Purpose
To compare the outcomes of complete repairs for large-to-massive rotator cuff tears between patients who underwent the margin convergence (MC) or interval slide technique (IS).
Methods
A retrospective study was conducted. The inclusion criteria included patients who received primary repairs using either MC or IS to address a large-to-massive rotator cuff tear between 2007 and 2020. Clinical outcomes, including visual analog scale score, American Shoulder and Elbow Surgeons score, and active shoulder forward flexion (FF), were assessed at the 2-year follow-up. Minimal clinically important difference (MCID) was calculated. Magnetic resonance imaging (MRI) was performed at the 2-year follow-up.
Results
The number of patients operated on with IS and MC technique was 59 and 24, respectively, including 42 male and 41 female patients, with an average age of 62.5 ± 10 years. The 2-year follow-up rate was 91%. Postoperative MRIs were performed at 17.8 ± 7.3 months. The rates of full-thickness retear were 88% for MC and 27% for IS. One patient (4%) who was operated on with MC, compared with 2 patients who underwent IS (3%), received revision surgeries. There were no differences between the 2 repair techniques in terms of visual analog scale score, American Shoulder and Elbow Surgeons Score, and FF at the 2-year follow-up. However, more patients in the IS group achieved MCID for ASES (93% and 67%, respectively; P =.006) and FF (62% and 30%, respectively; P =.016), compared with those who underwent MC. The odds ratio were 7.2 (95% confidence interval 1.6-33) and 3.7 (95% confidence interval 1.2-11.3), respectively.
Conclusions
Both margin convergence and interval slide techniques are effective methods for improving clinical outcomes in patients with large-to-massive rotator cuff tears, despite a 3-fold greater full-thickness retear rate observed on postoperative MRI and a lower likelihood of achieving MCID for ASES and FF in the MC group.
Level of Evidence
Level III, retrospective comparative case series.
Margin convergence (MC) is a technique commonly used in repairing large and massive rotator cuff tears. ,,,,, This technique initially was described for the repair of longitudinal rotator cuff tears, which take either a U-shaped or an L-shaped form. , The concept was extended to the repair of large and massive rotator cuff tears because MC helps reduce the mechanical strain at the tear’s margin. , The biomechanical advantages of the MC technique over conventional direct complete repair at time zero are supported by studies in cadavers. , Short-term clinical outcomes are favorable. ,,,, Patients who receive the MC technique for the treatment of large and massive tears have shown similar improvements in pain and shoulder function compared with direct complete repair. ,
Although the clinical outcomes are satisfactory, the radiologic results of using the MC technique to repair large and massive rotator cuff tears are less than satisfactory. ,,,,, The reported rate of full-thickness retears in postoperative magnetic resonance imaging (MRI) scans taken within the first year after surgery ranged from 21.4% to 85%. ,, When postoperative MRIs were taken at 2 years postoperation, the rate of full-thickness retears was 47.8%. Given that the presence of a full-thickness retear in a postoperative MRI is negatively related to clinical outcomes after rotator cuff repair, , there is a paradox in the current literature regarding the clinical and radiologic outcomes of MC in large and massive rotator cuff repair. ,,,,,
In contrast, to improve the reparability of retracted tendons in large and massive rotator cuff tears, the interval slide (IS) technique has been used to facilitate the complete repair of the torn stump to the humeral footprint. Despite satisfactory clinical outcomes, the repair of massive rotator cuff tears using the IS technique has been reported to have no advantage in cuff healing and integrity.
The purpose of this study is to compare the outcomes of complete repairs for large-to-massive rotator cuff tears between patients who underwent MC or IS. It was hypothesized that there would be no difference in the failure rate, whether radiologic or clinical, between patients who received an IS and those who underwent the MC technique for the treatment of a large or massive cuff tear.
Methods
The current study was approved by the local ethics committee at the author’s institute (institutional review board number: UW 25-045). The need to obtain informed consent from the patients was waived. This retrospective study, using prospectively collected data, was conducted at a single institution. It included patients who received shoulder arthroscopy for a large or massive rotator cuff tear between July 2007 and December 2020. Patients were included in the study if (1) they were diagnosed with a full-thickness rotator cuff tear involving the supraspinatus tendon; (2) the size of the tear was either large or massive, as defined by the Cofield classification ; (3) they received primary complete rotator cuff repair using either an MC technique or an IS as the treatment for the rotator cuff tear. Patients were excluded if (1) the torn stump was not repaired to the bone using a suture anchor; (2) there was an incomplete repair, which was defined as a visible gap in the repaired tendon at the end of the procedure despite attempts to perform the repair; (3) the rotator cuff tear was treated by a salvage procedure, including a patch graft or superior capsular reconstruction; (4) the repair was augmented with either artificial or biological material, including the long head of the biceps; or (5) there was a significant postoperative complication (e.g., deep infection) leading to a deviation from the standard rehabilitation protocol.
Surgical Technique
The surgeries were performed by W.P.Y. The patient was placed under general anesthesia, and the operated shoulder was positioned in 30° abduction and 20° forward flexion. A diagnostic arthroscopy of the glenohumeral joint and subacromial space was performed, followed by debridement of unhealthy, degenerated rotator cuff tissues. Concomitant subacromial decompression and operations on the long head of biceps were conducted as indicated.
The size of the rotator cuff tear was measured after the debridement and classified as small, medium, large, or massive according to the description by Cofield et al. In addition, the tear was considered massive if it involved 2 concomitant full-thickness, full-width tears of the rotator cuff tendons. The retraction of the supraspinatus tendon tear was classified using the Patte classification. The morphology of the tear was classified into crescent-shaped or longitudinal. A crescent-shaped tear is defined as a tear with a medial-to-lateral length that is less than the anterior-to-posterior width, and where the medial-to-lateral length is less than 2 cm. A longitudinal tear, which can either be U-shaped or L-shaped, is defined as a tear with a medial-to-lateral length greater than the anterior-to-posterior width, and where the anterior-to-posterior width is less than 2 cm.
After the debridement of the torn rotator cuff, bursal-sided and articular-sided releases for the retracted supraspinatus tendon were performed. The reparability of the rotator cuff tear was then assessed. A repairable supraspinatus tendon tear was defined as a tear where the torn end could be reduced to the footprint without tension. If there was a concomitant full-thickness tear of the subscapularis tendon, it was first repaired to the lesser tuberosity, regardless of whether the supraspinatus tendon tear was repaired using MC or IS. From 2007 to 2013, the large and massive tears were repaired using an MC technique. IS was not performed. The converged margin, usually the posterior one, was then repaired to the bone using suture anchors ( Fig 1 ). From 2014 to 2020, the MC technique was no longer performed, and IS technique was carried out whenever indicated. If the torn supraspinatus tendon could be repaired to the bone without tension, a complete repair would be performed with suture anchors ( Fig 2 ).
Complete rotator cuff repair using a margin convergence technique. The arthroscopic photos show the complete repair of a massive rotator cuff tear using a margin convergence technique. This was viewed in the subacromial space. Margin convergence was performed to approximate the torn tendons of the supraspinatus and infraspinatus (A). The converged lateral edge was then repaired to the humeral footprint using a double-row suture-bridge technique (B). (A) A bursal-side view of the right shoulder of a 65-year-old female patient, positioned in the lateral decubitus position with the arthroscope in the midlateral portal, shows the repair of a massive rotator cuff tear using a margin convergence technique.(B) Double-row suture-bridge repair, A bursal-side view of the right shoulder of the same patient shows the complete repair of the converged tendons to the humeral footprint using a double-row suture-bridge technique.
Complete rotator cuff repair using an interval slide technique. The arthroscopic photos show the complete repair of a massive rotator cuff tear using an interval slide technique. This is viewed in the subacromial space. An anterior interval slide was performed between the supraspinatus and subscapularis (A). A complete repair of the released tendon to the humeral footprint was then performed using a double-row suture-bridge technique (B). (A) Anterior interval slide. A bursal-side view of the right shoulder of a 54-year-old male patient, positioned in the beach-chair position with the arthroscope in the midlateral portal, shows the release of the coracohumeral ligament from the coracoid process during the anterior interval slide between the supraspinatus and subscapularis. (B) Double-row suture-bridge repair. A bursal-side view shows the complete repair of the tendons of the supraspinatus and subscapularis to the humeral footprint using a double-row suture-bridge technique.
Rehabilitation
All patients followed the same postoperative rehabilitation program. They were instructed to wear an abduction shoulder brace for 6 weeks and engage in regular home-based, out-of-brace pendulum exercises daily. During this period, patients attended regular physiotherapy sessions at the rehabilitation center as outpatients, where the physiotherapist provided passive mobilization of the operated shoulders. From the seventh week onwards, patients discontinued the use of the shoulder brace and were instructed to start assisted active mobilization of the shoulder. Full active mobilization began in the 13th postoperative week. Muscle strengthening exercises and passive stretching of the joint were started at the seventh month postoperation and continued for 12 months. Patients were advised not to return to vigorous shoulder activity until 1 year after surgery.
Follow-Up
Patients were regularly followed up in a designated shoulder clinic at the author’s institute at 1 week, 6 weeks, 3 months, 6 months, 9 months, and 1 year after the index operation. Subsequently, patients were scheduled for annual follow-up visits. The severity of pain, measured in terms of visual analog scale (VAS), shoulder function as measured by the American Shoulder and Elbow Surgeons (ASES) score, and physical examination findings of the shoulder, including active forward flexion of the involved shoulder (FF), were documented prospectively at each follow-up using a standard documentation form. Data were prospectively entered into an Excel database (Microsoft, Redmond, WA).
Magnetic Resonance Imaging
Postoperative MRIs were scheduled for all patients between 12 and 24 months after the rotator cuff repair, unless the patients refused. The in-charge radiologist was asked to comment on the presence of a full-thickness retear of the repaired tendon. Full-thickness retears were classified according to the Sugaya classification as either a type IV (i.e., the presence of a minor discontinuity in the postoperative MRI, suggesting a small tear) or a type V retear (i.e., the presence of a major discontinuity, suggesting a medium or large tear).
Clinical Outcome of the Study
Data regarding clinical outcomes (VAS, ASES, FF, and pseudoparalysis) were retrieved from the database for the 2-year follow-up. This included the proportion of patients who achieved MCID in VAS, ASES, and FF. Pseudoparalysis was defined as an inability to actively elevate the involved shoulder to 90° of abduction.
Failure of Surgery
Failure of surgery was defined as the presence of a full-thickness retear in the postoperative MRI, or the need for revision surgery. A full-thickness retear was defined as a Sugaya type IV or V tear identified on the postoperative MRI. Revision surgery was defined as revision complete rotator cuff repair, revision partial rotator cuff repair with patch graft augmentation, superior capsular reconstruction, or reverse total shoulder arthroplasty.
Statistical Analysis
The minimum clinically important difference (MCID) for VAS, ASES, and FF was calculated using the 0.5 standard deviation method. First, the difference in the score between the preoperative and 2-year follow-up for each patient was calculated. Then, the standard deviation was computed for the entire cohort. An improvement of the score by 0.5 standard deviations of the concerned outcome was considered the MCID. A positive value indicates an increase in the score from preoperation to the 2-year follow-up, while a negative value indicates a decrease.
Descriptive statistics were reported for (1) demographic data, (2) the proportion of patients who experienced surgical failures (i.e., full-thickness retears at the postoperative MRI, and the need for revision surgery), (3) clinical outcomes (i.e., VAS, ASES, FF, and pseudoparalysis) at the 2-year follow-up, and (4) the number of patients who achieved MCID for VAS, ASES, and FF. Changes in VAS, ASES, and FF values between the pre-operation stage and the 2-year follow-up was compared using a paired t test.
Continuous variables were compared using a Mann-Whitney U test, whereas categorical data were compared using a χ 2 test. The proportion of patients who achieved MCID in VAS, ASES, and FF at the 2-year follow-up was reported. The number of full-thickness retears, revision surgeries, and the proportion of patients who achieved MCID between the 2 repair techniques were compared using a χ 2 test. Statistical significance was assumed if the P value was less than.05. Odds ratios and the corresponding 95% confidence intervals (CIs) were reported for those with statistical significance.
Results
A total of 278 shoulder arthroscopies involving primary repairs of supraspinatus tendon tears were performed at the author’s institute between 2007 and 2020. Of these, 100 patients had either a large or massive tear. Seventeen cases were excluded on the basis of the exclusion criteria. Ultimately, the study included a total of 83 patients, 59 of whom were treated with an IS and 24 who underwent MC ( Fig 3 ).
Enrollment of patients
The average age was 62.5 ± 10 years, with a sex distribution of 42 male and 41 female patients. The 2-year follow-up rate was 90% for patients who received IS and 92% for those who underwent MC. Postoperative MRIs were performed in 75% of patients who received an IS and 71% of patients who underwent MC. The mean time between surgery and postoperative MRI as 17.7 ± 8.4 months and 18.5 ± 4.9 months, respectively.
The length of follow-up was longer in the MC group ( P <.001). More men were found in the IS group ( P =.045). Aside from these differences, there was no difference in demographic data between the 2 groups ( Table 1 ).
Table 1
Demographic Data
| Interval Slide |
Margin
Convergence |
P Value | |
|---|---|---|---|
| Number | 59 | 24 | − |
| Follow-up, mo | 56 ± 35 | 98 ± 40 | <.001 |
| Age, yr | 62.1 ± 8.3 | 63.3 ± 7.1 | .592 |
| Sex (male vs female) | 34 vs 25 | 8 vs 16 | .045 |
| Laterality (right vs left) | 47 vs 12 | 17 vs 7 | .385 |
| Dominant shoulder involvement, % | 81% | 70% | .34 |
| Premorbid shoulder activity(sedentary vs light vs moderate vs strenuous) | 6 vs 25 vs 28 vs 0 | 4 vs 11 vs 7 vs 1 (missing data = 1) | .212 |
| Smoker, % | 32% | 13% | .065 |
| Worker’s compensation issue, % | 25% | 26% | .951 |
| Diabetes mellitus, % | 31% | 25% | .616 |
| Hyperlipidemia, % | 44% | 50% | .623 |
| Psychiatric illness, % | 9% | 4% | .492 |
NOTE. “−” indicates statistical test not performed.
The details of the operative findings and the procedures are presented in Table 2 . There was a significant difference in the Patte grading ( P =.01) and in the number of biceps tendon surgeries performed between the group that received IS and the group that underwent MC ( P =.019). Other than this, no differences were found between the 2 groups in terms of operative findings and performed surgeries.
Table 2
Operative Data
| Interval Slide | Margin Convergence | P Value | |
|---|---|---|---|
|
Cofield tear size,
large vs massive |
16 vs 43 | 10 vs 14 | .19 |
|
Patte grading,
Patte 2 vs Patte 3 |
38 vs 21 | 8 vs 16 | .01 |
| Concomitant full-thickness infraspinatus tear, % | 75% | 71% | .726 |
| Concomitant full-thickness subscapularis tear, % | 56% | 46% | .403 |
| Concomitant subscapularis tendon repair, % | 53% | 50% | .834 |
| Concomitant acromioplasty, % | 81% | 67% | .149 |
|
Concomitant biceps tendon surgery,
Nil vs biceps tenotomy vs biceps tenodesis |
25 vs 27 vs 7 | 17 vs 3 vs 4 | .019 |
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