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Arthroscopic Rotator Cuff Repair: 4- to 10-Year Results

Eugene M. Wolf, M.D., William T. Pennington, M.D., and Vivek Agrawal, M.D.

Purpose: The purpose of this article is to report the 4- to 10-year results of arthroscopic repair of full-thickness rotator cuff tears. Type of Study: This is a retrospective study evaluating a series ofarthroscopic rotator cuff repairs performed by a single surgeon from February 1990 to February 1996.Methods: Retrospective chart reviews and telephone interviews were performed to evaluate theresults of arthroscopic repair of rotator cuff tears. Results were evaluated using a modified Universityof California, Los Angeles (UCLA), shoulder scoring system. Results: One-hundred five arthro-scopic rotator cuff repairs were performed in 104 patients between February 1990 and February 1996.Of these, 95 patients (96 shoulders) were available for follow-up evaluation at the time of this review.The mean UCLA score of all shoulders involved was 32. Fifty-one patients showed excellent results;39, good; 2, fair; and 4, poor according to the modified UCLA scoring system. In no case was anyloss of motion noted as a result of the surgical intervention. Conclusions: This retrospective studyis the largest series of arthroscopic rotator cuff repairs with the longest period of follow-up thus farreported. Of the patients available for follow-up evaluation, 94% of patients qualified as a good toexcellent result according to the UCLA shoulder scoring system. This study shows that patientstreated with this arthroscopic rotator cuff repair technique have maintained excellent clinicaloutcomes 4 to 10 years after surgery. Level of Evidence: Level IV. Key Words: Arthroscopic rotatorcuff repair—Shoulder arthroscopy—Rotator cuff tear.

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n 1911, Codman1 first described the open surgicalrepair of a supraspinatus tendon rupture that he

dentified as one of the major causes of the painfulhoulder. He advocated a deltoid splitting techniquehat did not include an acromioplasty. Rotator cuffathology is a common shoulder disorder experiencedn the orthopaedic patient population. The spectrum ofhese disorders ranges from inflammation to massiveearing of the rotator cuff musculotendinous unit.ince Codman’s first cuff repair, surgical techniquesave continually evolved in an effort to achieve anptimal outcome in the patient with a symptomaticisruption of the rotator cuff. The advent of shoulderrthroscopy prompted orthopaedic surgeons to explore

From the California Pacific Medical Center (E.M.W.), Sanrancisco, California; St. Luke’s Medical Center (W.T.P.), Mil-aukee, Wisconsin; and Central Indiana Orthopedics (V.A.), Mun-ie, Indiana, U.S.A.Address correspondence and reprint requests to Eugene M.olf, M.D., 3000 California St, San Francisco, CA 94115, U.S.A.-mail: genewolfmd@aol.com© 2004 by the Arthroscopy Association of North America0749-8063/04/2001-2705$30.00/0

tdoi:10.1016/j.arthro.2003.11.001

Arthroscopy: The Journal of Arthroscopic and Related

ew techniques, including arthroscopic assistedmini-open” techniques and purely arthroscopic tech-iques.The first arthroscopic cuff repairs were reported by

ohnson using a staple technique.2 Although successful,his technique had the disadvantage of placing a metaltaple in the greater tuberosity and subacromial space.his produced the need for secondary surgical proce-ures for staple removal but did allow for second lookshat showed remarkable healing in most cases. With thentroduction of Mitek suture anchors (Mitek Surgical,

estwood, MA) in 1989, the senior author (E.M.W.)eveloped an arthroscopic technique that paralleled stan-ard suturing techniques of open rotator cuff repairs, anderformed the first completely arthroscopic suture repairn February 1990.3 The purpose of this paper is to eval-ate the 4- to 10-year clinical results in patients whonderwent all-inside arthroscopic repair of a rotator cuffisruption by a single surgeon.

METHODS

One hundred and five consecutive arthroscopic ro-

ator cuff repairs in 104 patients were performed by

5Surgery, Vol 20, No 1 (January), 2004: pp 5-12

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he senior author over a 6-year period between Feb-uary 1990 and February 1996. Nine patients were lostn the follow-up period, leaving 96 shoulders in 95atients available for evaluation, with an average fol-ow-up time of 75 months (range, 48-122 months).atients included 60 men and 35 women, and theverage age at surgery was 57.6 years (range, 31-80ears). Conservative therapy failed in all patients, andhey continued to experience unacceptable pain andeakness in the affected shoulder.All patients were clinically evaluated by the senior

uthor (E.M.W.). An independent follow-up telephonevaluation of all patients was then performed by an-ther author (W.T.P.). Patients were evaluated usinghe modified University of California, Los AngelesUCLA), rating system. UCLA shoulder scores were

TABLE 1. Modified U

atient Satisfaction0 Patient feels proced5 Patient feels proced

ctive Forward FlexionRange of Motion

0 �30°1 30°-45°2 45°-90°3 90°-120°4 120°-150°5 �150°

trength of Forward Flexion0 No active contracti1 Evidence of slight2 Complete active fo3 Complete active fo4 Complete active fo5 Complete active fo

ain1 Present always and2 Present always, but4 None or little at res6 Present during heav8 Occasional and slig

10 Noneunction

1 Unable to use limb2 Only light activitie4 Able to do light ho6 Most housework, s

including fasteni8 Slight restriction on

10 Normal activitiesxcellent 34-35ood 28-33air 21-27oor 0-20

sed as the primary measure of outcomes (Table 1). p

Seventy-seven percent of patients had repairs of theominant shoulder, with 74 right and 22 left repairs. Allatients also had arthroscopic subacromial decompres-ions. Eighteen patients had other procedures performedoncurrently, including 9 arthroscopic Mumford proce-ures, 1 SLAP lesion repair, 2 SLAP lesion debride-ents, 1 debridement of a biceps tendon rupture, 1

apsular plication, 1 open Bristow procedure, and 3 oscromiale excisions. These 18 patients were initiallyxcluded to preserve a uniform study population. How-ver, because the clinical outcomes were identical withnd without these patients, they were included.

urgical Technique

The rotator cuff repairs were performed with the

houlder Rating Scale

s not successfuls a success

contraction, no active elevationexion with gravity eliminatedexion against gravityexion against gravity with some resistanceexion against gravity with full resistance

rable; strong medication, frequentlyle; strong medication, occasionally

ent during light activities; salicylates, frequentlyarticular activities only; salicylates, occasionally

lek or most activities of daily living, and driving possible; able to do hair and to dress and undress,

sieree to work above shoulder level

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7ARTHROSCOPIC ROTATOR CUFF REPAIR

he glenohumeral joint was inspected to evaluate forny significant intra-articular pathology. The cuff wasrst inspected from the articular side, and the marginsf the torn rotator cuff tendons were debrided in anffort to remove any devascularized or synovializedissue. An arthroscopic subacromial decompressionas then performed in all cases. The subacromialecompressions were conservative in nature, with careaken to preserve as much of the coracoacromial archs possible. The undersurface of the acromion wastripped of soft tissues with electrocautery. A burr wassed to perform the acromioplasty by reducing thenteroinferior prominence, while leaving the cora-oacromial ligament intact. The next step was thexcision of the bursal tissue in the subacromial spacehat covers the cuff tendons, especially in the anteriornd posterior recesses of the subdeltoid bursa. Thisas essential to evaluate the extent of the tear and theegree of involvement of the different rotator cuffendons. The bursectomy was also necessary to facil-tate visualization of the tips of suture hooks wherehey exit the cuff during suture repair. In large tears,isualizing the base of the spine of the scapula as itourses medially is also necessary. This was achievedy removing the fibrofatty tissue between the cuff andhe scapular spine. In cases of large tears, this ap-roach allowed us to trace the muscle tendon unitsedially, thereby better identifying the tendons and

etter determining the anatomic placement on theootprint of the tuberosity.

Next, the mobility of the rotator cuff was evaluatedy approximating the tear margins to the tuberosityith a grasper or nerve hook. A blunt nerve hook is an

xcellent tool for this purpose. The blunt tip was usedo puncture a point on the margin of the tendon anddvance it toward the tuberosity. If necessary, the cuffas further mobilized by freeing it from the under-

urface of the acromion or cutting the capsule on therticular side around the superior pole of the glenoidith an elevator, shaver, or radiofrequency device.he region of the greater tuberosity of the humerusas then abraded with a full-radius shaver, and a burras used to create a bed of bleeding bone to promoteealing of the reattached cuff. The excursion of thetump of the cuff when completely mobilized deter-ines the exact area of preparation. An attempt wasade to fit the cuff into an abraded and recessed area

f the tuberosity. All sutures were simple in naturend were used to drag the cuff over the abraded bed tonchors that were placed in undisturbed tuberosityone lateral to the bed. Placement of anchors directly

nto an area of tuberosity bone that has been weakened s

hrough the use of a burr on its surface is an invitationo suture anchor pullout.

Each tear was assessed and repaired with a side-to-ide, end-to-bone, or combination of side-to-side andnd-to-bone configurations. The most common con-guration was a combination of side-to-side and end-

o-bone. These were always relatively large tears thatad a soft tissue margin greater than the bony (tuber-sity) margin. We used an “L” or “Y” shaped config-ration to equalize the soft tissue and bony marginsnd avoid “dog ears” at the site of the repair. Side-to-ide repairs are technically simple and were all per-ormed using a Crescent suture hook (Linvatec, Largo,L) and No. 1 PDS suture. They were performedhere a relatively narrow “V” or “U” shaped tearccurred. All repairs are performed purely arthro-copically using variously shaped suture hooks (Lin-atec). An average of 4 sutures (range, 1-8 sutures)nd 1.2 suture anchors (range, 0-4 anchors) were useder cuff repair. A clinical example of an end-to-boneepair of a large crescent-shaped tear is depicted inigs 1-3.Repairs were performed exclusively with absorb-

ble PDS sutures in 79% of repairs, nonabsorbable

IGURE 1. This arthroscopic visualization of a large crescenthaped tear (R) from the subacromial space through the posterioriewing portal. The outflow cannula (C) is lying between therayed CA ligament (L) and overlying anterior subacromial spurS). The standard 5-mm universal cannula is seen placed throughhe mid-lateral portal and is used for CA ligament recession fromhe anterior rim of the acromion as well as to strip any soft tissuerom the undersurface of the acromion before arthroscopic sub-cromial decompression.

utures in 15%, and a mixture of PDS and Ethibond

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Ethicon, Somerville, NJ) in 6%. This includes 64houlders repaired with No. 1 PDS, 11 shoulders witho. 0 PDS, and one shoulder with 2-0 PDS. Ten

houlders were repaired with nonabsorbable No. 2thibond and 6 shoulders with a mixture of Ethibondnd PDS. Three repairs were performed with No. 2evdek (Deknatel, Fall River, MA) and one repair wasone with No. 2 Mersilene (Ethicon).Postoperatively, patients were placed in a simple

mmobilizer for 6 weeks. No abduction or airplaneplints were used. Patients were allowed immediatese of the arm with instructions to keep the elbow athe side. The patient was instructed to remove theulky dressing applied in the operating room on theorning after surgery and apply adhesive bandages to

he portal sites. No active elevation, pushing, pulling,r lifting was allowed for 6 weeks. Pendulum andulley exercises were begun at the first postoperativeisit (5 days) or as soon as tolerated.

RESULTS

Ninety-four percent of patients had good and excel-ent postoperative scores, with 51 excellent (53%), 39ood (41%), 2 fair (2%), and 4 poor results (4%). The

IGURE 2. The arthroscope is switched to use the mid-lateralortal for viewing during the repair process. This figure illustrateshe insertion of a rotator cuff anchor (A) (Mitek, Westwood, MA)nto the previously abraded tuberosity (T) through a threaded.4-mm working cannula (Arthrex, Naples, FL). Before anchornsertion, a No. 1 PDS suture was passed through the edge of theendon stump (R) with a suture passer. The leading end of theassed suture is inserted through the eyelet of the anchor before itsnsertion into the tuberosity of the humerus.

verage UCLA score was 32. Ninety-one of the 95 3

atients evaluated (96%) rated the surgery as success-ul and were satisfied with the repair. Four patientsated the surgery as unsuccessful.

The UCLA shoulder scoring system for strength,ain, and function were evaluated (Table 1). The meanesponse in all patients grading the strength was 4.6range, 2-5), mean response for pain was 8.8 (range,-10), and mean perceived function grade was 9.3range, 1-10). The average grade for forward flexionf the shoulder was 4.9 (range, 1-5). This was aetrospective study, and no preoperative scores werevailable for comparison.

No statistically significant difference in total UCLAcores was found when comparing repairs performedith absorbable and those with nonabsorbable sutures.he mean UCLA score for nonabsorbable sutures was2.2 versus 32.5 for repairs with absorbable suturesP � .63). Ninety-three percent of the patients re-aired exclusively with PDS qualified as having aood or excellent result, and 91% of patients repairedith exclusively nonabsorbable or a mixture of PDSith nonabsorbable suture had a good or excellent

esult.In 3 patients, this arthroscopic repair was a revision

f a previous open rotator cuff repair. The meanCLA score in these patients was 32.3 (range, 30-35).ive of the patients in the entire series had arthro-copic repair performed with a previous arthroscopicssisted mini-open repair performed on the contralat-

IGURE 3. This final arthroscopic photograph taken from theid-lateral working portal shows the anatomic reapproximation of

his large crescent-shaped tear (R) to the tuberosity (T) of theumerus. The repair was performed with 3 No. 1 PDS sutures with

Mitek rotator cuff anchors anchoring the torn cuff anatomically.

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ral shoulder. All of these patients stated that theyere more satisfied with the side in which the arthro-

copic repair was performed. They noted the percep-ion of a quicker period of recovery and return tounction than with the open repair.

Six patients rated the outcomes as fair or poor at theime of this study. Initial treatment failed in all 6atients. One of these patients underwent a Bristowrocedure at the index operation. Although this patientas satisfied with the procedure originally, he has

xperienced recent progression of shoulder pain,orsening clinical outcome. Despite subsequent sec-ndary procedures in the other 5 with failure of thendex operation, only one of these patients has pro-ressed to a satisfactory clinical outcome.

DISCUSSION

Published series of open rotator cuff repair of full-hickness tears have reported good results in 71% to2% of patients, improving pain, function, andtrength.4-12 Several authors have recommended ar-hroscopic subacromial decompression alone withoutotator cuff repair in select older patients with reportedutcomes of 77% to 88% good and excellent re-ults.13-15 Anatomic studies of elderly cadavers havehown asymptomatic rotator cuff tears that occur byttrition.16,17 Pain in these less-demanding patientsay be relieved by decompression of their impinge-ent, regardless of the condition of their rotator cuff.artsman18 and Ellman and Kay,14 however, have had

ess success with decompression alone, and other re-earchers6,19 have suggested that younger, more de-anding patients require repair of the symptomatic

otator cuff tears.Montgomery et al.20 compared the efficacy of ar-

hroscopic debridement and subacromial decompres-ion with that of open repair for chronic full-thicknessotator cuff tears in a prospective randomized study.e compared results of 50 patients (average age, 58)ith open repairs with those of 38 patients (average

ge, 66) with arthroscopic decompression alone at anverage 2- to 5-year follow-up times and found 78%ersus 61% satisfactory results. No correlation wasdentified among size of tear, patient age or activityevel, and results achieved with arthroscopic decom-ression. Ogilvie-Harris et al.21 prospectively studied5 patients with arthroscopic subacromial decompres-ion versus open rotator cuff repair and found painelief with both, but better functional scores with cuffepair, although recovery was longer.

6-8,22-24

A number of researchers have reported the p

esults of treatment of full-thickness rotator cuff de-ects by an arthroscopic assisted mini approach tovoid injury to the deltoid origin. In 1990, Levy et al.7

eported results of 25 patients (age, 21-75) with ainimum of 1-year follow-up study after arthroscopic

valuation, subacromial decompression, debridement,nd mobilization of full-thickness rotator cuff tearsith open repair via a limited deltoid-splitting ap-roach. They found 80% good and excellent results,ased on the UCLA shoulder scale, with 3 small, 5edium-sized, 15 large, and 2 massive-sized tears.inety-six percent of patients were satisfied with therocedure.Paulos and Kody6 later described their experienceith an arthroscopically enhanced mini approach to

ull-thickness rotator tears, with 88% good and excel-ent results in 18 patients, with an average follow-upime of 48 months. They noted a dramatic decrease inain and increase in function with associated increasen active forward flexion and strength. Patient satis-action was 94%.

Liu and Baker8 repaired 35 full-thickness rotatoruff defects with arthroscopic assistance and a deltoid-plitting incision with 85% good and excellent resultsnd 92% patient satisfaction. In a second study by theame authors, no difference in results was reportedetween open and arthroscopically assisted rotatoruff repairs.12

Blevins et al.23 evaluated the outcome of 78 arthro-copically assisted mini-open cuff repairs. Sixty-fouratients were interviewed, and 47 of these patientseturned for physical examination, with a follow-upuration of 12 to 65 months. They cited an 89%atient satisfaction rate with pain and function scoresnd active shoulder elevation increasing significantlyfter surgery.

Warner et al.24 reported their results for 17 patientsho underwent arthroscopic assisted rotator cuff re-air with an average follow-up period of 25 months.atients in that study showed no statistical difference

n strength evaluation of abduction and external rota-ion when compared with the contralateral nonopera-ive shoulder, and 14 of the 15 patients (93%) avail-ble for follow-up evaluation rated the results asxcellent. Therefore, in a review of the recent litera-ure, a range of 80% to 94% is reported in treatingatients with full-thickness rotator cuff defects with anrthroscopic assisted mini-open technique. Reviewinghe English language literature yields reports by aumber of researchers25-30 reporting clinical resultsor treating full-thickness rotator cuff tears with a

urely arthroscopic repair technique.

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In 1995, the senior author reported results on 54houlders after arthroscopic subacromial decompres-ion and purely arthroscopic rotator cuff repair at anverage of 27 months follow-up time (minimum, 1ear), with 85% good and excellent results. The ar-hroscopic approach allowed repair of several otherssociated lesions, and no complications with deltoidetachment occurred. Only 2 patients required a sec-nd repair for residual cuff defects, and 91% of theatients were satisfied with the procedure. This previ-us report also involved second-look arthroscopy in3 patients, with 19 in the office and 4 in the operatingoom (Figs 4, 5). Sixteen repairs (70%) were intact onecond-look arthroscopy, and 7 showed some commu-ication with the subacromial bursa.25 These resultsompared positively with previous studies evaluatinghe integrity of the rotator cuff after open repair tech-iques that showed residual rotator cuff defects in4% to 90% of patients who previously underwentpen rotator cuff repair.32-35 Although a difference inCLA shoulder scores was found between the intact

IGURE 4. Arthroscopic view through standard posterior viewingortal of the articular surface of the left rotator cuff in a patient 8ears after arthroscopic rotator cuff repair with 3 No. 1 PDS withside-to-side closure technique. The intra-articular portion of the

iceps long head of the biceps tendon (B) is seen just beneath theutflow cannula. The patient had an excellent result and wasndergoing an arthroscopic Mumford procedure for anterior cru-iate joint arthrosis that developed secondary to a type 2 acromi-clavicular separation sustained in a motor vehicle accident 6onths before this procedure. The articular surface of the rotator

uff (R) appears normal at its attachment to the greater tuberosityT) of the humerus.

nd defective cuffs seen at second-look arthroscopy n

30.6 and 27, respectively) in our patients, severalatients with communication to the subacromial bursaad good results, possibly because the tears had beeneduced in size to within Burkhart et al.’s36 rotatorrescent. Liu and Baker8 similarly found that the in-egrity of the cuff at follow-up evaluation does notetermine the functional outcome of the treated shoul-er.Gazielly et al.,28 in 1996, reported the results for 15

atients in whom arthroscopic rotator cuff repair waserformed. These patients showed an increase in Con-tant and Murley scores from 58.1 preoperatively to7.6 after arthroscopic repairs of full-thickness rotatoruff defects. Snyder et al,29 in 1996, reported on aeries of 47 patients with an 87% good to excellentesults after arthroscopic repair of full-thickness rota-or cuff tears.

In 1998, Gartsman et al.26 and Tauro27 reportedheir results using an all-inside arthroscopic techniquef rotator cuff repair with 90% and 92% good toxcellent results, respectively. Proposed advantages ofhis technique by these authors include smaller inci-ions, access to the glenohumeral joint to address

IGURE 5. Arthroscopic view of the same cuff’s bursal surface 8ears after arthroscopic rotator cuff repair through the posterioriewing portal inserted into the subacromial space. The rotator cuffR) is palpated with the probe through the mid-lateral portal, and

o evidence of prior repair was noted.

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11ARTHROSCOPIC ROTATOR CUFF REPAIR

oncomitant intra-articular pathology, no need for de-achment of the deltoid, and less soft tissue dissection.hese authors also suggested that this technique re-ulted in a better cosmetic result, decreased postoper-tive pain, and more rapid gains in motion whenompared with open surgical treatment of similar le-ions.

In 1999, Weber30 presented a study comparing ar-hroscopic repairs with mini open repairs. One hun-red eighty patients were evaluated in this study; 151atients underwent mini-open and 29 underwent com-letely arthroscopic repairs from 1991 to 1995. Theuthor reported 87% good to excellent results in pa-ients in this series. Twelve patients had an arthro-copic repair of the rotator cuff with contralateral openepair. All 12 of these patients rated the arthroscopi-ally repaired side superior to the other side repairedy open techniques. Although no statistical data wereresented to support this impression, the authors pro-osed another advantage of the arthroscopic repair toe decreased incidence of postoperative stiffnesshen compared with open techniques.This is the largest series of arthroscopic rotator cuff

epairs with the longest period of follow-up data re-orted to date. Our 94% good to excellent results at anverage of 75 months (range, 48 to 122 months)ompares favorably with previous reported results ofrthroscopic and arthroscopically assisted mini-openotator cuff repair. Suture type did not significantlyffect our results, and the majority (79%) of repairsere performed with exclusively absorbable sutureaterial.We believe that the arthroscopic evaluation of the

natomy of the rotator cuff tear is an essential step inestoring the anatomy of the disrupted rotator cuff.urkhart37 eloquently described the concept of tearargin convergence of the rotator cuff disruption al-

owing reattachment of the cuff without creating aension overload situation at any of the attachmentites. Burkhart stressed the importance of tear patternecognition with the employment of side-to-side su-ures when appropriate to create a situation of force-ouple balancing to the repaired cuff when it is reat-ached to the tuberosity. Burkhart suggests thatisualization of the tear from different arthroscopicortals allows the shoulder surgeon to obtain a-dimensionalnderstanding of the tear pattern superior to that ob-ained by open means. We echo this sentiment in thatrthroscopic repair of the rotator cuff allows a thor-ugh evaluation of the complete anatomy of the cuff

isruption. Furthermore, with each suture passed, theffect may be evaluated by direct visualization of the

uture’s impact on the entire cuff. This allows for thevaluation for the creation of any inappropriate flapsr “dog-ears” that may signify the creation of a non-natomic situation that may be doomed to failure overyclic loading because of force-couple imbalance.

This study has admitted shortcomings. Although theCLA shoulder scores are available 4 to 10 yearsostoperatively, this only signifies wellness at thatoment. Ideally, scores during the preoperative pe-

iod, with sequential scores during the perioperativeeriod, would provide conclusive evidence of the di-ect effect of treatment on function of the shoulder.ecause the outcomes assessment was performed viadetailed telephone interview, range of motion and

trength determinations are admittedly subjective. Fi-ally, a randomized, prospective clinical study withatients matched according to age, activity, and func-ion and comparing completely arthroscopic to mini-pen rotator cuff repairs would be required to advo-ate either method as superior.

The purpose of this study is to report our long-termesults of all-inside arthroscopic rotator cuff repairs.inety-one of 95 (96%) patients treated using thisethod believed that this technique was successful in

reating their rotator cuff tears. At 4 to 10 years afterurgery, 94% of patients rated their results as good toxcellent. We believe that this repair technique opti-izes evaluation of the rotator cuff defect with a

reater potential for anatomic restoration than withpen methods. Arthroscopic rotator cuff repair canchieve a high level of good and excellent results withinimal morbidity and minimal violation of the sur-

ounding soft tissue envelope.

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2. Johnson L. Arthroscopic rotator cuff repair using a staple.Presented at the Maui Sports Medicine Meeting, Kanapali,Maui, April 1992.

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3. Blevins FT, Warren RF, Cavo C, et al. Arthroscopic assistedrotator cuff repair: Results using a mini-open deltoid splittingapproach. Arthroscopy 1996;12:50-59.

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