Graph Showing the Relationship Between Tear Size and Number of Microlesions Used

Microfracture (number of holes)

7.00±2.00

5.68±0.89

4.22±1,

5.04±1.53

4.00±0.77

Very large tear Large tear Moderate tear Small tear Total

Figure 3.4. Graph showing the relationship between tear size and number of microlesions used

Comment: Based on the above chart, it shows that the larger the tear size, the more the number of holes creating micro-damage.

 Relationship between tear size and number of anchors used:

100%

90%

80%

70%

60%

50%

40%

30%

20%

10% 28.6

0% 0

Very large tear Large tear Moderate tear Small tear 1 anchor 2 anchors 3 anchors

100

71.4

94.7

27.8

72.2

5.3

Figure 3.5. Relationship between tear size and number of anchors used

Comment: Based on the above chart, it shows that for small tears, the rate of using 1 anchor is 100%, this rate is reversed for very large tears, there is no case of using 1 anchor during CX tendon suturing.

3.2.4. Results of treatment of rotator cuff tears with modified Mason-Allen tendon suture and microtrauma at the attachment area

 Postoperative follow-up time:

- The average postoperative follow-up time was 17.89+4.41 months. The minimum follow-up time was 11.13 months, and the maximum follow-up time was 24.07 months.

 Evaluation of shoulder joint function results after surgery:

- We used two ASES and UCLA scorecards for coordination.

Table 3.20. ASES scores before and after surgery

Average ASES score

Average ± SD

Median

Min-max

ASES before surgery

29.89±14.61

26.67

8.33-75

<0.01

ASES concludes study

96.04±4.71

96.67

76.67-100

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Wilcoxon Test

Comments: The mean ASES score before surgery was 29.89. The mean ASES score at the end of the study was 96.04 and the patient with the lowest ASES score was 76.67 and the patient with the highest ASES score was 100. To compare the mean ASES scores before and after surgery, we used the Wilcoxon Test, because p < 0.01, the improvement in ASES score after surgery compared to before surgery was statistically significant. Some patients were able to confidently return to playing tennis, doing pull-ups, lifting weights, holding grandchildren, and carrying heavy objects as before surgery.

The mean postoperative UCLA score of the patients was 33.02, which was classified as very good. The patient with the lowest UCLA score was 27 and the highest was 35.

Table 3.21. Postoperative UCLA score classification

Postoperative ULCA score classification

Quantity	Percentage
Very good	20	36.4
Good	34	61.8
Medium	1	1.8
Bad	0	0
Total	55	100

Comments: Based on the post-operative score classification table, the results of all patients were very good. Of which, 98.2% of patients had good and very good results after surgery and all were satisfied and felt better than before surgery. There was 1 patient with an average UCLA score, accounting for 1.8%.

Because only 39 patients agreed to undergo postoperative MRI re-evaluation out of a total of 55 patients who underwent surgery, based on Sugaya's classification, we have a postoperative tendon healing classification table.

Table 3.22. Postoperative MRI grading of tendon healing (n=39)

Postoperative MRI

n	Ratio
Level 1	21	53.9
Level 2	9	23.1
Level 3	4	10.2
Level 4	2	5.1
Level 5	3	7.7
Total	39	100

Comments: Based on the postoperative MRI evaluation table, it can be seen that the number of patients with postoperative tendon healing (grade 1, grade 2, grade 3 tendon healing) was the highest at 34/39 patients, accounting for 87.2%. There were 5 cases of re-rupture (grade 4, grade 5 tendon healing) accounting for 12.8%.

Analysis of factors associated with postoperative tendon healing

According to Sugaya's classification of postoperative tendon healing levels, it can be seen that with tendon healing levels 1, 2, and 3, there is no tendon discontinuity, and with tendon healing levels 4 and 5, there is a phenomenon of postoperative tendon discontinuity with different levels. For the convenience of analyzing factors related to postoperative tendon healing, we divide tendon healing levels 1, 2, and 3 into 1 group and tendon healing levels 4 and 5 into 1 group.

Table 3.23. Correlation between tendon healing on postoperative MRI and tear severity (n=39)

Degree of tendon healing

Classification of tears

Level 1,2,3	Degree 4.5	Total	p
Very big tear	1 (33.3)	2 (66.7)	3 (100)	0.008
Big tear	11 (78.6)	3 (21.4)	14 (100)
Medium tear	15 (100)	0	15 (100)
Small tear	7 (100)	0	7 (100)
Total	34 (87.2)	5 (12.8)	39 (100)

Fisher-exact test

Comments: Use the Fisher-exact test to compare the degree of tendon healing between tear levels. Based on the table above, it shows that 100% of small and moderate tears had continuous tendon healing on postoperative MRI. The rate of non-union of tendon (grade 4, grade 5) appeared in the very large and large tear groups, in which the very large tear group had the highest rate. The difference was statistically significant with p = 0.008 < 0.05.

Table 3.24. Correlation between postoperative MRI tendon healing and age (n=39)

Degree of tendon healing

Year old

Level 1,2,3	Degree 4.5	Total	p
<65	24 (85.7)	4 (14.3)	28 (100)	>0.05
≥65	10 (90.9)	1 (9.1)	11 (100)
Total	34 (87.2)	5 (12.8)	39 (100)

Fisher-exact test Comment: To find the relationship between the level of tendon healing and age, we divided the patients who had MRI scans into 2 groups, younger than 65 years old and older than 65 years old. The reason we chose the age of 65 years old and above is because according to author Boileau, at this age and above, the shoulder joint function will be very poor after CX 115 suture surgery . Using the Fisher-exact test for comparison, it can be seen that the rate of tendon healing of levels 1, 2, 3 in both groups is high, because p> 0.05 so the difference is not statistically significant.

Table 3.25. Correlation between postoperative MRI tendon healing between the traumatic and non-traumatic groups (n=39)

Degree of tendon healing Cause CT

Level 1,2,3	Degree 4.5	Total	p
Are not	16 (86.7)	2 (13.3)	15 (100)	>0.05
Have	21 (87.5)	3 (12.5)	24 (100)
Total	34 (87.2)	5 (12.8)	39 (100)

Fisher-exact test Comment: Using the Fisher-exact test to compare shows that both the group with no cause of injury and the group with cause of injury

All have higher tendon healing rates of level 1,2,3 than tendon healing rates of level 4,5. However, p > 0.05 so the difference is not statistically significant.

Table 3.26. Correlation between tendon healing on postoperative MRI in the trauma group according to time level (n=24)

Degree of tendon healing

TG injury

Level 1,2,3	Degree 4.5	Total	p
≤ 3 weeks	1 (50.0)	1 (50.0)	2 (100)	0.24
> 3 weeks	20 (90.9)	2 (9.1)	22 (100)
Total	21 (87.5)	3 (12.5)	24 (100)

Fisher-exact test Comment: We used the 3-week mark for patients with shoulder injuries because according to Gerald R. Williams et al., this is the mark to decide on intervention.

Early surgical intervention for trauma patients who do not improve after treatment58 . Using the Fisher-exact test for comparison, based on the table above, it shows that tendon healing of grades 1, 2, 3 in both the group with injury time less than 3 weeks and the group over 3 weeks are higher than grade 4, 5. However, p> 0.05 so the difference is not statistically significant.

Table 3.27. Correlation between postoperative tendon healing on MRI between male and female groups (n=39)

Degree of tendon healing

Gender

Level 1,2,3	Degree 4.5	Total	p
Male	16 (88.9)	2 (11.1)	18 (100)	>0.05
Female	18 (85.7)	3 (14.3)	21 (100)
Total	34 (87.2)	5 (12.8)	39 (100)

Fisher-exact test

Comment: Using Fisher-exact test for comparison because p>0.05, the difference in tendon healing level 1,2,3 and tendon healing level 4,5 between groups is not statistically significant.

Ultrasound evaluation of tendon healing was performed on 39 patients who agreed to undergo MRI to evaluate the effectiveness of Ultrasound compared to MRI. Using the Ultrasound tendon healing grading table based on Sugaya's classification113,114, we have the following table.

Table 3.28. Postoperative ultrasound results of tendon healing (n=39)

Classification of postoperative tendon healing

Quantity	Percentage
Level 1	19	48.7
Level 2	12	30.8
Level 3	3	7.7
Level 4	2	5.1
Level 5	3	7.7
Total	39	100

Comments: Among 39 patients who had their tendon healing evaluated by ultrasound after surgery, it can be seen that grade 1 tendon healing accounted for the highest rate of 19 patients (48.7%), followed by grade 2 tendon healing (30.8%).

Table 3.29. Comparison of postoperative MRI and ultrasound (n=39)

CHT

Level 1			Level 2			Level 3			Level 4			Level 5
Have	Are not	Total	Have	Are not	Total	Have	Are not	Total	Have	Are not	Total	Have	Are not	Total
Have	16	5	21	6	3	9	3	1	4	2	0	2	4	0	4
Are not	3	15	18	6	24	30	0	35	35	0	37	37	0	35	35
Total	19	20	39	12	27	39	3	36	39	2	37	39	4	35	39
	Se=76.2; Sp=83.3; PPV=84.2%; NPV=75.0%; Degree 79.5% accurate			Se=66.7; Sp=80.0; PPV=50.0%; NPV=88.9%; Degree 76.9% accurate			Se=75.0; Sp=100%; PPV=100%; NPV=97.2%; 97.4% accuracy			Se=100; Sp=100%; PPV=100%; NPV=100%; Degree 100% accurate			Se=100; Sp=100%; PPV=100%; NPV=100%; Degree 100% accurate

Comments: In cases of postoperative tendon re-tears (grade 4 and 5 tendon healing), Ultrasound gives postoperative examination results similar to MRI with 100% accuracy. The difference between Ultrasound and MRI is shown in cases of continuous tendon healing after surgery (grade 1, grade 2, grade 3), in which the biggest difference in Ultrasound assessment is in grade 2 with 76.9% accuracy compared to MRI.

Analysis of factors associated with postoperative outcomes

Table 3.30. Comparison of postoperative UCLA results between men and women

Gender