High Acromial Slope and Low Acromiohumeral Distance Increase the Risk of Retear of the Supraspinatus Tendon After Repair
Authors: Caffard Thomas , Kralewski Desdemona , Ludwig Marius , Dornacher Daniel , Fuchs Michael , Kappe Thomas , Reichel Heiko , Sgroi Mirco 
Published: January 2023

Abstract

Background
Retearing of the supraspinatus (SSP) tendon after repair is relatively common, but its cause is rarely clear. Although the role of acromion morphology and glenoid orientation in the pathogenesis of primary SSP tendon tears have frequently been analyzed, their association with the risk of rerupture of a repaired SSP tendon is poorly understood.

Questions/purposes
(1) Is acromial morphology associated with the risk of retear after SSP tendon repair? (2) Is there an association between inclination and version of the glenoid and the odds for retear of the SSP tendon after repair? (3) Are there differences in outcome scores between patients who had intact cuff repairs and those who had retears?

Methods
Between August 2012 and December 2015, we treated 92 patients for SSP tendon tears; all of these patients were considered for inclusion in the present study. We considered patients with complete tear of the SSP that was reconstructed with a double-row repair and a minimum follow-up of 2 years as potentially eligible. Based on these criteria, 28% (26 of 92) were excluded because they had a partial rupture and did not receive a double-row reconstruction. A further 9% (eight of 92) were excluded because of missing planes or slices (such as sagittal, axial, or frontal) on MRI, and another 3% (three of 92) were lost before the minimum study follow-up interval or had incomplete datasets, leaving 60% (55 of 92) for inclusion in the present analysis. All included patients had a minimum follow-up of 2 years; follow-up with MRI occurred at a mean duration of 2.3 ± 0.4 years postoperatively. All patients were asked to complete the Western Ontario Rotator Cuff Index and Oxford Shoulder Scores, and they underwent MRI of the operated-on shoulder. Preoperative true AP radiographs and MR images of the affected shoulders were retrospectively assessed by measuring the acromiohumeral interval, critical shoulder angle, acromial slope, acromial tilt, acromial index, lateral acromial angle, and glenoid version and inclination. The patients also underwent acromioplasty, in which the underface of the acromion was flattened. To rule out any change in the above parameters because of acromioplasty, these parameters were compared using preoperative and postoperative MR images and showed no difference. In addition, the tendon integrity and quality on postoperative MRI were analyzed independently of one another by the same two observers using the Sugaya and Castricini classifications, accounting for atrophy and fatty degeneration of the SSP muscle. To assess interobserver reliability, the two observers took measurements independently from each other. They were orthopaedic residents who completed a training session before taking the measurements. All measurements had excellent intrarater (Cronbach alpha 0.996 [95% confidence interval (CI) 0.99 to 1.00; p > 0.01) and interrater (interrater correlation coefficient 0.975 [95% CI 0.97 to 0.98]; p > 0.01) reliabilities. To answer the study’s first question, SSP integrity on postoperative MRI was compared with acromial morphologic parameters measured on preoperative AP radiographs and MR images. To answer the second question, the postoperative integrity and quality of the SSP tendon were correlated with glenoid inclination and glenoid version. To answer our third question, we compared outcome scores between patients with intact SSP tendons and those with reruptured SSP tendons. To investigate any correlation among the acromial morphology, glenoid orientation, and postoperative outcomes, a binomial logarithmic regression analysis was performed. Receiver operating characteristic curves were used to determine cutoff points for the radiologic parameters that showed a correlation in the binomial regression analysis.

Results
After controlling for potentially confounding variables such as acromioplasty or preoperative fatty infiltration as well as muscle atrophy, the only morphological parameters associated with a higher risk (adjusted odds ratio) of SSP tendon rerupture were the acromiohumeral interval (adjusted OR 0.9 [95% CI 0.9 to 0.99]; p < 0.01) and acromial slope (adjusted OR 1.4 [95% CI 1.1 to 1.8]; p < 0.01). The critical shoulder angle, acromial tilt, acromial index, and lateral acromial angle were not associated with the risk of rerupture. The cutoff values for acromial slope and acromiohumeral interval were 24.5° and 7.4 mm, respectively. Patients with an acromiohumeral interval smaller than 7.4 mm or an acromial slope greater than 24.5° had higher odds (acromiohumeral interval: OR 11 [95% CI 2 to 46]; p = 0.01 and acromial slope: OR 9 [95% CI 2 to 46]; p = 0.04) for rerupture of the SSP. No difference was found between patients with intact SSP tendons and those with reruptured SSP tendons in terms of glenoid inclination (6° ± 4° versus 6° ± 3°, mean difference 0.8° [-1° to 3°]; p < 0.48) and glenoid version (-2° ± 3° versus -3° ± 3°, mean difference 1° [-1° to 3°]; p < 0.30). No difference was found between the intact and reruptured SSP groups regarding clinical outcomes (Western Ontario Rotator Cuff Index: 98 ± 2 versus 97 ± 3, mean difference 0.73 [95% CI -0.30 to 0.31]; p = 0.96; Oxford Shoulder Score: 26 ± 13 versus 23 ± 10, mean difference 2.80 [95% CI -4.12 to 9.72]; p = 0.41).

Conclusion
The preoperative acromiohumeral interval and acromial slope are associated with SSP tendon rerupture after repair. Conversely, the critical shoulder angle, acromial tilt, lateral acromial angle, and acromial index had no association with the postoperative outcome. Additionally, glenoid inclination and version were not associated with the rerupture rate after SSP tendon repair. A detailed analysis of the acromiohumeral interval and acromial slope is recommended in clinical practice in patients undergoing SSP tendon repair. Surgeons should consider measuring the acromiohumeral interval and acromial slope preoperatively when performing SSP repair, especially in the context of planned acromioplasties. Future studies should investigate the role of acromioplasty during SSP repair in patients with a pathologic acromial slope and acromiohumeral interval. In this context, it should be determined whether a more-radical acromioplasty could reduce the risk of rerupture of the SSP in these patients.

Level of Evidence
Level III, therapeutic study.