Rotator cuff and capsule healing after shoulder arthroscopy: A second look arthroscopic study

Abstract

Background: Shoulder arthroscopy is commonly used for the repair of glenohumeral ligament avulsions or tendon tears. The success of the operation depends on the ability of the ligaments or rotator cuff tendon to heal to their original attachment site. Soft tissue healing can be evaluated with imaging methods or alternatively with second-look arthroscopy.

Aim: To investigate shoulder tendon and capsule healing after arthroscopic rotator cuff and instability repair using second-look arthroscopy.

Methods: In this study, 24 adult patients with rotator cuff tears (13 patients) or anterior shoulder instability (11 patients) were included. All patients were initially subjected to arthroscopic repair using suture anchors and were re-evaluated with second-look arthroscopy for reasons not related to the original pathology. The second operation was performed in 8 patients due to mild but persistent pain or stiffness, in 3 patients for recalcitrant stiffness, in 5 patients for secondary biceps tenotomy, in 6 patients for persistent acromioclavicular joint pain and in 2 patients for suture anchor prominence causing shoulder grinding. Soft tissue healing was evaluated visually and by probing, whereas clinical outcomes were evaluated using the University of California-Los Angeles (UCLA) and Rowe rating scales.

Results: In almost all patients, complete soft tissue healing occurred at the site of tissue reattachment, either on the glenoid articular surface or the greater humeral tuberosity. The strongest repair, as confirmed by probe palpation, was encountered at the site of suture passage through the soft tissue. All suture material was covered with bursal synovial tissue, with no cases of knot impingement or cartilage fraying. The mean preoperative and postoperative UCLA scores for rotator cuff repair patients were 1354 ± 3205 and 2931 ± 2898, respectively (P < 0.001), whereas for shoulder instability patients, the mean Rowe scores preoperatively and postoperatively were 2591 ± 1338 and 9272 ± 754, respectively (P < 0.001). The use of bioabsorbable implants did not cause synovitis or other tissue reactions.

Conclusion: Soft tissue healing in the shoulder is successful and strongest at the site of suture anchor placement.

Keywords: Arthroscopy; Instability; Rotator cuff; Shoulder; Soft tissue healing; Tendon.

Figure 1

Magnetic resonance imaging evaluation of a repaired rotator cuff 11 months after the first operation in a 63-year-old patient. A: Coronal magnetic resonance imaging (MRI) of the repaired rotator cuff. The rotator cuff tendons were reattached using a double row technique and absorbable suture anchors (arrowheads). Complete healing with restoration of tendon continuity is observed; B: Sagittal MRI showing restoration of the signal intensity of the rotator cuff tendons (arrowheads).

Figure 2

Transverse magnetic resonance imaging of the shoulder in a patient who underwent revision Bankart repair 5 months earlier. The anterior capsulolabral structures were reattached on the anterior glenoid rim using suture anchors (arrowhead). Remplissage was performed to cover a sizeable engaging Hill-Sachs lesion using another suture anchor (arrowhead).

Figure 3

Arthroscopic view of a left shoulder from the posterior viewing portal. A switching stick is inserted through the anterosuperior portal and used to palpate the area of capsule reattachment.

Figure 4

Arthroscopic evaluation of the glenohumeral joint 14 months after the first operation. A: The anterior capsule is viewed from the anterosuperior portal revealing complete, watertight healing to the glenoid rim; B: The knots are covered with synovium without causing articular surface fraying.

Figure 5

Arthroscopic view of the repaired rotator cuff tendons in the right shoulder from the posterior portal. A: The repaired rotator cuff is covered with synovium without evidence of synovitis or fraying. This patient was re-operated due to persistent acromioclavicular joint pain; B: The repaired rotator cuff is covered with synovium and an arthroscopic knot is evident (arrowhead). This patient underwent re-operation for stiffness.

Figure 6

Partial rotator cuff healing failure in the left shoulder viewed from the posterior portal. The suture cut through the tendon and the anchor is seen uncovered. The orthocord suture appears white because its purple-colored phytoene desaturase coating has been absorbed.