics of remodeling, biomechanical behavior and applicability in humans using animal or in vitro studies. Actually, the most studied group is that of the ECM such as “allograft” or “xenograft”, obtained through decellu-larization processes. These processes, which are chemi-cal, physical or enzymatic, often used in combination, aim to eliminate the cellular components (and therefore immunogenic components), preserving the three-dimen-sional structure and the collagenous and non-collagenous ECM components.Xenografts are membranes derived from animal (porcine or bovine) dermis, intestinal submucosa or equine peri-cardium, while allografts are typically membranes from human dermis.After implantation of these scaffolds, during the heal-ing process of the tendon, the gradual degradation of the scaffold shall issue a series of molecules that play a key role in recruitment and proliferation of different cell types, important for the remodeling of the rotator cuff tendons itself.It should be noted that each array implanted leads to a macrophage type host inflammatory response, which seems to be a crucial factor for future of the implanted scaffold. The inflammatory response is dependent on the chemi-cal process of crosslinking and the nature of the scaffold itself. The problem is that nobody knows yet what is the limit of acceptable reaction linked to these scaffolds. The chemical crosslinking process of the collagen structure reduces the recognition of the surface epitopes, and then the degradation process operated by the host. A recent


TABLE I: In summary the main features of commercially available scaffoldsZCR: Zimmer Collagen Repair

study on animals that compared the use of porcine cross-linked dermis compared with intestinal non-crosslinked porcine submucosa (SIS), showed a lower presence of cellular infiltrate in the case of the SIS. Consequently, regardless of the source of the ECM, the presence of a chemical crosslinking is associated with an absolutely not favorable host response. The presence of crosslinking at the level of the scaffolds was associated with the presence of foreign body gigantocellular reac-tions, chronic inflammation, accumulation of dense and poorly organized fibrous tissue. Furthermore, also the nature of the scaffold appears to be responsible for the different degradation and remodeling. In fact, scaffolds derived from SIS undergo rapid degra-dation and remodeling (days or weeks), while those of the dermal origin undergo a more slow remodeling and are gradually incorporated into the host tendon tissue. A recent laboratory study conducted to evaluate the re-sponse of cultured human tenocytes with different extra-cellular membranes (the same as the ones commercially available) showed that the major inflammatory responses were obtained in the presence of SIS scaffolds or from crosslinked dermis, while the best response was present in the case of uncrosslinked human or porcine dermis. This study confirms the clinical observations of the high rate of failure and inflammatory reactions founded in the case of grafting with SIS or crosslinked dermis. In two different clinical studies in which a non-crosslinked SIS ECM was used, it was observed the presence of a se-vere postoperative inflammatory reaction in 20%-30% of patients22-23. As a consequence, the use of this type of scaffold is no longer recommended.

The ideal scaffold must meet 10 core requirements:1. Extremely low rates of rejection.2. Minimum inflammatory response.3. Mechanical properties such as to reinforce the re-

pair at time zero.4. Being biological supportive and conduct the tendon

structure and enthesis. 5. Moderate elasticity to avoid the suture cut-out.6. Handiness.7. Reasonable cost.8. Stimulate cell proliferation.9. Optimal duration of storage.10. Easy to insert arthroscopically.

Table 1 summarizes the different scaffolds currently pres-ent commercially.The scaffold can be used as biological augmentation when a repaired tendon seems to have little biological healing capacities, or as a “bridging” when cuff injury is not repairable. The clinical use of crosslinked dermal scaffolds (ZCR: Zimmer Collagen Repair) has been reported in two retro-spective studies with conflicting results24-25. Bond report-ed a series of 16 patients with massive tear of the rotator cuff treated arthroscopically with graft scaffold (GJA)26. At 26.8 months follow-up, 15 patients were satisfied with the surgery and 13 patients showed a complete heal-ing of the repair in MRI examination after 1 year. Dopi-rak et al. reported the results of 16 patients with massive and irreparable rotator cuff lesion. At 2-year follow-up,

pRODUCT NAME COMpANY ORIGIN CROSSLINKING SIZE

GraftJacket Wright Medical Human dermal no Various (allograft) technology, Inc

Restore Ortobiologic Soft tissue Submucosa of the small intestine no 6x2 cm(Xenograft) Implant; Depuy Orthopaedics

CuffPatch arthrotek, Biomet Sports Submucosa of the small intestine Yes 6.5x9 cm (Xenograft) Medicine, Inc,

TissueMend Stryker Corporation Dermis of fetal bovine no 5x6 cm(Xenograft)

Permacol Zimmer Inc Porcine dermis collagen Yes 5x5 cm ZCR Patch (Xenograft)

Conexa tornier Inc Porcine dermis collagen no Multiple(Xenograft)

Biotape Wright Medical Porcine dermis collagen no 4x7 cm (Xenograft) technology, Inc 6x8 cm

OrthADAPT Pegasus Biologics, Inc native equine pericardium Yes Various (Xenograft)


Figure 2: Final image of a repair where the scaffold was used as

augmentation. After removing the water flow, it could be appreciated the

blood coming from the holes of the anchors that tends to form clots on

the scaffold.

75% of patients were satisfied with the surgery. MRI showed 3 recurrence of injury, 2 of which occurred in the first 6 months27. Burkhead has evaluated 17 patients treated with “GJA graft augmentation” for a massive tear greater than 5 cm. At 1.2 years follow-up, 3 recurrences were observed on 111 patients who underwent MRI or CT arthrography28. Barber, in a recent prospective study, evaluated the effectiveness of GJA used as augmenta-tion for chronic posterosuperior cuff tears (2 tendons). In this study it was shown that patients in which the scaf-fold has been used showed functional score and percent-age of tendons healing significantly higher than the con-trol group29.A recent clinical study has compared the use of biologi-cal scaffolds with a synthetic scaffold. As far as biologi-cal scaffolds is concerned, a patch of collagen has been used, while polypropylene has been used for synthetic scaffolds. At a 3 years follow-up was demonstrated the superiority of synthetic scaffolds in terms of lesion recur-rence and functional scores30.

CLINICAL STUDY

In the period between 2005 and 2011 a series of 21 pa-tients with degenerative full-thickness tear of the superior or posterosuperior rotator cuff (supraspinatus and infraspi-natus) were selected preoperatively and intraoperatively to undergo arthroscopic repair surgery associated with bio-logical graft scaffold. Eight patients had a non-traumatic recurrence of rotator cuff lesion after previous repair. The average age at sur-gery time was 57.6 years (range 45-65), and there were 8 males and 13 females. The patients were clinically evalu-ated preoperatively with the study of their arc of move-ment and with the UCLA (University of California, Los Angeles) shoulder scale, the VAS and the Constant score. All patients underwent an MRI to assess the tendon heal-ing. The surgery was performed with the patient under general anesthesia and in lateral decubitus position, with arthroscopic technique.Different types of scaffolds have been used. In particular, it has been used: the Matrix Graft Jacket (decellularized human dermis) (Wright Medical Technology, Inc, Arling-ton, Tenn) in 4 cases, the Biotape (porcine dermis) (Wright Medical Technology, Inc, Arlington, Tenn) in 3 cases and the Conexa (porcine dermis) (Tornier Edina MN) in 14 cases. In all cases, the scaffold has been used as augmenta-tion (Fig. 2).The minimum follow-up was 2 years.We did not observe any complication in terms of infection, fibrosis, and adverse reactions to scaffold or mechanical lock symptoms, nor in the immediate postoperative pe-riod nor during the period of follow-up in the study group. The patients showed a significant improvement of clinical scores. In particular, the UCLA went from an average of 14.5 preoperatively to 25.2, while the Constant score by an average of 37.2 to 66.5 at 2 years after surgery follow-up. Regarding the healing of the performed repair, the 1-year follow-up MRI showed a rupture recurrence or a non-heal-ing of the performed repair in 4 of 21 patients.

CONCLUSIONS

The integrity of the repair performed for the rotator cuff tears is influenced by several biological and surgical variables. In fact this surgery has reported in the literature a recurrence or not healing rate despite high innovation in surgical tech-niques and improved understanding of the biology. The repairs fail for scarce biological capacities of the ten-don in the throes of a degenerative lesion type. The prob-lem is that at present time we are unable to replicate the complex anatomy of tendon-to-bone junction. To achieve this process, we should stimulate a healing regenerative process that is different from the reparative one that is cur-rently performed. As a consequence, all the biological procedures in study at time, should aim not only at improving the mechanical prop-erties of the tendon, but especially at influencing a healing process that involves the least possible presence of a scar.

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30. Ciampi P, Scotti C, nonis a et al. the Benefit of Synthetic Versus Biological Patch augmentation in the Repair of Posterosuperior Massive Rotator Cuff tears: a 3-Year Follow-up Study. am J Sport Med Mar 2014: e-pub


Partial-thickness rotator cuff tear. Surgery: when and howManuela Rebuzzi, Paolo Baudi, Mauro Gialdini, Claudio Rovesta, Fabio CataniDepartment of Orthopaedics - Policlinico of Modena

INTRODUCTION

Rotator cuff tears are a common cause of shoulder pain and disability. The partial-thickness rotator cuff tears are those that do not communicate with both the gleno-humer-al joint and the sub-acromial space. Currently the infor-mations about the management of partial-thickness rotator cuff tears available in literature are few. Above all it needs to be improved some knowledge, their incidence and prev-alence, the risk factors, the tears long-term progression, to choose the appropriate treatment indication and to gain the better outcome. The prevalence is underestimated and growing 1, 2. Unfortunately, the data about this kind of partial tears show how the spontaneous healing is unlikely 3, 4.

INCIDENCE

The incidence of partial-thickness tears is unknown, be-cause most can only be identified as surgery findings and also the imaging diagnosis is difficult. Some data are from cadaveric studies that demonstrate these tears are more common than full-thickness. Fukuda et al 1 found 13%, with 18% bursal sided, 55% intratendinous and 27% intra-articular sided tears. But the clinical reports are slightly different. Sher et al 5 reported 20% of prevalence of par-tial-thickness tears in 96 asymptomatic shoulders by RMI. The incidence of partial tears increases with age, and the average age of operated population is about 50 years 6. A recent study moreover reported that patients treated for partial(and full)-thickness cuff tears have a significantly higher risk of having a tear also on the contralateral shoul-der 7. The supraspinatus tendon is almost exclusively in-terested by partial tears, that rarely may extend to the in-fraspinatus3.

pEARLS OF ANATOMY, BIOMECHANICS, pATHOGENESIS AND CLASSIFICATION

Cuff tendon insertion is divided in 3 parts: bursal, intraten-dinous and articular. The footprint anatomy is quite impor-tant to assess the depth of cuff tears and so their severity. Ruotolo et al 8 reported an average medial-lateral (coronal plane) footprint supraspinatus insertion from 11.6 to 12.1 mm confirming the data of other authors in the past.The biomechanical features are different: the bursal side is more strain tolerant and resistant, while the articular side is made of capsule-ligaments-tendon fibers that are

unstretchable and resists less to the rupture. This differ-ent composition leads bursal and articular side tears be-have differently causes easily intratendinous lamination by shear stress 9.In presence of partial-thickness cuff tears the strain pat-terns with the intact cuff are altered, with increased strain on the tendon adjacent to the damaged tissue leading to tear progression 10, 11, 12, 13.The pathogenesis is multifactorial, with an interplay of in-trinsic and extrinsic factors. Intrinsic could be: age-related tissue metabolic and vascular degeneration, different shear stresses during movements; extrinsic: subacromial im-pingement, repetitive microtrauma, single traumatic event, gleno-humeral instability, internal impingement 1, 2, 3. The incidence of a traumatic event is higher in articular-side and intratendinous tears as reported by Fukuda3.

ABSTRACT

To date information about the management of partial-thickness rotator cuff tears available in literature are few. The prevalence is underestimated, most can only be identified as surgery find-ings and also the imaging diagnosis is difficult. Partial cuff tears divided into three types: bursal, intratendinous and articular.The pathogenesis is multifactorial, with an interplay of intrinsic and extrinsic factors.In the young over-head athletes there are some peculiarities, like the symptoms onset and mechanisms involved.The patient presents with shoulder pain and dysfunction.The natural history is that of limited spontaneous healing and trend of tear progression. Most surgeons agree that the initial treatment should be conserva-tive regardless of size and location. Articular-sided cuff tears do better conservatively than bursal-sid-ed, which present more painful; when the conservative manage-ment failed, the first approach must be a diagnostic arthroscopy.Surgical treatment can involve two approaches: debridement alone or with acromioplasty, and tissue repair that may be trans-tendon or after completion tear with or without acromioplasty.Current thinking is that partial thickness rotator cuff tears less than 50% of the medial-lateral tendon depth at footprint, < 7 mm basing on anatomic studies, could be successfully in the short term treated with debridement +/- acromioplasty. The deeper par-tial tears sould be repair, above all if they are bursal sided. All treatment resulted in significant improvement in shoulder pain and function; however, long term results are more uncertain.There is yet no evidence to support a treatment algorithm for par-tial thickness tears.




Figure 1 A-B: Articular partial tears. A) Ellman 2; B) Ellman 3

Moreover the traumatic onset seems to correlated with the severity of tear depth. The subacromial impingement is intuitively much more responsible of bursal tears, however some studies have showed that subacromial impingement could generate strain sufficient to cause tear at any level 1, 3. Nevertheless, Ozaki et al 14 in 200 cadaveric shoulders have recorded that acromion was almost always intact in articular-side tears. Subacromial impingement can lead to cuff tear primarily or secondarily. The useful classification system is that of Ellman 15 that di-vided into 3 types the partial-thickness cuff tears basing on the location and the medial-lateral depth: A, articular - B, bursal – C, intratendinous; grade 1, <3 mm – grade 2, 3-6 mm – grade 3, >6 mm (Figure 1).Subsequently, Snyder et al16 have introduced the PASTA le-sion, a partial articular supraspinatus tendon avulsion cor-related with its traumatic aetiology; Conway17 described the PAINT one, a partial articular tear with intratendinous extension.

FOCUS ON PARTIAL-THICkNESS CUFF TEAR IN YOUNG OVER-HEAD ATHLETES

In the young over-head athletes there are some peculiari-ties. The tears occur on the articular side of the supraspina-tus tendon at the interval with the infraspinatus 6. There are different mechanisms involved: excessive ec-centric forces during deceleration of throwing; internal impingement 18, 19, exacerbated by anterior laxity; posteri-or-inferior capsular contracture; scapular dyskinesis; poor technical throwing act 6, 20. Often others pathological find-ings are associated: labral lesion, capsular laxity, internal rotation deficit, bone defects, instability.

CLINICAL AND NATURAL HISTORY

The patient presents with shoulder pain and dysfunction. The approach is similar to that of any patient with shoulder

pathology. It is important a solid history and physical ex-amination, signs and symptoms are often not specific 3. Pa-tients with Ellman grade 1 or 2 have more pain than grade 3 lesions 1, moreover bursal-side tears are significantly more painful than articular-side and intratendinous ones. Gotoh et al 21 found higher levels of substance P and im-munoreactive nerve fibers in subacromial bursae in partial thickness tears compared with full-thickness ones. These findings leading to the conclusion that the pain has a posi-tive correlation with the degree of subracromial bursitis and not with the degree of tear size 2. In young athletic patients laxity and instability should be assessed. Little is known about the natural history, but many stud-ies 3, 22, 23 showed a limited potential for spontaneous heal-ing after the development of tear and the trend is that of a tear progression.

IMAGING

To date the initial evaluation include X-ray to assess acro-mial morphology and exclude other shoulder pathology. US and MRI have become the modalities of choice with high sensitivity and specificity. It is difficult to distinguish partial tear from a small full-thickness tear. Small cuff defects can be missed with a detection rate of 41% for partial tear 24. MRI offers a large amount of details, should be closed and the strength of the magnetic field almost 1.5 Tesla. If the findings on US and/or MRI are not specific, should not be used alone as an indication for surgery: in these cas-es the correct diagnosis is possible only with arthroscopic inspection, that is the gold standard for the assessment of partial thickness rotator cuff tears.

TREATMENT

When?After the suspected diagnosis of partial thickness rota-tor cuff tear the patient needs medications for pain: these should included steroidal anti-inflammatory drugs at low doses and mild narcotic analgesics, it is preferable not to administer non-steroidal anti-inflammatory medications

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because of their potential damage on the rotator cuff ten-dons. Most surgeons agree that the initial treatment should be conservative regardless of size and location: rest, ice, modification of activities, exercises to recover the range of movement, time. The purpose of conservative approach is to relieve inflammation and restore muscle balance. Articular-sided cuff tears do better conservatively than bursal-sided, which present more painful 1, 3.The use of subacromial injections deserves attention, these should be take into consideration when: the oral medica-tions have not given a significant relief from pain or as coadjuvant of physical therapy regimen. The first could be corticosteroid injection, then it is preferable to use two or three ialuronic acid preparations. The available literature does not show real evidence about injections efficacy 2, but most patients reported benefit.Unfortunately, the spontaneous healing of the partial thick-ness cuff tears is infrequent. When the partial cuff tears are developed by overhead ath-letes the conservative treatment is indicated for a long pe-riod, because the surgical results reported in literature are poor, with few throwing athletes that return to the same or higher level of sporting activities: Reynolds et al 25 and Budoff et al 26 showed similar findings about 50% of return to play. Nevertheless, some overhead athletes continue to refer shoulder discomfort also after conservative treatment because of the concurrent symptomatic pathologies as mi-cro-instability.When symptoms persist of sufficient intensity for a long time regardless physical exercises and clinical examina-tion and imaging findings suggest the diagnosis of partial-thickness or small full-thickness rotator cuff tear, there is the indication to surgical management. The timing varies in literature 3, but surgical approach should be consider after 4-6 months; some authors including Fukuda 1 have taken into consideration the possibility to operate soon af-ter diagnosis the bursal-sided tears because more painful and disabling.

How?The first approach must be a diagnostic arthroscopy. The open surgery must be avoided because of many disadvan-tages as deltoid split, coracoacromial ligament division and impossibility to assess intra-articular findings associated specially, although it has shown good results in the past 3. With the development of arthroscopic technique there is no doubt regarding its superiority. Arthroscopy is the gold standard for diagnosis of partial thickness tears: it permits a direct evaluation of rotator cuff from an intra-articular and a sub-acromial point of view, providing the advantage to assess directly the quality of the rotator cuff tissue and diagnose the concurrent pathologic findings. You have to determine the depth of the tear as the exposed footprint with a know size arthroscopic instrument, palpate the tissue for softening or thinning areas distinguishing also false partial thickness tears from small full-thickness ones, investigate the tendon surface for identification of the “bubble sign” in case of intratendinous tears that re-main the most difficult diagnosis to do 2, 27.Also for the surgical treatment the arthroscopy is the gold

standard if the partial thickness diagnosis is confirmed, without a second step with mini-open technique.Surgical treatment can involve two approaches: debride-ment alone or with acromioplasty, and tissue repair that may be trans-tendon or after completion tear with or without acromioplasty. Several factors influence surgical decision-making: patient’s features as occupation, sport, comorbidities; type and size of the tear; surgeon’s skills 3.

Debridement with or without subacromial decompressionWhen a partial thickness cuff tear is identified, debride-ment with the shaver is to performed to assess the effective size and excised the torn tendon until normal tendon fibers are visualized. In bursal-sided tears synovial proliferation can mask small defects of the cuff 3. After debridement a subacromial decompression may be performed, including a flattening of the acromion under-surface and a partial removal of its antero-lateral part de-pending on acromion morphology, with the goal of creat-ing a flat acromion free of impingement. In a systematic review by Strauss et al6 including studies reporting clinical outcomes after surgical treatment with a minimum of 12 months follow-up, 7 studies treated partial tears with de-bridement, 4 of these with acromioplasty in all patients. Overall good to excellent results were obtained. It does not appear, based on the current evidence, that subacromial decompression leads to better outcomes when compared with debridement alone2, 6. Instead, acromioplasty alone has been shown to be inadequate2.Park et al28 reported on 37 Ellman 1 and 2 partial thickness tears treated with debridemnt and acromioplasty that pain and function were better in bursal-sided, but no difference at 1 and 2 years. Cordasco et al 29 reported on 105 Ellman 1 and 2 partial tears treated similarly followed up for 2 to 10 years that articular-sided fared better regards to failure rate with 3% compared to 29% of bursal-sided tears. Find-ings of these studies support that bursal partial tears have worse outcomes than articular tears and Ellman grade 3 tears are not adequately treated with debridement alone. Similar, Liem et al 30 and Kartus et al 31 showed that ar-throscopic debridement and acromioplasty in patients with partial thickness cuff tears do not protect cuff tendon from degeneration progression until a full-thickness tear, and that the bursal-side clinical outcomes were worse. Current thinking is that partial thickness rotator cuff tears less than 50% of the medial-lateral tendon depth at foot-print, < 7 mm basing on anatomic studies 7-8, could be successfully in the short term treated with debridement +/- acromioplasty. However, long term results are more uncertain 2, 3, 31, 32. So Ellman grade 1 and 2 articular side tears could be ap-proached with this technique, performing subacromial de-compression if necessary, instead bursal tears should be approached more aggressively with this technique only in grade 1 as suggested by literature 2, 6. Budoff et al 33 found that after debridement alone grade 2 had significantly better results than grade 3: 86% of good to excellent out-comes compared with 54%. The grade 3 articular tears (> 6 mm) and grade 2 and 3 bursal sided (> 3 mm) shoul be repaired.


Figure 3: Articular tear completion before repair

Figure 2: Articular sided tear targeting by spinal needle

for visualization from subacromial space

Trans-tendon repairSome surgeons prefer intra-tendinous repair techniques, that have been reported with good clinical results and bio-mechanical properties 2, 6. In particular a proposed advan-tage is the maintenance of the rotator cuff footprint still attached, which allows for a more accurate anatomic repair and so minimizing any length-tension mismatch created by repair 2, 20, 34. Trans-tendon repairs believe that provide a more accurate restoration of the footprint, increasing the mechanical strength 32.If an articular partial thickness cuff tear is found, a gentle debridement of the torn surfaces is needed, to evaluate the real extent of the tear. Then arthroscope can pass in the subacromial space and the bursa must be completely excised, so that the sutures can be easily visualized sub-acromially without having to shave around. To localise the joint tear from the bursal side, use a spinal needle (18 gauge) for marking on the bursal surface the partial tear as the technique developed by Snyder et al 16 (Figure 2). This spinal needle becomes also the guide to percutane-ous suture anchor placement through the intact bursal side into the medial portion of the great tuberosity 6. Prepare the footprint, then place one or two anchors according to the anterior-posterior size. Ide et al 35 used a single anchor when tear size was less than 1.5 cm, and two anchors when was more. Use a suture passer to pass suture limbs from the anchor through rotator cuff, tie the sutures subacromi-ally searching the best angle of approach, a supero-lateral portal near to the acromion 27. In this way you performed a sort of double-row repair, exploiting the tendon yet at-tached. To judge the final outcome you have to assess two features: subacromial, the good indentation of the tendon by knots; intra-articular, the good restoration of the foot-print 27.If a bursal partial thickness cuff tear is found, a gentle deb-ridement of the torn surfaces is anyway necessary. Palpate the defect to assess and confirm the intact medial wall of cuff, prepare the footprint to a bleeding base and perform a single or double row repair 27. Use suture passer for ante-grade or retrograde passage of sutures.

Completion tear and repairSome surgeons prefer tear completion and more tradi-tional repair techniques, that have been reported with good clinical results too. In case of an articular or bur-sal partial thickness cuff tear, the torn poor quality tis-sue must be excised by shaver to complete tear to a full thickness (Figure 3): the palpation of tissue is necessary to judge which kind of repair carry out. The bone bed at footprint should be prepare until bleeding removing residual soft tissue all the way to the cartilage margin27. The repair both of articular or bursal sided could be ex-ecute using a single (Figure 4) or double row, a suture bridge or a transosseous repair technique.

Intra-tendinous partial tear: pearls and pitfallsTheir diagnosis is quite difficult: the key is the assess-ment of cuff surface from the joint and bursal points of view by palpation searching if tissue plane is entered by probe and if relative motion between layers is present. If you suspect this tear, connect a syringe with saline to a spinal needle and put the tip in this defect: as the cuff defect fills with fluid (1-2 ml saline), it forms a dome shaped “bubble” 27. Another important possible sign is the capsular “dimple” at rotator crescent portion. Often these intratendinous laminations are associated with bur-sal or articular partial tears 36. After diagnosis you have to debride the torn tissue and complete the tear. The lami-nations have not been excised totally, as demonstrated by Sonnabend et al 37, who suggest to remove only the synovial lining. Then you should perform the repair with single or double row techniques.

Treatment in over-head athleteThe partial thickness cuff tear of an overhead athlete is often associated with other pathologies. The approach should be an aggressive trial of nonoperative manage-ment. If this conservative course fails, cuff debridement with the treatment of concurrent symptomatic patholo-gies is indicated 2, 10. The subacromial decompression is rarely needed 3. In general, the outcome of cuff tears re-


Figure 4 A-B: Ellman 3 bursal partial tear.

A) prepared footprint; B) repair after completion

with single row

pair in overhead athletes have been discouraging, with few athletes able to return to the same or higher level of competition 2.

DISCUSSION

All treatment resulted in significant improvement in shoulder pain and function. However a 6.5 to 34.6% of tear progression to full-thickness tears is present6 regard-less operative or not operative treatment. The patients with tear progression had poorer outcomes6, and retear rate in-creases with time 4.There is no reliable report on the conservative treatment of partial thickness, because real incidence of diagnosis is unknown. For partial thickness less than 50% subacro-mial decompression does not lead to better outcomes when compared to debridement alone 2, 6, and the results of deb-ridement alone are quite variable 3. The literature suggests that there is no significant difference between transtendon and tear-completion repair, as reported also in a prospec-tive comparative study by Castagna et al 38. In this study they noted only one difference not statistical significant: an higher improvement in strength in tear-completion repair group, and they have just reported a 41% incidence of per-sistent shoulder pain after trans-tendon repair 39. In articu-lar partial tears trans-tendon repairs require the placement of anchors through a tissue that is already poor in quality and thinned, moreover the anchor positioning is more dif-ficult 32. On the other hand this surgical technique provides the avoidance of potential length-tendon mismatch 20, 34. Both repairs have been shown effective in restoring the anatomic footprint: a recent study reported that using a magnetic resonance arthrography to assess cuff structural integrity the rate of retear was not significantly different between articular and bursal sided tears at 6 months, re-spectively 8% and 11% 40. Another more recent study by

Kim KC et al 41 showed post operative rate of retear that differs but not significantly between high grade articular 0% and bursal 9.5% sided tears treated with full thickness-conversion and repair at 35.5 months mean follow up. An-other complication mentioned in some studies is that of stiffness: partial thickness cuff tear repairs seem to lead a higher incidence of stiffness if compared with full-thick-ness repairs, 18% to 8%, but only few cases need capsular arthroscopic release4. Comparing the post operative clinical outcomes between articular and bursal sided tears it seems that there is no significant difference regard to pain and functional scores, and both guarantee a good to excellent result ranging from 86% to 94.1% 6.

CONCLUSION

There is to date no evidence to support a treatment algo-rithm for partial thickness tears: surgical techniques pro-vide good to excellent clinical results. We need prospective studies with long-term follow up: these kind of tears may be complicated by progression in long term, regardless of a correct and adequate treatment.

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ABSTRACT

A variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief can be today addressed by advances in techniques and ma-terials for rotator cuff surgery. Instead a large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. Mainly the surgery technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient’s work or sport or daily activities after surgery and expectations of recovery must also be assessed. A tailored rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist’s choice of correct pas-sive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of bio-logical tissue healing, surgical technique and focused rehabilita-tion exercise, a conceptual protocol in four phases could be ap-plied, tailoring the protocol for each patient. It starts with sling rest with passive and small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobili-sation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and “core” stabilisation. In phase four full strength recovery integrated with the recov-ery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

Rotator cuff rehabilitation Marco Conti, Raffaele Garofalo* Unità di Riabilitazione Funzionale, Istituto Clinico “Humanitas”, Milano * Unità Chirurgia della Salla, Ospedale “F. Miulli”, Acquaviva delle Fonti, Bari

In the framework of shoulder pathologies the rotator cuff tendon lesions are pathology frequently found [1], espe-cially among patients aged over 45. However younger people are increasingly subjecting their scapular-humeral joints to significant stress and can therefore suffer from this type of lesion, especially in sports and overhead working activities, but the presence of a rotator cuff ten-don lesion does not necessarily suggest the need for sur-gical operations [2–5]. There is in fact increasing agreement that surgery is indi-cated after failure of preventive rehabilitation treatment carried out for a period of at least 3–4 months, or in the cases in which significant and progressive rotator cuff tendon insufficiency occurs [6], or in relationship with di-mension of lesions related to the patients expectations or needs.The progression of technology allows surgeon to per-form today surgical repair of a rotator cuff tendon tear (RCT) using a variety of methods, open, mini-open and arthroscopic techniques [7], and the post-op results are generally good and substantially comparable [8–11]. A great topics of discussion is not therefore today the surgi-cal technique to use but rather post-surgery recurrence. When minor re-ruptures occur, patients may still show improvement of the clinical symptoms compared with the pre-operative period, while patients with massive re-ruptures do not benefit in any way from the surgical operation [5–12]. Therefore the level of healing of the repaired tendon [13], seems to be increasingly the key point for therapeutic success and clinical result. Many factors can influence The healing of the repaired tendon seems to be influenced by many factors [14, 15]: we can in fact distinguish between surgical factors associ-ated with recognition of the type of lesion (forms and number of tendons involved), the size of the lesion, the technique such as the mobilisation of the tendon tissue that was possible to obtain intra operatively, the tendon quality, the degree of muscular hypo-atrophy, as well as adequate subacromial decompression, correct prepa-ration of the humeral tuberosity, and the anchoring and suturing method. Then a series of factors related to the patient such as age, lifestyle and the presence of other shoulder complaints or systemic illnesses [7] that either must be taken in account (such as diabetes, thyroid pa-thologies, hormonal imbalances).In this light, the post-surgery rehabilitative treatment as-sumes great importance as it must be able to protect the re-pair in the early stages, to prevent post-op stiffness and then restore the function of the scapular-humeral joint [15, 16].

Many rehabilitation protocols have been proposed, often based only on empirical experiences, without fully taking into account biological aspects relative to the healing steps of the repaired tendon [17-19-44-49]. Furthermore post-surgical rehabilitation of the suture of rotator cuff tendons can vary from patient to patient, bearing in mind (all together in the same time) the surgical technique, the patient’s expecta-tions and functional demands, the number of tendons re-paired and therefore the grade of the lesion, the quality of the tissue and any associated surgical actions [16].


TENDON HEALING

The biological time for the tendon to heal must be taken as the one of the most important aspects the rehabili-tation protocol must take into account is. This process involves tendon healing at the bone footprint if the ten-don has been reinserted into its anatomical place using a technique with anchors and sutures or trans osseous su-ture technique or alternatively tendon with tendon heal-ing if a suture technique with latero-lateral stitches has been carried out. The reparative phenomena follow a cascading series of mechanisms one after another in healthy individuals [20]. The first stage is the inflammatory one: during the first week it is characterised by an increasing number of inflammatory cells like leukocytes, lymphocytes and monocytes, which release histamine and bradykinin, which increase vascular permeability and therefore allow the plates to reach the level of the repair site. The fibrin with the fibronectin form a fragile scar which reduces the haemorrhagy process without any real adhesion between tendon and bone. The inflammatory stage lasts for a pe-riod which varies between 1and 2 weeks and which is generally transformed into the proliferative stage. During the proliferative stage a tighter adhesion between the tendon and the bone surface is obtained thanks to the inflammatory tisssue that is gradually replaced by fibroblasts, myofibroblasts and endothelial cells, which organise themselves with a new extracellular matrix to form a granulation tissue which guarantees the adesion between two so different tissues. Then the fibroblasts starts to produce type III collagens fibers , which are therefore immature, and glycosaminoglycans; then there is significant neoangiogenesis. This stage lasts about 10 days and commences after the first 15 days after surgical repair. The last stage of maturing and remodelling then follows, which therefore begins around the third week and is char-acterised by maturing of the scar tissue. The immature type III collagen is replaced by type I with the formation of dense connective tissue. By now the fibroblastic cells will have replaced the inflammatory cells. The process continues during the following weeks until the tendon is completely integrated with the bone surface. Tendon healing studies have mainly been carried out on animal models and therefore the remodelling and maturing stag-es have been seen to vary in duration depending on the animal model used. Some authors have described peri-ods of 12–16 weeks for the tendon to recover its tensile strength [20], while other authors who have studied sheep models have reported times of as much as 26 weeks (4 months) [21]. These studies obviously reveal a set of limits linked to the model studied while, furthermore, human ruptured tendons reveal a series of degenerative altera-tions which can negatively influence and therefore pro-long the healing time. The recognition of the role of the biological timing is very important and must be properly recognised by the doctor and the therapists to modulate the rehabilitative timing.

IMMOBILISATION AND SLING

On the basis of the biological healing stages of the re-paired cuff tendon tissue, it is clear that precocious and aggressive mobilisation or violent muscular contraction can exceed the mechanical strength of the repair and dam-age it, even though precocious mobilisation could reduce the risks of articular stiffness. The purpose of a reasoned rehabilitative process after a rotator cuff repair is there-fore to obtain cuff tendon healing by recovering mobility and shoulder function gradually. From this starting point an adequate immobilisation of the limb is crucial during the initial post-operative stage in order to guarantee ef-fective tendon healing. Study on rats highlighted that the cuff tendons that were immobilised after surgical sutur-ing revealed excellent orientation of the collagen fibres and enhanced organisation of the extracellular matrix compared with rats that were left free after the repair [22]. Adequate immobilisation must however take into account the vascular and biomechanical characteristics of the ro-tator cuff [23]. The use of an abduction sling during the early weeks seems capable of reducing tension at suture level and improving vascularisation of the scar. In fact we know that the hypovascular zone of a healthy supraspina-tus tendon is about 1.5 cm from the greater tuberosity of the humerus and the position of the head of the humerus influences tendon vascularisation significantly [24]. Assessing tendon microcirculation in relation to the head position, Rathbun and Macnab showed that there is a re-duction of the haematic flow to the tendon when the arm is in a total adduction position [25]. Based on these obser-vations, it seems prudent to recommend post-op immo-bilisation in a sling with the arm abducted at least to 30 for the first 4–6 post-operative weeks in order to improve microcirculation and reduce the stress on the operated tendon, especially in the case of a repair carried out on an inveterate tendon lesion [26, 27].A recent study of our group (still in printing at this time) compared, in patients treated for RCT repair for the same lesion with the same type of repair, the use of a sling in abduction 30° and external rotation 15° with a sling in abduction 30° and internal rotation 15°. The data dem-onstrated in the group of Abd 30° and ER 15° sling a significantly greater passive mobility at 1 and 3 months, a significantly greater Constant score at 3 months and a minor VAS for pain still at 3 months. Same results for the two groups at 6 months. This study suggest that the use of a sling in Abd 30° and ER 15° seems to be more suitable for the patient.

CONTINUOUS pASSIVE MOBILISATION

Few studies in the literature help us to understand if this therapeutic aid (obtained today with electronically con-trolled automatic programmable mobiliser) can be of ben-efit in the rehabilitation of patients operated by suturing the rotator cuff. As a general rule this continuous passive mobilisation (CPM) can be applied in the immediate post-op period applying a low mechanical stress on the repair. Hatakeyama et al. have shown that the safety position after


this surgery is 30° of elevation on the scapular plane with an external rotation range between 0 and 60° [28]. In a double-blind randomised study of patients treated with repair of the cuff and subacromial decompression, Raab et al. [29] showed that three months after the surgical operation there were no differences in the various scores between patients treated with physical therapy and CPM and those treated with physical therapy only; however the range of movement and pain level were better in patients in the first group. Recently, Michael et al. [30] seemed to confirm these data and also showed how the recovery of the range of movement is faster in patients treated with CPM in the post-operative period. In another randomised prospective study on 31 patients operated for repair of the rotator cuff, Lastayo et al. [31] compared 2 groups, one treated with CPM in the first 4 weeks while the other was subjected in the same period of time to a physical therapy programme with passive recovery of mobility. A follow-up carried out after 22 months found that there were no statistically signifi-cant differences in the scores of the two groups or in pain and isometric muscular strength. Our figures [32] relating to a randomised prospective study on 100 patients seem to indicate that the precocious use of CPM for at least two hours daily overall, for one month after the operation, can permit better recovery of the passive ROM in both abduc-tion and external rotation and in forward flexion with sig-nificant data already at two and a half months. It therefore seems, from the analysis of the literature, that in the me-dium and long term, CPM succeeds in substantially influ-encing the recovery of the range of movement only, while it remains to be seen whether it can have a positive effect on faster recovery of working activities or of common ev-eryday activities. It is also not yet known if the use of CPM can influence healing of the repaired tendons to any extent. Certainly, however, this method can be used in patients who have a cuff lesion associated with adhesive capsulitis in the pre-operative period and who can therefore benefit from a recovery, or at least from a non-loss, of the range of movement already gained during the surgical operation.

POST-OPERATIVE FUNCTIONAL REHABILITATION

Multiple factors, which the surgeon and rehabilitation therapist must share, are the variables that, from what we have said so far, the rehabilitative management after RCT repair must take into account. On top of the processes and biological timing of tendon healing also must be taken in account the size of the tendon lesion treated, the quality of the treated tendon, the type of repair made (type of cuff suture made, if partial or total, if a mono or pluri-tendon suture, and if the repair is tendon–tendon or tendon–bone type; knowledge of the type of implant used – reabsorb-able or not reabsorbable – is also important), any associ-ated surgical actions (acromion plastic surgery, resection of the distal clavicle or, in younger patients, repair of an associated lesion of the SLAP type, tenotomy or tenodesis of the long end of the biceps and possibly knowledge of the type of tenodesis technique – whether static or dynam-ic – to the soft parts of the cuff), the physiological age and

expectations of the patient, and the range of pre-op move-ment of the operated shoulder. The degree of fatty degeneration of the tendon and of mus-cular atrophy, the size of the lesion treated and the extent of reduction of the range of movement in the pre-op period In particular, must be also seen with particular attention because of the fact that the prognosis after repair can be significantly related to [12, 13, 35]. In this sense, communications and coordination between the surgeon, physiatrist and physiotherapist are fundamen-tal in order to obtain an optimum result for the patients themselves. The current general consensus in the literature [14, 15, 19, 36–39] is to subdivide the post-operative rehabilitative treatment into four stages, each one with different aims.The aim of the first stage is to prevent articular stiffness because of post-surgical adherences by means of exercises of the passive type, which help to minimise loading at the repair site. The aim of the second stage is the progressive recovery of the passive range of movement without scapular compen-sation by means of exercises of the assisted /active type which begin gradually to apply work loads on the repaired tendons. The aim of the third stage is to recover strength and physi-ological scapular-humeral rhythm by means of toning ex-ercises focusing on the recovery of power and the strength of the rotator cuff tendons. The aim of the fourth stage is the best recovery of the strength and normal actions for both work and sports. These stages naturally interweave and overlap without any break and it is possible, in the same stages, to find a series of variables linked to all the conditions regarding the pa-tient and type of lesions treated and to the type of surgical technique used. The first rehabilitation stage runs from the immediate post-op period until the 4th–6th week. During this stage the patient will be asked to wear the abduction/er sling (up to 5-6 weeks for complete lesions; up to 4-5 weeks for partial and incomplete lesions) and it is only removed 3–4 times per day to carry out passive abduction, front flexion and external rotation mobilisation exercises, as pendulum exercise. During this stage the loads on the repair made must be minimal and, in fact, this stage is characterised biologically by a slight coagulation of fibrin with type III collagen; therefore exercises with active muscular contrac-tion on the operated limb must be avoided at this stage. The recovery of the passive movement must be carried out inside a safety range and the patient must work without pain and with the avoidance of maximum stretching. In the case of an associated subscapular repair, external pas-sive rotation must be limited to 0°. Therefore patients can make active movements of the wrist, hand and elbow. The active flexion–extension of the elbow must be modulated and limited in this stage if a tenodesis of the long end of the biceps has been carried out, especially if of the dy-namic type at the rotator cuff. Pendulum exercises are use-ful at this stage, to be carried out with extreme relaxation of the musculature and with the trunk tilted 30° forward. Furthermore, preference must be given to active and pro-prioceptive work of the scapular/thoracic joint. Once the


skin suture stitches have been removed the passive mobili-sation and slight stretching exercises can also be carried out in a pool [26]. Ice is an useful anti-inflammatory aid for use in this stage, especially in the first 10–15 days and after the physiotherapy sessions [39]. Also CPM can be useful in this stage, particularly with patients who have had a reduc-tion of the physiological range of movement or capsulitis in the pre op phase.The second stage runs from the 4th–6th week until the end of 3rd month. This is because, from the 6th week after the operation, the extent of healing of the tendon to the bone and of the tendon to tendon begins to be suf-ficient to allow the introduction of active movements at a minimum load. The mobilisation exercises can also be carried out by a therapist at this stage and it is possible to begin greater and greater stretching, with decoaptation of the humeral head in order to begin to recover the range of movement towards the greatest angles without induct-ing a subacromial iatrogenous conflict. It is possible at this stage to begin to use aids such as pulleys and sticks. In this case too it is necessary to continue to take care of some strategies. If, for example, the top fibres of the sub-scapular muscle have been sutured, the recovery of exter-nal rotation should preferably be obtained by means of an abduction of the limb to 45° (and with the elbow raised 4–6 cm from the couch to reduce stress on the sutures to a minimum if the execution is carried out in a supine po-sition). Hydrotherapy is very useful from the 6–8 weeks to begin the active mobilisation exercises in a condition of reduced mechanical stress for the repair because the reduced force of gravity. The patient can be allowed to swim breaststroke and when front passive flexion reach-es around 130° some modified backstroke can be added, without submerging the limb but ending the movement at surface level. At this stage, therefore, it is possible to start active movements without important loads and therefore the use of the arm is permitted in everyday activities. The proprioceptive exercises on the scapular-thoracic joint are intensified as the active toning of the active scapular stabilizer muscles. Particularly important at this stage is the use of neuromuscular biofeedback sys-tems which, help the therapist to get the patient to “re-learn” the ability of voluntary and coordinated control of the fundamental muscle groups for scapulo-humeral stabilization and which, have been mal-functioning for some time because the profound alteration of the motor patterns induced by the cuff lesion, by the pain and by the compensation mechanisms implemented instinctively to permit the spatial positioning of the hand on the basis of living needs. At the end of the third month (10th–12th week) can start the third stage : is the muscular toning stage with pro-gressive functional recovery. The start of this stage ob-viously depends on various factors. As we have already said, one of the most important factors is the type of le-sion repaired. This is because more serious is the tendon lesion repaired, more this stage is delayed. Furthermore, the start of this rehabilitation stage is sec-ondary to recovery of a satisfactory range of active move-ment of the operated limb, especially in terms of front flexion and external rotation. This is because repeated

attempts to tone a shoulder which is still stiff can give rise to pain, subacromial conflict and excess stress on the repair itself. Patients who are still unable to actively raise the arm against gravity at this stage should begin to carry out reinforcement exercises without resistance in a su-pine position that virtually eliminate the gravity weight and the patient can begins to raise the limb over 90° and reinforce the deltoid. This exercise can be carried out at the beginning with the elbow flexed and then gradually increasing the lever arm by extending the elbow progres-sively with a small weight in the hand or using an elastic resistance system [40]. At this rehabilitation stage it is important to respect the pain while the intensity of the exercises must be properly monitored staring with sub-maximal isometric contractions which permit the appli-cation of controlled force through the repaired tendon. If the supraspinatus has been repaired, toning must be carried out first attempting to reinforce the pair of front (subscapular) and rear (subspinatus) forces by means of exercises with the limb abducted to 30°– 45° and then 60°, to limit the possibility of a subacromial conflict that can entail pain as well as mechanical stress on the repair made. Isometric reinforcement is followed by a isotonic rein-forcement stage with elastic bands initially concentrate on the execution of many repetitions with low loads. Re-membering that muscular toning is dependent on the ar-ticular angle, it is necessary to seek different angular po-sitions of the humerus at which to carry out the same ex-ercises so that with each exercise all fibers of the involved muscle will be involved then changing the exercise and the humerus spatial position the infraspinatus, the teres minor, the subscapular, the deltoid (first front and then rear), the mid and inferior parts of the trapezius and the rhom- boideus or costoscapularis muscles could be pro-gressively involved [45]. The exercises must be modulated to spare the repaired tendon as much as possible at the beginning. Takeda et al. [41] have shown that with the arm abducted on the scapular plane the supraspinatus is iso-lated and that this would therefore be the ideal position for the reinforcement of this tendon, if not involved in the repair or in the late stages of the process of healing. However it is necessary to be very careful with the hu-meral rotation in this position. Some NMR studies have shown that in the abduction and internal rotation position the subacromial space is reduced in a dynamic manner and gives rise to stress on the repair [42], and this is why abduction positions of less than 90° are recommended if internal or external rotations are associated with them

[26]. At this stage it is also necessary to continue to im-prove the range of movement with exercises for stretch-ing the capsulo-ligamentous structures, in particular on the antero-inferior and postero-inferior capsule that is always stiff at this stage. The proprioceptive work of the scapular stabilisers must be intensified without forgetting “core” stabilisation (the muscular system of the abdomi-nal, oblique, dorsal and gluteus muscles), fundamental for correct positioning of the scapula [48].A crucial role in progressive functional recovery is played by proprioceptive exercises in a closed kinetic chain first below and then above the breast .


Around the 16th week, and always on the basis of the functional recovery attained by each patient, generally begins the fourth and last rehabilitation stage of the re-habilitation process that last until the 6th month. This stage is a progression of the third stage, and its end point is different depending on the type of patient [43]. This is because at this stage a patient with a low functional de-mand will continue to improve in a progressive manner in a programme of exercises prevalently home based with an increasingly complete recovery of the normal activi-ties of everyday life and the resumption, with great cau-tion, of overhead activities. With regard to young patients and athletes [47], generally more high demanding, these last stage begin with exer-cises first in an open kinetic chain with increasing ARoM and velocity and then go on to specific sports recovery exercises first for the gesture and then with force applied to the specific sports gesture itself, while workers begin to carry out activities which simulate the working activ-ity in a specific and progressive manner. Is a therapist’s job to teach patients appropriate strategies for limiting at the minimum the stress on the repaired tendon during the sports or work activities.

CONCLUSIONS

Evident is the consensus about how post-operative reha-bilitation is a progressive, integrated and tailored process (rather than a “protocol”) in which a fundamental role is played by the passage of information between the sur-geon and the physiotherapist, as well as the sharing of knowledge regarding the characteristics of each individ-ual operation both in terms of surgical technique and in terms of the biological and anatomical characteristics of the repaired tissues. Only through the integration of this information with data regarding the patient’s lifestyle and expectations it will be possible to establish a tailored re-habilitation programme which can not ignore the times and processes of biological tissue healing in order to achieve the best possible result both in terms of func-tional recovery and of management of the symptoms.

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Figure 2: Single step suture passer perforating tendon

Figure 1: Single step suture passer

Modern technique of arthroscopic suture in reparable rotator cuff tears. Actual standards and limitationsRoberto Leo, Valentina Fogliata, amos Maria Querenghi, Marco Pivetta, Bruno Michele MarelliDipartimento di Ortotraumatologia Generale e Chirurgie Ortopediche Specialistiche,Struttura Semplice Dipartimentale Chirurgia Spalla e Gomito, Istituto Ortopedico G. Pini, Milano

INTRODUCTION

The treatment of rotator cuff lesions got great improve-ments through the decades. In fact, before 1970s these lesions weren’t treated surgically. Afterwards, between 1970s and 1980s, open surgical treatment of rotator cuff tears was the gold standard for treating this kind of lesion. More recently, from 1990s and the beginning of the new century, open surgical treatment was slowly and progres-sively replaced by the new mini-invasive arthroscopic treatment.Over the years, several studies compared the outcomes of open-surgical technique and arthroscopic one1,2,3 demon-strating that there is no difference between the two tech-niques, considering both the possibility of repairing wide lesions and the quality of tendon-to-bone fixation4.The effectiveness of tissue repair, apart from biological re-sponses, depends also on the mechanical resistance of the construct including anchor fixation, knot reliability, stabil-ity of the suture loop, and suture configuration. All of these are key points in a good tendon healing process.The aim of this paper is to describe how the modern ar-throscopic surgery developed in order to achieve results comparable to the one of the traditional open techniques. First of all, we’ll analyse the tools used by the surgeon to obtain the suture, considering hardware and materi-als. Then we will also analyse suture techniques used to achieve the best tendon-to-bone repair.

EVOLUTION OF SURGICAL TOOLS AND MATERIALS

The evolution of materials comprises: 1) Surgical tools; 2) Anchors; 3) Sutures.

1) Surgical toolsThere are mainly 3 kind of suture passing instruments:

- Single step suture passer: it is a tool that grasps the tissue and, at the same time, thanks to a needle, it passes the suture through the tendon. Nowadays, this 3rd generation of suture passer is available and it increases the rate of success in passing the suture through the tendon (Figures 1, 2),

ABSTRACT

The aim of this paper is to describe how the modern arthroscopic surgery developed in order to achieve results comparable to for-mer traditional open techniques.New materials available in shoulder surgery, new surgical tools and new suture techniques developed by surgeons lead today to better final outcomes than at the beginning of arthroscopic sur-gery. For this reason in our paper we described the main used suturing techniques (single row, double row, transosseous equiva-lent suture bridge, triple row, and transosseous) comparing their virtues and vices.Finally me must conclude that modern mini-invasive techniques are based not only on the surgeon learning curve but also on the improvement of suture materials and tools that are available for surgery. In the future, by one side better understanding of the bio-logical processes causing tendon damage and, in the other side, better knowledge of the processes that lead to tendon to bone reparation after surgery seems to be the key for improving clini-cal results and then patient satisfaction.


Figure 3: Double step suture passer

Figure 4: Perforating tool

- Double step suture passer (for example Spectrum® - Conmed TM or Accu-Pass® Suture Shuttle – Smith & Nephew): it is a perforating tool that, after passing through the tendon, releases a shuttle su-ture wire that works as a real shuttle for anchor-wire (Figure 3).

- Perforating tool (also called ‘Bird beak’): it is a tool that penetrates the tissue, grasps the suture and makes it passing through the tendon with a retro-grade movement. In the beginning this tool was straight or slightly curved but, nowadays, ‘bird beaks’ are available curved in different directions, in order to make this device suitable for almost all cases (Figure 4).

Each surgeon has his favourite set of tools, so an ideal in-strumentations for performing a suture doesn’t exist. How-ever, it is compulsory to understand all the characteristics, indications and limitations of every single tool to make possible the best repair of every kind of lesion.

2) AnchorsDifferent kinds of anchor exist, from metallic to entirely resorbable ones. This evolution is due to the need to im-prove the tendon-to-bone healing5.The first models of anchors produced were made up of metallic alloy with non-resorbable suture-wires and, in the beginning, they made possible to achieve good results even if further studies demonstrated presence of complica-tion such as incarceration or migrations of the anchors6-8. For that reason non-resorbable anchors were produced9,10. The materials with the greatest history and most com-monly used are polyglycolic acid (PGA) with a degrada-tion time of 3 to 4 months and polylactic acid enantiomers (PLA, naming levo-stereoisomer PLLA and dextro-ster-eoisomer PDLA) with a degradation time between 10 to over 30 months.One of the first use of this anchors was Suretac® system, made of PGA and used in arthroscopic Bankart repair. Even if a few authors describe a good long term results using this device,9 there are several studies that showed as it produced massive synovitis, loose fragments spread in joint cavity and induced a foreign-body reaction11,12. After this one, PLLA anchors were presented; they showed a longer time of reabsorption. Several studies, e.g. Dejong et al.13, stated that the reabsorbable PLA suture anchor construct, tested in an in vivo intra-articular model, had similar strength over a 12-week period of implanta-tion with a comparable metal anchor construct. So they showed that resorbable anchors are a good alternative to metallic ones, since they have a function and a pull-out resistance comparable to metallic ones, in addition to the advantage linked to the resorbable materials (e.g. no in-terference to MRI). But we must notice that using this biomaterial there were concerns that an excessively long period of degradation would not allow a complete osseous replacement leading potentially to complications similar to metallic anchors 14.In order to reduce the anchor degradation time, the amor-phous nature of PLLA has been increased, using copoly-mers of the levo- and dextro-stereoisomers of lactic acid and PGA the polylactide-co-glycolide (PDLLA-co-PGA) or PLGA, in which the composition range of the polymers can be variable15-17. This evolution led to the introduction of biocomposite anchors made by new generation materials, improving


stimulation of reabsorption and subsequent stimulation of bone ingrowth. They are generally a blend of tricalcium phosphate (TCP) and PLA. One of this copolymer is com-posed by 30% TCP and 70% PLGA. Another one copo-lymer of this family is composed by 15% TCP and 85% PLA. Both are reported to produce a few tissue reaction and sub sequential good bone ingrowth.Polyetheretherketone (PEEK) is a stable material, highly unreactive, that is resistant to chemical, thermal, and ra-diation-induced degradation. It has been widely used in trauma and orthopedics. PEEK-based anchors are strong, relatively inert, radiolucent, and can be easily removed during revision surgery 18..

More recently have been introduced the so-called “soft anchors” made by all-soft flat-braided high-strength polyester non resorbable suture wire (for example Jug-gerKnot®, Biomet - Y-knot®, Conmed Linvatec - Su-turefix Ultra®, Smith&Nephew). In these devices the construct does not require a rigid body for bone engage-ment. In fact after they are inserted into the pilot hole, as soon as they are released, the suture wire forms a “ball” inside the tunnel immediately under the humeral cortical layer. This “ball” can function as a real biosorbable stiff anchor. The key point in these types of anchors is that they eliminate every kind of tinny and stiff material in-side the joint. All these great new anchors biomechanical properties are suitable for several cases in arthroscopic shoulder surgery.

3) Sutures The ideal suture wire would be strong but biologically inert and must simply dissolve in body fluids loosening resistance at the same time that repaired tissue gains me-chanical resistance. Modern sutures are close to the above mentioned ideal suture. At the same time we must say that even if there have been great improvements in suture materials, no single suture can be perfect in all circumstances.We must distinguish from absorbable and non-absorbable suture noticing that in any case suture wire act as a foreign body inside our tissues.Talking about rotator cuff surgery the most used sutures are yet the non-absorbable ones who keep the same resist-ance for all the period during which the tendon is repair-ing on the bone.One of the most famous non-absorbable suture is Ethi-bond®. Ethibond® is a non-absorbable, braided and sterile sur-gical suture composed of Polyethylene terephthalate. It is prepared from fibers of high molecular weight, long-chain, linear polyesters. It is uniformly coated with poly-butilate and this highly adherent coating acts as a lubri-cant to mechanically improve the physical properties of sliding and flexibility, improving in this way his handling qualities. The pitfall of this suture is the lower mechanical resistance during the knot tightening and, sometimes, the suture is sheared by using the knot pusher.Nowadays companies improved the quality of sutures used in rotator cuff repair and so now they offer high re-sistance wires that are able to withstand much better to the strength applied while tightening the knot. In fact the

resistance of the construct and consequently the quality of the repair depend on the reliability of the knot and on the elongation of the system (suture and loop); therefore, the increased material resistance may minimize suture break-age due to either “sharp” devices or overthightenig19.Biomechanical tests made by companies demonstrate that the resistance to traction of the knot pusher in this new kind of suture is doubled than in Ethibond®.As following, we analize the characteristics of four kind of high-resistance sutures produced by four of the main companies:

- Orthocord® (De Puy Mitek): it’s a braided and synthetic suture composed of resorbable polydiox-anone (PDS®) and non-resorbable non-colored polyethylene fibers. The suture is covered by a par-tially resorbable copolymer (90% Polycaprolactone and 10% Glycolide) to facilitate the sliding during the tightening of the knot.

- FiberWire® (Arthrex): it’s a multi strand structure suture composed by a central core of ultra high mo-lecular weight polyethylene (UHMW) covered in a braided coating composed of fibers of ultra high density polyester and polyethylene. This pattern gives a high resistance to rupture and friction. How-ever, this suture has a high stiffness that must be considered in case of tendon-to-bone suture since the excessive tightening of the knots could reduce the tissue blood supply and so worsen the healing process.

- Hi-Fi® (Conmed Linvatec): it’s a braided suture composed of ultra high molecular weight poly eth-ylene fibers without central core. It offers high re-sistance to the rupture caused by the knot pusher and it is mainly non-resorbable.

- Ultrabraid Suture® (Smith&Nephew): It’s once again a non-absorbable suture composed of a spe-cial ultra high molecular weight (UHMW) polyeth-ylene fiber featuring a unique braid configuration without central core.

SUTURE TECHNIQUES

One of the most important thing to consider in arthroscopic repair is to understand the shape of the lesion: partial (ar-ticular or bursal) or complete, usually divided in crescent-shaped, U-shaped, L-shaped and massive tears20. In fact, understanding the shape of the lesion allow the surgeon to use the most reliable and suitable technique to restore the normal anatomy of rotator cuff if possible.The main purpose of the surgical procedure is to re-attach tendons to the bone at their anatomical insertion. The sta-bility of the tendon-to-bone fixation and its tight contact (a so called ‘watertight cuff repair’) are the essential assump-tions for an appropriate tendon-to-bone healing and so for good clinical outcomes.For this reason in arthroscopic surgery there has been an evolution of the technique, both considering the devices, the wires and the surgical managing, in order to adapt sur-gery to the anatomy of the tendinous lesion, after evaluat-ing its shape, width and the quality of the tissue.


Figure 5: Single row construct

Figure 6: Mason Allen stitch modified for arthroscopy

The main used suturing techniques could be divided into 5 types:

- single row,- double row,- transosseous equivalent suture bridge,- triple row,- transosseous.

Single RowIn this technique the surgeon implants a single row of an-chors parallel to each others and perpendicular to the gle-noid articular surface. As in other techniques right place-ment of the anchor is very important for the biomechanics of the final construct.Firstly, considering the superior surface of the greater tuber-osity, the inclination of the angle should comply the concept

of the ‘deadman angle’ by Burkhart21. Also the distance from the articular humeral cartilages must be considered and it de-pends on the grade of retraction of the tendon: the more is the tendon retracted, the more the anchor should be medialized.There are different ways of passing suture wire through the tendon: ‘simple’ (only a wire into the tendon – Figure 5), ‘double’ or ‘mattress’ (both sides of the suture pass through the tendon), and more complex ones, such as the arthroscop-ic Mason-Allen (Figure 6) or the Italian modification of the latter, the Alex stitch22. Usually, this technique doesn’t need high duration of surgery and it has lower costs compared to the techniques described below. In our experience, we get very good outcomes, even though several studies23,24 demonstrated that not always this technique achieves a good tendon-to-bone fixation on the anatomical footprint if compared to double row or transos-seous equivalent technique.


Figure 7: Double row construct

Figure 8: Suture bridge transosseous equivalent

Double RowThis kind of suture is performed using 2 rows of anchors, one near to the articular border of the humeral head and the other one more lateral near to the top of the great-er tuberosity. It is possible to perform simple knots for every anchors or to perform simple knots for the medial anchors and a mattress knot for every lateral anchor, as described by Lo and Burkhart25 (Figure 7). In this way, every anchor acts like an independent point of support with the advantage of increasing the area of tendon-to-bone contact and, as a consequence, the process of ten-don-to-bone healing.Disadvantages of this technique are higher costs (it needs a doubled amount of anchors than single row technique) and higher duration of surgery. Another disadvantage is that the high number of sutures could excessively in-crease the compression of the tendon resulting in a poten-

tial decrease of blood supply and, as a consequence, of all growth factors involved in the process of tendon-to-bone healing.There are several studies that compared single row to double row techniques. Kim et al26 evaluated both tech-niques in terms of cyclic loading, gap formation and fail-ure loads and they stated that double row technique got 42% less gap formation, 46% more stiffness and 48% higher ultimate load to failure. The strain experienced in the footprint of double-row repair was 1/3 of that seen in single row.In their study, Saridakis and Jones27 stated that double-row sutures get a more stable structural repair than single row, but there isn’t a significant statistical difference in term of clinical outcomes in lesion of less than 3 cm if compared with single-row suture. Instead, Duquin et al28 stated that in case of lesions of more than 1 cm, double-


Figure 10: Schematic drawing of the suture wire through the tendon and

inside the transosseus tunnels

Figure 9: Triple row construct

row technique has a much lower rate of recurrence of le-sions if compared to single-row technique. In their study, Ma et al29 showed that patients with lesions of more than 3 cm repaired with a double-row suture have a higher value of strength if compared with a repair with a single-row suture; however, after repairing every kind of lesions, they didn’t find a significant statistical difference in rotator cuff integrity at a 2-years follow-up.

Transosseous equivalent suture bridgeIn this technique, presented by Park et al.30, the surgeon knots the sutures of the medial anchors at the lateral ones after crossing them (Figure 8 - Transosseous equivalent su-ture bridge). In this technique simple knots are performed at the medial anchors and then the insertional part of the tendon is pulled till the great tuberosity and it is fixed here by special anchors (like for example PushLock® by Ar-threx) that lock the terminal part of the sutures into the holes inside the anchors without further knots . Nasson et al.31 demonstrated that this technique brings to a more water-tightening repair if compared with single row technique. The main pitfalls are the increase of surgical time and of costs of the procedure.

Triple RowThis technique was introduced by Ostrander and McKin-ney32 in 2012 considering that the most anatomical repair could lead to a decrease of recurrence in massive lesions. This technique, a sort of suture bridge-modified, requires a further anchor in median position between the row of medial anchors and the row of the lateral ones (Figure 9). Ostrander and McKinney32 demonstrated that this tech-nique showed a higher pressure at the area of contact with a larger tendon-to-bone area at the footprint if compared to double rows and to suture bridge techniques. However this technique needs a longer duration of the sur-gery and it is burdened by considerable costs.Furthermore, from our point of view, the use of 5 anchors for performing this technique could considerably weaken the bone increasing the risk of iatrogenic or late fractures.

Arthroscopic transosseous techniqueThe transosseus repair of rotator cuff lesions was largely used when it was performed with open surgery. Since this technique is able to achieve a good seal respecting anato-my without using anchors, a specific tool was developed to perform the arthroscopic transosseous suture33. Recently, Garofalo et al.34 tested a new device (ArthroTunneler® device by Tornier) that makes possible to perform an ar-throscopic transosseous tendon repair taking advantage of mini-invasive surgery and the reliability of transosseous open repair. Furthermore, without using anchors, this tech-nique avoids all complication linked to it, such as pull-out or osteolysis of great tuberosity. Moreover, Park et al. (2007) demonstrated that all techniques of tendon repair with anchors lead to an increase of circumferential tension but a low compression at the tendon-bone interface35.In this technique, the lateral tunnel is performed 1,5 cm distally to the superior border of the great tuberosity but,


Figure 11: Transosseous construct

in order to increase the mechanical strength of the tran-sosseous suture of the tendon, this tunnel could be per-formed at more than 10 mm far from the extremity of the great tuberosity36 (Figure 10, 11).This technique represents surely an effective alternative to the use of anchors for the treatment of rotator cuff lesions but, nowadays, biomechanical and clinical evaluations should be performed again.Several authors described different techniques for ar-throscopic transosseous repair such as Fleega37, Fox38, Frick39 et al. whom presented techniques in which they used needle of great dimension to perform the transosseous suture. The pitfalls of these techniques are the reproduc-ibility, the possible breakdown of the bone-tunnel, the rup-ture of the needle inside the tunnel and possible lesions of the axillary nerve depending on the angle of insertion used by the surgeon that is very variable. Indeed, this new device (ArthroTunneler® device – Torn-ier) could perform the transosseous tunnels in a very re-producible way avoiding most of the pitfalls and com-plications caused by the free-hand techniques previously presented.

CONCLUSIONS

In the last 40 years, the surgery of the tendinous lesions got a significant evolution and nowadays the shoulder surgeon performers arthroscopically almost all kind of cuff repair with the same reliability of the older open surgical tech-niques. The only lesion that already requires, in the majority of the cases, an open technique is the traumatic complete full thickness subscapularis tendon tear.In any case one can say that modern arthroscopic techniques are based not only by the completion of the surgeon learning curve but also by the improvement of suture materials and tools now available. The surgeon skills lead today to real-ize even more effective sutures that increase tendon-to-bone adhesion minimally affecting tendon vascularisation.Last but not least, we must consider the increased knowl-

edge about biological mechanisms that are at the base of tendon-to-bone healing processes, that is essential for good clinical outcomes.In the future better understanding of the biological pro-cesses that lead to tendinous rupture and then that lead to restoration of the cuff anatomy after surgery seems to be the key for improving clinical results and then patient sat-isfaction.

REFERENCES

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7. Silver MD, Daigneault JP. Symptomatic interarticular migration of glenoid suture anchors. arthroscopy 2000;16: 102-105

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11. Burkart a1, Imhoff aB, Roscher e. Foreign-body reaction to the bioabsorbable suretac device. arthroscopy 2000; 16:91-95

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32. Ostrander RV 3rd, McKinney BI. evaluation of footprint contact area and pressure using a triple-row modification of the suture-bridge technique for rotator cuff repair. J Shoulder elbow Surg 2012; 21:1406-1412

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Subscapularis tendon tear. Modern surgical approachDario Petriccioli, Giacomo Marchi, Celeste BertoneDepartment of Orthopedics, Istituto Clinico Città di Brescia, Brescia

For a long time, the subscapularis tendon, was not con-sidered as a basic structure in the shoulder biomechanics, gaining the term “forgotten tendon” with a high percentage of unrecognized injuries (hidden lesion) 1.Over the past 10 years, thanks to authors like Walch, Ger-ber, Bennet and others, we realized its real importance and considerable disability in the case of its breakage2,3.The etiology can be both traumatic and degenerative, of-ten in association with LHB instability, dislocations or impingement, mainly with coracoid process. We can find isolated lesions or in association with other rotator cuff tendons in percentages ranging from 3.5 to 20.8%4.A correct and modern surgical approach to the subscapu-laris lesions, needs their systematic staging through the many classifications that literature offers.Generally we use the 2007 Lafosse classification (CT or MRI) to select an appropriate surgical treatment:5

I Partial lesion of superior one-third

II Complete lesion of superior one-third

III Complete lesion of superior two-thirds

IV Complete lesion of tendon but head centred and fatty degeneration classified as less than or equal to Goutallier stage III

V Complete lesion of tendon but eccentric head with coracoid impingement and fatty degeneration classified as more than or equal to Goutallier stage III

we can summarize the surgical protocol that we have cho-sen, in the following way:

STAGE I-II: Arthroscopic repair or conservative treatment, in elderly patients with low functional demands and limited pain

STAGE III: Arthroscopic or open repair with pos-sible reinforcement using pectoralis minor transfer (Wirth procedure)

STAGE IV: Open repair and, if necessary, augmen-tation with synthetic scaffold or pectoralis minor transfer

STAGE V: lesions that tend to be non-repairable re-quiring pectoralis major transfer (Gerber or Resch technique)

STAGE I-II 6, 7, 8 (PIC. 1)

The arthroscopic approach can be made in lateral decubi-tus, with about 40° limb abduction, or in beach chair po-sition (best technique for the author) with back reclined approximately 60° and in general anesthesia associated with interscalene block. The technique involves first posterior portal, approxi-mately 1 cm medial and 1 cm under rear corner of the ac-romion, and anterior-superior and lateral portals. Some-times it can be useful an antero-medial portal near the lateral margin of the conjoint tendon. The next step is the intra-articular evaluation of capsule-ligament and tendon structures with particular attention to the subscapularis insertion, sometimes can be useful internal rotation motion to relax the foot-print fibers and obtain better visualization. Particular attention must be paid to the biceps tendon and its groove, trying medial and lateral dislocation with a probe. In instability situation (Walch classification), is neces-sary LHB tenotomy or tenodesis, in order to improve the visualization of the subscapularis and to protect its suture. In frying situations (partial tear) we do a simple debri-dement of the tendon top edge and lesser tuberosity in the footprint area; in the case of superior one-third tear, its repair through a double suture anchor in the bicipital groove is performed. (Figure 1) Sometimes a triple suture anchor can be used to realize both subscapularis repair and LHB tenodesis.9

ABSTRACT

Operative treatment on the subscapularis tendon tears has be-come more minimally invasive and selective over the past de-cade. This requires high-quality preoperative imaging evalua-tion for better knowledge of the relevant anatomical consider-ations. Arthroscopic repair has become the operation of choice for most patients presenting with small and not retracted tear. In case of larger tears the open operative treatment remains the unique solution, especially in irreparable tears who requires a tendon transfer.


Figure 2: Open subscapularis repair with synthetic augmentation. The biceps tendon is found medially subluxed out of its groove with subscapularis complete ruptures (A). The subscapularis is fixed on the lesser tuberosity using simple transosseous sutures (B, C) and then reinforced with a synthetic augmentation (D)

Figure 1: Arthroscopic surgical repair of subscapularis tendon superior one-third. Once the tenotomy of the biceps has been done, the visualization for subscapularis repair is greatly improved (A). Using traction sutures to pull the subscapularis as far laterally as possible (B), the tendon is fixed on the lesser tuberosity.


Figure 3: Subscapularis Reconstruction with Pectoralis Major Transfer over (Gerber technique, A) or under (Resch technique, B) the conjoined tendon.

STAGE III 10, 11 (PIC. 2)

In this situation it is essential to evaluate the tendon qual-ity and muscle trophism at the pre-operative exams (usu-ally MRI). In situations of good tendon and muscle qual-ity, with preserved thickness and trophism, we prefer to perform an arthroscopic approach, always in the beach chair position. Always evaluate and eventually treat LHB tendon pathology. In the upper two thirds tears is cru-cial evaluate the possibility of a proper reduction of the tendon to avoid any tensions; in this case it may be nec-essary its release with detachment of LGOM from the subscapularis deep surface, and remove any adhesions with the conjoined tendon superficially. In this case, it is recommended to pay special attention medial to the conjoined tendon, for the presence of the circumflex and musculo-cutaneous nerve, axillary artery and the cords of the brachial plexus. The repair is carried out, generally, using 2 double suture anchors. First one with “U” stitches to fix the lower part of the tendon, and the second one, always in correspon-dence of the bicipital groove for its upper third. In the case the MRI showing a poor quality tendon or muscle we prefer an approach in open surgery (deltoid-pectoral), always in the beach chair position, in order to perform a best release of the tendon and a fixation with multiple trans-osseous stitches, using synthetic augmentation, to

increase the tightness of the suture in a poor tissue. In a poor and atrophic muscle, at the end of the subscapularis repair, we perform pectoralis minor transfer sec. Wirth as a biological augmentation 12.

STAGE IV 10,11

In the case of the full subscapularis tendon tear (all thick-ness and all length) our choice is always directed towards an open deltoid-pectoral approach. The surgical technique is the same described in stage III, with multiple trans-os-seous stitches and synthetical augmentation (Figure 2) or pectoralis minor transfer. At this stage it’s not always pos-sible direct repair, especially in advanced tendon retraction (over the glenoid). The open surgery technique permits more chance of mobilization and release of muscle-tendon complex and, in a case of failure, allows us to perform pectoralis major transfer, to supply the lack of the subscap-ularis tendon, reducing the progressive anterior displace-ment of the humeral head, and its arthropathy.

STAGE V 10,11,12 (PIC. 3)

These lesion are generally old, previously unrecognized, with important tendon retraction and fatty infiltration of


muscle. These are non-repairable lesions and our choice is directed to the palliative treatment of pectoralis ma-jor transfer in an attempt to reduce the inevitable and progressive anterior humeral head displacement and ar-thropathy, improve active intrarotation and strength. Sur-gery is performed in beach chair position (30 ° of back flexion), with general anesthesia and interscale brachial plexus block. Using a delto-pectoral approach we detach the 2/3 of pectoralis major sternal part from the humerus. The transfer to the less tuberosity can be performed in according to the Gerber technique13, above the conjoint tendon or (author favorite), as in Resch technique14, un-der the conjoint tendon after isolation and protection of the musculocutaneous nerve (Figure 3). In way you can create a pulley effect that permits (espe-cially in male) to reach strength values slightly higher. The humeral fixation is obtained using trans-osseous stitches or charging high resistence wires used to prepare the tendon, in one or more impact anchors. The treatment algorithm just described, required a correct “timing” in diagnostic and surgical path. After the literature and our daily evaluation, the subscapularis tendon should always be repaired in a short time, especially in young patients with traumatic injuries. This problem is an urgent surgery situation, because the fast retraction of the tendon can lead to a not raparable tear. In this case is necessary, in young and adult patients, a tendon transfer to supply the subscapularis actions.

REFERENCES

1) C.Gerber, R.J.Krushel Isolated rupture of the tendon of the sub-scapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br 1991; 73:389-394

2) Bennett WF Subscapularis, Medial, and Lateral Head Cora-

cohumeral. Ligament Insertion anatomy: arthroscopic appear-ance and Incidence of “Hidden” Rotator Interval Lesions. ar-throscopy 2001; 17: 173–180

3) Walch G, nove-Josserand L, Levigne C, Renaud e. Complete ruptures of the supraspinatus tendon associated with “hidden lesions” of the rotator interval. J Shoulder elbow Surg 1994; 3:353-360

4) Lo IK, Burkhart SS the etiology and assessment of Subscapularis tendon tears: a Case for Subcoracoid Impingement, the Roller-Wringer effect, and tUFF Lesions of the Subscapularis. arthros-copy 2003; 19:1142-1150

5) L. Lafosse, B. Jost, Y.Reiland et al. Subscapularis tear Classifica-tion. J Bone Joint Surg am. 2007; 89:1184-1193

6) adams CR, Schoolfield JD, Burkhart SS the Results of ar-throscopic Subscapularis tendon Repairs. arthroscopy 2008; 24:1381-1389

7) Burkhart SS, Brady PC technical note. arthroscopic Subscapu-laris Repair: Surgical tips and Pearls a to Z. arthroscopy 2006; 22:1014-1027

8) Lafosse L, Jost B, Reiland Y et al. Structural Integrity and Clinical Outcomes after arthroscopic Repair of Isolated Subscapularis tears. J Bone Joint Surg am 2007; 89:1184-93

9) Walch G, nové-Josserand L, Boileau P, Levigne C Subluxation and dislocation of the tendon of the long head of the biceps. 1998; 7:100-108

10) Sewick a, Kelly JD, Leggin B Subscapularis tears: Diagnosis and treatment. University Of Pennsylvania Orthopaedic Journal. 2011; 21:25-30

11) edwards tB, Walch G, Sirveaux F et al. Repair of tears of the Subscapularis. J Bone Joint Surg am 2006; 88:1-10

12) Wirth Ma, Rockwood Ca Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg am. 1997; 79:722-31

13) Jost B, Puskas GJ, Lustenberger a, Gerber C Outcome of Pectora-lis Major transfer for the treatment of Irreparable Subscapularis tears. J Bone Joint Surg am. 2003; 85:1944-51

14) Resch H, Povacz P, Ritter e, Matschi W transfer of the Pectoralis Major Muscle for the treatment of Irreparable Rupture of the Subscapularis tendon J Bone Joint Surg am 2000; 82:372-382

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Painful shoulder: the Rheumatologist’s point of viewLuigi Sinigaglia, Francesca Zucchi, Massimo VarennaDivision of Rheumatology DH, Gaetano Pini Orthopedic Institute, Milan

INFLAMMATORY ARTHRITIDES AFFECTING THE SHOULDER Rheumatoid Arthritis (RA) of the shoulder not only af-fects synovium within the gleno-humeral joint but also involves the distal third of the clavicle and various bur-sae and rotator cuff. Usually shoulder involvement is seen preferably in the most severe forms of the disease. Pain in the shoulder(s) is a common onset in elderly patients with RA. Severe shoulder pain is often bilateral and can lead to sleep disorders because of difficulty to find a comfortable position. In a series of 200 consecutive patients with RA studied by arthrography, 21% had rotator cuff tears and an additional 24% had evidence of frayed tendons 1. The most likely mechanism leading to rotator cuff tears is that ten-don insertion is vulnerable to erosion by the proliferative synovitis. Marked soft tissue swelling of the anterolateral aspect of the shoulders commonly accompanying RA may be caused by chronic subacromial bursitis rather than by glenohumeral joint effusions. Synovial proliferation of the subdeltoid bursa might explain the resorption of the distal end of the clavicle. Rarely the shoulder joint may rupture, with symptoms resembling those of obstruction of venous return from the arm.A true gleno-humeral involvement in Psoriatic Arthritis (PsA) is rare. PsA should be suspected in a patient with an asymmetric joint involvement who may have additional clinical features such as dactylitis, enthesitis or inflamma-tory type back pain and who is negative for rheumatoid factor. Since PsA presents a prominent entheseal involve-ment, rotator cuff enthesitis can be a manifestation of the disease.The girdle or “root” joints (hips and shoulders) are the most frequently involved extra-axial joints in Ankylosing Spondylitis (AS), and pain in these areas is the present-ing symptom in up to 15% of patients. Shoulder involve-ment may cause considerable physical disability. Hips and shoulders are involved in the course of the disease in up to 35% of patients. In these patients coexisting inflammatory back pain is the usual clue to the early diagnosis of AS or of axial spondyloarthritis.

OSTEOARTHRITIS

The shoulder is a common source of pain in patients with Osteoarthritis (OA), although the symptoms are more often due to osteophytosis and narrowing of the acromioclavic-ular and/or sternoclavicular joints than the glenohumeral joint itself. Primary OA of the shoulder joint is uncommon,

except in elderly women. It is the joint site with the old-est age of onset in OA. Apart from age and sex there are no obvious associations, except with the link with rotator cuff damage which is also very common in the elderly. Most OA of the shoulder presents with pain on movement and a restricted range of motion, especially external rota-tion and elevation. The radiograph shows evidence of OA, with joint space narrowing, subchondral sclerosis, cysts in the glenoid and often large inferior osteophytes on the glenoid.

SEpTIC ARTHRITIS

Septic arthritis of the shoulder can mimic any of the condi-tions affecting gleno-humeral joint. Sepsis must be includ-ed in any differential diagnosis of shoulder pain because early recognition and prompt treatment are mandatory to achieve a good functional result. The diagnosis is con-

INTRODUCTION

Shoulder pain is one of the most common musculoskeletal com-plaints and may arise from diverse causes. Accurate diagnosis of shoulder pain is made difficult by the unique anatomy and posi-tion of the shoulder, which serves as a link between the upper ex-tremity and the thorax. A variety of Rheumatological conditions can affect the shoulder and when examining the patient , a pre-liminary approach includes topography of pain, mono or bilateral localization, circumstances of occurrence of pain ( inflammatory or mechanical pain), existence of accompanying pain related to other structures of the musculoskeletal system and the presence of constitutional signs and symptoms which can drive the clinician to a definitive diagnosis. Such a preliminary approach can help the clinician in the differential diagnosis of shoulder pain which includes not only common local disorders but also considera-tion of etiologies arising from distant anatomic sites by referred pain-mediated pathways. Furtherly, systemic arthropathies can occasionally present with shoulder disease and often involve the shoulder over time. Early assessment in these patients is essential in order to reach a definitive and correct diagnosis, thus avoid-ing waste of time and therapeutic unfinalized efforts. This paper provides a practical overview of painful shoulder disorders that may be encountered in a rheumatology or general practice. The majority of these clinical entities are as well commonly encoun-tered by the Orthopedic, suggesting that a combined approach, when directed by a high level of suspicion, can be the best way to diagnose ad treat the patient.


Figure 1: Osteonecrosis of the humeral head

(Crescent sign)

firmed by joint aspiration with synovial fluid analysis and culture. Cultures should include aerobic, anaerobic, myco-bacterial and fungal studies.

MILWAUKEE SHOULDER SYNDROME

Milwauke shoulder syndrome was first described by Rob-ert Adams in 1857, subsequently well defined and called “chronic rheumatic arthritis of the shoulder”2 and later on also named l’épaule sénile hémorragique 3, cuff-tear ar-thropaty 4, idiopathic destructive arthritis 5, apatite associ-ated destructive arthritis 6, arthropatie destructrice rapide de l’épaule 7. It is a destructive shoulder arthropathy asso-ciated with deposition of basic calcium phosphate (BCP) crystals, characterized by the presence of large amount of synovial fluid and a complete rotator cuff tear. It is pre-dominantly found in elderly women and is bilateral in more than 50% of cases 8, predominantly affecting the dominant side. Some predisposing factors have been demonstrated, as high energy trauma or recurrent microtrauma, recurrent sub-luxations, concurrent calcium pyrophosphate dehy-drate (CPPD) crystal deposition, neurological diseases (syringomyelia, cervical root compression) or renal failure with hemodialysis 9-12, but a lot of cases are idiopathic. The incidence in the general population is not known as well as the pathogenesis. Some Authors speculated that BCP crys-tals are phagocytosed by synovial lining cells stimulating them to produce metalloproteinase (MMP), and also caus-ing them to proliferate, which contribute to progressive joint damage 13. In vitro studies have shown that calcium-containing crystals contribute to mitogenic and inflam-matory responses in various cell types 14. BCP and CPPD crystals can also stimulate fibroblast to produce various MMP; matrix metalloproteinase-8 has now been identified as another enzymatic product of fibroblast stimulation by calcium-containing crystals 15.The patient generally refers moderate shoulder pain lasting several months or years, but in some cases the pain may be acute and rapidly progressive, usually most apparent at night and on joint use with functional impairment. Char-acteristically, large joint effusion is present extending into the subdeltoid region and the synovial fluid is frequently blood tinged, containing low, predominantly monuclear, cells count. Rupture of the effusion can lead to a massive extravasation of blood and synovial fluid into the sur-rounding tissue. The extensive destruction of periarticu-lar tissue, including the rotator cuff, leads to instability of the shoulder. Although the shoulder predominates, knees, hips, elbows and other joints may be involved 6, 16.Generally, the plain radiograph findings can be sufficient for the diagnosis, showing upward subluxation of the homerus, causing subcromial impingement that in time can erode the anterior portion of the acromion and the acromi-on-clavicular joint. Other findings may include cystic de-generation of the humeral tuberosities, erosion of cortical bone at the side of insertion of rotator cuff, degenerative changes of the humeral head and/or glenoid of the scapula, degenerative changes of the acromion-clavicular joint and calcifications of the tendineous rotator cuff. Eventually the soft, atrophic homerus head can collapse and an extensive

atrophic destruction and loss of bone of both the acromion and the glenohumeral joint can be recognized 4,17.Further imaging tools as ultrasound and MRI can provide more information about cartilage damage, bone marrow edema, synovial hypertrophy, joint effusion, calcifications, tendineous and soft tissue damage 18.The natural history of this condition has not a standard fea-ture, but many cases seem to stabilize after a year or two, with reduction of symptoms, joint effusions and no further radiographic changes. No specific therapies are nowadays available 19 and the treatment of symptomatic phase is gen-erally unsatisfactory. A conservative approach, including analgesics and NSAIDs, repeated shoulder aspirations fol-lowed by injection of methylprednisolone acetate 20 can be sometimes useful. As pain subsides, functional rehabilita-tion must be started. Anatomic damage of the joint needs an orthopedic evaluation for surgical approach.

OSTEONECROSIS Osteonecrosis of the humeral head is seen in association with a variety of conditions. Apart from traumatic causes, the commonest condition leading to this complication is steroid therapy provided in conjunction with organ trans-plantation, systemic lupus erythematosus, systemic vascu-litides, miscellaneous steroid-sensitive diseases or asthma. Other conditions associated with necrosis of the humeral head include hemoglobinopathies, pacreatitis, hyperba-rism or alcohol abuse. Symptoms arise from synovitis and joint incongruity resulting from resorption, repair and re-modeling. Early diagnosis is difficult because the presence of symptoms is often delayed. Magnetic Resonance Imag-ing is highly sensitive and more specific than scintigraphy. Plain radiographs show progressive phases of necrosis and repair. In early stages the x-ray may be normal or may show osteopenia or bone sclerosis. A crescent sign repre-senting subchondral fracture ( Fig. 1) or demarcation of the necrotic segment appears during the reparative process. Patients who fail to remodel show collapse of the humeral


Table 1. PMR classification criteria scoring algorithm. Pre-required criteria: age ≥50 years, bilateral shoulder aching and abnormal CRP and/or ESR 24

head with secondary degenerative changes. A considerable discrepancy is usually noted between symptoms and radio-graphic involvement.

pOLYMIALGIA RHEUMATICA

Polymialgia Rheumatica (PMR) is a syndrome of un-known etiology characterized by aching in the proximal portions of the extremities, often involving the neck and girdles. There are no specific diagnostic tests or patholog-ic findings, so that the syndrome is defined on a clinical ground. PMR is relatively frequent with an average annual incidence rate of 52.5 cases per 100.000 persons aged 50 years or older 21. The prevalence of PMR (active plus re-mitted cases) is approximately 600 per 100.000 persons aged 50 years and older. The features included in most definitions of PMR are as follows: (1) aching and morn-ing stiffness lasting half an hour or longer in the shoulders, hip girdle, neck or some combination; (2) duration of these symptoms for 1 month or longer; (3) age older than 50 years; (4) laboratory evidence of systemic inflammation with increase in acute phase reactants; (5) rapid response to small doses of glucocorticoids such as prednisone 10 mg per day. Nearly half of the patients have systemic manifes-tations such as malaise, low-grade fever and weight loss at disease onset. Pain may develop abruptly or evolve insidi-ously over weeks or months. In most patients the shoulder girdle is the first to become symptomatic. The discomfort may arise in one shoulder or hip but usually becomes bi-lateral within weeks. Symptoms are located at proximal limbs, axial musculature and tendon attachments. Morning stiffness resembling that of RA and “gelling” after inac-tivity are usually prominent. Distal joint pain and swell-ing occur only in some cases. Pain at night is extremely common and movement during sleep usually awakens the patient. Muscle strength is generally unaffected. Pathogen-esis include bursal inflammation and synovitis. Diagnostic and classification criteria for PMR have been proposed in 1982 22, reviewed in 1984 23 and recently redeveloped to

incorporate informations provided by ultrasound evalua-tion 24 (Table 1). Diagnostic criteria underscore that the di-agnosis of PMR is clinical and depends on eliciting symp-toms. Distinguishing PMR from early RA with proximal joints onset can be difficult especially in patients who are rheumatoid factor negative and in those who have not yet developed prominent synovitis of the small joints of the hands and feet. Furtherly, distal joint pain and swelling oc-cur in some cases of PMR including diffuse distal extrem-ity swelling with pitting edema. Patients with polymiositis complain much more of weakness than pain. Although patients with neoplasms may have generalized musculo-skeletal aching, there is no association between PMR and malignancy. Therefore a search for an underlying tumor is not necessary except in cases of “atypical PMR” and poor response to low-dose prednisone. This therapeutic approach is usually sufficient to control pain and leads to normalization of laboratory tests. Usually prednisone must be tapered slowly, according to acute phase reactants and a full drug-free recovery is achievable in 9-12 months. Flares are common, and are seen in 30% of cases neces-sitating dose increase to achieve remission. Some, but not all, studies suggest that oral Methotrexate can reduce the long-term need for corticosteroids.A large body of evidences support the idea that PMR is related to Giant Cell Arteritis (GCA). Since these patients are considered at high risk for vascular complications such as vision loss or ischemic events including irreversible blindness, stroke or large artery disease, a high index of suspicion must be kept in mind since early treatment of this disease can prevent these dramatic complications. Be-tween 30 and 50% of patients with GCA develop PMR and approximately 10 to 15 % of patients with PMR have positive temporal artery biopsies. For these reasons a tem-poral artery biopsy is strongly recommended in the pres-ence of accompanying symptoms such as headache, jaw claudication, visual symptoms or high fever. Color duplex ultrasonography can be of aid in these situations, showing abnormalities of the temporal artery with a sensitivity of 93%. Glucocorticoid therapy must be commenced as soon

Points without US (0-6)

Points with US (0-8)*

Morning stiffness duration >45 minutes 2 2

Hip pain or limited range of motion 1 1

Absence of RF or ACPA 2 2

Absence of other joint involvement 1 1At least 1 shoulder with subdeltoid bursitis and/or biceps tenosynovitis and/or gle-nohumeral synovitis (either posterior or axillary) and at least 1 hip with synovitis and/or trochanteric bursitis

NA 1

Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis NA 1

A score of 4 or more is categorized as Polymyalgia Rheumatica (PMR) in the algorithm without ultrasound (US) and a score of 5 or more is categorized as PMR in the algorithm with US. CRP = C-reactive protein; ESR = erytrocyte sedimentation rate; RF = Rheumatoid Factor; ACPA = anti-cytrullinated protein antibody; NA = not applicable

*optional US cyteria


as the diagnosis of GCA is strongly suspected with predni-sone doses between 40 and 60 mg/day in order to prevent loss of vision.

NEURALGIC AMYOTROpHY (PARSONAGE-TURNER SYNDROME)

Neuralgic Amyotrophy (NA) was first clinically defined by Parsonage and Turner in 1948 25 and is typically char-acterized by attacks of neuropathic pain and subsequent patchy paresis in the upper extremity. The reported inci-dence is 2-3 per 100,000 individuals per year in the gen-eral population but the true annual incidence, considering underdiagnosis and misdiagnosis, seems to be 20 to 30 cases per 100.000 26,27,28; the highest incidence is between the third and seventh decades of life and male are predomi-nantly affected 26,29. The cause of NA is still unknown but the available evidences suggest that neuralgic amyotrophy has a complex pathophysiology that includes an underly-ing predisposition, a susceptibility to dysfunction of some peripheral nerve structures, and an autoimmune trigger for attack 30. Available literature suggests that possible triggers include viral infections, immunization, and the periopera-tive and peripartum periods as well as a previous period of strenuous exercise 26, 31. The few histological studies have demonstrated evidence of an autoimmune etiology, with mononuclear inflammatory infiltrates in the brachial plexus biopsies 32,33 or increase in complement-fixing an-tibodies to peripheral nerve myelin in the acute phase of the disease 34.NA occurs in both idiopathic and hereditary forms; the second one, ten times less common than the first one, is an autosomal dominant monogenic disorder with high but incomplete penetrance, caused by mutation in the gene septin 9 on chromosome 17q23 35,36.In most cases patients affected by NA present acute, severe shoulder pain that radiates to the arm or neck and lasts for several hours to weeks; the pain frequently can awaken patients from sleep and may be exacerbated by shoulder and elbow motion. As the pain subsides, a flaccid paralysis with muscle weakness, muscle atrophy, and sensory loss of shoulder girdle and arm develops, with a characteris-tic patchy distribution. The most common sites of sensory loss are over the deltoid, the lateral aspect of upper arm, and the radial aspect of the forearm. Bilateral brachial plexus involvement occurs in 10 to 30% of cases, although symptoms are usually asymmetric 25,37-39. In about 17% of sporadic NA and 56% of hereditary NA, involvement of nerves outside brachial plexus can occur, most commonly the lumbosacral plexus, phrenic nerve and/or recurrent la-ryngeal nerve and occasionally the facial, hypoglossus or intercostal nerves 26,31. In approximately 15% of patients signs of involvement of the peripheral autonomic nervous system were documented, such as vegetative and trophyc skin changes, edema in the involved extremity at the onset of the attack, temperature dysregulation, increased sweat-ing, and changes in nail growth 31.At the beginning, clinical presentation of NA is not specif-ic; the differential diagnosis must include not only neuro-logic and orthopaedic condition, but also thorax diseases.

Despite of a complete clinical examination, no currently available tests can unequivocally confirm or exclude the diagnosis of NA. MRI can demonstrate edema involv-ing one or more muscles innervated by brachial plexus in early phase of the disease, and signal suggesting atrophy with fatty infiltration in one ore more muscle groups of the shoulder in the late phase 38,40. EMG examination can be abnormal and suggesting NA revealing acute denervation (with positive sharp waves and fibrillation potential) 3 to 4 weeks after the onset of the disease, present in both a peripheral nervs and nerve root distribution 37; an EMG performed 3 to 4 months after the onset of initial symp-toms may show chronic denervation and early reinnerva-tion with polyphasic motor unit potentials 26,37.No specific treatment is nowadays available; early corti-costeroids therapy may have a positive effect on pain in some patient as well as opioid in combination with long-acting NSAIDS 36 . The patient should be encouraged to use the affected limb as fully as possible. The disease can last 2-3 years before symptoms and impairment fully dis-appear.

SHOULDER-HAND SYNDROME

Complex regional pain syndrome type I (CRPS-I), for-merly known as reflex sympathetic dystrophy, is a se-verely disabling pain syndrome characterized by sensory and vasomotor disturbance, edema and functional impair-ment 41 that in most cases developed following a trauma or surgery42. The pathogenesis is still unknown and no spe-cific test is currently available for the diagnosis. Recently updated Budapest Criteria are widely accepted to make a clinical diagnosis 43, 44 (Table 2). In 1947 Steinbrocker first described the shoulder-hand syndrome 45, a CRPS-I involving the shoulder and the hand. The clinical course was historically described as divided in three main stages, according to the clinical manifestations: stage 1, lasting 3-6 weeks to 6 months, with painful shoulder, swelling, pain and stiffness in the hand; stage 2, lasting from 3 to 6 months, with gradual lessening of shoulder pain and resolution of the swelling at the hand with increasingly stiff with flexion deformity of the fingers and atrophy of subcutaneous tissue and thickening of the palmar fascia; stage 3, that may last many months, characterized by a smooth, glossy skin with trophic changes and atrophy with thickened palmar fascia and Dupuytren-like contracture. The main predisposing factor to hand-shoulder syndrome is stroke (12.5%-27%) 46 but also other conditions are rec-ognized (myocardial infarction, thoracic disease, injury as glenohomeral subluxation, Herpes Zoster infection) 45. The relationship with shoulder-hand syndrome and the assumption of Phenobarbital is historically important. Pathology, patient’s age, prior motor deficit, and duration from onset of stroke may affect the appearance of this syn-drome. Diagnosis of CRPS in stroke patients is more dif-ficult than in other diseases since the paretic upper limb is frequently painful, edematosus, with altered heat and tactile sensitivity and slight dystrophic skin secondary to non-use syndrome.Conventional radiology may reveal the classic patchy os-


Table 2. Proposed clinical diagnostic criteria for CRPS type I

teoporosis at the shoulder and/or at the hand that may ap-pear generally within 4-8 weeks or later, after the onset of the disease, a feature present in only 40% of patients. Three-phase scintigraphy with technetium has been re-ported to have high sensivity but low specificity. At MRI bone marrow edema is the most frequent finding, with soft tissue anomalies and skin thickening, subcutaneous edema and muscular atrophy.Several therapeutic approaches have been employed in CRPS-1 with different results but recent studies provide conclusive evidence that the use of i.v. bisphosphonate is the treatment of choice 47. A well-planned physiotherapy program after stroke can help to prevent the late complica-tions of the disease 48.

MISCELLANEOUS CONDITIONS AFFECTING THE SHOULDER

In the increasing group of patients undergoing chronic he-modyalisis, a shoulder pain syndrome known as Dyalisis Shoulder Arthropathy (DSA) has been described. It is characterized by shlouder pain, weakness, loss of motion and functional limitation. The pathogenesis of this condi-tion is not fully elucidated although rotator cuff disease, pathologic fracture, bursitis and local amyloid deposition have been implicated as causative factors. Patients gener-ally respond poorly to local steroid injections or NSAIDs, but their condition may improve with the correction of un-derlying metabolic disorders such as ostemalacia or sec-ondary hyperparathyroidism.Primary neoplasms can cause shoulder pain by direct inva-sion of the musculoskeletal system or by compression with referred pain. Primary tumors are more likely to occur in younger individuals. More common lesions have a typi-cal distribution such as the predilection of a chondroblas-toma for the proximal humeral epiphysis or an osteogenic sarcoma for the metaphysis. Neoplasms also may involve the shoulder through metastases to the region. Pancoast tu-

mor may manifest as shoulder pain or cervical radiculitis caused by invasion of the brachial plexus or invasion of the last cervical roots.Cervical pathology may manifest with associated shoul-der pain. The area of referred pain has a dermatomal pat-tern, consistent with the distribution of dermatomal nerve roots. Because conditions causing cervical neck pain and conditions causing shoulder pain may coexist it is often difficult to distinguish which lesion is responsible for the symptoms.The thoracic outlet syndromes often manifest as a vague shoulder pain and deserve a deep clinical evaluation.Finally, from a clinical standpoint, it must be remembered that shouder pain may be unrelated to musculoskeletal dis-eases and can be a manifestation of referred pain linked to a variety of visceral causes. The main gastrointestinal diseases causing shoulder pain are gallstone disease, liver cancer or abscess and splenic breakage. In all of these cases pain referral depends on the innervation of the diaphragm. Furtherly, the most common cardiological causes of shoul-der pain are related to myiocardial ischaemia, pericarditis, aortic dissection and pulmonary embolism. These condi-tions underscore the value of a full-blown clinical evalu-ation of the patient with shoulder pain which represent a true critical challenge in clinical practice.

REFERENCES

1. ennevaara K. Painful shoulder joint in rheumatoid arthritis: a clinical and radiological study of 200 cases with special refer-ence to arthrography of the glenohumeral joint. acta Rheuma-tol Scand 1967; 11:1-116

2. McCarty DJ. Robert adams’ rheumatic arthritis of the shoulder: “Milwaukee shoulder” revisited. J Rheumatol 1989; 16:668-70

3. Lamboley C, Bataille R, Rosemberg F et al. L’épaule senile hé-morragique: à propos de 9 observations. Rheumatologie 1977; 29:323-30

4. neer CS, Craig eV, Fakuda H. Cuff-tear arthropathy. J Bone Joint Surg 1983; 65a:1232-44

To make the clinical diagnosis, the following criteria must be met:

1. Continuing pain, which is disproportionate to any inciting event

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trophic changes (hair, nail, skin)

3. Must display at least one sign at time of evaluation in two or more of the following categories: Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or

deep somatic pressure and/or joint movement) Vasomotor: Evidence of temperature asymmetry (>1°C) and/or skin color changes and/or asymmetry Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/

or trophic changes (hair, nail, skin)

4. There is no other diagnosis that better explains the signs and symptoms


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Platelet Rich Plasma in Arthroscopic Rotator Cuff Repair: State of the ArtPietro Randelli, Vincenza Ragone, alessandra Menon, Riccardo D’ambrosi, Filippo Randelli, Paolo CabitzaDipartimento di Scienze Medico-Chirurgiche, Università degli Studi di Milano; IRCCS, Policlinico San Donato, Milano

CLINICAL EVIDENCE

Surgical use of PRP in arthroscopic rotator cuff repairThe rotator cuff literature has shown that PRP can be ap-plied by either direct injection or physical application of a PRP matrix scaffold to repaired tissues. The main char-acteristics of clinical studies analyzed in this paper are reported in Table 1.

Randelli and colleagues6 demonstrated in a pilot study of 14 patients who underwent arthroscopic repair of the rotator cuff, that the use of PRP in combination with au-tologous thrombin, injected locally in the surgical repair is a safe procedure and effective, no side effects. Later the same authors published7 the results of a ran-domized controlled trial on the effectiveness of the use of PRP in the intraoperative arthroscopic repair of rotator cuff injuries. The pain in the treatment group was signifi-cantly lower compared to the control group at 3, 7, 14 and 30 days after surgery. The clinical scores were signifi-cantly better in the treatment group compared to the con-trol group at 3 months after surgery. There was no differ-ence between the two groups after 6, 12 and 24 months. The MRI performed 12 months after surgery showed no significant difference in the rate of re-injury of rotator cuff (treatment group: 40%, control group: 52%).

Ruiz-Moneo and colleagues8 using a different technol-ogy for the preparation of platelet concentrate, at clinical evaluation did not observe any difference between the group treated with the platelet preparation in the absence of leukocytes (N = 32) and the control group (N = 31). Patients of both groups were subjected to arthroscopic repair of lesions with the difference that in patients ran-domized to the treatment group the plasma rich in growth factors was injected at the site of repair. The healing of the repair of the cuff occurred in 34% of cases in the treatment group and in 25% of cases in the control group (p > 0.05).

Antuna and colleagues9 have recently investigated wheth-er the platelet-rich fibrin improves healing of arthroscop-ic repair of massive cuff lesions (> 50 mm). The authors applied the fibrin rich in platelets at the site of repair of the lesion in 14 patients and compared the clinical and radiological results with a control group of 14 patients. The clinical score and the rate of re-injury (71% in the treatment group versus 64% in the control group) were similar in the two groups at 24 months after surgery.

Gumina and colleagues10 have more recently evaluated the clinical results obtained from the magnetic resonance of the arthroscopic repair of rotator cuff with and without the use of a membrane enriched of platelets and leuko-cytes in patients with a large posterior-superior cuff tear.Eighty consecutive patients were randomized to treat-ment with membrane-enriched leukocytes and platelets (PRP group: 40 patients) or without (control group: 40 patients) inserted between the tendons of the rotator cuff and its insertion. At a follow-up post-operative mean of

INTRODUCTION

Rotator cuff tendinopathies represent the vast majority of shoul-der injuries in adult patients and are a common contributing fac-tor to shoulder pain and occupational disability, which prevalence in the population is rising 1.The use of platelet-rich plasma (PRP) as a biological solution to improve rotator cuff tendon healing has gained popularity over the last several years. Platelet rich plasma (PRP) is a whole blood fraction containing high platelet concentrations that, once activated, provides a re-lease of various growth factors that participate in tissue repair processes: transforming growth factor beta (TGF-b), fibroblast growth factor (FGF), platelet derived growth factor (PDGF), vas-cular endothelial growth factor (VEGF), connective tissue growth factors, and epidermal growth factor (EGF) 2. Platelets also have dense granules that contain a variety of impor-tant bioactive molecules. These proteins function in an autocrine or paracrine fashion to modulate cell signaling and chemotaxis promoting tendon healing 3.

There are clear differences in PRP formulations in terms of growth factor concentration and catabolic enzyme content4. A PRP clas-sification system exists which is based on the presence or absence of white blood cells and whether the PRP is used in an activated or unactivated form. PRP may be prepared via centrifugation as a pure platelet concentrate suspended in plasma (leukocyte-poor PRP) or as a mixture with white blood cells (leukocyte-rich PRP)5. Platelets can be activated ex-vivo with thrombin and/or calcium. Use of PRP in an unactivated manner, without thrombin or calcium relies on in-vivo activation via endogenous collagen.

This paper discuss and explores the available evidence to de-termine the efficacy of the PRP in treatment of rotator cuff in-juries. Emphasis will be placed on published, peer review data investigating the role of this biologic tool in rotator cuff tendon healing.


13 months, were observed re-cuff lesions only in the con-trol group.

A prospective level II cohort study11 has shown that PRP application during arthroscopic rotator cuff repair did not accelerate recovery with respect to pain, range of motion, strength, functional scores, or overall satisfaction when compared with controls at any follow- up time point. The investigators did, however, note a reduced retear rate in the PRP group compared with the control group, but this difference did not reach statistical significance. The same authors12 have recently published the results of a rand-omized controlled trial on the use of 3 platelet rich fibrin clots in the arthroscopic repair of massive cuff lesions (lesion size:> 30 mm). The rate of re-injury was 20% (4/20) in the group treated with PRP and 55.6% (10/18) in the control group (p=0.02).

Recently Zumstein et al.13 hypothesized that arthroscopic rotator cuff repairs using leukocyte- and platelet-rich fibrin (L-PRF) results in a higher vascularization re-sponse and watertight healing rate during early healing. They have treated 20 patients, 10 with arthroscopy plus L-PRF and 10 only with arthroscopy. Clinical examina-tions including visual analogic scale (VAS), Constant, and Simple Shoulder Test scores and measurement of the vascularization with power Doppler ultrasonography

were made at 6 and 12 weeks. The study concludes that arthroscopic rotator cuff repair with the application of L-PRF is technically feasible and yields higher early vas-cularization. Increased vascularization may potentially predispose to an increased and earlier cellular response and an increased healing rate.

Several authors used the Cascade Autologous Platelet System (Cascade Medical Enterprises, Wayne, NJ) to create a platelet rich plasma from autologous blood.

Castricini and colleagues14 conducted a study in prospec-tive randomized controlled double-blind trial of 88 pa-tients who underwent arthroscopic repair of the rotator cuff with the addition of platelet-rich fibrin matrix au-tologous (43 patients) and without (45 patients). The au-tologous fibrin membrane was integrated into the suture and placed at the interface between the tendon and the greater tuberosity under continuous arthroscopic lavage. For an evaluation of 16 months follow-up, there was no statistically significant difference in terms of Constant and magnetic resonance imaging. However, the rate of re-injury resulted of 10.5% in the control group compared to 2.5% in the treatment group with a trend curve which approaches the significance. Arnoczky15 has re-evaluated the data of magnetic resonance imaging in this work us-ing the chi-square test for binomial and concluded that

Authors Evidence PRP formulation Surgical technique No. patients

Randelli et al. (2011)

Level 1Randomized controlled

Injectable PRP (GPS system) Single row 53

Ruiz-Moneo et al. (2013)


Injectable PRP (PRGF Endoret System) Double row 63

Antuna et al..(2013)

Livello 2Randomized controlled

Injectable PRP (Vivostat system) Single row 28

Gumina et al.(2012)


Suturable PRP (RegenKit-THT system) Single row 76

Jo et al.(2011)

Livello 2Prospective cohort

Suturable PRP (COBE spectra system) Transosseous equivalent 42

Jo et al. (2013)


Suturable PRP (COBE spectra system) Transosseous equivalent 48

Zumstein et al. (2014)


Suturable PRP (PRF Process) Transosseous equivalent 20

Castricini et al. (2010)


Suturable PRP (Cascade system) Double row 88

Rodeo et al.(2012)

Livello 2Randomized controlled Suturable PRP

(Cascade system)Single OR Double row/ Transosseous-equivalent 67

Barber et al.(2011)

Livello 3Case control study

Suturable PRP (Cascade system) Single row 40

Bergeson et al(2012)

Livello 3Cohort study

Suturable PRP (Cascade system) Single OR Double row 37

Weber et al.(2013)


Suturable PRP (Cascade system) Single row 60

Table 1: Studies investigating the use of PRP in arthroscopic rotator cuff repair.


PRP improved the results of cuff repair compared to con-trol.

Using the same technology for the preparation of the fi-brin matrix rich in platelets autologous Weber and col-leagues16 have revealed no statistical difference in the percentage of re-injury between the treatment group and the control group (43% and 29%, respectively) after an average of 3-5 months after surgery. A randomized controlled study from Rodeo et al.17 sup-ported the work of Castricini and questioned the early healing benefits of PRP by showing no differences be-tween repairs augmented with autologous fibrin mem-brane and the control group in terms of vascularity and clinical outcomes. In addition, the authors found that 67% of the repairs in the PRP group were intact compared with 81% of the repairs in the control group (p=0.2) which suggests that autologous fibrin membrane may in fact be detrimental to tendon healing in the rotator cuff.

In a case-control study performed by Barber and col-leagues18 clinical outcomes were no difference between the PRP-augmented arthroscopic rotator cuff repair group and the control group. This study did find, interestingly, that the observed incidence of retears on magnetic reso-nance imaging was significantly lower in the PRP group than in the control repairs. Of note, a total of 3 and 2 PRP fibrin gels were used in each study, respectively.

A similar cohort study performed by Bergeson and col-leagues19 showed no improvement in terms of retear rates or functional outcomes in the PRP-augmented repair group compared with controls. Two platelet-rich fibrin matrix (PRFM) clots were used to augment cuff repair of 16 patients with rotator cuff tears at risk for retears inserted into the repair site in this study.The PRP group was compared to a historical control group of 21 patients with similar at risk tears who under-went standard repair without PRP augmentation. Single or double row techniques were performed at the discretion of the surgeon in both the PRP and control group. Passive range of motion was started at 4 to 6 weeks postopera-tively. MRI studies at a minimum of one year follow-up showed a significant difference in the re-tear rate in favor of the control group (PRP group: 56%, Control group: 38%, p=0.024). The significant difference remained when double row repairs were removed from the analysis (PRP group: 62%, Control group: 40%, p=0.022).

PRP injections for rotator cuff tendinopathyRha and colleagues20 reported a study comparing PRP in-jection (Prosys PRP Platelet Concentration System) with dry needling in patients with tendinosis or a partial tear less than 1.0 cm, but not a complete tear. Two procedures in both groups were applied at a 4-week interval. The in-jection of PRP was superior to dry needling with respect to pain, function, and range of motion over a 6-month pe-riod. These findings suggest that treatment with platelet-rich plasma injections is safe and useful for rotator cuff disease.

Kesikburun and colleagues21 investigated the effect of PRP injections on pain and shoulder functions in patients with chronic rotator cuff tendinopathy. Forty patients were randomized to a PRP group (n = 20) or placebo group (n = 20). Patients received an ultrasound-guided injection into the subacromial space that contained either 5 mL of PRP prepared from autologous venous blood (GPS system) in an unactivated manner or 5 mL of sa-line solution. All patients underwent a 6-week standard exercise program. Clinical outcomes were assessed at baseline and at 3, 6, 12, and 24 weeks and 1 year after injection. This study sustains a PRP injection is no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic rotator cuff tendinopathy.

Recently Scarpone and colleagues22 recruited from an outpatient sports medicine clinic patients with rotator cuff tendinopathy refractory to physical therapy and cor-ticosteroid injection. They received one ultrasound-guid-ed injection of 3.0 mL of 1% xylocaine followed by 3.5 mL of PRP at the lesion and surrounding tendon. The au-thors found that a single ultrasound-guided, intralesional injection of PRP resulted in safe, significant, sustained improvement of pain, function, and MRI outcomes.

DISCUSSION

Surgical use of PRP in arthroscopic rotator cuff repairClinical studies have produced conflicting results on the effectiveness of the use of PRP in tendon repair of the rotator cuff, making it now difficult to draw definitive conclusions.The clinical studies published to date have different ex-perimental designs and with a level of evidence that var-ies from 1 to 3. Moreover 7 different systems of prepara-tion of PRP were used between studies (Table 1). The experimental protocol presents variations between differ-ent, as regards the volume of autologous blood, speed and time of centrifugation, method of administration, activating agent, the presence of leukocytes, the final volume of PRP and final concentrations of platelets and factors growth. The surgical technique (transosseous equivalent, single or double row) and the rehabilitation protocol (standard or rapid) were not the same among the different studies. Despite the differences in surgical techniques, in the formulation of the PRP, the sizes of the lesions, the re-injury rate has been recalculated by combining the avail-able data from studies in order to determine the potential of the PRP to improve the healing of surgical repair of the rotator cuff. The analysis of all 12 studies examined showed that there was no significant difference in the rate of re-rupture between the PRP and the control group. The re-injury rate was 31% (90 of 292) and 36.6% (103 of 281), respectively (p-value > 0.05).Three studies have identified small and medium tears of rotator cuff such as those measuring less than 3 cm in length11,14,18. Randelli and colleagues7 have classified


the lesions according to the amount of retraction. If the lesion exposed the head of the humerus, but the tendon retraction did not come to the surface of the glenoid, was defined as a small or medium injury.A significant difference was found when a stratified anal-ysis was performed to analyze the results of small and medium lesions of the rotator cuff. The rate of re-injury was 7.9% among patients treated with PRP compared to 26.8% of those treated without PRP (p-value = 0.002, Chi-square test).It is important to emphasize that with the exception of two cases of infection, has not been reported any com-plication from the use of PRP. Bergeson and colleagues19 showed an infection rate of 12% among patients treated with fibrin matrix rich in platelets (Cascade Autologous Platelet System) compared to 0% in the control group. However, this difference did not reach statistical signifi-cance, and no difference in the rates of infection or com-plication rates was found in the remaining studies. Although clinical studies have produced conflicting re-sults, the data on PRP suggest a beneficial effect on the healing process when applied during the repair of the ro-tator cuff. The stratified analysis of small or medium lesions showed a significant rate of re-injury overall lower in the group PRP. Therefore currently it seems the PRP can improve the healing of arthroscopic repair of small and medium lesions that seem more prone to a biological response to treatment with growth factors.Namazi has recently highlighted the main mechanisms by which PRP can reduce the rate of re-injury of the ro-tator cuff23. The level of interleukin 1β (IL-1β) is corre-lated with the degeneration of the tendons of the cuff. In contrast, TGF-β can improve the strength of the repair of these tendons. Recent studies have shown that the PRP can not only inhibit the inflammatory effects of IL-1β, but also enhance the production of TGF-β24,25. A recent in vitro studies on the effect of PRP on human tenocytes from rotator cuff with degenerative lesions, have shown that the growth factors released by platelets may enhance cell proliferation of tenocytes and promote the synthesis of extracellular matrix tendon26,27. Further-more an in vivo animal study has shown than that the type of application, injection or absorption from a sponge did not influence the effect of PRP on rotator cuff heal-ing28.The PRP is certainly a source of bioactive growth factors, however the optimal preparation, activation, as well as the quantification of the various growth factors present in the PRP is a controversial subject. Further prospective randomized controlled trials (level 1 evidence) will be necessary.

PRP injections for rotator cuff tendinopathy Injections of PRP have gained popularity in the treatment of tendinopathy based on its promoting effects on ten-don cell proliferation, collagen synthesis, and vascular-ization, which have been shown in animal and in vitro studies29,30.As regards the use of PRP for chronic rotator cuff ten-dinopathy there is a limitation of well designed studies

testing the effectiveness of PRP injections in the subac-romial space.In a systematic review of the literature we have found only two randomized controlled trials evaluating the use of PRP injections in rotator cuff tendinopathy20,21.

These studies have reported controversial results on the effectiveness of the use of PRP injection in chronic cuff tendon diseases.The systems of preparation of PRP were not the same across the trials and different treatment protocols were used (single or double PRP injections). Furthermore the presence of some bias including the concomitant stan-dard exercise program and the needle stimulus effect can have influenced the results of studies.Furthermore rotator cuff tendinopathy has a multifacto-rial origin. Extrinsic factors including anatomic prob-lems and alterations in kinematics of the joint or intrinsic factors including age-related degenerative changes and vascularity changes may play a role in developing such disease. The effect of PRP can change according to dif-ferent mechanisms underlying rotator cuff tendinopathy. The nature of rotator cuff disease was not the same across the studies and patients who didn’t respond to physical therapy and corticosteroid injection seem to be advan-taged from the PRP use. Whether PRP may be beneficial in a more specific group of patients refractory to a stan-dard exercise therapy needs of additional research.More studies with a high level of evidence are required to justify PRP injections in rotator cuff tendinopathy.

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23. namazi H. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation: a novel molecular mechanism. arthroscopy; 2011:1456; author reply -7

24. Kakudo n, Minakata t, Mitsui t, Kushida S, notodihardjo FZ, Kusumoto K. Proliferation-promoting effect of platelet-rich plas-ma on human adipose-derived stem cells and human dermal fibroblasts. Plast Reconstr Surg 2008; 122:1352-60

25. Savitskaya Ya, Izaguirre a, Sierra L, et al. effect of angiogenesis-related cytokines on rotator cuff disease: the search for sensi-tive biomarkers of early tendon degeneration. Clin Med Insights arthritis Musculoskelet Disord 2011; 4:43-53.

26. Hoppe S, alini M, Benneker LM, Milz S, Boileau P, Zumstein Ma. tenocytes of chronic rotator cuff tendon tears can be stimulated by platelet-released growth factors. J Shoulder elbow Surg 2013; 22:340-9

27. Jo CH, Kim Je, Yoon KS, Shin S. Platelet-rich plasma stimulates cell proliferation and enhances matrix gene expression and syn-thesis in tenocytes from human rotator cuff tendons with de-generative tears. am J Sports Med 2012; 40:1035-45

28. ersen A1, Demirhan M, atalar aC, Kapicioğlu M, Baysal G. arch Orthop trauma Surg. Platelet-rich plasma for enhancing surgi-cal rotator cuff repair: evaluation and comparison of two ap-plication methods in a rat model. 2014;134:405-11

29. Jo CH, Kim Je, Yoon KS, Shin S. Platelet-rich plasma stimulates cell proliferation and enhances matrix gene expression and syn-thesis in tenocytes from human rotator cuff tendons with de-generative tears. am J Sports Med. 2012; 40:1035-1045

30. de Mos M, van der Windt ae, Jahr H, et al. Can platelet-rich plasma enhance tendon repair? a cell culture study. am J Sports Med. 2008; 36:1171-1178

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Platelet rich plasma in rotator cuff diseaseUmile Giuseppe Longo, alessandra Berton, Giacomo Rizzello, Giuseppe Salvatore, Vincenzo Denaro Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Roma

pRp BIOLOGY

Platelet-rich plasma (PRP) gained popularity over the last years thanks to its potential as a biological solution to im-prove rotator cuff tendon healing.It is a blood fraction containing high platelet concentrations, high density of growth factors and structural proteins. PRP acts upon tendon healing by modulating inflamma-tion, activating fibroblast migration, promoting angiogen-esis, and increasing cell proliferation1. Platelets become activated at the site of tissue injury and release intracellular stores. They are predominantly alpha-granules (50-80 alpha-granules per platelet), dense gran-ules (3-5 granules per platelet) and lysosome 2. Alfa-granules contain more than 300 proteins. Basic growth factors identified include PDGF, TGF, FGF, en-dothelial growth factor (EGF), hepatocyte growth fac-tor (HGF), connective tissue growth factor (CTGF) and VEGF. Those play important roles in cell proliferation, chemotaxis, cell differentiation, and angiogenesis. Specif-ically, TGF-β promotes matrix synthesis PDGF, together with platelet factor-4 and CXCL7, activates fibroblasts’ migration3, PDGF-B, bFGF and CXCL5 are involved in the homing of precursor cells4, HGF is a potent antifibrot-ic that may help to reduce scar formation around tendon tissues5 and, together with VEGF promote angiogenesis6. The role of platelets in angiogenesis is complex because a-granules also contain anti-angiogenic proteins such as Thrombospondin-1 (TSP-1), angiostatin, endostatin, fi-bronectin and the tissue inhibitors of metalloproteinases (TIMPs -1 to -4)7. They are stored separately and should

be released differentially thanks to an agonist-specific mechanism 8. Platelets also modulate inflammation by secreting high levels of chemokine such as CXCL1/GRO, ENA78/CXCL5, monocyte chemoattractant protein-1 (MCP-1), CCL5, IL8 9. Moreover, platelets secrete platelet basic protein (PBP) and connective tissue activating peptide-III (CTAP-III)). Those are precursors of b-thromboglobulin [(CXCL7 or neutrophil activating peptide-2, (NAP-2)], a strong chemoattractant and an activator for neutrophils. Dense granules contain bioactive factors that have impor-tant effects on biologic aspects of wound healing. Hista-mine and serotonin increase capillary permeability, al-lowing inflammatory cells to migrate toward the area of inflammation. Moreover, they activate macrophages10,11. Studies show that the nature of the stimulants or the com-bination of stimulants on macrophage can lead to different kind of activation. ‘classical’ macrophage activation may determine an anti-inflammatory environment compared to ‘innate” activation 12.PRP therapies also contain cell adhesion molecules in-cluding fibronectin, fibrin, and vitronectin. Those add to the potential biologic activity of PRP by forming three-dimensional scaffolds where cells can adhere and begin the wound healing process.

pRp COMpOSITION

PRP therapies includes several formulations that differ in their pharmacological and material characteristics. Those characteristics influence the biology and potential effects. The main difference between plasma concentrates is leu-cocytes content and fibrin network. Four categories have been identified: leucocyte-poor or pure platelet-rich plas-ma (P-PRP), leucocyte- and platelet-rich plasma (L-PRP), leucocyte-poor or pure platelet-rich fibrin (P-PRF), leuco-cyte- and platelet-rich fibrin (L-PRF).A further division is between activated (ex vivo activation with thrombin and/or calcium) and unactivated form (in vivo activation via endogenous collagen)13,14. There are no definitive data to support the use of L-PRP or PRP. Studies showed L-PRP had pro-inflammatory ef-fect when injected in rabbits15 and increased the levels of MMPs when assayed in tenocyte cultures compared with pure PRP16.On the other hand, leucocyte in PRP has a positive role as anti-infectious and immune regulatory agents 17-20. Studies showed decreased pain and inflammation when used for treatment of tendonitis 21,22.

ABSTRACT

Platelet-rich plasma (PRP) is an emerging strategy to enhance tendon healing. Its increased used in the clinical setting is due to its safety. However, definitive evidence on PRP potentiality still need to be clarified. Only some molecular mechanisms have been described and many others need to be studied. The knowledge of the healing process will also help to identify optimal formulations and protocols for the clinical use. The available clinical studies on PRP for rotator cuff disease not only reported conflicting results but they are difficult to compare because of different experimental designs, level of evidence, PRP formulations, surgical technique, rehabilitation protocol, size of the lesion or nature of the disease. To date, clinical benefits of PRP are not demonstrated and powered randomized controlled trials are necessary.


The ratio between fibrinogen and thrombin concentrations is another aspect that is still under-researched. It is respon-sible for fibrin polymerization and its biochemical archi-tecture that represent the support cytokine enmeshment and cellular migration23-25.Further studies are needed define the optimal PRP formu-lation to manage rotator cuff lesions.

CLINICAL STUDIES ON pRp IN ROTATOR CUFF LESIONS AND TENDINOpATHY

There are still many questions about the biologic mecha-nisms of the action of PRP, however the safety and feasi-bility of PRP therapies allowed clinical studies and patient-oriented research to be performed. PRP has been used both on acutely injured tendon and de-generative tendon. The underlying cellular and molecular processes are quite different between these two disparate clinical conditions, thus they should be considered sepa-rately. Clinical studies on PRP in rotator cuff lesions not only re-ported conflicting results but they are difficult to compare because of different experimental designs, level of evidence, PRP formulations, surgical technique, and the rehabilitation protocol. At the moment, studies that have been published are: seven level 126-32 and two level 233,34 randomized control-led trials , one level 2 prospective cohort study 35, two Level 3 case control studies 36,37 and one level 3 cohort study38. Four of them investigated the effect of injectable PRP in arthro-scopic rotator cuff repair26,27,33,36 while the others applied su-turable PRP28-32,34,35,37,38. Plasma products were heterogenic, in terms of volume of autologous blood collected, speed and time of centrifugation, method of administration, activating agent, presence of leukocytes, final volume of PRP, and fi-nal concentration of platelets and growth factors. The surgi-cal technique was single row26,28,32-34,37,38, double row27,31,34,36 or transosseous equivalent29,30,35. The rehabilitation protocol was could be standard or rapid. All those factors might have important implications for clinical outcomes and arise the need for comparative effectiveness research. Clinical outcomes were no different between PRP group and control group in all studies. Only Randelli et al26 de-tected a statistically significant improvement in the Con-stant, SER, UCLA, SST at the 3 month follow-up and Bar-ber et al37 detected a statistically significant difference in the Rowe score (mean follow-up of 31 months). Postoperative tendon healing showed no significant differ-ence both at MRI26,31,37 or ultrasound34 imaging.Re-rupture rates between PRP and control group was not significantly different in all studies. However, Barber et al37 showed a statistically significant difference in the rates of tendon re-rupture (60% vs 30%; P = 0.03) at 4 months from surgery. Moreover, a stratified analysis the results of small and medium lesions of the rotator cuff showed lower rate of reinjury (7.9%) among patients treated with PRP, compared to those treated without PRP (26.8%)39.To date, there are not definitive evidence to support the routine use of PRP in rotator cuff repair. Further rand-omized prospective trials are necessary to achieve defini-tive answers in this field.

Clinical studies on PRP injections for rotator cuff tendin-opathy are just few despite the great popularity in the clini-cal setting40,41. Also in this case there are methodological limitations and difficulties in comparisons. There are two randomized controlled trials on PRP injec-tions for rotator cuff tendinopathy, one supporting PRP superiority with respect to pain, function, and range of motion over a 6-month period40, the other showing no dif-ference for quality of life, pain, disability, and range of motion at 1 year41. They used different treatment proto-cols, Rha et al.40 used 2 PRP (3 mL) injections at a 4-week interval, and Kesikburun et al.41 used 1 injection of PRP (5 mL) with concomitant standard exercise program. Moreo-ver the nature of the disease was not the same, maybe in-fluencing the results. Further studies are needed to acquire higher level of evi-dence and define the role of PRP injection for rotator cuff tendinopathy.

CONCLUSION

Platelet-rich plasma (PRP) is an emerging strategy to en-hance tendon healing42-46. Its increased used in the clinical setting is due to its safety. However, definitive evidence on PRP potentiality still need to be clarified. Only some mo-lecular mechanisms have been described and many others need to be studied. The knowledge of the healing process will also help to identify optimal formulations and proto-cols for the clinical use. The available clinical studies on PRP for rotator cuff dis-ease not only reported conflicting results but they are diffi-cult to compare because of different experimental designs, level of evidence, PRP formulations, surgical technique, rehabilitation protocol, size of the lesion or nature of the disease. To date, clinical benefits of PRP are not demon-strated and powered randomized controlled trials are nec-essary.

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Biology of rotator cuff tendinopathyantonella Murgo, Orazio De Lucia, Chiara Crotti, Pier Luigi MeroniDivisione e Cattedra di Reumatologia, Istituto Ortopedico Gaetano Pini, Milano

GENETIC ASSOCIATIONS

Although it has been suggested that some individuals dis-play a genetic predisposition to the development of ten-dinopathy (variants of tenascin-C gene with 12 and 14 guanine-thymine repeats or COL5A1 BstUI restriction fragment length polimorphisms), a specific genetic asso-ciation is still matter of research. The difficulty in finding such association may be explained by the existence of a complex interactions between multiple genes 3.

CELLULAR AND MOLECULAR pATHOGENESIS

Cell infiltrates, thinning and disorganization of the tendon fibers, granulation tissue and fibrocartilage alterations have been described in rotator cuff tendinopathy and linked to tension force decrease and rupture tendency 4. Histopatho-logical changes are consistent with a generalized hypoxia. Immunohistochemical and microarray studies have dem-onstrated the presence of neo-vascularization and the in-crease of neurotransmitters (in particular substance P), which would partially explain the origin of chronic pain in tendinopathy 5.The definition of cellular infiltrate is a milestone in the acknowledgment of rotator cuff tendinopathy. The early stages of tendon damage could result from an inflamma-tory response to a mechanical stress. The difficulty in achieving appropriate experimental models leads to a lack of information concerning the role of inflammatory cells and mediators. A significant increase of neutrophils, mac-rophages and mast cells can be found in the early stages of tendinopathy; inflammatory cells produce different an-giogenic, pro-inflammatory and degenerative factors, that promote degenerative and reparative processes into the extracellular matrix 6.An increasing number of studies suggest that cytokines (TGF-β, IL1, IL6, IL15, IL18) are active in various steps of tendinopathy, affecting cell-chemotaxis, proliferation and differentiation, matrix synthesis throught an autocrine or paracrine signaling. These effects are particularly re-markable under the influence of transforming growth fac-tor β (TGF-β) produced by macrophages. The family of TGF-β is required for proper fetal development of tendons and plays a major role in the healing process.It has been shown that TNF-β increases the production of collagen and proteinase activity 7, with the result of stimulating the formation of small fibrovascular scars. This event initially would play a protective and reparative role, but later it could cause a weakening of the structure,

facilitating tendon rupture. TGF-β helps the production of matrix proteins (fibronectin, glycosaminoglycans) and the maturation of monocytes into macrophages, amplify-ing the inflammatory response. The role of IL-6 has been recently investigated: its expression is up-regulated in pathological tendons. IL-6 has both pro-inflammatory and anti-inflammatory effects and its expression, as a media-tor of cyclooxygenase-2 (COX2) in pathological tendon, its expression does not necessarily support an inflamma-tory state. IL-6 expression is different in the Achilles and posterior tibial tendinopathy; it remains unclear whether this finding is related to differences in load, structure or progression of tendinopathy 8. Although this study does not analyze the rotator cuff tendons, in our opinion, it suggests the complexity of tendinopathy biomechanical processes.IL-1β increases the synthesis of COX-2, PGE2 production and matrix metalloproteinases (MMP-1, MMP-3, MMP-13) which cause matrix destruction, a loss of tendon bio-chemical properties. Moreover IL1β displays pro-apop-

INTRODUCTION

Tendinopathy is a frequent condition and cause for referral to orthopedics and rheumatologists. Rotator cuff tendons (espe-cially the supraspinatus) are the most vulnerable and commonly involved structure; the incidence increases with age up to 40% in subjects aged >70 years 1. The etiopathogenesis of the rotator cuff tendinopathy is still poorly defined despite its high frequency. Better understanding of the biological processes lying behind the tendon-bone junction damage is needed in order to have more therapeutical options.The clinical syndrome characterized by pain, impaired perfor-mance and swelling due to the increased thickness of tendons and/or the surrounding structures, is called tendinopathy. Because of the presence of symptoms usually related to inflammation, the term “tendinitis” had been used to describe this condition for long time. However, the evidence of degenerative lesions, character-ized by disorganization of tendon ultrastructure, not always ac-companied by a significant inflammatory component, has led to prefer the generic term tendinopathy 2.Rotator cuff tendinopathy is mediated by extrinsic mechanisms (i.e. anatomical, biomechanical) and intrinsic processes (i.e. al-terations in biological and mechanical properties, in morphology, in vascularization), both responsible for the possible damage of the whole tendon. It is commonly described as a progressive dis-order, beginning with an acute phase followed by a condition in which degenerative aspects are prevalent and potentially ending in a complete rupture.


totic activity and strongly down regulates several gene expression 9.

THE ROLE OF THE ExTRACELLULAR MATRIx

Extracellular matrix (ECM) is a complex entity that sur-rounds and supports the tendon cells; it is composed by col-lagen fibers and elastin. In addition to structural proteins it contains specialized proteins (eg fibronectin and fibrillin) and proteoglycans. In order to play its physiological role, ECM undergoes to a continuous remodeling process, me-diated by some enzymatic activities (mainly MMP). Since the interaction between cells and matrix is bi-directional, extracellular changes may arise from cellular processes (proliferation, migration, apoptosis, and morphogenesis), or may originate from extracellular microenvironment 10. According to several Authors, the imbalance between syn-thesis and degradation of ECM components would lead to the deterioration and degeneration of the tendon structure.The balance between MMP and their inhibitors is essen-tial in the maintenance of tendon ECM homeostasis and an imbalance may result in uncontrolled tendon damage. These enzymes play a major role in the matrix degrada-tion during development, repairing process and may play a key role in the pathogenesis of tendinopathy. An in vitro study demonstrated that MMP inhibitors can prevent the activation of MMp-13 and inhibit pericellular matrix de-generation and the loss of material properties associated with stress deprivation 10.Collagen is the main component of the tendon. The colla-gen portion is made up of 95% type I collagen with small amounts of 27 other types of collagen. Following TGF-β1 secretion, there is an increase in collagen production, es-pecially in favor of less represented variants (type I, III, V) and of “altered” forms (high percentage of denatured collagen) 11.The loss of balance between synthesis and degradation of ECM has also a negative impact on proteoglycans, which are protein/polysaccharide complexes. Proteoglycans, and their constituent glycosaminoglycans (GAGs), are involved in several physiological processes and may dis-play both a structural and signaling role. Unfortunately the changes occurring in proteins different from collagen are still poorly known in tendinopathies. It has been document-ed that some GAGs, such as fibronectin and tenascin-C, promote the migration of fibroblasts and their adherence to fibrin. A persistent increase in expression of fibronec-tin and tenascin-C has been reported in tendinopathies and may contribute to the pathogenic remodeling 12.A disintegrin-like and metalloprotease with thrombospon-din motifs (ADAMTS), a novel family of extracellular proteases, seems to play an important role in proteogly-can turnover in tendon, although the informations on this mechanism are not enough 13.Tenocytes, a fibroblast-like cell type, are the regulators of the ECM remodeling process. Before the development of tendinopathy, tenocytes undergo significant changes in morphology and proliferation, become necrotic or apop-totic and increase the local expression of insulin-like growth factor (IGF-1) 10. IGF-1 increases DNA synthesis

in tenocytes, GAG production and collagen synthesis; its stimulating effects affect other cell types such as cartilage, bone and muscular cells.It has been observed that rotator cuff tendon cells display a fibrochondrogenic phenotype nearby the affected areas. An increased expression of cartilage genes, such as CO-L2A1, SOX9 and aggrecan, has been described in animal models of supraspinatus tendinopathy 9.

THE ROLE OF ApOpTOSIS

Apoptosis, or programmed death of tenocytes, plays a definite role in the genesis of rotator cuff tendinopathy. Apoptosis is triggered and tuned by intrinsic and extrinsic mechanisms. Fibroblast or fibroblast-like apoptosis may play a critical role in the maintenance of the extracellu-lar matrix of rotator cuff tendons. BNip3, a pro-apoptotic member of the BcL-2 family, has been specifically linked with hypoxia and inflammation-induced apoptosis. Ben-son et al. reported an almost 3-fold increase in apoptosis within full-thickness rotator cuff tears compared with con-trol groups 14.

MECHANICAL CAUSES

Repetitive microtraumas/stressing conditions are thought to play a main pathophysiological role in tendinopathies. More recently it has been demonstrated that repeated trau-mas and the related stromal tissue damage can affect cell responses through the receptor recognition of intracellu-lar proteins released by necrotic cells. Among them, heat shock proteins (HSPs), also called damage-associated mo-lecular patterns (DAMPs), are rapidly released following non-programmed cell death, are key effectors of the in-nate immune system and restore homeostasis of the tissue. HSPs, released from stressed tenocytes, play a role in early tendon damage as they regulate both the tissue healing re-sponse and the inflammatory reaction with a fine balance between reparative versus degenerative changes 6.Repetitive micro-traumas/stresses are also responsible for ischemia, and consequent hypoxia, which represents potential trigger and cause of rotator cuff tendinopathy, recently correlated with an increased apoptosis. Cytok-ines play a key role in oxidative stress-induced cellular apoptosis, which is mediated by the activation of caspases (cysteine-dependent aspartate-directed proteases, a group of proteolytic enzymes) 15.Hypoxia also triggers the expression of vascular endothe-lial growth factor (VEGF), which promotes angiogenesis and increases the expression of MMPs. Both these events can cause weakening of the tendon structure.VEGF and von Willebrand factor messenger RNA (mRNA) expression levels were significantly increased in a rat model of sovraspinatus tendon overuse injury, but it is unclear whether the increase in these angiogenic cytokines is part of the early healing response cascade or just reflects the response to injury 16.Hypoperfusion is also responsible for the increase of free radicals, which can cause a direct cell damage. In fact, the


expression of peroxiredoxin 5, an antioxidant enzyme that protects cells from free radicals- induced damage, is in-creased in tenocytes during tendinopathy. However small amounts of free radicals can be harmless and stimulate the fibroblast proliferation. For example, nitrix oxide (NO), can enhance tendon healing. NO is synthesized by a fam-ily of enzymes, the nitric oxide synthases (NOSs) that can be induced by bacterial cell wall products and proinflam-matory cytokines (eg. IL-1 and TNF).Three NOS isoforms are expressed by fibroblasts during tendon healing and NO production increase seems to be related to an improvement in mechanical properties of damaged tendons, through the stimulation of fibroblast proliferation and ECM synthesis. Existing data indicate that several proinflammatory agents (e.g. cytokines, prostaglandins, growth factors and neu-ropetides) may initiate rotator cuff tendinopathy and that apoptosis play a key role in the development and progres-sion of the process.Our understanding of the biology of tendinopathy is poor, mainly because of the difficulties in defining the sequence and chronology of the pathogenic events taking place in such a complex process.

REFERENCES

1. Meislin RJ, Sperling JW, Stitik tP. Persistent shoulder pain: epi-demiology, pathophysiology and diagnosis. am J Orthp 2005; 34:5-9

2. Maffulli n, Kahn KM. Clinical nomenclature for tendon injuries. Medicine and Science in Sports and exercise 1999; 31:352-3

3. Mokone GG, Schwellnus MP et al. the COL5a1 gene and achil-les tendon pathology. Scand J Med Sci Sports 2006; 16:19-26

4. Blevins Ft, Djurasovic M, Flatow eL, Vogel KG. Biology of the ro-tator cuff tendon. Orthop Clin north am 1997; 28:1-16

5. Schubert te, Weidler C, Lerch K, Hofstadter F, Straub RH. achil-les tendinosis is associated with sprouting pf substance P posi-tive nerve fibres. ann Rheum Dis. 2005; 64: 1083-1086

6. Millar nL, Wei aQ, Molloy tJ, Bonar F, Murrell Ga. Cytokines and apoptosis in supraspinatus tendinopathy. J Bone Joint Surg Br 2009; 91:417-24

7. Hays PL, Kawamura S, Deng XH, Dagher e, Mithoefer K, Ying L, et al. the role of macrophages in early healing of a tendon graft in bone tunnel. J Bone Joint Surg am 2008; 90:565-79

8. Legerlotz K, Jones eR, Screen HRC, Riley GP. Rheumatology 2012; 51:1161-1165

9. archambault JM, tsuzaki M, Herzog W, Banes aJ. Stretch and interleukin-1beta induce matrix metalloproteinases in rabbit tendon in vitro. J Orthop Res 2002; 20: 36-39

10. arnoczky SP, Lavagnino M, egerbacher M. the mechanobiologi-cal aetiopathogenesis of tendonpathy: is it the over-stimolation or under-stimulation of tendon cells? Int J exp Pathol 2007; 88:217-226

11. Riley G. the pathogenesis of tendinopathy. a molecular per-spective. Rheumatology 2004; 43:131-142

12. Xu Y, Murrel GaC. the Basic science of tendinopathy. Clin Or-thop Relat Res 2008; 466: 1528-1538

13. Jones GC, Riley GP, aDaMtS proteinases: a multi-domain, multi-functional family with roles in extracellular matrix turnover and arthritis. arthritis Res ther 2005; 7:160-169

14. Benson Rt, McDonnell SM, Knowles HJ, Rees JL, Carr aJ, Hulley Pa, tendinopathy and tears of the rotator cuff are associated with hypoxia and apoptosis. Journal of bone and joint surgery. 2010; 92B:448-53

15. Yuan J, Murrell GaC, trickett a, Wang MX. Involvment of cy-tochrome c release and caspase-3 activation in the oxidative stress-induced apoptosis in human tendon fibroblasts. Biochim-ica et Biophysica acta. 2003; 1641:35-41

16. Perry SM, McIlhenny Se, Hoffman MC, Soslowsky LJ. Inflammatory and angiogenic mRna level are altered in a supraspinatus tendon overuse animal model. J Shoulder elbow Surg 2005; 14:79S-83S


ABSTRACT

The high incidence of recurrent tendon tears after repair of mas-sive cuff lesions is prompting the research of materials aimed at mechanically or biologically reinforcing the tendon. Among the materials studied so far, the Extracellular Matrix (ECM) scaf-folds of human origin have proved to be the safest and most efficient, but the current legislations on grafts and transplants preclude their use in Europe. In order to overcome this condition in 2006 we started a project on the production of an ECM scaffold of human origin which could be implanted in Europe too. In 2009 the clinical study began with the implantation of dermal matrix scaffolds in 7 middle-aged patients affected with wide/massive cuff lesions and tendon degeneration. Out of 5 cases followed for at least 1 year in which the scaffold was employed as an augmentation device, there were 3 patients with complete healing, 1 partial re-tear and 1 total recurrence. The absence of adverse inflammatory or septic complications allows to continue this research line with a prospective con-trolled study in order to define which might the real advantages and correct indications offered by scaffold application.

Scaffold augmentation in rotator cuff tears repairsRoberto Rotini, alessandro Marinelli, enrico Guerra, Graziano Bettelli, Michele Cavaciocchi, Lorenzo Zaccarelli, Milena Fini*, elena Bondioli**Shoulder and Elbow Unit, Rizzoli Orthopaedic Institute, Bologna* Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopaedic Institute, Bologna** Burn Intensive Care Unit and “Regione Emilia Romagna” Skin Bank, Bufalini Hospital, Cesena

INTRODUCTION

The lesion of the rotator cuff is present in 40% of patients over the age of sixty, in a high percentage, the injury causes disability due to pain and functional limitation or because it demonstrates evolutionary causing a progressive loss of strength.1 Remarkable advances in the surgical technique of rotator cuff tears over the last 15 years offer nowadays the opportunity to effectively repair most of the lesions. Prog-ress has either involved manufacturing suture anchors that now present higher pull-out strength and are treated with multiple reinforced sutures, as well as improvement in repair techniques.2-6 In particular margin convergence techniques, that allow to reduce the stress of the repair, better “suture grasping” techniques and double row or transosseous equiv-alent repair techniques, that permit to widen the contact sur-face between tendon and foot-print, allow to obtain suture repairs mechanically stronger than in the past.7However there are still several conditions where limits of reparative surgery are evident. A high incidence of failure follows repair of wide/massive lesions, particularly when the lesion is old and the tendon shows degenerative chang-es.8 Failure can happen after a time (re-tear), but in many of

these cases it can be the effect of missed healing. The main factors that can cause a missed tendon-to-bone healing are mechanical (low strength of the tendon or of the suture, ex-cessive tension on the repair) or biological (low quality and vitality of tendon and bone). Recently, in order to overcome the limits of traditional reparative surgery, techniques of re-generative medicine are under investigation; they are aimed at enhancing and directing the tissue repair with formation of a tendon tissue having histological and mechanical prop-erties resembling those of the native tendon. Most of the research studies are focused on obtaining scaffolds able to provide an initial mechanical augmentation to the repaired cuff, absorbing part of the stresses and thereby protecting the suture. At the same time the scaffold should be, already in the initial phases, a ground for hosting cells colonization, leading to the formation of a tendon structure with the same histological, architectural and mechanical features of the na-tive one, but with a higher thickness. Additional requisites for these scaffolds should be a full biocompatibility and tolerability, a complete resorption at the end of the healing process, high suture retention properties and being easily to handle and fit for arthroscopical application.The materials that have been studied and employed as aug-mentation devices can be divided into synthetic and biologic (Tab. 1).

A. Synthetic scaffolds, as Mersilene meshes or Polytetra-fluoroethylene patches, have been used for rotator cuff re-pair, but regardless of their excellent tensile strength9-10 they are not recommended due to the lack of biological proper-ties, the possibility to obstacle the tissue tendon growth and the risk of foreign body reactions. In recent years the nov-elty among synthetic scaffolds has been the development of absorbable materials obtained through the electrospinning techniques (electrospinning). This method, through the pro-cessing of synthetic nanofibers, allows to create a three di-mensional structure that mimics the normal orientation of collagen fibers;11 on these materials, so far only tested in vitro, can also be applied growth factors or stem cells.B. Biologic scaffolds can be classified into: B1) autologous tissues from fascia lata 12 or biceps ten-don; 13-15 B2) homologous tissues from rotator cuff 16-17 or patellar tendon allografts, Achilles tendon allografts and quadri-ceps tendon allografts18 that were used to treat massive, irreparable rotator cuff tears have been associated with un-satisfactory or variable not reproducible results; B3) allografts or xenograft from extracellular matrices (ECM scaffolds) obtained through decellularization pro-


Table. 1 Materials employed as augmentation devices for rotator cuff repair.

cesses. This group is nowadays the most extensively studied to obtain biologic scaffolds. The decellularization process based upon chemical or physical processes eliminates the cellular DNA containing the immunogenic components, but preserves unaltered the extracellular matrix with its three-dimensional structure and its content in collagen fibres. The three-dimensional architecture, the presence of col-lageneous and not collageneous proteins and growth factors (GFs) are fundamental to create an adequate environment for cell adhesion, proliferation and differentiation. During the healing process the progressive degradation of the scaf-fold releases molecules that also play a role in determining the recruitment and proliferation of appropriate cell types during tissue remodeling.

ECM scaffolds available on the market for surgical repair of cuff lesions can be divided into:B3.a) Xenografts – membranes deriving from animal der-mis, intestine, pericardiumB3.b) Allografts – membranes deriving from human dermis or fascia lata

Scaffolds from animal origin (B.3a) meet the criteria dictat-ed by FDA; the EU approve which approves their use as de-vices for reinforcement after tendon repair (augmentation), but not as devices to patch the rotator cuff hole (bridging).

In some cases this kind of scaffolds has proven to be immu-nogenic, so their use in cuff repair surgery is now discour-aged (Fig. 1).19-23

Human-derived membranes (B.3b), like the human dermal matrix - Graft Jacket (GJA) or Allopatch, are classified as human tissues for transplantation and each Country has to follow National Regulatory Transplantation Center rules for the control of human-derived tissue transplants. Due to the differences between transplant laws between Europe and USA, commercial membranes derived from human tissue and produced in USA currently cannot be implanted all over Europe.In 2005, before Italian and European laws forbid its use, we obtained good results in some patients treated with GJA (un-published data). Confirmations on the effectiveness of acel-lular human dermal matrix come from several researches. A study performed at our Istitute confirms that GJA presents suitable biological properties for in situ tissue engineering and in vitro bioengineering of rotator cuff tendons24 and has been shown to increase the mechanical strength of the re-pair.25 In two different animal studies where GJA was used to bridge large full thickness tendon tears, Adams and Ide

noted the histological evidence of native cell infiltration and neotendon development already at 6 weeks; moreover in few months after surgery histological incorporation of the acellular dermal matrix graft into a structure resembling

A. SYntHetIC: Use regulated by FDa (USa) or Ce (europe)

Product tissue type & Source Company

SportMesh Soft Tissue Reinforcement Poly (urethanaeurea) Biomet Sports Medicine X-Repair Poly-L-Lactide Synthasome

B. BIOLOGIC:

1) Autografts (Long Head fo the Biceps, Fascia Lata)

2) Allografts unprocessed tissues (Rotator cuff, Achilles, Cutis, Fascia Lata)

3) Allograft or Xenograft decellularized tissues (Small Intestinal Submucosa, Derma, Pericardium, Fascia Lata)

a) Xenografts Use regulated by FDA (USA) or CE (Europe)


Restore SIS-Porcine Depuy Orthopaedics CuffPatch SIS Porcine Biomet Conexa Dermis Porcine Tornier TissueMend Fetal Dermis Bovine Stryker Orthopaedics Permacol Dermis Porcine Zimmer Bio-Blanket Dermis Bovine Kensey Nash OrthADAPT bioimplant Pericardium Equine Pegasus Biologics

b) Allograft Use regulated by National Transplantation Centers


Graft Jacket Human Dermis Wright Medical Technology Allopatch Human Fascia Lata Muskulosk. Foundation


Figure 1. MRI image DP Fat Sat, coronal oblique, sagittal and axial. Patient of 28 aa with important inflammatory

arthrosynovitis 6 months after implantation of a scaffold equine that required a

re-operation for removal of the membrane in arthroscopy and joint lavage.

2) Evaluation of the biologic properties and features of the membrane:24, 35

- the product was analyzed with optic and electronic microscopy techniques to confirm the conservation of the tridimensional collagenic structure which is necessary for tendon tissue regeneration

- optic and electronic microscopy techniques as well as biochemical tests were employed to rule out the persistence of residual vital cells, an important as-pect to avoid possible immunological reactions

- the anabolic activity of tenocytes grown on the AHDM was investigated through the analysis of Cell Proliferation (WST-1), the ECM production tissue, Collagen I (CICP), Proteoglycans (PG), Fi-bronectin (FBN), and Transforming Growth Fac-tor β1 (TGFß1), Interleukin 6 (IL-6) evaluation.

From a comparison between AHDM and control cultures a significant higher amount of collagen I, fibronectin, proteoglycans, and TGFβ1 was ob-served in AHDM cultures.34

3) Evaluation of adequate mechanical properties: - through traction test (Sintech-1/M, MTS Adamel

Lhomargy, Ivry sur Seine, France) both the direct resistance and the resistance between suture stitch and AHDM were tested (Fig. 2).

A comparison with some other commercially avail-able membranes showed that AHDM had a failure mode similar to other membranes as described in lit-erature and has superposable mechanical properties.

4) Evaluation of the membrane histocompatibility by implantation of membrane samples in rats subcutis. No inflammatory reaction was observed.

After obtaining these laboratory results and with the approv-al of the Hospital Ethical Committee, in 2009 we started the clinical application of the AHDM in a selected group of patients. The study was aimed at reporting the preliminary results of our experience with AHDM membrane implanted as augmentation in a subset of rotator cuff lesions having a high recurrence risk. This group consisted of middle-aged high-demand patients affected with large/massive and old postero-superior cuff lesions. Patients were controlled both clinically and with imaging techniques to evaluate safety, excluding adverse reaction of inflammatory or septic nature,

normal tendon was evident.26-27 Even if no one is a case-control study, in all clinical studies published so far GJA showed good results either if used asaugmentation28, or as bridging29-31 device. Snyder led in 2010 a clinical study of 45 patients with massive and irreparable rotator cuff tear treated with arthroscopic implantation of Graft Jacket used as bridging, resulting in more than two years of follow-up significant clinical improvement in the absence of inflam-matory reactions and discards.31 In one of his histological study on a biopsy specimen taken from a rotator cuff aug-mented 3 months earlier with GJA scaffold, incorporation and remodelling was demonstrated, with alignment of colla-gen fibers, presence of revascularization signs, repopulation with host cells and little or no inflammatory response.32

METHODS AND MATERIALS

The need to have a decellularized bioactive collagenic mem-brane available in our clinical practice for the treatment of large/massive rotator cuff lesions with high risk of retear induced us in 2006 to organize a multidisciplinary group aimed at its production. This led to a cooperation between the Rizzoli Orthopedic Institute in Bologna and the Cutis Bank of the Burns Unit of the Bufalini Hospital in Cesena. From 2008 this activity is included in the Research Program Regione Emilia Romagna-University 2008-2011: “Regen-erative Medicine in Osteoarticular Disease”.33 The study included 4 steps:

1) Development of a proprietary decellularization tech-nique of dermis coming from multiorgan and mul-titissue donors. Such technique is protected by an international patent of AUSL Cesena and Rizzoli Orthopedic Institute and allows to produce an Acel-lular Human Dermal Matrix (AHDM) that fits the indications of the Italian and European laws about grafts and transplants.

A b C


Figure 3a, 3b. Implantationof AHDM in open surgery

after rotator cuff repair

Figure 2. Mechanical Test of tensile strength between suture and membrane

AHDM (Instron machine).

and efficacy of the membrane.36 Between March 2009 and December 2010 in our Shoulder and Elbow Unit about 400 surgical procedures of cuff repair have been performed. In 7 patients with specific clinical and imagine characteristics we employed the AHDM, as an augmentation in 6 cases and as a bridging device in 1 case with the cuff proved to be ir-reparable. One of the 6 augmentation cases was excluded due to insufficient follow-up. The remaining 5 cases satis-fied the following pre-operative selection criteria.Inclusion criteria:

- healthy subjects with high functional requests - age below 55, affected with large to massive lesion

according to Gerber involving supraspinatus and in-fraspinatus tendons, tendon retraction ≤ 3 according to Thomazeau and fatty degeneration ≤ 3 according to Goutallier, with possibility at surgery to obtain tendon reduction.

- Follow-up 1 year or moreExclusion criteria:

- arthritic degeneration even mild according to Samil-son

- frozen shoulder - symptomatic acromioclavicular arthritis - inability to cope with an adequate post-operative re-

habilitation regimen - autoimmune connective tissue disease - allergy for penicillin and pork meat

The patients had the same preoperative workout and the same postoperative regimen that we use for normal cuff repair sur-gery. Preoperative study included standard clinical examina-tion, x-ray and MRI. Anaesthesia consisted of interscalenic block and intraoperative sedation. Antibiotic prophylaxis was done with single shot cefazolin administration.

AHDM harvesting, processing and distribution was per-formed according to national rules on tissues for transplan-tation. Then sample of human dermis 1.5-mm thick was first taken from multi-organ and/or multi-tissue donors and then transported to the Skin Bank of Bufalini Hospital, Cesena-Italy for processing; here the tissues were processed to der-mis separation from epidermidis, decellularization and stor-age in nitrogen vapors at -180 °C. Twenty-four hours before surgical implantation a sample of tissue of requested sizes was prepared, and then sent in a sterile condition from Skin Bank of Bufalini Hospital to our Hospital, and here con-served at a temperature of 4° C until its use.

SURGICAL TECHNIQUE

The tendon repair and scaffold implantation was performed with an open technique in 3 cases and with arthroscopic tech-nique in 2 cases. In all cases Peek (Poly-Eter-Eter-Keton) anchors were employed, to allow better MRI visualization at follow-up controls. The anchors were in 3 cases a 5.5 mm Healix anchor [DePuy Mitek, Raynham, MA] loaded with 3 Orthocord sutures and in 2 case a 4.5 mm CrossFT anchor [ConMed Linvatec, Largo, FL] loaded with 3 Hi-Fi sutures. The surgical technique was the same for open and arthroscop-ic repair (Fig. 3a, 3b), with two of the three anchor sutures

A b


Figure 4. Arthroscopic surgical technique: the scaffold is sutured with STIK (Short-Tailed Knotted

Interference), nodes for the transport of the membrane within the shoulder.

Table 2. Patients treated data

used for the rotator cuff repair and the other suture used to fix laterally the scaffold. Additional stitches were used to fix the scaffold to the cuff medially, as well as anteriorly and posteri-orly. In arthroscopy for the transport of the scaffold within the shoulder was used the Snyder’s technique (Fig. 4).31 The patients wore an abduction pillow sling for 30 days and then started gentle rehabilitation, with standard rehabilita-tion protocol for the repairs of the rotator cuff.Patients were seen at follow up at 1, 3, 6 and 12 months. Clinical evaluation was done by the Constant-Murley scor-ing system. A control MRI was performed at about 12 months after surgery in all cases.

RESULTS AND COMpLICATIONS

All 5 patients were male with mean age 48 years old (range from 37 to 55). At the latest follow up of at least 1 year all the patients showed symptoms improvement after surgery. The average Constant score raised from 64 pts (range 55-75) in the pre-operative evaluation to 87 pts (range 77-95) postoperatively, with an average increase of 23 pts (range 20-30). None of the 5 patients treated with AHDM showed adverse inflammatory or septic reactions. Between 3 and 5 months all the patients, in spite of prudential recommendations, took on again full heavy work or sport activity. On the basis of MRI study and clinical evaluation in 3 cases it was possible to assist to a tendon repair integrity (Fig. 5a, 5b), with patients showing excellent shoulder function with also strength recovery; 1 patient, agonist yachtsman, felt a tear sensation during a sailing competition at 4 months postoperatively, with shoulder ache for 2 weeks. In the MRI at 1 year it is possible to observe a partial lesion with MRI images showing substantial scaffold integrity and presence of re-tear of the tendon cuff (Fig. 6a, 6b). In one case, with-out any history of trauma postoperatively, a complete re-tear was present; this case was the only one with pre-operative Goutallier stage 3 muscle-fatty degeneration. The patients data are summarized in Table 2.

CONCLUSIONS

The research on materials capable of increasing the biologi-cal and mechanical response of the tendon after the repair is in continuous development. Indeed, the repair of lesions of the rotator cuff is often a challenge both mechanical and biological healing. It is increasingly clear that a thinned and

Patient Age Shoulder trauma

Preop Test

Pre-oper MRI Surgery Activity

resumption F.U.SCORE Preop to postop

Postop MRI Oppositeshoulder

R.S. 37 2005 Jobe +Patte +

T 2/3G 1

Open repair, large le-sion, thin tendon, LHB

tenodesis, 1 anchor4 months 18

months 75 à 95Repair inte-

grity, scaffold incorporation

Tendinopathy

B.R. 50 2008 Jobe +Patte +

T 3G 3

Scope repair, massive lesion, sub-optimal

tendon repairability: 2 anchors, LHB ok and

untreated

4 months 13 55 à 77 Complete rerupture Partilal lesion

R.C. 55 2005 Patte + T 2/3G 1

Scope repair, massive lesion, complete reduc-ibility: 2 anchors, LHB

tenotomy

5 months 13 66 à 90Repair inte-

grity, scaffold incorporation

Partial lesion

F.G. 54No

trauma reported

Jobe + Patte +, ERLS

+

T 3G 2

Open repair, large lesion, degenerative

tendon, complete reducibility, 1 anchor

LHB tenotomy

5 months 12

55à85 ERLS – Jobe e Patte +

Repair inte-grity, scaffold incorporation

Tendinopathy

M.V. 48 2008 Jobe +

T 2 G 2 LHB

spontaneous tenotomy

Open repair, large lesion, degenerative

tendon, complete reducibility, 1 anchor

3 months (trauma at 4th month)

12 70 à 95

Partial tendon rerupture,

graft incorpo-ration

Partial lesion


Figure 5a. 3 months follow up Magnetic Resonance

paracoronal image, T2-weighted Fast Spin-Echo Fat Suppression: integrity of

the repair with integration between tendon and scaffold;

degenerated tendon cannot heal even if is performed a tech-nically correct repair and mechanically valid. If the failure in elderly patients can be tolerated, in young patients with high functional demands the problem remains open. In the past 15 years have been studied and tested various materials to improve healing of the tendon repaired by mov-ing gradually attempts to stimulate a biological response of host tissues.The ideal scaffold for rotator cuff repair should comply with the following ten characteristics:

- Biologically active- Biocompatible- Absorbable- No risk of disease transmission- Mechanically resistant to traction- High resistance to seal the suture- Available in different sizes (size and thickness)- Easy to handle both in arthroscopic surgery and in

open surgery- Can be used as augmentation that as bridging- ready available in the operating room

Among the various materials studied, the human-derived der-mal matrices (AHDM) now appear to be able to get closer to the ideal characteristics of the scaffold while the scaffold of animal origin and the scaffolds of synthetic origin produced disappointing results due to frequent tissue reaction events.Preclinical studies on the AHDM confirmed excellent bio-logic characteristics as scaffolds, mechanical tests con-firmed good mechanical strength and suture retention quali-

ty, animal studies showed excellent tolerability. MRI studies showed the reabsorption of the material with an incorpora-tion with the native tendon. Differently from animal scaf-fold, the human one can be also used for bridging, if needed. Even if the possibilities to transmit infectious diseases is ex-tremely low, either for the strict control of the human donors and for the physical and chemical treatments of processation and conservation, a blood control after 6 months from op-eration is mandatory to rule out infectious diseases, like B or C hepatitis or HIV infection. All the analyses conducted on the patients treated until now gave negative response. At the moment the AHDM is available in different sizes, but not in different thicknesses. Another negative aspect is that AHDM needs to be prepared 24 hours before surgery, and this aspect can condition and limit the use of that scaffold. The use of scaffolds with feature augmentation is in our opinion indicated in the young patient (under age 55) who has a lesion of the rotator cuff large or massive but repair-able (negative hornblower’s signs), with high functional demands and poor quality of the tendon, in this group of patients alternative “replacement” surgeries like tendon transfers or shoulder prosthesis have no indication; in our experience we have observed that a case with muscle atro-phy of the supraspinatus Goutallier 3° prematurely failed and is currently considering candidates for this surgery only patients with fatty degeneration with Goutallier <3°. The group of patients candidate to augmentation represents about 2-3% of the patients operated for rotator cuff repair in our Unit in the recent years and less than 1% of patients with a diagnosis of complete rotator cuff lesion who seek for treatment in our outpatient ward. These patients deserve

A b

Figure 5b. 1 year follow up Magnetic Resonance

paracoronal image, T2-weighted Fast Spin-Echo Fat Suppression:

Integrity of the repair.


Table. 3: Symptomatic Rotator Cuff Tear Treatment Algorithm

Figure 6a. 3 months follow up magnetic

resonance paracoronal: Integrity of the repair with

scaffold still visible.

the wider efforts also on an economic point of view to re-duce the incidence of re-rupture. The scaffold with bridg-ing function can be implanted as first responders or in the treatment of recurrences in patients highly symptomatic un-der the age of 60-65 years suffering of irreparable injury of the supraspinatus, with negative horn-blower sign and the subscapularis tendon valid. In our Department an algorithm was developed to guide treatment indication on the basis of patient age, size of lesion, and tendon quality (Tab. 3).From the point of view of surgical technique we believe it is technically possible to use the membrane AHDM ar-

throscopically, although we believe that the technique up to now used by us should be improved; are in fact currently being studied techniques that facilitate the transport of the scaffold inside of the shoulder and its fixation to the ten-don. The open technique is definitely more reproducible, especially in the correct tensioning of the scaffold, which is useful to reduce the mechanical stress acting on the newly repaired tendon sutures.MRI is the gold standard for the study of evolution of the scaffold and its integration. In particular, the sequences in T2 FatSuppression coronal oblique and sagittal oblique ap-

Lesion size < 55 ys 55/65-70 ys > 65/70 ys

Partial Conservative treatment* Conservative treatment * Conservative treatment *

Small RepairConservative treatment *

RepairConservative treatment *

Large/massiveRepair

Augmentation°Repair

Conservative treatment *Repair

IrreparableMargin convergenceTendon transposition

Bridging

Margin convergenceBridging

Conservative treatment *Reverse arthroplasty

if arthropathy

* at least for a period non less than 6 months ° chronic lesion, degenerative and thin tendon, hypotrophic muscle, Goutallier < 3

A b

Figure 6b. 1 year follow up paracoronal image,

Fast Spin-Echo T2-weighted Fat Suppression: small and partial articular leasion with apparent integrity of the bursal side of the tendon and scaffold.


pear to be the most useful; anchor made of PEEK compared to titanium allow you to see better the MRI healing signs of the repaired tendon and the incorporation of the scaffold.Only through close cooperation between research and sur-gery will be possible to produce a scaffold well tolerated able to promote tendon healing. Multicentre randomized controlled studies will clarify the many questions still open about the type of scaffold to be used, indications and the surgical technique of application.

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11. Hakimi O, Mouthuy P-a, Carr. a Synthetic and degradable patch-es: an emergingsolution for rotator cuff repair. Int J exp Pathol 2013; 4:287-292

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14. Rhee YG, Cho nS, Lim Ct, Yi JW, Vishvanathan t. Bridging the gap in immobile massive rotator cuff tears: augmentation using the tenotomized biceps. am J Sports Med 2008; 36:1511-1518

15. Cho nS, Yi JW, Rhee YG. arthroscopic biceps augmentation for avoiding undue tension in repair of massive rotator cuff tears. arthroscopy 2009; 25:183-191

16. neviaser JS, neviaser RJ, neviaser tJ. the repair of chronic mas-sive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff. J Bone Joint Surg am 1978; 60:681-684

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ment of global rotator cuff tears. Clin Orthop Relat Res 1988; (228):218-226

18. Moore DR, Cain eL, Schwartz ML, Clancy WG Jr. allograft recon-struction for massive, irreparable rotator cuff tears. am J Sports Med 2006; 34:392-396

19. Sclamberg SG, tibone Je, Itamura JM, Kasraeian S.Sixmonth magnetic resonance imaging follow-up of large and massive rotator cuff repairs reinforced with porcine small intestinal sub-mucosa. J Shoulder elbow Surg 2004; 13:538-541

20. Iannotti JP, Codsi MJ, Kwon YW, Derwin K, Ciccone J, Brems JJ. Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. a randomized, controlled trial. J Bone Joint Surg am 2006; 88:1238-1244

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Rational approach to the irreparable cuff tears - from “functional” repair to muscle transferFabrizio Campi, Paolo Paladini, Carlo Buononato, antonio tartarone, Giovanni Merolla, Giuseppe PorcelliniShoulder and Elbow Unit - Cervesi Hospital - Cattolica, Rimini

IRREpARABILITY CRITERIA

There is no precise algorithm for the treatment of irreparable rotator cuff tears (RCTs). Surgical treatment should always be suggested in symptomatic patients, even if a complete repair is not possible 15, 16. However, there are clinical and imaging predictors:

Clinical criteria:in anterosuperior chronic tear with anterosuperior sublux-ation of the humeral head, head under the skin and pseu-doparalytic arm flexion the tear cannot be repaired. In pos-terosuperior chronic tears the inability to flex the shoulder is a irreparability sign, it is often not associated with pain and in this lesions if the arm is abducted passively to about 90 degrees, the patient should not be able to maintain the arm in the abducted position. A true dropping sign indicates fatty infiltration of Goutallier 17 stage 2 and cannot be repaired.

Imaging criteria:a simple anteroposterior X-Ray in neutral rotation may show a acromionhumeral gap less than 7 mm, indicative of a irreparable RCTs. The gold standards to assess tendon le-sions and muscle fattyinfiltration are the CT and, especially, the MRI 18. A grade 3 or greater indicates irreparable tear of the tendon involved. Finally, another important factor is the time elapsed between injury and observation because affect the tissue quality.

Criteria for functional demands:a RCT may not cause disability when the limb rests on the side. The problem arises when the patient tries to move the limb in space. So many patients, informed of the possible benefits and risks, with poor functional life activities decide to avoid surgery.

THE FUNCTIONAL REpAIR

The glenohumeral joint is particularly unstable so rotator cuff represents an essential stabilizer, especially in the mid range of movement. There is a continuous balance between agonist and antagonist muscles (like between the infraspi-natus / teres minor complex and subscapularis), because an important role of the entire cuff is to center the humeral head in the glenoid during deltoid contraction to give the right fulcrum. On the basis of these notions, Stephen Bur-khart dictated five criteria which must have a functional rotator cuff 19:

1. Force couples must be intact in the coronal and trans-verse planes.

2. A stable-fulcrum kinematic pattern must exist.3. The shoulder’s “suspension bridge” must be intact.4. The tear must occur through a minimal surface area.5. The tear must possess edge stability.

Based on these insights, Burkhart developed the idea of “suspension bridge” in order to balance the force couple without repair the entire rotator cuff, thus providing an an-atomically deficient but biomechanically intact shoulder.The surgical treatment of large or massive RCTs can be technically difficult, and the results are less reliable20,21,22,23. The size of the tendon tear and fatty infiltration of the muscles are strictly correlated to clinical outcomes. In par-ticular, arthroscopic repair of large and massive RCTs can lead to excellent pain relief and improvement in the abil-ity to perform daily life activities at short-term follow-up, despite the high rate of recurrent defects; however, at a minimum follow-up of 2 years, the clinical results seems to deteriorate. Although many RCTs and the majority of massive RCTs can be completely repaired to bone, a sig-nificant part of these cannot be sutured by these traditional techniques for the size of tendon tear and the tendon retrac-tion. Numerous operative techniques have been described for the treatment of massive RCTs with severe retraction when anatomic repair is impossible, such as arthroscopic debridement and/or biceps tenotomy, tendon transfers and grafting, partial repair of the remaining rotator cuff ten-

INTRODUCTION

The rotator cuff tears are very frequent diseases affecting 20.7% of the population, but few patients are symptomatic. Lesions are more frequent in elderly subjects (especially after 60 age), male, heavy workers and the dominant limb is most often affected 1. Rotator cuff tears are often the result of a chronic lesion, associ-ated with myotendinous retraction, loss of elasticity, muscle fatty infiltration, superior subluxation of the humeral head and, ulti-mately, osteoarthritis. Acute trauma is a less frequent cause 2,3,4. A universally accepted definition of massive irreparable injury to the rotator cuff does not exist. Cofield and Rockwood et al. defined irreparable a massive tear (>5 cm) that cannot be repaired for size or retraction 3, 5. Gerber classificates as irreparable a tear that cannot be reduced without excessive tension with shoulder abducted to 60°, in a cuff with a massive lesion (> 5 cm or with two tendons completely broken) 6. The treatment of these lesions is extremely pleomorphic, ranging from conservative treatment to arthroscopic debridement with biceps tenotomy, partial suture, tendon transfer or reverse arthroplasty 4, 7, 8, 9, 10, 11, 12, 13, 14.


Figure 1

dons. Burkhart et al first introduced the concept of “func-tional repair” of the cuff to restore the force couple of the humeral head and to increase the acromion-humeral dis-tance (AHD). In these arthroscopic procedures, complete cuff repair was not considered essential to restore the nor-mal biomechanics. The technique allows the repair of the peripheral margins of the tear to restore the force couples, anterior and posterior, and the ‘‘suspension bridge’’ sys-tem of force transmission in the shoulder. Outcomes are obviously inferior than in complete rotator cuff repair but remain stable for AHD in medium-term follow-up. Previ-ous authors have introduced the radiographic evaluation of the AHD as a standard exam before orthopaedic treatment. A decreased AHD is the most reliable radiographic finding for RCTs; an AHD of less than 6 mm has been considered proof of an RCT and narrowing of the AHD is strictly re-lated to the size of the cuff tear.We wrote a study to evaluate clinical results and radiologic changes of AHD in patients treated with arthroscopic par-tial suture of irreparable tears of the supraspinatus tendon at long-term follow-up (5 years) 24, 25. Our initial hypothesis was that arthroscopic partial suture of the cuff leads to pain relief and functional improvement for patients with resto-ration of the AHD. In our case-series study, 153 consecu-tive patients with irreparable RCTs were arthroscopically treated with partial repair from January 2000 to March 2004. All patients had a symptomatic shoulder treated conservatively at least for 6 months, 51 with poor results. Of the patients, 72 (47%) had a posterior-superior lesion involving supraspinatus and infraspinatus tendons and 38 (25%) had an anterior- superior lesion involving supraspi-natus and subscapularis tendons, whereas 43 (28%) had a global lesion involving infraspinatus, supraspinatus, and subscapularis tendons. We considered only patients af-fected by posterior-superior cuff lesion with grade I or II fatty degeneration of the infraspinatus and grade III or IV fatty degeneration of the supraspinatus (72 patients). None of these patients had a Hornblower sign, drop-arm sign, or pseudo-paralysis of the shoulder. The teres minor was intact in all cases.Exclusion criteria were:• Age older than 70 years• Fatty degeneration of the infraspinatus of grade III or IV• Fatty degeneration of supraspinatus of grade 0 or I• All subscapularis tears• Previous surgery• Nerve palsy• Cuff tear arthropathy (CTA) and arthritis of grade II or

more following the Samilson-Prieto classification• Inflammatory arthropathy and diabetes or hypercholes-

terolemia

This study indicates that, in cases of massive RCT with no subscapularis tear, long-term results of partial repair of the posterior cuff with covering of the infraspinatus footprint showed improved outcome scores. In addition, AHD in-creased minimally and was stable at final follow-up. These results were superior to those of a simple arthroscopic de-bridement in active patients. The target patient for partial

repair of the cuff has good balancing of the cuff without signs of complete disruption of the posterior cuff, with no drop-arm or Hornblower sign, and with good function of the subscapularis.

pECTORALIS MINOR TRANSFER

When an irreparable anterior-superior RCTs occours, a transfer of the pectoralis minor should be indicated to re-place the function of the subscapularis tendon and to restore the anterior functional sling (Fig. 1). The subscapularis muscle is the largest and most powerful of the rotator cuff providing alone about 50% of the rotator cuff strength and it is important for the elevation of the limb. The rupture of the subscapularis tendon may also cause an imbalance on the forces couple acting on the shoulder, causing pain and disability. The lesions of the subscapularis tendon are un-common, representing in agreement with the literature 5% of all lesions of the rotator cuff. Subscapularis injuries usu-ally occur more frequently in association with other lesions of the rotator cuff, rarely are isolated 26. The reparability of rotator cuff lesion is influenced by tendon retraction, atro-phy muscle and fatty infiltration. Lafosse classification has an important prognostic value too, some lesions allow an open or arthroscopic repair with good results that are main-tained over time. In addition, the subscapularis tendon re-pair appears to reduce the stress on a supraspinatus tendon repaired, protecting it, in anterior superior rotator cuff le-sions. The irreparable injury represents a difficult problem to treat, an option is represented by muscle transfer. One of the historical options was the transfer of the acromial por-tion of the trapezius. Recent experiences have shown that the transfer of the pectoralis major appears to be the most reliable option in the treatment of irreparable subscapularis lesions. The transfer of the pectoralis major and pectoralis minor muscles have been described for the first time by Wirth and Rockwood in 1997 27, in a study with 13 patients suffering for recurrent anterior dislocation of the shoulder associated with an irreparable subscapularis tear. Of the 13 cases, 7 were treated with pectoralis major transfer, 5 with pectoralis minor transfer and 1 of both. The result to 5 years


Figure 2

Figure 3

of follow-up was good in 10 patients and poor in 3 cases. In the work of Wirth and Rockwood the pectoralis minor was transferred with coracoacromial ligament, before discon-nected from its acromial insertion, to compensate the poor length of tendon. Several authors have used the transfer of the pectoralis major for the treatment of irreparable lesions of the subscapularis. Jost et. al in 2003 28 reported the re-sults of the transfer of the pectoralis major performed in 28 patients for a total of 30 shoulders treated with a mean fol-low-up of 32 months. The results showed an increase of the CS from 47% preoperatively to 70% postoperatively with statistically significant increases for pain, anterior elevation and strength in abduction. In addition the Constant score value, in patients whit an irreparable injury of the supraspi-natus tendon, was minor compared to those with supraspi-natus repairable lesions with value respectively of 49 % and 79%. The pre-operative lift-off test was positive in all 30 shoulders and continues to be positive in 23 postoperatively. Resch et al29 reported their experience in the treatment of ir-reparable lesions of the subscapularis using pectoralis major transfer with a modified surgical technique: passing the 2/3 upper tendon of the pectoralis major posted below the con-joined tendon to recreate the ubscapularis anatomy. Results showed a statistically significant improvement in terms of pain (mean 1.7 and 9.6, respectively, pre-and post-opera-tive), with an improvement in functional score of 43 points (23 pre- post). Moreover, no nerve injury was reported as complication. We decided to investigate whether open pec-

toralis minor transfer would improve short-term functional outcomes in patients with lesions of the upper portion of the subscapularis tendon 30. The objectives of this study were therefore to explore the following:

1. The anatomic feasibility to use the pectoralis minor tendon as a graft to repair lesions of the upper por-tion of the subscapularis tendon, given the elonga-tion that the muscle must withstand and the length of the neurovascular pedicle.

2. The safety of the procedure in relation to the prox-imity of the brachial plexus and the musculocutane-ous nerve.

3. The scope of this technique in improving the func-tion of the (healthy) lower portion of the subscapu-laris tendon.

After careful debridement of the subscapularis footprint and of the interval between the coracoid and the humeral head, the pectoralis minor tendon was detached from the coracoid with a bone fragment (Fig. 2) to foster the healing process and avoid muscle wasting. Two stay sutures placed over the osteotomy were used to drag the pectoralis minor tendon, which usually reaches the lesser tuberosity without exces-sive tension, under the coracoid. The pectoralis minor was then carefully released, the musculocutaneous nerve was identified and protected, and the tendon was finally sutured in areas 2 and 3 described by Arai et al 31, 32 (Fig. 3).Preoperative functional status was evaluated in relation to a number of outcome measures that included active ROM as part of the Constant score, total Constant score, Simple Shoulder Test (SST) score, liftoff test, and belly-press test. There were no cases of musculocutaneous nerve or brachial plexus injury or graft failure. Active forward flexion im-proved from 127° to 177°; external rotation with the arm on the side declined by 11°. The Simple Shoulder Test score improved by 5 points and the Constant score by 41 points, although the strength subscore did not rise significantly.This study showed that it is anatomically feasible to use the pectoralis minor tendon as a graft to treat upper subscapu-laris lesions; the procedure is safe for brachial plexus and musculocutaneous nerve injury; and pectoralis minor trans-fer can improve shoulder function and provide pain relief in patients with Lafosse grade III subscapularis tears, likely through a tenodesis effect, even in the the presence of ir-reparable supraspinatus tears.

LATISSIMUS DORSI TRANSFER

Massive and irreparable postero-superior cuff tears actu-ally represent a difficult problem for treatment. Combined latissimus dorsi transfer and teres major transfer were used by L’Episcopo in 1934 to regain external rotation in obstet-ric plexus paralysis 33. Gerber in 1988 34 was the first to use latissimus transfer to treat massive and irreparable postero-superior cuff tears in active patients with pain, weakness or loss of overhead elevation, with an external rotation lag sign and with integrity of subscapularis tendon. In the original tecnique patient was in beach-chair position, through two incisions and the anchoring point of the tendon was there


by the tip of great tuberosity. The results in patients under-gone to latissimus dorsi tranfer show an improvement in the shoulder function, range of motion, strenght and pain relief. Subscapularis muscle insufficiency, advanced teres minor muscle atrophy and need for revision surgery were corre-lated with poor functional outcomes in some studies35, 36. A more complete discussion of the topic will be developed in another section of this text.

CONCLUSION

To determine the best treatment for each individual, ad-equate radiologic images and a careful examination of an experienced shoulder surgeon are required. Treatment op-tions and the results depend on many factors, not least the rehabilitation team.Despite all the previous options, massive irreparable rotator cuff tears are difficult to manage, treat effectively and with a limited goal.

REFERENCES

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Figure 1: position of the transposed

latissimus dorsi tendon on the greater tuberosity

INTRODUCTION

EpidemiologyThe majority of the rotator cuff tears can be repaired with surgery, either open or arthroscopically. Although relatively to the total amount the percentage of the ir-reparable lesions is low, these are frequently symptomatic, as much as to require a solution: surgical, rehabilitative, or both. The frequency of the rotator cuff lesions increases with age; this is due to biological laziness of the tendon, age-related, or due to toxic factors (e.g. smoke), or even to the damage consequent to mechanical stresses: local factors (subacromial impingement) or external ones (heavy working activities or strenuous sports). Acute post-traumatic onset of symptoms, mainly pain and loss of function, typically reveals the extension of a pre-existing injury, even if asymptomatic. The resultant functional disability is a true ataxia, with loss of spatial control of the hand in the most severe cases.Assuming that the percentage ratio between massive irreparable tears and the repairable ones does not vary with the age, the ma-jority of lesions occur in the elderly population; its patients’ need is to reduce pain and improve the function for the daily-live ac-tivities. The goal for young people is often challenging, aiming to achieve power for re-start a stressful manual job. The heterogene-ity among different needs and expectations gives rise to different treatment options, although the massive tears can be similar to each other.

Arthroscopically-assisted latissimus dorsi transferenrico Gervasi, alessandro Spicuzza Ospedale Civile di Latisana, Udine

HISTORY

The surgery of the rotator cuff in the 80s enters a phase of evolution of orthopaedics, where immobilization, repeated infiltrations of corticosteroids (the same way as tonics), manipulation, give way to the scalpel.The surgeon is careful to repair the anatomical damage of the rotator cuff; only after he will shift the attention to restore the function rather than to repair the “hole in the tendon.” The “evidence based” medicine, the attention in the analysis of the results, checked by imaging, demon-strate the ineffectiveness of techniques of direct repair of the rotator cuff documenting the failures or the recurrences in many massive injuries, even when at the time of surgery the tendons appear firmly repaired to the bone. The role of

biology in the healing process is getting to be understood; the functional one of each motor unit throughout the ki-netic chain is analysed. The goal of the surgery is aimed at restoring the function rather than to repair the injured tis-sues. The search for effective alternatives to direct repair leads to consider the muscle-tendon units transfer, used in the past to treat neurological injuries, obstetrical paralysis consequences of dystocic births. In these the external rota-tion is impaired, the fifth cervical root being more often the one involved. In this affection the internal rotators become predominant over the external rotators, resulting in the ina-bility of the patient to bring the hand to the mouth or neck. The L’Episcopo surgical technique 1, that proposed balanc-ing the postero-superior rotator cuff deficit, is forerunner of modern transpositions: it provides for the separation of both tendons, latissimus dorsi and teres major, off from the edge of the bicipital groove and their reinsertion to the diaphyseal cylinder, rotated in the opposite direction: from medial and posterior to lateral and anterior. At the end of the 80s Gerber remakes it 2, modifying and adapting it to the repair of the rotator cuff; in 2003 we translated it for use in endoscopy 3. Why does the arthroscopic choice? The arthroscope reaches any district, better than the scalpel and with less damage to the tissues being passed through. This principle led our group to conceive and establish arthro-scopic techniques for “at distance” tendon transfers. The deltoid sparing thus obtained also guarantees a way out in case of failures, when the pathology rises towards a cuff


tear arthropathy and the joint replacement with a reverse prosthesis becomes necessary. Finally we abandon the idea of using part of the transferred tendon to close the hole, fixing it to the residual medial cuff as proposed by other authors until then; we fix it, vice versa, to the most anterior part of the greater tuberosity in an autonomous way, thus acting as stabilizer of the humeral head, even passively Figure 1. In a similar way to the constraint of a reverse prosthesis, this favours the action of the deltoid; only partially the transposed latissimus dorsi acts as active external rotator.

METHODS

Patient selectionThe ideal candidate for surgery is the patient with massive, irreparable, rupture of the rotator cuff with a limitation of the function of the upper limb incompatible with the daily-live activities. If local anaesthetic injected into the subac-romial space act as painkiller regaining function, then a different, limited procedure as the biceps tenotomy and the smooth contouring of the greater tuberosity can be consid-ered. It could be defined that the muscle-tendon transfer is therefore recommended when is impossible or inadequate by direct repair to recover the function, lost and function-ally essential, of the native rotator cuff. The function that has to be resuscitated depends on topography of the cuff lesion. The brain is set by function rather than by activity of individual muscles. The transposed tendon is not affect-ed by regressive phenomena (degeneration), as conversely happens to the cuff tendons working in the subacromial space. The success of the “tendon-transfer surgery” is less influenced by the typical “lazy biology” of the torn cuff. The age also is not crucial in the decision-making: other factors as important as tendon vitality should be consid-ered: patient activity, his involvement in recreational sports (if any), the expectations. Furthermore is important the pa-tient’s intellectual capacity to understand objectives and limits of the rehabilitation program, in order to take part to one, lasting several months. It is based on reprogramming the neuro-motor skills, with stimulation of the transposed unit. At the early rehabilitation phase is used the mechani-cal improvement given by the tenodesis effect of the trans-fer. However patients “over 70” must be carefully drafted to a complex surgery also in terms of rehabilitation, since the implantation of a reverse prosthesis is a viable alter-native, which requires a simpler and shorter rehabilitation program. The choice between the two procedures beyond the boundary of the age of 70 years, when the prosthe-sis is rarely indicated, is played on other factors: integrity of cartilage, biological age (transfer indicated in youths), subscapularis integrity or reparability. The damage of ar-ticular surfaces orient toward the prosthesis. Coexisting le-sions of the subscapularis and previous surgeries can lead to significant improvement despite the final outcome is less satisfactory compared to the average. Some patients have a large size or massive cuff lesion functionally compensated.If at medical examination their concern is pain, whilst the function is preserved, the long head of biceps tenotomy

can be a viable solution, even palliative. In this case the transfer is rarely the procedure of choice, because it lacks the pre-requisite of loss of the essential function. These shoulders have a relatively stable humeral epiphysis. The contact surface between humerus and the acromion is the fulcrum acted by the deltoid to elevate the limb. The ra-diographic examination performed in patients with mas-sive rupture of the rotator cuff shows different patterns of images: by the cranial migration of the humeral head with minimal signs of bone adaptation to others in which the acromion and its anterior osteophyte, large, gets to contact the humeral head, thus limiting either the humeral migra-tion and the loss of relation between its centre of rotation and the centre of the glenoid. The intact acromial arc op-poses to the cranial migration of the humeral head; thus, preventing the excessive shortening of the deltoid muscle fibres, the linear movement produced by the contraction shifts in a rotational one. The described effect is greater the more congruent are the surfaces of the neo acromial-humeral articulation, modified by taking an acetabular pat-tern. Even the remaining rotator cuff takes advantage of it, not depriving muscle strength to the rotations, which would be spent, vice versa, by the humeral head centring action. This explains how the acromiplasty sometimes leads to a functionally catastrophic result: the shoulder with weakness in elevation becomes pseudo paretic fol-lowing the surgery. The transformation towards the neo-cotyloid appearance is given from wear by friction of the bone surfaces, related to their mutual movement. Patients with valid movement and massive cuff tear can be expect-ed to show at radiographic examination that “compensa-tory” aspect of centred glenoid wear, rather then off centre, light of the movement itself. Individuals with acute onset of severe deficit are often the ones affected by traumatic extension of an existing lesion; it happens in the absence of gradual adaptation, thus the bone surfaces are anatomi-cally regular. According to some authors, the reduction of the humeral-acromial space and cranial migration of the humeral head is a contraindication to tendon transfer; they report that it cannot contribute in any way to the distal re-centering of the humeral head. Surgery is contraindi-cated when the humeral-acromial contact determines bone changes, humeral, of the glenoid (cotyloid aspect) Figure 2 or acromialis. The rounding of the greater tuberosity after all is acceptable.The impossibility to repair the subscapularis tendon gets the latissimus dorsi transfer ineffective. This rule has anec-dotal exceptions, whose biomechanical justification (why sometimes the transposed tendon is still effective) is not yet clear. The combined transfer, anterior and posterior, is definitively rare in the literature and the reported results are unsatisfactory. It requires the about impossible reor-ganization of a motor engram reprogramming either, the external and internal rotation.The transfer is not suitable for patients who need to recover the function of the limb for a repetitive manual work: be-cause the force is only partially restored, is exhaustible, has no resistance to fatigue or to cyclic loading. The weight of the limb itself, when significant, adversely affects progno-sis. I give the patient the example of those who suffer a se-rious heart attack: the recovery, even when good, is never


Figure 2: cotyloid aspect of the gleno-acromial arch

complete and the considerable effort must be avoided.The goals of surgery, limitations, as well as the possible complications should be discussed during the visit with the patient.

CHOOSING THE GRAFT

Several solutions have been suggested to treat chronic rotator cuff deficiency: debridement4, partial rotator cuff repair5, subscapularis tendon transfer6, transfer of the sub-scapularis and teres minor7, transfer of the long head of triceps8, teres major transfer9,10, interposition of a biceps tendon autograft11, freeze-dried rotator cuff allograft12, and use of synthetic grafts13.The muscle-tendon unit candidate to be transferred (sub-stitute) must replicate the lost function.The suitability depends on the amounts of certain quali-ties: strength (size and the plane on which lies the vector), the excursion, and synergy, present when substitute and replacing are naturally agonists for the function to be vi-cariate. Besides these is specially relevant the accessibili-ty, which makes possible withdrawing and transferring the graft with the lowest damage to healthy structures to pass through and with the lowest risk of damage to vessels and nerves. By the term “consistent” we mean the structure that has characteristics suitable to the specific transposi-tion. The study of Herzberg shows an analysis essential for the choice of the graft, the one among various transplants in use today, ideal for to take place of specific functions of the torn cuff. The bias is that this study is based on prepa-rations obtained from cadavers. Possible substitutes are

categorized into three series: thoraco-scapular, thoraco-humeral and scapular-humeral. Of each muscle are anal-ysed the following characteristics: the length at rest, the potential range of elongation in cm. and the relative basal tension, related to a ratio of its sectional area and that of the whole group of muscles acting on the shoulder. The relative basal tension and the excursion of the units to be replaced are compared with those of the transfer, to esti-mate its suitability to the new work. The analysis consid-ers, however, the action on just two planes: the sagittal sec-tion, for the measurement of the cross-sectional size of the muscle belly, and the coronal one, for to assess length and elongation. The third plane of the space, where the vector of force lies on, is not considered. Some of the energy pro-duced by the graft is in fact is dissipated by spready forces, inconsistent with those to be replaced. From this study it appears that the problem lies in the strength rather than in the intended stretchability of the graft. Let us now consider the latissimus dorsi, isolated or combined with the teres major pro posterior cuff. The latissimus dorsi isolated lacks basal relative tension, recoverable with the simultaneous transfer of the teres major. Our choice, of transposing the latissimus dorsi isolated, is given by the limited elongation capacity of the teres major. If the teres major is transferred as a unit along with the non-autonomous latissimus dorsi, the teres restrains the possibility that the latissimus reaches the very anterior area of the greater tuberosity, wrapping itself on this as on a flywheel. The volume of both muscle bellies, moreover, would be likely to compete for space with the circumflex nerve, putting it at risk of a canalicular disease. In conclusion, the latissimus dorsi isolated seems at the moment the more “consistent” transfer for massive “irreparable” postero-superior cuff tears.

THE TRANSFER OF THE LATISSIMUS DORSI ASSISTED BY ENDOSCOpY

Patients eligible for transfer of the latissimus dorsi are those set by the posterior cuff deficiency. When associated the lesion extends to the subscapularis and has to be re-paired. Absolute contraindications to transfer are: humer-al-scapular evolved arthropathy, the chronic dehiscence and irreparability of the deltoid, the axillary nerve palsys. The preoperative diagnostic imaging includes a series of radiographic projections: AP “normalized”, “outlet” of Lamy and axillary view. Examination reveals, if any, signs of arthropathy (glenohumeral space reduced) and acetabu-lar transformation of the acromial arch, with changes of the upper glenoid profile. Those factors make this surgery contraindicated. Magnetic resonance imaging is routinely performed: it evaluates the tendon defect on coronal and axial planes; the sagittal plane allows to get the occupation index of the scapular fossa (Zanetti) and the degree of fatty infiltration (Thomazeau) Figure 3, expression of the tro-phism of the muscle and of the eventual irreversibility of the changes. When planning is important to know whether you should repair the subscapularis: that because the setup of the operating room is then set by placing the patient in the “ modified beach chair “ rather than in lateral decubitus position , as a rule. The physical examination assesses the


Figure 4: Humeral head re-centered.

a) preoperative X-ray b) postoperative X-ray

Figure 3: oblique sagittal

MR view shows fatty

degeneration of posterior superior

rotator cuff (a: supraspinatus

muscle, b: infraspinatus

muscle, c: teres minor muscle)

integrity of the deltoid and the presence of rigidity, this relatively frequent in patients who come to the transfer as revision of a previous surgery or in trauma cases. The expected results in revisions are less favourable. The stiff-ness, even inconspicuous, prejudices the possibility of hu-meral re-centring with respect to the glenoid and then the functional effectiveness of the transfer.

pOSTOpERATIVE TREATMENT

The postoperative protection of the transfer follows the general rules of the surgery for massive rotator cuff in-juries. Before surgery and in preparation to it, patients are instructed to perform analytic exercises for the vari-ous muscles. After the surgery, because of pain (however slight) and awe to use anatomical elements involved in the surgical trauma, learning would be very difficult.During the first period the active movement is under strict control. The adoption of a mini-sling in 15° of external rotation or an abduction pillow is continued for 6 weeks. Meanwhile patients are allowed for few pendulum exer-cises to limit adhesions between teres minor and deltoid. Elbow flexion and hand exercises are encouraged, as well as those for the scapulothoracic articulation, trunk and lower limbs. The maintenance of kinetic chains of joints not involved by the surgery promotes functional recovery. The rehabilitation in water (hot pool) is useful since the sixth week and throughout the period of functional recov-ery. The exercises are performed with both limbs to use the “mirror” effect, favouring the trophism and the recov-ery of motor engram. In the rehabilitation program the limb lifting against gravity is carried out gradually. The patient starts the exercises lying on the unoperated side, the back tilted 30 degrees backward, in order to place the glenoid parallel to the ground and thereby reducing shear forces acting on the humeral head. The elbow maintained is flexed at first, reducing the lever arm. The gradual erec-tion of the trunk gets ready to perform exercises in a full upright position. Rehabilitation takes many examples from

the actions of everyday life to motivate the patient. Func-tional recovery takes place ranging from a few months to a year after surgery. The transposed latissimus dorsi gets ability to work actively, as shown in the transpositions car-ried out for obstetric paralysis, in which it is moved around the diaphyseal cylinder.

RESULTS

Results and complicationsWe evaluated a first cohort of 25 patients who underwent to latissimus dorsi transposition assisted by endoscopy, performed by the senior author, with at least three years of follow up (data being published). In this series there were no major complications, as conversely recorded in a more recent one (two neurological involving the circum-flex nerve: one primary, one subsequent to infection and


debridement). The infection occurred in one patient af-fected by acne. Few patients developed blood or serous ef-fusion in the area subject to release of the latissimus dorsi muscle. Superficial tissues for a first time after the release do not adhere to the muscle, thus leading to “third space” progress. Our attention to coagulate the vessels crossing distally from muscle to subcutaneous made negligible this complication. When it occurs, the drainage through a skin incision in the most distal part of the collected fluids solves the problem.As already reported in the literature for the revision of previous failed cuff surgery gets less favourable results, especially after large acromioplasty. The integrity of the subscapularis is crucial although some patients with a tear found to be irreparable at the time of surgery equally ben-efit from the procedure. The weight of the limb seems to play as disadvantage. The postoperative centring of the hu-meral head over the glenoid, even if partial, is favourable to functional recovery. Postoperative radiographic study quantifies it Figure 4. The comparative long term rx stud-ies show the reduction of the space humerus-acromial over time and the progression of arthritic changes14. These also show an impression on the tuberosity, as it would be carved by the action of the transposed tendon. The humeral cen-tring is greatly favoured by the capsuloligamentous release we currently perform extensively. Gain about the external rotation strength is moderate. In conclusion we consider the technique of latissimus dorsi transfer assisted by ar-throscopy as the procedure of choice for the irreparable posterior superior rotator cuff tears functionally disabling. The basal tension of the latissimus dorsi is insufficient to replicate the whole force of the postero-superior cuff; the position we choose for the fixation improves elevation more than external rotation. The combined transfer with that of the teres major as a single not separated unit, limits the graft possibility of sliding and crowds the passage from the armpit to the subacromial space. It increases the risk of compression of the circumflex nerve or need for fixing the graft at back site with respect to the desired point.

REFERENCES

1 L’episcopo JB. tendon transplantation in obstetrical paralysis. am J Surg. 1934; 25:122–125

2 Gerber C, Vinh tS, Hertel R, Hess CW Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. a pre-liminary report Clin Orthop Relat Res 1988; 232:51–61

3 Gervasi e, Causero a, Parodi PC et al arthroscopic latissimus dorsi transfer, arthroscopy 2007; 23:1243.e1-4

4 Rockwood Ca Jr, Williams GR Jr, Burkhead WZ Jr. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg am 1995; 77:857-66

5 Duralde Xa, Bair B. Massive rotator cuff tears: the result of par-tial rotator cuff repair. J Shoulder elbow Surg 2005; 14:121-7

6 Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982; 154:667-72

7 neviaser JS. Ruptures of the rotator cuff of the shoulder. new concepts in the diagnosis and operative treatment of chronic ruptures. arch Surg 1971; 102:483-5

8 Malkani aL, Sundine MJ, tillett eD, Baker DL, Rogers Ra, Morton ta. transfer of the long head of the triceps tendon for irreparable rotator cuff tears. Clin Orthop Relat Res 2004; 428:228-36

9 Wang aa, Strauch RJ, Flatow eL, Bigliani LU, Rosenwasser MP. the teres major muscle: an anatomic study of its use as a ten-don transfer. J Shoulder elbow Surg 1999; 8:334-8

10 Celli L, Rovesta C, Marongiu M et al transplantation of teres major muscle for infraspinatus muscle in irreparable rotator cuff tears, J Shoulder elbow Surg 1998; 7:485-490

11 neviaser JS. Ruptures of the rotator cuff of the shoulder. new concepts in the diagnosis and operative treatment of chronic ruptures. arch Surg 1971; 102:483-5

12 neviaser JS, neviaser RJ, neviaser tJ. the repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze- dried rotator cuff. J Bone Joint Surg am 1978; 60:681-4

13 Ozaki J, Fujimoto S, Masuhara K, tamai S, Yoshimoto S. Recon-struction of chronic massive rotator cuff tears with synthetic materials. Clin Orthop Relat Res 1986; 202:173-83

14 Hamada K, Fukuda H, Mikasa M, Kobayashi Y Roentgeno-graphic findings in massive rotator cuff tears. a long-term ob-servation, Clin Orthop Relat Res 1990; 254: 92-6


Figure 1: immagine RMN che evidenzia

retrazione del tendine che

parzialmente ancora ricopre la testa

omerale

The rotator cuff irreparable tears: latissimus round muscle transferFerdinando Odella, Simona Odella*Istituto Clinico San Siro, Milano * Ortopedia Traumatologica per la Chirurgia della Mano, Istituto Ortopedico G. Pini, Milano

INTRODUCTION

The factors that affect the type of treatment of lesions of the rotator cuff are the patient’s age the functional require-ments, the painful symptoms and the type of lesion.The repairability of the lesion depends on three main ele-ments:

• the extension of the lesion, we distinguish partial-thickness tendon injuries (bursal, intratendinous, joints) and those with full-thickness which we be-lieve should not be evaluated on the basis of cm but in view of the number of tendons involved, we define a lesion as massive if affecting two or more tendons, you must also consider the location of the lesion which, according to Patte1 can be higher, su-perior- posterior, superior- anterior or massive;

• retraction of the tendon which we evaluate the en-tity in three grades:

Grade 1: slight retraction, occurs only in small tears;

Grade 2: Average tendon retraction, (figure 1) the tendon still partially covers the head of the humer-us and the retraction is at the level of the acromio-clavicular joint;

Grade 3: severe tendon retraction, the humeral head is uncovered and the tendon is retracted to the gle-noid;

but the most important element is• fixity or elasticity of this retraction, we recognize

three stages Stage 1 : The cuff injury is recent, the tendons are

still healthy and mobile, the muscle retains its func-tion and the joint is stable;

Stage 2 : the injury occurred more than six weeks, the tendons are hypomobile but recoverable in ana-tomical site in spite of being already an initial de-generation of the tendon and muscle, the joint has a dynamic instability;

Stage 3: the lesion is deep-rooted, the retraction of the tendon is fixed, the muscle and tendon tissue is gone to meet fatty infiltration, the glenohumeral joint is unstable, in this case it is not possible to make a direct repair but you must perform a muscle transposition.

The quality of the tendon tissue and of the muscle belly depends on the fatty infiltration, Goutallier 2 in 1996, iden-tifies five stages according to the relationship between the

degenerated muscle volume and the volume of healthy muscle. Because there is a good result functional muscle degeneration must not be higher than the second stage (Figure 2).Ide3 in agreement with Romeo4 considers that the exten-sion of the lesion, if it exceeds 5 cm, results in clinically unsatisfactory results, in fact, in our opinion is not the ex-tent of the lesion but its fixity the element that determines the repairability of the lesion while the functional outcome depends on the quality of the tendon tissue and of the resi-due muscle trophism.Fuchs5 observed that, in the cuff repaired that had a mus-cular atrophy of tendons involved in the lesion, this condi-tion does not regress, but in case of rupture of the tendon of the supraspinatus atrophy is stable if the injury heals in case of involvement of the subscapular tendon, although healed after repair, not just the atrophy does not regress but increases also the fatty infiltration of the infraspinatus tendon that was not involved in the lesion. The authors do not exclude the possibility of suffering neurological due to technique of repair.

ABSTRACT

The transfer of the tendon of the muscle large round is one of the surgical solutions used in the treatment of the massive irreparable supero-posterior rotator cuff tears. The purpose of this retrospec-tive study is to report the long-term validity of the results with the change in the treatment characterized by suturing the tendon of the subscapularis tendon also transferred intact as well as the greater tuberosity.


Object of our study are the lesions that can not be repaired, the massive tears with severe fatty infiltration of the mus-cle bellies, in these cases, in patients older than 70 years, you can perform muscle transfers: if the lesion is poste-rior superior is necessary that the front wall, represented mainly by the subscapularis is intact to have a good focus during the elevation of the limb. If possible it may be use-ful to anchor the tendon transferred to the tendon of the subscapularis muscle; if the lesion is superior anterior we are used to transpose the anterior tendon of the pectoralis major muscle.

MATERIALS AND METHODS

From 1998 to 2012 142 patients underwent surgical treat-ment (transfer of large round muscle in superior- posterior rupture massive irreparable rotator cuff). The median age was 67.8 years in the female population, 71.4 years in male population. Males constitute 60 % of the population. At mean follow-up of 7 years, the constant total score is equal to 66, the front elevation 158 degrees external rotation in adduction 41 degrees, 66 degrees external rotation in ab-duction, and the strength of 2.4 according to the cs.Patients who have undergone surgical treatment of great

round transfer had an irreparable rupture of the rotator cuff tendon of the superior- posterior with subscapularis intact; were excluded unmotivated patients with moderate pain and age over 75 years, in addition to patients with glenohumeral osteoarthritis, retractile capsulitis, or neuro-logical problems.Surgical treatment was performed in the open surgery with two skin incisions, postoperative treatment provided by a sling immobilization for 40 days at 45 degrees of abduc-tion, followed by a re-education for 6 months.The transfer of the latissimus round requires as a necessary condition for the integrity of the tendon of the subscapu-laris muscle. We recently rechecked the 10 patients in our series and subjected to evaluation as well as clinical, elec-tromyographic and all patients were satisfied with regard to pain and function even if the recovery of strength was not equal to the contralateral limb, and in eight of the ten patients examined, we observed electromyographic acti-vation of the muscle passed during external rotation with limb adduct the hip (Figg. 3-5).

DISCUSSION

For massive lesions according to Patte and Elman we in-tend lesions involving two or more tendons.To choose a proper treatment we must consider several im-portant parameters, such as: type of injury, age and activity of the patient and the patient’s motivation.To evaluate the type of lesion should consider the follow-ing elements: the location, the extension and the form, the retraction of musculotendinous and quality of the muscle tissue.A retraction of the tendon to the glenoid make it very dif-ficult if not impossible to complete repair of the lesion, also a muscle fatty degeneration (visible by NMR) of 3° - 4° degree by Goutallier is a negative prognostic factor. Therefore, in these conditions a massive lesion can be con-sidered as irreparable.Different types of treatment for massive lesions have been described: the conservative treatment, the simple open or arthroscopic debridement (5. 6), generally associated to an acromioplasty; partial repairs; tendon allograft and syn-thetic, and the muscle transfers.Many patients with chronic massive lesions can be treated conservatively with success through modification of activ-ities, NSAIDs, physiotherapy and infiltration of corticos-teroids in the sub acromial space. Bokor et al6 have noted an improvement between 50 % and 85 % of patients treat-ed conservatively. Many studies on the other hand showed a negative correlation between the number of preoperative infiltration of corticosteroids and the results obtained after repair of tendon injury.Rockwood in a 1984 study reported satisfactory results in the treatment of full-thickness lesions with debridement and subacromial decompression in the open air7. Always Rokwood in 19958 demonstrated that the simple debri-dement and acromioplasty in massive lesions irreparable gave satisfactory results, but at a distance of time, follow up > 5 years, tended to deteriorate. Several authors have obtained similar results using a similar technique but al-

Figure 2: immagine RMN che evidenzia

degenerazione grassosa di 2 grado secondo Gouttalier

Figure 3a, b: quadro RMN lesione massiva della cuffia dei rotatori, si

osserva retrazione tendinea alla glena e degenerazione grassosa di 3 gradi secondo

Gouttalier

A b


ways without arthroscopic repair of the lesion5.In contrast to other authors have described unsatisfactory results in the long term with the only decompression and debridement9-12. A study of Melillo et all, 199713 showed that in a group of 52 patients, 27 treated by repair of ten-don injury and 25 with debridement and decompression, only 8% of patients treated with the latter procedure was satisfied, compared to 87 % of patients who underwent cuff repair.This type of treatment can be taken into consideration for elderly patients with few requirements, in which the test Neer with subacromial injection of anesthetic is able to resolve the pain with improved function. You can also per-form the resection and tenodesis of the long head of the biceps, thereby eliminating the biological causes of pain (inflammatory synovial tendon reaction) and the mechani-cal action of the medial displacement of the clb against the tendon of the subscapularis (Burkart 1996)10.To achieve good results in the treatment of massive inju-ries, tendon repair should be respected by prognostic fac-tors set out above. In a study conducted by Wolf et all. in 2000 14, we wanted to demonstrate just that the quality of the results is directly proportional to the respect of pre-operative prognostic factors. To this were included in the study patients with a tendon degeneration not exceeding at stage 2 of Goutallier, absence of pseudoparalysis, absence of anterior-superior subluxation of the humeral head. The results were positive, with a mean postoperative Constant score of 85.5.The results obtained by different authors who have not taken account of prognostic factors have not been up to expectations .Lately in elderly patients with irreparable lesions with in-volvement of the subscapularis and cuff tear arthropathy space is treated with reverse prosthesis. While, in irrepa-rable injury posterior superior muscle transfers represent a

true palliative treatment, as they use muscles of the shoul-der joint in order to recover the functions of stability and movement of his cuff muscles degenerate irreversibly.The indication to muscle transfers occurs in the presence of massive lesions or relapsed chronic pain in patients with active and severe functional deficit highly motivated to functional recovery.By contrast, in the presence of joint stiffness, severe bone and joint abnormalities of the glenohumeral joint, insuf-ficiency of the deltoid muscle and nerve damage, muscle transfers are contraindicated.Transfers muscle can be divided into local and regional.The first uses the remaining tendon tissue by rotating to cover the head using subscapularis. (Cofield 1982)15 or the small round (Paavolainen 1988)16. With this type of treat-ment, there is the risk of clinical worsening (loss of eleva-tion of the limb) if the tendon insertion in the new location does not heal.Debeyre, Patte, Goutallier 17 suggest a muscle-tendon ad-vancement of the elements of the rotator cuff.The reinsertion of tendon after lateral movements of the muscle bellies of the supra and infraspinatus, creates a technique that restores the ‘ anatomy as close to normal as possible.The results of this method are questionable and there are conflicting opinions in the literature. Patte 1 reported good results in 41% of patients, 11 % Walch (1992)18 and Patte Goutallier 17 36%.The best results are obtained when the humeral head is centered with moderate muscle degeneration.Experimental studies on cadavers carried out by Warner and Gerber (1992)19 show that this technique allows a lim-ited traverse and risk to damage the neuro-muscular struc-tures. Combes and Mansat 20 think that this treatment is il-logical because it uses muscles retracted and not working.We agree, in fact the fibrous structure - muscle, in the case

Figure 4a, b: riscontro intraoperatorio della lesione

massiva della cuffia dei rotatori, la testa è scoperta il tendone retratto, sutura del

tendine trasposto

A b

Figure 5a, b: clinica pre e post operatoria

A b


of chronic injury, is retracted and little expandable and the possible muscle fatty degeneration makes this technique useless.In the case in which the trophism is good it is supposed that the lesion is recent and the mobilization of the muscle-tendon is possible with a capsular release.The regional transfers can use a deltoid flap (Augereau-Apoil 198521, Takagishi 22, Vandenbussche (2004)23, the trapezius (Mikasa)24, the muscle angle of the scapula (Celli 1986) pro supraspinatus. The big round (Combes - Mansat 1993)20 and the latissimus dorsi (Gerber 1987) 25,27 can be used to vicariare the infraspinatus.The pectoralis can be used in the rare, but serious degen-eration of the subscapularis (Chaffaï - Mansat 1988)26.

DISCUSSION

The rupture of the rotator cuff is a common disease in the aging population, repair techniques and the means avail-able are varied but relapses are equally present. Factors that should be considered to address the repair of the rotator cuff of the shoulder, such as age, pain, patient motivation, muscle trophism, the status of the long head of the biceps, make it difficult to systematize this disease. Not all broken rotator cuff must be treated surgically. MRI has allowed us to assess not only the size of the lesion but also the trophic muscle, which together with the pain and the functional needs of the patient allows us to give an indication to the appropriate treatment for the individual patient.Mc Laughlin 28 in 1944 describes a technique in repair of tendon injuries of the shoulder by means of sutures tran-sosse tendon to the greater tuberosity, several authors sub-sequently studied various fixation techniques to achieve a better seal to the bone, but the method of McLaughlin and subacromial decompression is still the most widely adopt-ed with excellent or satisfactory in 80% of cases according to Cofield 29.

REFERENCES

1. Patte D Classification of rotator cuff lesions. Clin Orthop Rel Res 1990; 254:81-6

2. Goutallier D, Postel JM, Boudon R et al. a study of the neuro-logic risk in tendino-muscular advancement of supra-spinatus and infra-spinatus in the repair of large rotator cuff rupture. Rev Chir Orthop Reparatrice appar Mot. 1996; 82:299-305

3. Ide J, Maeda S, Katsumasa t. a comparison of arthroscopic and open rotator cuff repair. arthroscopy 2005; 21:1090-1098

4. Romeo aa, Hang DW, Bach BR, Shott S. Repair of full thikness rotator cuff tears. Clin Orthop 1999; 367: 243-255

5. Fuchs B, Gilbart MK, Hodler J, Gerber C. Clinical and structural results of open repair of an isolated one tenson tear of the rota-tor cuff J Bone Joint Surg 2006; 88:309-316

6. Bokor DJ, Hawkins RJ, Huckell GH et al. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Or-thop Rel Res1993; 294:103-110

7. Szalay ea, Rockwood Ca. Injuries of the shoulder and arm. emerg Med Clin north am. 1984; 2:279-294

8. Rockwood Ca, Williams GR, Burkhead WZ. Débridement of de-generative, irreparable lesions of the rotator cuff. J Bone Joint Surg 1995; 77:857-866

9. Baleani M, Schrader S, Veronesi Ca et al. Surgical repair of the rotator cuff: a biomechanical evaluation of different tendon grasping and bone suture fixation techniques. Clin Biomech 2003; 18:721-729

10. Burkhart SS, athanasiou Ka, Wirth Ma Margin convergence: a method of reducing strain in massive rotator cuff tears. arthros-copy 1996; 12:335-338

11. accousti KJ, Flatow eL, technical pearls on how to maximize healing of the rotator cuff. Instr Course Lect 2007; 56:3-12

12. Baring t., emery R, Reilly P Management of rotator cuff disease: specific treatment for specific disorders. Best Practice and Re-search. Clin Rheumatol 2007; 21: 279-294

13. Melillo aS, Savoie FH, Field LD. Massive rotator cuff tears: debri-dement versus repair. Orthop Clin north am 1997; 28:117-124

14. Wolf BR, Bries aD, nepola JV Greater tuberosity osteotomy and teres minor transfer for irreparable superior rotator cuff tears. Iowa Orthop J 2007; 27:65-70

15. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982; 154:667-672

16. Björkenheim JM, Paavolainen P, ahovuo J, Slätis P Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results. Clin Orthop Rel Res 1988; 236:148-53

17. Patte D, Goutallier D, Debeyre J Ruptures of the rotator cuff. Results and perspectives of the retrostructure. Orthopade 1981; 10:206-215

18. Walch G, Maréchal e, Maupas J, Liotard JP Surgical treatment of rotator cuff rupture. Prognostic factors. Rev Chir Orthop Repara-trice appar Mot 1992;78:379-388

19. Warner JP, Krushell RJ, Masquelet a, Gerber C anatomy and re-lationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears. J Bone Joint Surg 1992; 74:36-45

20. Bonnevialle P, Savorit L, Combes JM et al. Value of intramedul-lary locked nailing in distal fractures of the tibia. Rev Chir Orthop Reparatrice appar Mot 1996; 82:428-436

21. apoil a, augereau B Deltoid flap repair of large losses of sub-stance of the shoulder rotator cuff. Chirurgie 1985; 111:287-290

22. takagishi K, Kaibara n, Hotokebuchi t et al. Serum transfer of collagen arthritis in congenitally athymic nude rats. J Immunol 1985; 134:3864-3867

23. Vandenbussche e, Bensaïda M, Mutschler C et al. Massive tears of the rotator cuff treated with a deltoid flap. Int Orthop 2004; 28:226-230

24. Hamada K., Fukuda H., Mikasa M., Kobayashi Y.Roentgenographic findings in massive rotator cuff tears. a long-term observation. Clin Orthop Rel Res 1990; 254:92-96

25. Gerber C, Ganz R, Vinh tS Glenoplasty for recurrent posterior shoulder instability. an anatomic reappraisal. Clin Orthop Rel Res1987; 216:70-79

26. Chaffaï Ma, Mansat M anatomic basis for the construction of a musculotendinous flap derived from the pectoralis major mus-cle. Surg Radiol anat 1988; 10:273-282

27. Jost B, Zumstein M, Pfirrman CWa, Gerber C. Long term out come after structural failure of rotator cuff repairs. J Bone J Joint Surg 2006; 88:472-479

28. McLaughlin, HL, Lesion of the muscolotendinous cuff of the shoulder. the exposure and treatment of tears with retraction. J Bone Joint Surg 1944; 26:31-51

29. Cofield HR, Parvizi J, Hoffmeyer PJ et al. Surgical repair of chron-ic rotator cuff tears. J Bone Joint Surg 2001; 83:71-77


INTRODUCTION

Prof. Grammont’s reverse total shoulder arthroplasty (RTSA) re-liably reduces pain and improves shoulder function by increasing active abduction and forward elevation in patients with massive rotator cuff tears (RCT) and cuff tear arthropathy (CTA). Several works have been published in the last years, mirroring the increas-ing interest this kind of prosthesis received after FDA approval in 2003. Since that year, popularity of RTSA grew up among the ini-tially skeptic surgeons in USA and furtherly increased in Europe and other countries as well. We can actually identify more than 400 works, when looking for shoulder reverse arthroplasty in the PubMed engine, most of which are reviews of the literature. We aimed at focusing our work mainly on the controversial aspects about RTSA. Sharing our own 13 years experience, we tried and carry out a fruible critical reading of the available literature, and some practical advices too, for surgeons approaching this fasci-nating surgery.

Reverse shoulder arthroplasty with and without tendon transfer for arthropathy with massive rotator cuff tear: personal experience and critical analysis of the literaturenicola Ivaldo, Giovanni Caione, Mario Rossoni, tony Mangano*GSL - Gruppo Sanitario Ligure, Ospedale S.M. di Misericordia, Albenga*Clinica Ortopedica e Traumatologica, IRCCS S. Martino - IST, Genova

INDICATIONS AND RATIONALE FOR REVERSE SHOULDER ARTHROpLASTY IN CTA

The first cases of glenohumeral arthritis occurring with tears of the rotator cuff were described by Adams and Smith in the 1850s1. In 1983 Neer defined this condition “cuff tear arthropathy” and described it as a massive rota-tor cuff tear with superior humeral migration and dimin-ished acromionhumeral distance, erosion of the great tu-berosity (“femoralization”) and other arthritic changes in the glenohumeral joint2.Goal of the reconstructive surgery should be to repair the rotator cuff, restoring a balanced shoulder in which the ro-tator cuff tendons keep the humeral head within the cen-ter of the glenoid during arm elevation, allowing motion while maintaining joint stability. Unfortunately, in severe massive RCT tendons retraction often makes repair im-possible. Sometimes, despite a moderate retraction and technically possible repair, tendons degeneration makes the repair biomechanically useless. If the anterosuperior or posterosuperior cuff is compromised, dynamic and/or static superior humeral subluxation may occur, and this ultimately lead to an unbalanced shoulder, with decreased acromionhumeral distance and function impairment. In this condition indeed, when deltoid muscle fibers contract the humeral head will migrate superiorly, instead of allow-ing arm elevation, leading to painful acromial erosions and glenohumeral arthritis. If a balanced shoulder cannot be restored through a standard RC repair, alternative treat-ment options should be considered in order to improve symptoms3,4. However, when pseudoparalysis develops, RTSA may be the sole treatment option able in restoring the glenohumeral joint function, recreating a stable joint fulcrum on which the deltoid can lever and raise the arm5. Patients must be made aware, however, that full range of motion may not be obtained, with good anterior elevation and abduction recovery, but limited and not predictable gain in internal and external rotation. Despite shoulder motion may be improved compared with preoperative lev-els, it may not be completely restored.

ALTERNATIVE TREATMENT SOLUTIONS AND RTSA: WHERE IS IT THE BOUNDARY?

A potential error is to implant an RTSA in a patient with a painful massive irreparable RCT with good function and without arthritis. If the patient has nearly normal ac-tive elevation, then the shoulder is still balanced and the RTSA would be an overtreatment. Nonoperative modali-

ties should be considered first, as subacromial steroid in-jections coupled with stretching exercices and, after pain resolution, strenghtening excercices. In refractory cases, the arthroscopic joint débridement is indicated and, if the biceps is still in place, biceps (LHB) tenotomy3,4. Despite good results are published, several factors may lead to a negative outcome after débridement with or without LHB tenotomy: preoperative superior migration of the humeral head, presence of a subscapularis tear, presence of gle-nohumeral arthritis and decreased range of motion6,7.We did not find research works specifically addressed at simple débridement in presence of a spontaneously rup-tured biceps tendon. Klinger et al. compared the outcome of simple débridement with and without LHB tenotomy, and reported similar results8. After considering the safety of the procedure and the low risk of (solely) cosmetic dam-age, we actually proceed with tenotomy in our practice.Sometimes, patients show a complete active elevation but are unable to lift even low weights. In this situation, we always suggest an initial physiotherapic approach but, in case of failure, an RTSA could be considered for function-al recovery, even if pain is not prominent9.

RTSA IN UMBALANCED MASSIVE CUFF TEARS WITHOUT ARTHRITIS

In the recent past, surgeons were reluctant to implant RTSA in case of pseudoparalysis without clear degenera-tive arthropathy. Actually, several works report about this


subgroup of patients10. In particular Hyun et al. warned about possible errors in indication, when a cause for func-tional impairment different from the RC tear is underesti-mated (e.g. neurological lesion), and in case the functional recovery possibilities are overestimated, in patients with preoperative preserved active forward elevation greater than 90°. Both of these conditions are unlikely to benefit from RTSA11.

WHAT CAN WE DO WHEN MEDICAL THERApIES AND CONSERVATIVE SURGERY FAIL?

The role of the latissimus dorsi (LD) transfer in massive RCT has been extensively cleared by Gerber, who also identified limits for this procedure. In particular, a not reparable subscapularis tear and a Goutallier grade II or more fatty degeneration of the teres minor represent in-dependent negative prognostic factors. On the other hand, we should consider that when these muscles are not com-promised, most of shoulders show an acceptable function, which excludes them from substitution with RTSA.Weening and Willems reported about 16 patients treated with LD transfer, where they found a 26° mean recovery in active elevation (from 79° to 105°) and did not observed the humeral head recentering in most of cases. Mean func-tional results in this series are worse than those obtained with RTSA in similar cases12-14.In our practice, we gradually limited the isolated LD transfer, considering the correct indication still unclear. We reserve the combined transfer of LD and teres major (TM) to patients in which, due to massive posterosuperior RCT and teres minor impairment, preserved active elevation and abolished exter-nal rotation are shown. Furthermore, we use the same trans-fer procedure in association with RTSA in cases of combined forward elevation and external rotation deficits. Recently, Savarese and Romeo reported a technical note about using a biodegradable subacromial spacer able in re-centering the humeral head at the glenoid. This device could represent a possible new and original solution, and we wait for clinical results15.

RTSA FOR YOUNG pATIENTS

Despite not frequently, it is possible to find out a massive RCT with severe function impairment in patients aging the V or VI decade of life. Most of works state RTSA should be reserved for patients aged 70 years or more, because of the risk of components wear. Our personal choice is to consider the possibility of a RTSA implantation together with younger patients, clearly presenting them the even-tual doubts concerning components wear due to strenuous activities, and the need for frequent radiographic follow-up evaluations. It is not unfrequent that after extensive explanations these patients accept the proposed solution. Two recently published works seem to support this be-haviour. Sershon et al.16 report a short term success rate of 75% in a series of patients, most of which treated for post-traumatic arthropathy or revision surgery, indication subgroups known to have a worse prognosis than CTA and massive RCT. Neukom et al. describe good results in the long term follow-up, despite evidencing an high complica-tion rate17. Of note, most of the complications described have been treated successfully without compromise to clinical outcome.

RESULTS OF RTSA IN CUFF TEAR ARTHROpATHY AND MASSIVE ROTATOR CUFF TEARS

Favard et al.18 recently published the largest series (464 patients with a 7.5 years mean follow-up) of RTSA im-planted for CTA. Reported mean active anterior elevation (AAE) improved from 69.3° to 128.6°, active external ro-tation (AER) with the abducted arm improved from 23.5° to 42.1°, while AER with the arm at the side showed little improvement, from 4.9° to 10.6°. Survivorship free of re-vision was 89% at 10 years with a marked break occur-ring at 2 and 9 years. Survivorship to a Constant-Murley score of less than 30 points was 72% at 10 years, with a marked break observed at 8 years. They observed pro-gressive radiographic changes after 5 years and increas-ing frequency of large notches with long-term follow-up. Of note, most of the surgeons were at the beginning of their experience with RTSA, then data could suffer from the learning curve. Frankle et al.19 reported results of sixty patients with a rotator cuff deficiency and glenohumeral arthritis, with a mean follow-up of 33 months. The mean total score on the American Shoulder and Elbow Surgeons score improved from 34.3 to 68.2. The score for function on the visual analog scale (VAS) improved from 2.7 to 6, and the VAS score for pain improved from 6.3 to 2.2. AAE increased from 55° to 105.1°, and 41 of the sixty patients (67.2%) rated the outcome as good or excellent. Sirveaux et al.20 reviewed 80 shoulders with a mean follow-up of 44 months. Three implants had failed and had been revised. Mean Constant-Murley score increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. Mean AAE increased from 73° to 138° (table 1). Studying a series of patients treated with RTSA, Wall et al. demonstrated that patients with primary CTA or massive RCT had better clinical outcomes than other diagnosis21.

Table 1

StudyMean FU (months)

Revision rate

Function Scores

Sirveaux et al.20 44.5 4% 67 (Constant-Murley)

Werner et al.23 38 18%72% (Relative Constant-Murley)

Frankle et al.19 33 13% 68.2 (aSeS)

Favard et al.18 91 5% 61 (Constant-Murley)

nolan et al.24 24 0%62 (Constant-Murley), 76 (aSeS)

Functional results and revision rate in published series of RTSA for massive RCT with or without glenohumeral arthritis.


Figure 1. a) High degree scapular

notching at 8 years follow-up.

b) Delta III RTSA with upwards directed inferior screw: no sign of notching

at 7 years follow-up.

The same conclusion can be found in a precedent work from Boileau et al.22

Furthermore, comparing results on two series of patients treated for primary or revision surgery, Werner et al. stated that patients in the two groups showed similar amounts of improvement. However, this observation should be taken with caution, because authors included in the “primary sur-gery” group also previously operated post-traumatic cases, probably biasing final results. In our experience, cases with sequelae from previous reduction and synthesis sur-geries are more consistently comparable to revisions, with respect to technical difficulties and outcome results23.

RADIOLOGICAL RESULTS: FOCUS ON SCAPULAR NOTCHING

RTSA is associated with higher complication rates than ana-tomic shoulder arthroplasties. Most common complications include baseplate failure, instability, infection, nerve lesion, surgical site haematoma and scapular fracture. Despite a systematic treating is out of the purpose of this work (for review, see ref. 25) we agree with other authors in that we have only very limited series relating to RTSA in specific indications and we need to know how likely each complica-tion is in a specific patient and not in completely different circumstances. Behind this consideration, we would tribute particular attention to the almost constantly reported radio-graphic complication of scapular notching.Infraglenoidal scapular notching in RTSA is a frequent find-ing related to mechanical impingement by the medial rim of the humeral cup against the scapular neck in adduction and internal-external rotation (Fig. 1a). This complication typically occurs within the first few months after RTSA24 and the reported incidence ranges from 44% to 96%. The in-fluence of infraglenoidal scapular notching on clinical out-come has not been fully delineated yet and is still controver-sial in the current literature. Sirveaux20 showed a negative effect of scapular notching on the Constant-Murley score. On the contrary, Lévigne et al.26 do not report a correlation of scapular notching with clinical findings. Recent series with longer follow-up have demonstrated notching can be progressive and associated with reduced shoulder ROM,

strength, decreased subjective shoulder scores and relative Constant-Murley score, and increased polyethylene wear and potential for implant loosening27. Most of high-grade scapular notching cases is found between patients with lon-ger follow-up18,27. This could reflect not only the progression of notching itself, but also technical changes that took place in the years, with actual trend towards a lowered and tilted positioning of the glenoid metal back.Whatever its final involvement be in implant stability and survival, attention should be paid, in our opinion, in order to minimize the occurrence of scapular notching. An infe-rior tilt of the metal back (10-15°) is auspicated. Just a little trick: the inferior screw fixating the metal back should be parallel to the central peg, and not inferiorly directed (Fig. 1b). When correctly placing the metal back in the lower part of the glenoid, this will avoid the inferior screw to pierce the cortical bone and, in case of notching, the polyethylene liner to take contact with the screw itself (with foreseeable con-sequences in terms of components wear). At this moment, it is not clearly defined how much the incidence of notching could be limited by using an inverted tribology (i.e. gleno-sphere in PE, metallic liner), while it is bona fide accepted that major diameter glenosphere could carry some advan-tages. Furthermore, some authors recently demonstrated good results in terms of limited notching incidence by using a glenosphere with eccentric design28.

RTSA COMBINED WITH MUSCLE TRANSFER FOR COMBINED PSEUDOPARALySIS

Some patients show a combined deficit of active anterior ele-vation (AAE) and external rotation (AER), also referred to as combined pseudoparalysis. This condition generally relates to a massive posterosuperior tear of the rotator cuff, involv-ing a ruptured or, more frequently, ipotrophic teres minor, with Goutallier grade III-IV fatty degeneration and positive hornblower’s and dropping signs. Both a massive RCT and CTA could underlie this pathology, and patient’s quality of life is often blunted. Activities of daily living such as eating, holding a phone or combing hair become difficult or impos-sible, since the patient cannot control the spatial positioning of his upper limb while raising an object with the hand30,31.


Figure 2. a) Missing postoperative

AER recovery after RTSA in a patient devoid of a functional teres

minor muscle. b) T1-weighted MRI cut

showing severe fatty degeneration of the

posterior muscle of the rotator cuff (teres minor

is highlighted).

RTSA allows the restoration of active overhead elevation in patients with a massive rotator cuff tear and pseudoparaly-sis of elevation. However, it does not restore active external rotation, the lack of which can substantially compromise the functional outcome.The teres minor muscle contributes to AER, and its defi-ciency may impair the clinical outcome after RTSA (Fig. 2). Simovitch et al.32 published results of 42 RTSA and corre-lated results to teres minor integrity and fatty degeneration. Shoulders with stage 0, I or II fatty infiltration of the teres minor muscle (group 1) had a significantly better Constant-Murley score and subjective shoulder value, than shoulders with stage III or IV (group 2). Group 1 had a net gain of 9° of external rotation with the arm at the side compared with an average loss of 7° in group 2. Authors therefore conclud-ed that teres minor stage III or IV fatty infiltration compro-mises the clinical outcome of RTSA for massive RCT.Although AER deficit can be treated with a tendon transfer surgery, this technique alone may be inadequate to power external rotation and elevation with such global dysfunc-tion, and is contraindicated when arthritic changes are present32-36.In our early experience with RTSA (without tendon trans-fer) we observed some patients functionally disabled after surgery. This was probably due to the absence of external rotator cuff muscles (infraspinatus and teres minor) with consequent no counterbalance for the strong functional in-ternal rotators (pectoralis major, latissimus dorsi, teres ma-jor and subscapularis). Several surgeons, and we too, tried and find a solution by mean of a tendon transfer combined with the RTSA proce-dure. Gerber chose a double approach solution with transfer of the latissimus dorsi (LD) alone37. On the contrary, Boileau chose a combined transfer of LD and teres major (TM) by mean of a single deltopectoral approach, inspired by the old technique Merle D’Aubigné used for the treatment of ob-stetric paralysis (also referred to as modified L’Episcopo)38. And this was our first orientation. With this technique we obtained good results in recovering AER, with a significant loose in active internal rotation (AIR). Therefore, we hy-pothesized a single LD transfer where the tendon was passed through a split TM, by mean of a deltopectoral approach, but results were unsatisfactory again due to great variability.

Because of this, we finally came back and aligned with Boi-leau’s idea, accepting the residual AIR deficit39.Candidates for the combined procedure (RTSA & tendon transfer) are those patients showing severe active anterior elevation deficit with impossibility in keeping shoulder ex-ternal rotation with the arm adducted, independently from the X-ray status of the joint. In most of these patients, the hornblower’s sign can’t be evidenced because of pain, lim-ited elevation or joint stiffness, and the quantitative evalua-tion of ER with 90° arm abduction is sometimes not possi-ble. This parameter would be of great interest when looking for functional results after transfer surgery but, because of the aforementioned reasons, few published series reported it37,38. In our practice, we evaluate the preoperative AER at maximum abduction, with the examinator sustaining the pa-tient’s elbow. In the postoperative follow up visit the same evaluation is taken, at the same degrees of abduction, in or-der to obtain comparable measures. The indication for a combined procedure should be corrobo-rated by imaging studies like CT or MRI, with axial and oblique-sagittal cuts directed to teres minor evaluation.In some cases, the indication is considered in the operative setting, after direct evaluation of the low quality of the teres minor and the high quality of muscles to be transferred. This is not an obvious find, because LD and TM could be damaged by rheumatoid pathologies, steroid therapies and previous surgeries as well, particularly at their humeral in-sertion. Some advantages are foreseeable, in such cases, for the single approach procedure with respect to Gerber’s tech-nique, in which the preparation of the LD tendon precedes the prosthesis implantation and takes place through a differ-ent access.

RTSA WITH LD/TM TRANSFER THROUGH DELTOpECTORAL AppROACH: SURGICAL TECHNIQUE

With the patient in a beach-chair position, we use a clas-sical deltopectoral approach, with distal extension to pec-toralis major humeral insertion. This is cut 1,5 cm from the lateral margin of the biceps groove, allowing final re-insertion. Both the anterior axillary vessels and the axil-


Figure 3. a) LD/TM tendon transfer

showed in a cadaver specimen before reinsertion.

b) Transferred LD and TM tendons after insertion

at the teres minor insertion site.

lary nerve should be identified at the inferior border of the subscapularis. In these patients the subscapularis tendon is generally conserved, and it should be accurately de-tached form the lesser tuberosity and tagged40. The LHB is identified in its groove and it is cut or tenodesed, and the intra-articular portion resected. The humeral head is dis-located anteriorly allowing the RTSA to follow a standard technique. Medial reflection of the pectoralis major then exposes the combined insertions of the LD/TM. With the arm in internal rotation, these tendons are detached from the humerus. Heavy, nonabsorbable sutures are placed in the free ends of the combined tendons in a baseball stitch fashion. Both tendons are released to gain length, with at-tention in avoiding damage to the neurovascular pedicles. Adhesions are released with bluntly dissection when it is pushed medially, and always with the arm in adduction and flexion to relax the brachial plexus. Dissection should not venture beyond 6 cm medial to the tendon insertions, as anatomic studies identified the neurovascular pedicles of LD and TM at a minimum distance of 7.4 cm proximal to the humeral insertions41. When sufficient length is ob-tained (approximately 3–5 cm), the humerus is dislocated anteriorly and the tendons are transferred around its pos-terolateral aspect. The transferred tendons are fixed at the level of teres minor insertion, using transosseous sutures (Fig. 3). The sutures are placed before implantation and cementation of the definitive humeral prosthesis, reinforc-ing the construct by passing them around the prosthetic neck. When the tendon transfer is completed the prosthesis is reduced, and the subscapularis tendon reattached to the

lesser tuberosity with transosseous sutures passed through the bone at the bicipital groove level (also placed before cementation of the final implant). The pectoralis major is repaired then, and the wound closed under suction drain-age. After surgery, the arm is placed in a sling in slight abduction and neutral rotation that is maintained for five weeks.

RESULTS AND DISCUSSION

Boileau reported on seventeen consecutive patients who underwent the modified L’Episcopo procedure through a single deltopectoral approach and were followed for at least 12 months. Mean AAE increased from 74° preop-eratively to 149° postoperatively, and AER increased from -21° to 13°42.In our experience, we followed 17 patients for an aver-age of 30 months, basically managed with the same pro-cedure proposed by Boileau. We prefer to call it Merle D’Aubigné procedure since he described in 1947 LD/TM-transfer through a single deltopectoral approach, suturing the transferred muscles on the pectoralis major stump, for treatment of birth brachial plexus palsy43. Our results were presented in Lyon Secec Meeting on September 2011 but are unpublished so far.In our series mean Constant-Murley score improved of 31 points (from 34 to 65), SSV 45% (from 29% to 74%), mean AER with the arm at the side improved 17° (from -12° to +5°). We also evaluated external rotation in ab-

Table 2

Sirveaux et al.20

Boileau et al.29

Werner et al.23

Simovitch et al.27

Nolan et al.24

Lévigne et al.26

Wall et al.21

Mizuno et al.28

N of prosthesis 80 45 58 77 71 337 152 47

Follow-up (months) 44,5 40 38 44 24 47 40 30.4

notching 64 % 68 % 96 % 44 % 49 % 62 % 51 % 40 %no notching 36 % 32 % 4 % 56 % 51 % 38 % 49 % 60 %Grades 1 & 2 74 % 82 % 54 % 59 % 76 % 66 % 63 % 95 %Grades 3 & 4 26 % 18 % 46 % 41 % 24 % 34 % 37 % 5 %

Incidence of scapular notching in the main published series is summarized.


duction, with the aforementioned technique, and gain was 32° (from 8° to 40°). Functional external rotation gain was excellent: 4.1 points (from 3.5 to 7.6), reflecting improve-ment of both elevation and external rotation. Patients were able to use the arm over the head level postoperatively, while they used it at the level of the sternum in the pre-operative setting. Internal rotation significantly worsened: from a preoperative level of L1-L2 to buttock at follow-up. This worsening reflects what we call the “short blanket ef-fect“: we explain to our patients that the price to pay to im-prove external rotation is to loose the opposite movement. This should be clearly discussed with the patient when the indication is given, taking into account internal rotation in the opposite limb: in presence of a bilateral deficit of inter-nal rotation, to avoid a serious handicap in activities that involve such a movement (e.g. hygiene care), we believe the transfer procedure inadvisable.Boughebri et al.44 published results about 14 patients man-aged with the combined procedure through single delto-pectoral approach. At an average 33.2 months follow-up, mean AAE and AER with the arm at the side improved sig-nificantly, from 64° to 126°, and from -9° to 27° (gain 36°) respectively. In their series, contrary to all the published ones and ours too, authors did not evidence a worsening of active internal rotation.Ortmaier et al.45 reported on 13 patients treated with RTSA in combination with latissimus dorsi transfer with a modi-fied technique, harvesting the LD with a small piece of bone. At a mean 6 years follow-up, mean AAE improved from 55° to 138° and mean AER improved from -16° to 21° (gain 37°). They conclude that the modified technique leads to good tendon integrity, low rupture rates and good clinical outcome.Recently, Puskas et al.46 published results about 32 cas-es followed up for an average of 53 months after RTSA with LD transfer through a double approach technique. The age-related mean Constant-Murley score significantly increased from a preoperative value of 45% to 89%. The mean SSV increased from 33% to 75%. AER significantly improved from a mean of 4° to 27° (gain 23°). A preopera-tive external rotation lag sign could be corrected in 25 of the 32 shoulders. In their series, authors described a wors-ening of AIR, despite at a lower extent with respect to the AIR loss Boileau and we observed.

CONCLUSIONS

Reverse total shoulder arthroplasty represents a useful so-lution in case of cuff tear arthropathy or massive rotator cauff tear with function impairment. Due to its inherent design, this kind of implant is able in recovering active anterior elevation at the overhead level in most of patients, despite lower results could be expected for active external and internal rotation. In presence of severe loss of active elevation and external rotation, combined latissimus dorsi transfer and reverse to-tal shoulder arthroplasty can restore both AAE and AER. In our experience, the overall functional improvement in these patients is excellent: AER with the arm at the side improves of relatively few degrees, but AER in abduction

improves of more than 30 degrees. Active internal rotation clearly worsen and it requires a thoughtful and eclectic be-havior in presence of bilateral disease, for consequences inherent the activities of daily living. In some patients, tendons that should be transposed show a poor tissue quality due to prolonged corticosteroid therapy or iatrogenic lesions. In these cases, the decision about executing the transfer procedure should be considered in the operative setting, according to directly verified tendon quality. Surgery through a single deltopectoral approach is easier and faster compared to the dual access technique. Further-more, according to our experience, it is also burdened by a lower complication rate.In our practice, we observed some cases in which RTSA without muscle transfer in patients completely devoid of the posterior cuff finally resulted in a sensible recovery of AER. The role the posterior deltoid muscle could lead in these situations and, more generally, in recovering AER has not been clearly defined yet. Finally, when considering indication for adding a tendon transfer, surgeons must keep in mind that most of expert authors indicate it in no more than 10-15% of their patients requiring RTSA for cuff tear arthropathy or massive rota-tor cuff tear.

REFERENCES

1. Smith JG. Pathologic appearance of seven cases of injury of the shoulder joint with remarks. London Medical Gazette. 1834; 14: 280

2. neer CS 2nd, Craig eV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg am. 1983; 65: 1232-44

3. Boileau P, Baque F, Valerio L, ahrens P, Chuinard C, trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg am. 2007; 89: 747-57

4. Walch G, edwards tB, Boulahia a, nove-Josserand L, neyton L, Szabo I. arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and ra-diographic results of 307 cases. J Shoulder elbow Surg. 2005; 14: 238-46

5. Grammont PM, Baulot e. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993; 16: 65-8

6. Klinger HM, Steckel H, ernstberger t, Baums MH. arthroscopic debridement of massive rotator cuff tears: negative prognostic factors. arch Orthop trauma Surg. 2005 May; 125

7. Liem D, Lengers n, Dedy n, Poetzl W, Steinbeck J, Marquardt B. arthroscopic debridement of massive irreparable rotator cuff tears. arthroscopy. 2008; 24(7): 743-8

8. Klinger HM, Spahn G, Baums MH, Steckel H. arthroscopic deb-ridement of irreparable massive rotator cuff tears - a compari-son of debridement alone and combined procedure with biceps tenotomy. acta Chir Belg. 2005; 105(3): 297-301

9. Drake Gn, O’Connor DP, edwards tB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010; 468(6): 1526-33

10. Harreld KL, Puskas BL, Frankle Ma. Massive rotator cuff tears without arthropathy: when to consider reverse shoulder arthro-plasty. Instr Course Lect. 2012; 61: 143-56

11. Hyun YS, Huri G, Garbis nG, McFarland eG. Uncommon indica-tions for reverse total shoulder arthroplasty. Clin Orthop Surg. 2013; 5(4): 243-55

12. Gerber C. Latissimus dorsi transfer for the treatment of irrepa-


rable tears of the rotator cuff. Clin Orthop Relat Res. 1992; 275: 152-60

13. Costouros JG, espinosa n, Schmid MR, Gerber C. teres minor integrity predicts outcome of latissimus dorsi tendon transfer for irreparable rotator cuff tears. J Shoulder elbow Surg. 2007; 16(6): 727-34

14. Weening aa, Willems WJ. Latissimus dorsi transfer for treat-ment of irreparable rotator cuff tears. Int Orthop. 2010; 34(8): 1239-44

15. Savarese e. and Romeo R. new solution for massive, irreparable rotator cuff tears: the subacromial “Biodegradable Spacer”. ar-throsc tech. 2012; 1(1): e69-e74

16. Sershon Ra, Van thiel GS, Lin eC, McGill KC, Cole BJ, Verma nn, Romeo aa, nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder elbow Surg. 2014; 23: 395-400

17. ek et, neukom L, Catanzaro S, Gerber CJ. Reverse total shoul-der arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder elbow Surg. 2013; 22(9): 1199-208

18. Favard L, Levigne C, nerot C, Gerber C, De Wilde L, Molé D. Re-verse prostheses in arthropathies with cuff tear: are survivor-ship and function maintained over time? Clin Orthop Relat Res. 2011; 469(9): 2469-75

19. Frankle M, Siegal S, Pupello D, Saleem a, Mighell M, Vasey M. the reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients. J Bone Joint Surg am. 2005; 87: 1697-705

20. Sirveaux F, Favard L, Oudet D, Huguet D, Walch G, Molé D. Gram-mont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff: results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004; 86: 388-95

21. Wall B, nove-Josserand L, O’Connor DP, edwards tB, Walch G. Reverse total shoulder arthroplasty: a review of results accor-ding to etiology. J Bone Joint Surg am. 2007; 89: 1476-85

22. Boileau P, Watkinson D, Hatzidakis aM, Hovorka I. neer award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder elbow Surg. 2006; 15: 527-40

23. Werner CM, Steinmann Pa, Gilbart M, Gerber C. treatment of painful pseudoparesis due to irreparable rotator cuff dysfunc-tion with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg am. 2005; 87: 1476-86

24. nolan BM, ankerson e, Wiater JM. Reverse total shoulder ar-throplasty improves function in cuff tear arthropathy. Clin Or-thop Rel Res. 2011; 469(9): 2476-82

25. Farshad M, Gerber C. Reverse total shoulder arthroplasty from the most to the least common complication. Int Orthop. 2010; 34(8): 1075-82

26. Lévigne C, Boileau P, Favard L et al. Scapular notching in reverse shoulder arthroplasty In: Walch G, Boileau P, Molé D, Favard L, Lévigne C, Sirveaux F: Reverse shoulder arthroplasty: Clinical results, Complications, Revisions. ed. Sauramps Médical, Mont-pellier, France 2006, pp. 353-72

27. Simovitch RW, Zumstein Ma, Lohri e, Helmy n, Gerber C. Predic-tors of scapular notching in patients managed with the Delta III reverse total shoulder replacement. J Bone Joint Surg am. 2007; 89: 588-600

28. Mizuno n, Denard PJ, Raiss P, Walch G. the clinical and radio-graphical results of reverse total shoulder arthroplasty with ec-centric glenosphere. Int Orthop. 2012; 36(8): 1647-53

29. Boileau P, Watkinson D, Hatzidakis aM, Balg F. Grammont re-verse prosthesis: design, rationale and biomechanics. J Shoulder elbow Surg. 2005; 14: 147S–51S

30. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Clin Orthop Relat Res. 1994; 304: 78-83

31. Walch G, Boulahia a, Calderone S, Robinson aH. the ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br. 1998; 80: 624-8

32. Simovitch RW, Helmy n, Zumstein Ma, Gerber C. Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty. J Bone Joint Surg am. 2007; 89: 934-9

33. Covey DC, Riordan DC, Milstead Me, albright Ja. Modification of the l’episcopo procedure for brachial plexus birth palsy. J Bone Joint Surg Br. 1992; 74: 897-901

34. edwards tB, Baghian S, Faust D, Willis RB. Results of latissimus dorsi and teres major transfer to the rotator cuff in the treat-ment of erb’s palsy. J Pediatr Orthop. 2000; 20: 375-9

35. Freund RK, terzis JK, Jordan L, taylor G. Modified latissimus dorsi and teres major transfer for external rotation deficit of the shoulder. Orthopedics. 1986; 9: 505-6

36. Gerber C, Maqueira G, espinoza n. Latissimus dorsi transfer for the irreparable rotator cuff tears. J Bone Joint Surg am. 2006; 88: 113-20

37. Gerber C, Pennington SD, Lingenfelter eJ, Sukthankar a. Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. a preliminary report. J Bone Joint Surg am. 2007; 89: 940-7

38. Boileau P, Chuinard C, Roussanne Y, Bicknell Rt, Rochet n, tro-jani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res. 2008; 466: 584-93

39. Ivaldo n, Rossoni M, Caione G, Franzi P. Latissimus dorsi transfer associated to Grammont reversed shoulder prosthesis: results at 22 months of follow up. Minerva Ortop traumatol. 2006; 57: 329-36

40. Boileau P, Chuinard C, Roussanne Y, neyton L, trojani C. Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty. J Shoul-der elbow Surg. 2007; 16: 671-82

41. Bartlet SP, May JW, Yarenchuk MJ. the latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg. 1981; 67: 631-6

42. Boileau P, Rumian aP, Zumstein Ma. Reversed shoulder arthro-plasty with modified L’episcopo for combined loss of active el-evation and external rotation. J Shoulder elbow Surg. 2010; 19: 20-30

43. Merle D’aubigné R. Paralysie obstétricale du plexus brachial trai-tée par transposition des tendons du grand rond et du grand dorsal. Mémoire académie de Chirurgie 1947; 73: 561

44. Boughebri O, Kilinc a, Valenti P. Reverse shoulder arthroplasty combined with a latissimus dorsi and teres major transfer for a deficit of both active elevation and external rotation. Results of 15 cases with a minimum of 2-year follow-up. Orthop traumatol Surg Res. 2013; 99: 131-7

45. Ortmaier R, Resch H, Hitzl W, Mayer M, Blocher M, Vasvary I, Mattiassich G, Stundner O, tauber M. Reverse shoulder arthro-plasty combined with latissimus dorsi transfer using the bone-chip technique. Int Orthop. 2014; 38:553-559

46. Puskas GJ, Catanzaro S, Gerber C. Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder. J Shoulder elbow Surg. 2014; 23: 49-57


Shoulder arthroplasty’s rehabilitation Rossella Costantino, Lorenzo Panella, elisa PriscoU.O.C. Medicina fisica e riabilitazione, Istituto Ortopedico G. Pini, Milano

REHABILITATION TREATMENT

Rehabilitation begins immediately after surgery. The reha-bilitation program has the following purposes (Brotzman SB, Wilk KE)1: passive amplitudes recovery; active motion recovery; muscular strengthening and returning to normal activities of daily living. This protocol takes long time and a few months pass between the first passive movements and the complete recovery of motion and strength. The phases of rehabilitation following a logical sequence that must be respected carefully. The time that is dedicated to each stage in order to move to the next one is not con-stant, but extremely variable from one patient to another. It also depends on the goals he intends to reach, his overall physical conditions which are often related to age and status of the periarticular structures before the surgery. For this reason it is not possible to determine fixed deadlines between one phase and the other of the rehabilitation pro-gram, but only general indicative lines on the timing which is normally required to reach a certain goal. Therefore, through exercise, the rehabilitator must assign

to the patient some tasks, which must have as purpose the specific activation request to local strategies compromised and not to the attainment of the final result or to the muscle strengthening. Thus it must be activated the capacity deriv-ing from the ability to connect central and peripheral mech-anisms in a variable dynamic way. The exercises, that are gradually included, before passive then active assisted and active lastly, do not replace each other, but they are added to those already acquired previ-ously. In the end they allow an overall recovery of motility (clearly dictated by individual variables). Generally a series of rehabilitation programs are applied be-cause of the compliance with the various biological phases of traumatized tissues repair by careful exercises of passive, segmental and global motility, isotonic exercises in a par-ticular joint range and isometric exercises. It also provides a strengthening of the insufficient musculature through exer-cises in a closed kinetic chain, exercises against increasing resistance, isokinetic and proprioceptive exercises. The passive mobilization is the first physiotherapic opera-tion implemented in all types of shoulder pathology. It is performed by the therapist, but also through practices of gravitational and self-assisted mobility. Traditional exercis-es are usually preferred. Permforming them you must check that the mobilization takes place in the scapular plane. Actu-ally, the exercises executed on this level guarantee a correct biomechanical alignment. The first few weeks of treatment are usually set up with cau-tion because of the pain4. In this first phase, the scar treat-ment is important to encourage the flow of the underlying tissues and to soothe the pain of the pulled cutis. Generally, at the beginning of the session, we prefer to start with the treatment of relaxation of the trapezius and paravertebral through cervical pompages and the help of deep breathing5. It continues with a cautious passive motility of the elbow to retrieve the extension, also using postures of relaxation in extension. The patient is educated on the movements he has to avoid when he practices them at home because they might endanger the stability of the prosthesis and self-mobilization exercises of hand, wrist and elbow6.Through the exercises defined commuters, proposed by Codman, we try to get mobilization by the force of gravity, making a pendulum movement to be performed first in the frontal, then sagittal and finally, in a circular, clockwise and counterclockwise way. After the first stage of passive exercises, we will switch to an active phase, in which we distinguish an initial segmen-tal treatment following by another defined global. The first step is dedicated to the recovery of motility, maintaining, initially, a free range from pain, using the scapular plane

INTRODUCTION

The shoulder joint is often subject to different kinds of traumatic events or various degenerative diseases which may become dis-abling in course of time. The most common reasons that cause imbalances in the shoulder are injuries to the soft tissues (rotator cuff), osteoarthritis, arthritis, avascular necrosis and fracture of the proximal humerus. For the rehabilitation therapist is necessary to know the pathol-ogy of disease accurately, the choices and the modus operandi of the surgeon who performed the prosthesis surgery, in order to draw up a careful rehabilitation program that bears the patient’s peculiarities in mind. The rehabilitation program is applied following a temporal se-quence. This allows the tissues healing, the joint mobilization and, finally, the strengthening muscle and the functional recov-ery1. Mobility, strength and stability are the three functional ele-ments of the shoulder that can be compromised by an acute or chronic injury and they must be restored. The physiotherapist has to inform the patient about the possibility to run into functional limitations and must instruct him the strate-gies to be able to carry out everyday activities using better the potentialities of the “new” articulation2.However, we must always remember that while the therapist evaluation parameters can and must be others as well, for the pa-tient one of the main valutation measures of the operation and of rehabilitation success will be the disappearance of pain3.


and having the foresight to support the arm and then extend more and more the motility range. The initial movements, which are performed in the supine position trying to avoid as much as possible any compensations, are aimed at the recovery of flexion and extension . In addition, you can begin the passive motility of the shoul-der blade sliding it slowly on the chest wall, in the directions physiological scapulars, trying to restrict acromion move-ments in the lateral decubitus position on the healthy side. Afterwards abduction and adduction movements will be introduced always in a supine position. At a later time, you can devote to the strengthening of the individual muscles. Currently, for the shoulder pathology, strengthening exercis-es aimed at the individual muscle are suggested, performing them either against the resistance offered by the therapist, or against the resistance made by the patient himself or with his help. Beside exercises which require the voluntary con-traction of individual muscles, defined segmental, at a later stage of treatment, the use of global type exercises in which the activation of a large number of muscles is requested is raccomanded. In later stages, rotational movements, both internal and ex-ternal, are added. When you plan the exercises you will need: to identify the function which is involved in the ability of the shoulder to participate in organizational processes (for instance, func-tion of indication, tracking, achievement, pressure and boost, etc.); to identify which contribution the shoulder gives to the retrieval object function; to identify through which ways the shoulder is able to cope with the need to allow the relation-ships among the various body segments in relation to differ-ent functions. The exercise must be a cognitive problem to be solved by the selection and splitting of some body segments and, therefore, it will be based on the development and testing of perceptual hypotheses aimed at solving the problem.

pROpRIOCEpTIVE ExERCISES

Starting from this premise, we propose a initial group of ex-ercises directed specifically to enable local strategies which affect the relationship among the sternum, clavicle and scapula in order to ask the patient the building of a correct relationships. The patient suffering from shoulder disorders, hardly presents a perfect symmetry of body towards the midline. Problems posed by this situation can be controlled through the application of touch operations, evoked through the request for the recognition of sponges of different texture in a sitting position2. The exercise proposed to recognize contact-pressure information, through the use of sponges of different consistency. Therapists place these sponges signifi-cantly, in correspondence of the scapula, in the direction of the movement of the rear position of the track, in correspon-dence of the clavicle, in relation to the direction of elevation movement of shoulder and in correspondence of the front part of the track for anteposition movements. With this type of information you are able to reconstruct more accurate reports of fragmentation among different joints, through proper use of muscle systems. In this way an evolution of the scapula motility occurs. From an initial

static breakaway, i.e. to not relations with the trunk, it starts to build more meaningful relationships, also of dynamic type, which enable the movements for the proper mainte-nance of the correct position of upper limb. From this first step an improvement in pain symptoms may also derives. Its genesis is to be found both in the antalgic contracture, and in a sort of deafferentation, but also in a reduced ability to perceive correctly the somesthetic information. In the third group of exercises the requests made to the patient are designed to require the activation of spatial operations, characterized by a broader hike and more attention is given to the mobility of the glenohumeral joint, whose movements and informative activities are interested in solution of spatial type tasks. In this group of exercises, the preference is given to the pursuit and achievement of trajectories, among which you should preferred circular paths as there are substantial evidences which support some hypothesis that the upper limb movements occur within strategies related to move-ments with conical apex at the level of the glenoid and they allow full activation of all muscle components of the joint. The solution of the problem posed by this exercise to the patient requires the construction of a correct rotational ori-entation of the humeral head with the glenoid; the exercise evolution allows the hand the reacquisition of freedom to move properly in a broader space.

IDROKINESITHERApY

For nearly a century, both in orthopedics and traumatology, and in neurological field, we tried to use water as a rehabili-tative means exploiting its inherent characteristics. For the last thirty years, however, this branch of rehabilitative medi-cine has taken on its own identity. It has been the subject of scientific studies and critical evaluation in order to define precise clinical indications and protocols to be followed in every single diseases. Rehabilitation in water can be active and passive, instrumen-tal or it can be consisted on physical exercises performed in water, not necessarily of swimming type. In any case, we use the water capacities, from the principles of hydrody-namics to the ludic effect7. Inherent properties of water play an important role in the therapeutic targets, and they can be amplified through appropriate techniques enriching the therapeutic possibilities. It also important to point as the motor activity, carried out in water, offers the possibility of a recovery of “schemes and images” motility which, although partially summoned af-ter the trauma or disease are been “lost”, forgotten, because they have been exercised no more. Moreover, the use of wa-ter can lead significant changes to the components of motor deficit hindering functional recovery and finally it integrates itself with the other rehabilitative strategies. Therefore, the intervention must seek the best conditions for the patient to move in everyday life, through a process of adaptation to a situation of dipping, or confronting the physical properties of water and the constraints that follow. In other words, he can use the facilities and difficulties, that exercising in the water offers, for progressively recover the best motor conditions on earth. Rehabilitation in water is a strong tool for a rehabilitation treat-


ment because the practice of this activity takes as the meaning of a complement to the rehabilitation program implemented in the gym and it agrees with the therapeutic goals. There are many parameters that should be taken into con-sideration for a good personalization of a therapeutic pro-gram. Everything can undergo same changes, from the time of application to the number of sessions, its approach may change and, not least, the patient’s intrinsic aquatic ability affects the treatment. In conclusion, the progress of stages and phases of the pa-tient should illuminate the rehabilitation process. Some ob-jectives are often longer than expected, but in the other side, other objectives amaze for the simplicity and speed in their implementation7. Thanks to the properties of water it is possible to earn both objectively a wider and fluid range of motility and give the possibility of muscular strengthening, and subjectively it gives a positive psychological feedback to patients. It will be illustrated below rehabilitation programs for two common situations, in which greatly vary rehabilitation time and manners2:

1. Shoulder prosthesis with anatomic rotator cuff valid; 2. Reverse shoulder replacement with rotator cuff invalid.

1. SHOULDER pROSTHESIS WITH ANATOMIC ROTATOR CUFF VALIDPhase - I ( 1st -5th week)1st week: after the surgery is packaged in a brace abduction of 10 °, to be maintained for 15-20 days. We Use removable brace, to allow personal hygiene and mobilization of the el-bow of the hand. 2nd-3rd week: the brace is removed to perform physical therapy. It is possible passive mobilization of the shoulder, without reaching painful amplitudes. It is permitted up to 90° flexion and 45° abduction. Passive mechanical immobilizers (CPM) appear useful at this stage, with a programming of the arc allowable move-ments type. The patient should perform independently the commuters Codman exercises and the passive motility in flexion with the help of the other arm. 4th Week: the use of the brace is limited at night and a few hours a day. 5th week: patient leaves the brace and the assisted exercises in flexion-extension and abduction are allowed. The patient can begin rehabilitation in water. Phase II (6th -12th week)6th week: we switch to active physiotherapy in flexion-ex-tension and larger movement arc. Rotation are begun. Some stretching movements are useful to counteract the tendency of the capsule to stiffen, especially in his back. When patient has reached a good range of motility, we start with muscular strengthening. In the end of the period, patient starts the re-ceptive exercises for restoring efficiency and speed in auto-matic gestures. Phase III (13th -16th week) 13th week: we continue with the muscular strengthening and training of perception; the other muscular chains are involved in a more intensive way, in order to re- inscribe the shoulder in its natural context of “pivot” between the creative gestures of upper arts and the task of supporting his own lower limbs2,8.

2. REVERSE SHOULDER REpLACEMENT WITH ROTATOR CUFF INVALID The rehabilitation of the reverse prosthesis requires from the rehabilitator the knowledge of the peculiarities of the plant. In addition, as this is often used in absence of the rotator cuff, it is important to know the conditions of the pre-operative group of the deltoid muscle, even if the valid-ity of deltoid typically has already been established by the surgeon in pre-operative phase, because this is essential for the prosthesis function. Generally, the plant input allows the recovery of the abduc-tion bending within acceptable limits for a discreet personal autonomy, as these movements are simplified by the po-sitioning of the center of rotation in a lower and laterally way with respect to the norm. The achievement of an active elevation between 100-150 ° is a frequent result. Rotations are limited, but still possible, due to the preservation of the front cuff (subscapularis) and rear (small round and remain-ing portion of the infraspinatus)9. The reverse prosthesis often represents the final attempt to rescue a situation that is already compromised. Therefore, the main objectives of rehabilitation should be the pain re-duction for the patient and a decent autonomy. An exagger-ated quest for an unlikely extension of the joint range may expose the patient to risks that are not relatable to the hypo-thetical advantages. This kind of prosthesis allows a rehabilitation more or less earlier than the endo and arthroplasty in sliding2 . Phase - I ( 1th -3th week) 1st week: after surgery, the shoulder is immobilized with a brace in slight abduction and neutral rotation for 15-20 days; elbow and hand are free and must be mobilized early. 2nd week: if the absence of the headset is complete and it has not been made any reconstruction of the subscapularis, after about seven days, the limb can be temporarily released from the brace and mobilized passively in flexion and abduction, from 45° to 60°, taking care to respect the limits obtained by intraoperative measurements. Commuters exercises can be carried on for a few minutes, several times a day. 3rd week: you can begin the assisted mobilization. At the same time, you can start a rehabilitation cycle in pool. Phase II (4th - 5th week) 4th week : we allow the use of discontinuous brace, which is left at night for a few hours. Then, we begin the kinesith-erapy. 5th week: the brace is removed. We seek the muscular com-pensation, if the amplitude of joint allows it. We will assist the patient in the realization of possible movements, insert-ing them in the functional diagrams, and most common and useful for him. Measures in the rehabilitation of shoulder replacement in fracture.Functional recovery after shoulder replacement surgery in fracture is more delicate than prosthetic interventions per-formed with other indications such as osteoarthritis and rheumatoid arthritis. This functional recovery is based on the opposite need to mobilize early the patient to avoid the formation of adhe-sions that can limit the range of joint motility and to protect the tuberosity osteosutured carefully by the surgeon. This seemingly irreconcilable requirement finds its manifes-


tation identifying the type of patient to be treated and dedi-cating a physiotherapist for each patient in the early stages of immobilization of replaced joint . The identification of the patient is based, first, on the “re-port” provided by the surgeon who will indicate with “good”, “satisfactory” or “poor “ the mechanical quality of tuberosity osteosuture; on the other hand, it will be based on the study of the patient performed by the physiatrist . Physiatrists must investigate the following parameters for each patient candidated for a rehabilitation of prosthesis on fracture: the resilience of motor pattern; the ability to follow directions provided by the therapist in the delicate phase of passive mobilization; the quality of bone, muscle and ten-don tissues; personal response to pain, possibly basing on a carefulness collection of the history of previous works car-ried out by the patient; personal motivations for a maximum recovery.At this point, we identify two kinds of patients to who will be devoted as many types of customized rehabilitation programs, always aiming to minimize the immobilization time10.

1) The normal rehabilitation program. It is dedicated to patients whose osteosuture quality was judged sufficient, and in which there is inability to per-form a true passive mobilization. The patient protection will be total for 16-18 days. Then, we will begin with an elevation passive which should get to 90° after 25-30 days. Rotations will be protected for about four weeks, and then gradually increase the range of motility in a selective manner, while we enhance the elevation.

2) Deleyed rehabilitation program. It is dedicated to patients whose osteosuture quality was judged poor and in who there is a poor tolerability to pain, resulting an inability to perform a true passive mobilization. It is recommended maximum protection for four weeks. Passive elevation recovery begins after four weeks, expecting to reach 90° in a few weeks. Rotation re-covery starts after about 50-60 days from the surgery with extreme caution. In this category of patients, introducing hydrokinetic may be useful after four weeks post-surgery in order to reduce joint stiffness that always accompanies long periods of immobilization.

CONCLUSIONS

The results obtained after surgery of the shoulder prosthesis are closely related to a careful study of pre-operative of pa-tient for a correct direction, the proper positioning of pros-thesis and a personalized program of functional rehabilita-tion. Actually, it is noted as the rehabilitation program will vary, sometimes considerably, depending on the disease and the type of surgery performed1.

Therefore, it is necessary for the rehabilitation therapist a deep understanding of the disease pathology and the surgi-cal technique used, in order to make a precise and timely rehabilitation daily program, taking care the peculiarities of

the patient, and that lasts up to several months after inter-vention. However, in literature, the results obtained appear to be the best in terms of articulation, functionality and disappearance of pain in those patients who have had the opportunity to ac-cess treatments hydrokinetic in the course of rehabilitation. In fact, hydrokinetic becomes essential in the shoulder treatment because: the articulation gradually returns with-out stressing the articular heads; it allows the execution of movements ever wider, respecting the recovery times; it allows to perform exercises in a tridimensional space and to change positions easily and without effort; it limits pain, reduces recovery times and forces to postural symmetry, re-ducing fees11. In addition, results improve significantly in those patients who, despite having completed the cycle of re-education, performed regularly recalls with a rehabilitation therapist or independently. In fact, these calls allow to avoid complica-tions and, above all, to preserve over time the results ob-tained in the months following the intervention. In conclusion, we feel in any case to support the importance of a rehabilitation program also taken up to several months after surgery, focusing on respect for the physiological time of tissue healing, a careful and conscious articulation motil-ity, and finally, a muscular strengthening and functional re-covery which uses the physical characteristics of the aquatic environment as a rehabilitation setting preferred in diseases of the upper track.

REFERENCES

1. Brotzman SB, Wilk Ke La riabilitazione in ortopedia. II ed., excerp-ta Medica, Milano 2004

2. Valobra Gn, Gatto R, Monticone M Medicina fisica e riabilitazi-one. Utet 2008: cap. 55-56-108-112

3. Di Domenica F, Galletti R, Leo R Riabilitazione dopo intervento di osteosintesi o protesi di spalla in frattura. arch Ortop e Reumatol 2011; 122: 31-3

4. Marinko Ln, Chacko JM, Dalton D, Chacko CC the effectiveness of therapeutic exercise for painful shoulder conditions: a meta-analysis. J Shoulder elbow Surg 2011; 20(8): 1351-9

5. Gleyze P, Flurin PH, Laprelle e, et al. Pain management in the reha-bilitation of stiff shoulder: prospective multicenter comparative study of 193 cases. OtSR 2011; 97: S195-203

6. Gleyze P, Georges t, Flurin PH, et al. Comparison and critical eval-uation of rehabilitation and home-based exercises for treating shoulder stiffness: prospective, multicenter study with 148 cases. Orthopaedics & traumatologi, surgery and research: OtSR 2011; 97: S182-94

7. Becker Be aquatic therapy: Scientific Foundations and Clinical Rehabilitation applications. Bruce american academy of Physical Medicine and Rehabilitation. PM&R 2009; 1:859-872

8. Seitz WH, Michaud eJ Rehabilitation after shoulder replacement: be all you can be! Semin arthr 2012; 23: 106-113

9. Marrero L, Garcia G, Pacheco I early outcomes of reverse total shoulder arthroplasty. Boletín de la asociación Médica de Puerto Rico 2009; 101:34-7

10. Inglese F, Creta D, Biondi M Fratture dell’estremo prossimale dell’omero e protesi di spalla: trattamento riabilitativo. Lo Scalpel-lo 2009; 23:70-4

11. Castillo-Lozano R, Cuesta-Vargas a, Gabel CP analysis of arm el-evation muscle activity through different movement planes and speeds during in-water and dry-land exercise. J Shoulder elbow Surg 2013; 23:159-65

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