Abstract
Purpose
Rotator cuff (RC) repair—especially in the elderly population—is problematic since the patients suffer to a high extent from bone mineral density loss at the reattachment site. Therefore, the study was primarily driven by the question whether it is possible to reach more or qualitatively better cancellous bone and thus a more stable postoperative result if anchors with greater length are used for RC repair and/or the conventional anchors are screwed deeper into the bone. In anatomical terms, the question is raised whether cancellous bone is of better quality close to or far off the RC enthesis.
Methods
Axial HRqCT scans (X-tremeCT, Scanco Medical) of 36 human cadaveric humeral heads (75 ± 11 years) were performed to determine the ratio of bone volume to total volume (BV/TV), trabecular thickness (Trab Th), number of trabecles (Trab N), trabecular separation (Trab Sp) as well as non-metric indices such as connectivity density (Conn Dens) and structure model index (SMI). Within the greater tuberosity (GT), 6 volumes of interest (VOI) (A1, B1, C1, A2, B2, C2), in the lesser tuberosity (LT) 2 VOIs (D1, D2) and one control VOI in the subchondral bone were set. The analyzed bone cylinder of each VOI was divided into a superficial and a deep portion.
Results
The parameters BV/TV, Trab N, Trab Th and Conn Dens in all volumes of the GT and LT revealed higher values in the superficial portion reaching different levels of significance (p < 0.001/<0.05). The only parameter presenting a higher value in the deep portion was Trab Sp, but this was the case for all GT and LT regions. Interestingly, the difference between the superficial and deep portion reached significance for the non-metric parameter SMI in no volume of the GT/LT, although the higher values were found superficially.
Conclusions
Our data show that cancellous bone presents with decreasing bone quality when analyzing increasingly deeper portions of the bone cylinders of the GT and LT starting at the articular surface. This information seems to be crucial for shoulder surgeons, especially when treating elderly patients. Our results clearly prove that screwing in anchors to a deeper extent will not improve stability, since the deeper bone stock is of worse quality.
Similar content being viewed by others
References
Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB (1991) Shoulder disorders in the elderly: a community survey. Arthritis Rheum 34(6):766–769
Fuchs S, Chylarecki C, Langenbrinck A (1999) Incidence and symptoms of clinically manifest rotator cuff lesions. Int J Sports Med 20(3):201–205. doi:10.1055/s-2007-971118
Tingart MJ, Apreleva M, Lehtinen J, Zurakowski D, Warner JJ (2004) Anchor design and bone mineral density affect the pull-out strength of suture anchors in rotator cuff repair: which anchors are best to use in patients with low bone quality? Am J Sports Med 32(6):1466–1473. doi:10.1177/0363546503262644
Kirchhoff C, Braunstein V, Milz S, Sprecher CM, Fischer F, Tami A, Ahrens P, Imhoff AB, Hinterwimmer S (2010) Assessment of bone quality within the tuberosities of the osteoporotic humeral head: relevance for anchor positioning in rotator cuff repair. Am J Sports Med 38(3):564–569. doi:10.1177/0363546509354989
Park JY, Kim MH (2004) Changes in bone mineral density of the proximal humerus in Koreans: suture anchor in rotator cuff repair. Orthopedics 27(8):857–861
Charousset C, Bellaiche L, Kalra K, Petrover D (2010) Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older? Arthroscopy 26(3):302–309. doi:10.1016/j.arthro.2009.08.027
Djahangiri A, Cozzolino A, Zanetti M, Helmy N, Rufibach K, Jost B, Gerber C (2012) Outcome of single-tendon rotator cuff repair in patients aged older than 65 years. J Shoulder Elbow Surg. doi:10.1016/j.jse.2012.03.012
Tingart MJ, Bouxsein ML, Zurakowski D, Warner JP, Apreleva M (2003) Three-dimensional distribution of bone density in the proximal humerus. Calcif Tissue Int 73(6):531–536
Pietschmann MF, Frohlich V, Ficklscherer A, Gulecyuz MF, Wegener B, Jansson V, Muller PE (2009) Suture anchor fixation strength in osteopenic versus non-osteopenic bone for rotator cuff repair. Arch Orthop Trauma Surg 129(3):373–379. doi:10.1007/s00402-008-0689-4
Kirchhoff C, Braunstein V, Milz S, Sprecher CM, Kirchhoff S, Graw M, Imhoff AB, Hinterwimmer S (2012) Age and gender as determinants of the bone quality of the greater tuberosity: A HR-pQCT cadaver study. BMC Musculoskelet Disord. 13(1):221. doi:10.1186/1471-2474-13-221
Hildebrand T, Ruegsegger P (1997) Quantification of bone microarchitecture with the structure model index. Comput Methods Biomech Biomed Engin 1(1):15–23
Mittra E, Rubin C, Qin YX (2005) Interrelationship of trabecular mechanical and microstructural properties in sheep trabecular bone. J Biomech 38(6):1229–1237. doi:10.1016/j.jbiomech.2004.06.007
Davison KS, Siminoski K, Adachi JD, Hanley DA, Goltzman D, Hodsman AB, Josse R, Kaiser S, Olszynski WP, Papaioannou A, Ste-Marie LG, Kendler DL, Tenenhouse A, Brown JP (2006) Bone strength: the whole is greater than the sum of its parts. Semin Arthritis Rheum 36(1):22–31. doi:10.1016/j.semarthrit.2006.04.002
Odgaard A, Gundersen HJ (1993) Quantification of connectivity in cancellous bone, with special emphasis on 3-D reconstructions. Bone 14(2):173–182
Guo XE, Kim CH (2002) Mechanical consequence of trabecular bone loss and its treatment: a three-dimensional model simulation. Bone 30(2):404–411
Cheng H, Gary LC, Curtis JR, Saag KG, Kilgore ML, Morrisey MA, Matthews R, Smith W, Yun H, Delzell E (2009) Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data. Osteoporos Int. doi:10.1007/s00198-009-0835-z
Favard L, Bacle G, Berhouet J (2007) Rotator cuff repair. Joint Bone Spine 74(6):551–557. doi:10.1016/j.jbspin.2007.08.003
Cadet ER, Hsu JW, Levine WN, Bigliani LU, Ahmad CS (2008) The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears. J Shoulder Elbow Surg 17(1):73–77. doi:10.1016/j.jse.2007.04.017
Jiang Y, Zhao J, van Holsbeeck MT, Flynn MJ, Ouyang X, Genant HK (2002) Trabecular microstructure and surface changes in the greater tuberosity in rotator cuff tears. Skeletal Radiol 31(9):522–528. doi:10.1007/s00256-002-0536-6
Macneil JA, Boyd SK (2008) Improved reproducibility of high-resolution peripheral quantitative computed tomography for measurement of bone quality. Med Eng Phys 30(6):792–799. doi:10.1016/j.medengphy.2007.11.003
Boutroy S, Bouxsein ML, Munoz F, Delmas PD (2005) In vivo assessment of trabecular bone microarchitecture by high-resolution peripheral quantitative computed tomography. J Clin Endocrinol Metab 90(12):6508–6515. doi:10.1210/jc.2005-1258
Barber FA, Feder SM, Burkhart SS, Ahrens J (1997) The relationship of suture anchor failure and bone density to proximal humerus location: a cadaveric study. Arthroscopy 13(3):340–345
Meyer DC, Fucentese SF, Koller B, Gerber C (2004) Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg 13(3):333–337. doi:10.1016/S1058274603003306
Yamada M, Briot J, Pedrono A, Sans N, Mansat P, Mansat M, Swider P (2007) Age- and gender-related distribution of bone tissue of osteoporotic humeral head using computed tomography. J Shoulder Elbow Surg 16(5):596–602. doi:10.1016/j.jse.2007.01.006
Acknowledgments
We thank the AO Research Institute for their experienced support. We also acknowledge the assistance throughout the entire study of Andrea Tami. We also thank Sven Duda, Ben Ockert and Fabian Kriner for their assistance throughout the study. The study was supported by the research grant “Innovationsfond Forschungsförderung” of the Bavarian state government.
Conflict of interest
We did not receive any outside funding or grants from commercial partners in support of our research or preparation of the work. There is no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kirchhoff, C., Kirchhoff, S., Sprecher, C.M. et al. X-treme CT analysis of cancellous bone at the rotator cuff insertion in human individuals with osteoporosis: superficial versus deep quality. Arch Orthop Trauma Surg 133, 381–387 (2013). https://doi.org/10.1007/s00402-012-1663-8
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-012-1663-8