Clinical and radiological outcome after arthroscopic rotator cuff repair using PEEK-CF anchors

PURPOSE

The goal of this study was to evaluate the clinical and radiological outcome after arthroscopic rotator cuff repair using new carbonfiber reinforced polyetheretherketone (CF-PEEK) suture anchors.

METHODS

One hundred (n=100) patients with rotator cuff tears were enrolled at seven French hospitals between July 2019 and June 2020. Pain levels, Constant score and Subjective Shoulder Value (SSV) were taken preoperatively and 6months postoperatively. Ultrasonography (US) was performed at 6months postoperatively to evaluate tendon healing using the Sugaya classification. Statistical analysis was done with the Student t-test with 95% confidence intervals.

RESULTS

One hundred patients of the 100 patients were followed at 6months. The mean SSV and Constant score improved from 40.1% preoperatively to 78% at 6months (p<0.0001) and from 43 points preoperatively to 65 points at 6months (p<0.0001), respectively. The mean level of pain, as measured with the visual analogue scale, decreased from 5.9 to 1.6 (p<0.001). There were no postoperative complications that resulted in revision surgery.

CONCLUSION

The study showed good results at 6months follow-up using carbonfiber reinforced PEEK anchors with improved Constant and SSV scores as well as a high ultrasonographic tendon healing rate, making PEEK-CF anchors safe to use, comparable to commonly used anchors.

LEVEL OF EVIDENCE

IV.

Artificial Intelligence Aids Detection of Rotator Cuff Pathology: A Systematic Review

PURPOSE

To determine the model performance of artificial intelligence (AI) in detecting rotator cuff pathology using different imaging modalities and to compare capability with physicians in clinical scenarios.

METHODS

The review followed the PRISMA guidelines and was registered on PROSPERO. The criteria were as follows: 1) studies on the application of AI in detecting rotator cuff pathology using medical images, and 2) studies on smart devices for assisting in diagnosis were excluded. The following data were extracted and recorded: statistical characteristics, input features, AI algorithms used, sample sizes of training and testing sets, and model performance. The data extracted from the included studies were narratively reviewed.

RESULTS

A total of 14 articles, comprising 23,119 patients, met the inclusion and exclusion criteria. The pooled mean age of the patients was 56.7 years, and the female rate was 56.1%. The area under the curve (AUC) of the algorithmic model to detect rotator cuff pathology from ultrasound images, MRI images, and radiographic series ranged from 0.789 to 0.950, 0.844 to 0.943, and 0.820 to 0.830, respectively. Notably, 1 of the studies reported that AI models based on ultrasound images demonstrated a diagnostic performance similar to that of radiologists. Another comparative study demonstrated that AI models using MRI images exhibited greater accuracy and specificity compared to orthopedic surgeons in the diagnosis of rotator cuff pathology, albeit not in sensitivity.

CONCLUSIONS

The detection of rotator cuff pathology has been significantly aided by the exceptional performance of AI models. In particular, these models are equally adept as musculoskeletal radiologists in using ultrasound to diagnose rotator cuff pathology. Furthermore, AI models exhibit statistically superior levels of accuracy and specificity when using MRI to diagnose rotator cuff pathology, albeit with no marked difference in sensitivity, in comparison to orthopaedic surgeons.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors

BACKGROUND

The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).

METHODS

This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.

RESULTS

There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.

CONCLUSIONS

In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Massive and irreparable rotator cuff tear treatment by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only

BACKGROUND

The aim of this study was to compare the clinical and radiologic outcomes of 2 treatment methods for massive and irreparable rotator cuff tears (RCTs): partial repair (PR) and PR with long head of the biceps tendon (LHBT) augmentation. Biceps tendon augmentation is believed to promote better healing at the bone-tendon junction, leading to improved clinical and radiologic outcomes.

METHODS

This retrospective comparative study included patients with chronic, massive and irreparable RCTs involving both the supraspinatus (SSP) and infraspinatus muscles. Only patients with failure of nonoperative treatment and at least 1 year of follow-up between 2013 and 2018 were analyzed. The patients were divided into 2 groups based on the chosen treatment method. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the SSP after complete release, typically corresponding to a Goutallier classification of stage ≥ 3 and Patte classification of stage 3. The clinical assessment protocol involved measurements of range of motion and shoulder strength, as well as the Constant-Murley score (CMS) and Simple Shoulder Test score. Radiologic assessment comprised measurements of the acromiohumeral distance, Hamada classification, Sugaya classification, and Goutallier classification of both the SSP and infraspinatus.

RESULTS

The study included data from 60 patients (30 in each group) with a mean age of 62.5 years and a mean follow-up period of 34.5 months. The retear rate was 43.3% for PR with LHBT augmentation and 73.3% for PR alone (P = .036). During the final examination, statistically significant differences in favor of PR with LHBT augmentation were observed for the CMS (76.2 ± 10.9 vs. 70.9 ± 11.5, P = .034), Sugaya classification (3.5 ± 1.1 vs. 4.1 ± 0.9, P = .035), and acromiohumeral distance (5.8 ± 2 mm vs. 4.7 ± 1.3 mm, P = .021). There were no significant differences between the groups in range of motion, shoulder strength, Hamada classification, Simple Shoulder Test score, and postoperative Goutallier stage.

CONCLUSION

PR with LHBT augmentation for patients with irreparable, massive RCTs provides a lower retear rate and better humeral head centralization, as well as improved results measured by the CMS, compared with PR alone.

[Shoulder-clinical introduction]

BACKGROUND

Radiological imaging plays a significant role in the diagnostics of shoulder pathologies. Based on a patient's medical history, physical examination and radiological imaging, it is possible to plan the further conservative or surgical treatment.

OBJECTIVES

Common pathologies of the shoulder and the correct radiological imaging are presented.

CONCLUSIONS

A rational and targeted use of radiological imaging, together with the medical history and physical examination allows correct diagnosis of pathologies of the shoulder joint.

Superior capsular reconstruction for irreparable posterosuperior rotator cuff tears

Although the superior portion of the shoulder joint capsule is a clearly distinct structure, its ability to prevent vertical humeral head translation in irreparable rotator cuff tears remains controversial. The clinical results of superior capsule reconstruction (SCR) in this context are satisfactory but the radiological outcomes are poor in up to two-thirds of patients. Moreover, there is no proof that SCR is more beneficial than simply doing a subacromial debridement, a partial repair or a tenotomy of the long head of biceps. Furthermore, graft healing is not predictive of success. Given the lack of comparative studies with high level of evidence (level 1 or 2), we cannot conclude that this surgical technique (and its many variants) has a place in our treatment paradigm. Also, it seems that xenografts are no longer being used given the high rate of structural failure seen on MRI and the large number of complications. If the long head of biceps tendon is still intact at the time of surgery, it is a feasible option for SCR given the reasonable cost and minimal complications. If it is not - but the subscapularis tendon is intact or repairable - an allograft or a non-local autograft should be considered, despite its unpredictable clinical results. Surgeons should inform patients of the high rate of radiological repair failure and the worse results if a reverse shoulder arthroplasty should be needed subsequently. Level of evidence: 4.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction

BACKGROUND

Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures.

PURPOSE

To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure.

RESULTS

The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M.

CONCLUSION

Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

Development and Clinical Application of Artificial Intelligence Assistant System for Rotator Cuff Ultrasound Scanning

OBJECTIVE

We developed an intelligent assistance system for shoulder ultrasound imaging, incorporating deep-learning algorithms to facilitate standard plane recognition and automatic tissue segmentation of the rotator cuff and its surrounding structures. We evaluated the system's performance using a dedicated data set of rotator cuff ultrasound images to assess its feasibility in clinical practice.

METHODS

To fulfill the system's primary functions, we designed a standard plane recognition module based on the ResNet50 network and an automatic tissue segmentation module using the Mask R-CNN model. The modules were trained on carefully curated data sets. The standard plane recognition module automatically identifies a specific standard plane based on the ultrasound image characteristics. The automatic tissue segmentation module effectively delineates and segments anatomical structures within the identified standard plane.

RESULTS

With the use of 59,265 shoulder joint ultrasound images, the standard plane recognition model achieved an impressive recognition accuracy of 94.9% in the test set, with an average precision rate of 96.4%, recall rate of 95.4% and F1 score of 95.9%. The automatic tissue segmentation model, tested on 1886 images, exhibited a commendable average intersection over union value of 96.2%, indicating robustness and accuracy. The model achieved mean intersection over union values exceeding 90.0% for all standard planes, indicating its effectiveness in precisely delineating the anatomical structures.

CONCLUSION

Our shoulder joint musculoskeletal intelligence system swiftly and accurately identifies standard planes and performs automatic tissue segmentation.

A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders

OBJECTIVE

To perform a systematic review of clinical practice guidelines (CPGs) covering the management of common shoulder disorders.

DATA SOURCES

A systematic search of CPGs on specific shoulder disorders was conducted up to August 2022 in relevant databases.

STUDY SELECTION

Twenty-six CPGs on rotator cuff (RC) tendinopathy, RC tear, calcific tendinitis, adhesive capsulitis, glenohumeral (GH) instability, GH osteoarthritis, or acromioclavicular disorders published from January 2008 onward were screened and included.

DATA EXTRACTION

CPGs methodological quality was assessed with the AGREE II checklist. All recommendations from CPGs were extracted and categorized by shoulder disorder and care components (evaluation, diagnostic imaging, medical, rehabilitation, and surgical treatments). After semantic analysis of the terminology, recommendations for each shoulder disorders were classified by 2 reviewers into "recommended," "may be recommended," or "not recommended." Disagreements were resolved by discussion until reviewers reached consensus.

DATA SYNTHESIS

Only 12 CPGs (46%) were of high quality with major limitations related to the applicability and editorial independence of the guidelines. The initial evaluation of shoulder pain should include patient's history, subjective evaluation focused on red flags, and clinical examination. Magnetic resonance imaging is usually not recommended to manage early shoulder pain, and recommendations for X-rays are conflicting. Acetaminophen, oral non-steroidal anti-inflammatory drugs, and rehabilitation including exercises were recommended or may be recommended to treat all shoulder pain disorders. Guidelines on surgical management recommendations differed; for example, 6 CPGs reported that acromioplasty was recommended or may be recommended in chronic RC tendinopathy, whereas 4 CPGs did not recommend it.

CONCLUSIONS

Recommendations vary for diagnostic imaging, conservative vs surgical treatment to manage shoulder pain, although several care components are consensual. The development of evidence-based, rigorous CPGs with a valid methodology and transparent reporting is warranted to improve overall shoulder pain care.

Serial Changes of Fatty Degeneration and Clinical Outcomes after Repair of Medium-Sized Rotator Cuff Tears

Background

This study was designed to longitudinally analyze quantitative intramuscular and perimuscular fat and evaluate clinical outcomes according to healing degree after rotator cuff repair.

Methods

From June 2013 through October 2018, patients who had undergone repair due to medium-sized rotator cuff tears and serial chest computed tomography (CT) preoperatively and at early (6-12 months) and late (at least 3 years) postoperative follow-ups were included. Supraspinatus (SST) intramuscular fat fraction ratio (IFFR) and perimuscular fat fraction ratio (PFFR) were calculated using chest CT. The rotator cuff integrity was categorized as healed, smaller retear (SRT), and larger retear (LRT) by comparing the preoperative tear size and retear size in shoulder CT arthrography at postoperative follow-ups. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder rating scale, and the Constant score preoperatively and at early and late postoperative follow-ups.

Results

In the LRT group, compared with the preoperative values, there were increases in the SST IFFR and PFFR at the early (p = 0.002 and p = 0.006, respectively) and late (p < 0.001 and p < 0.001, respectively) postoperative time points. Late postoperative clinical scores (UCLA and Constant scores) were not improved compared to preoperative scores (p = 0.156 and p = 0.094, respectively). In the SRT group, there was no difference in the mean SST IFFR and PFFR between preoperative and early postoperative time points (p = 0.766 and p = 0.180, respectively), but the late postoperative values were higher than preoperative values (p = 0.009 and p = 0.049, respectively). Late postoperative clinical scores (ASES, UCLA, and Constant scores) in the SRT group improved compared to preoperative time (p < 0.001, p < 0.001, and p = 0.016, respectively). In the healed group, compared with the preoperative values, there was no difference in the mean SST IFFR and PFFR at postoperative time points; however, the late postoperative clinical scores (ASES, UCLA, and Constant scores) were improved (all p < 0.001).

Conclusions

In the SRT group, IFFR and PFFR progressed in the late postoperative period and clinical scores improved over time. However, in the LRT group, IFFR and PFFR progressed in the early and late postoperative periods and clinical scores did not improve at the late postoperative follow-up.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

PURPOSE

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up.

METHODS

We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed.

RESULTS

In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105).

CONCLUSIONS

In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic Surgery Versus Nonoperative Treatment for Calcific Tendinitis of the Shoulder: A Retrospective Cohort Study

BACKGROUND

Treatment options for calcific tendinitis (CT) of the shoulder remain controversial. A consensus for an operative indication for this condition is lacking.

PURPOSE

To compare nonoperative versus operative treatment for shoulder CT and analyze factors affecting the prognosis after treatment.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 180 patients diagnosed with symptomatic CT between January 2017 and September 2021 were evaluated in this retrospective cohort study. There were 103 patients treated nonoperatively at our institution, which included the use of nonsteroidal anti-inflammatory drugs, acupuncture, steroid injections, extracorporeal shock wave therapy, and ultrasound-guided needle aspiration/percutaneous irrigation. However, 77 patients were treated with arthroscopic surgery after 6 months of failed nonoperative treatment. The visual analog scale (VAS) for pain, the Constant-Murley score, and imaging were used to assess and evaluate outcomes. Descriptive data, functional outcomes, and imaging findings were compared between the operative and nonoperative groups before and after propensity score matching. Additionally, prognostic factors including calcium deposit size, tendon infiltration by calcium deposits, involvement of single or multiple tendons, and occurrence of rotator cuff tears were analyzed by comparing the groups to determine their effect on treatment options and recovery.

RESULTS

Magnetic resonance imaging showed that the supraspinatus tendon (66.7%) was most commonly involved, followed by the infraspinatus (42.8%) and subscapularis (21.1%) tendons. Tendon infiltration by calcium deposits was observed in 84.4% of the patients, and rotator cuff tears occurred in 30.0% of the patients. After propensity score matching, there was no significant difference in changes in the Constant-Murley score (48.1 ± 25.4 vs 49.0 ± 22.8, respectively; P = .950) and VAS score (4.9 ± 2.3 vs 4.5 ± 1.9, respectively; P = .860) between the operative and nonoperative groups at the final follow-up. However, for patients with shoulder CT and without rotator cuff tears, there was a significant difference in changes in the Constant-Murley score (52.93 ± 25.18 vs 42.13 ± 22.35, respectively; P = .012) and VAS score (5.21 ± 2.06 vs 3.81 ± 1.98, respectively; P < .001) between the operative and nonoperative groups, but the recovery time in the operative group was longer than that in the nonoperative group (86.92 ± 138.56 vs 30.42 ± 54.97 days, respectively; P = .016). The results also showed that calcium deposit size, involvement of multiple tendons, and tendon infiltration by calcium deposits did not affect the recovery time after treatment. The survival analysis showed that rotator cuff tears affected the complete recovery of shoulder function.

CONCLUSION

This study demonstrated no significant difference between nonoperative and operative treatment for patients with shoulder CT, on the whole. However, for patients with shoulder CT and without rotator cuff tears, the effect of operative treatment was better than that of nonoperative treatment; yet, operative treatment was shown to prolong the recovery time. Calcium deposit size, tendon infiltration by calcium deposits, and involvement of multiple tendons did not correlate with recovery time or the recovery of function. A rotator cuff tear was the only factor affecting the complete recovery of shoulder function.

Changes in the Lateral Acromion Angle in Rotator Cuff Tear Patients with Acromioplasty

BACKGROUND

Arthroscopic surgery has been established as an efficacious intervention for the treatment of rotator cuff tears. The primary aim of this study was to analyze the modifications in the lateral acromial angle (LAA) subsequent to rotator cuff repair surgery using single-row rivet fixation and double-row rivet fixation techniques. Furthermore, we sought to investigate the influence of LAA on the prognosis of rotator cuff repair surgery.

METHOD

This observational study retrospectively enrolled 105 patients diagnosed with degenerative rotator cuff tears who underwent arthroscopic rotator cuff repair between 2016 and 2019. Following the exclusion of two patients with subscapularis or superior labrum anterior and posterior (SLAP) tears, as well as three patients who were lost to follow-up, a cohort of 100 patients was included for clinical and imaging evaluation. Among these individuals, 50 were assigned to the double-row repair group, whereas the remaining 50 comprised the single-row repair group. Bilateral shoulder magnetic resonance imaging (MRI) scans were conducted no less than 24 months post-surgery. Experienced arthroscopic surgeons, blinded to the LAA measurements, assessed the rotator interval (RI) using a control MRI. Functional assessment was performed using the University of California, Los Angeles (UCLA) quick disability of the shoulder and arm, shoulder and hand (qDASH) score. The Wilcoxon signed-rank test for dependent samples was employed to compare data between the pre- and post-intervention groups. Pearson correlation coefficients were calculated to evaluate the relationship between different parameters.

RESULTS

The study population consisted of 73 female patients and 27 male patients, with a mean age of 58.32 ± 5.29 years and a mean follow-up duration of 25.88 ± 8.11 months. Preoperatively, the mean LAA was 75.81° ± 11.28°, RI was 4.78 ± 0.62, UCLA score was 17.54 ± 2.44, and qDASH score was 2.45 ± 0.25. The average tear size was 8.95 ± 2.11 mm. A statistically significant difference in LAA was observed between the preoperative and postoperative measurements, with the double-row repair group exhibiting a greater LAA than the single-row repair group. Finally, a significant correlation was identified between LAA, RI, and qDASH scores after a 24-month follow-up period.

CONCLUSION

According to our findings, the utilization of double-row rivet fixation has a greater LAA angle than single-row rivet fixation. Moreover, this preservation of LAA is significantly associated with the functional recovery of the shoulder joint.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears

Background

Many older adults with glenohumeral osteoarthritis without rotator cuff tears experience muscle atrophy and fatty degeneration. In these cases, range of motion (ROM) recovery and clinical results after total shoulder arthroplasty (TSA) could be poor, with low subjective satisfaction after surgery. The purpose of this study was to compare the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. We hypothesized that the clinical outcomes of anatomical TSA would be better than those of RSA.

Methods

This single-center, retrospective comparative study involved patients who underwent TSA or RSA from 2013 to 2020. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and active ROM preoperatively and at the follow-up. Walch classification and glenoid version angle were measured using preoperative computed tomography, and fatty infiltration of supraspinatus and infraspinatus muscles were checked through preoperative magnetic resonance imaging.

Results

Of the 67 patients included in this study, TSA was performed in 41 patients (TSA group), and RSA was performed in 26 patients (RSA group). The two groups had no clinical differences in the patients' preoperative demographic and radiographic data. At the final follow-up, both groups showed improved pain, ROM, and functional outcomes. Moreover, the TSA group demonstrated significantly better postoperative ASES (86.8 ± 6.3 vs. 81.6 ± 5.5, p = 0.001) and Constant-Murley (80.4 ± 5.7 vs. 73.4 ± 6.2, p < 0.001) scores than the RSA group. The TSA group showed a significantly better postoperative active ROM than the RSA group regarding forward flexion as well as external and internal rotations (p < 0.001). All patients in the RSA and TSA groups exceeded the minimal clinically important difference.

Conclusions

In older adult patients with degenerative glenohumeral osteoarthritis wherein the rotator cuff is preserved without excessive bone loss, anatomic TSA and RSA can improve pain, ROM, and clinical outcomes. However, clinical results and ROM were better with TSA than with RSA during the short- and mid-term follow-up periods.

When and how much does the muscle strength recover after arthroscopic superior capsular reconstruction?

BACKGROUND

Recently, arthroscopic superior capsular reconstruction (SCR) has been performed for irreparable large to massive rotator cuff tears and excellent clinical results have been reported. Although the muscle strength is reported to recover, it has not yet been clarified when and how much it recovers. The purpose of this study was to determine the recovery pattern of muscle strength after SCR.

METHODS

We retrospectively reviewed 35 patients (mean age, 65 years) who met the following inclusion criteria: (1) patients with large to massive irreparable tears of the rotator cuff including the supraspinatus and infraspinatus tendons; (2) those with severe muscle atrophy and fatty change; (3) those who underwent assessment of muscle quality and strength by magnetic resonance imaging and dynamometry at 6 months, 1 year, and 2 years; (4) those with a minimum follow-up period of 2 years; and (5) those without severe osteoarthritis. The isometric muscle strength of scaption (ie, scapular-plane elevation), internal rotation, and external rotation in adduction was measured twice for each motion by a dynamometer.

RESULTS

Relative to the muscle strength on the uninvolved side, the involved side showed 61% ± 21% in scaption, 63% ± 20% in external rotation, and 103% ± 29% in internal rotation at 2 years after surgery. Whereas no significant differences were observed between the 1-year and 2-year follow-up assessments, a significant difference in muscle strength of scaption was found between 6 months and 1 year (P = .0174). Graft retear was seen in 5 cases (14%). There was a trend that the muscle strength of scaption and external rotation in the no-retear group was greater than that in the retear group despite no significant difference (P = .0717 and P = .0824, respectively).

CONCLUSION

The recovery of the muscle strength after SCR was observed until 1 year after surgery, and the muscle strength of scaption and external rotation returned to 60% of that on the uninvolved side at 2 years.

[Lesions of the rotator cuff and biceps tendon]

CLINICAL/METHODOLOGICAL PROBLEM

The rotator cuff is a complex anatomical structure and the integrity is pivotal for the shoulder functionality. The pathologies are often multifactorial, resulting from degenerative, vascular, traumatic and mechanical factors.

RADIOLOGICAL STANDARD PROCEDURES

Radiography, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) form the pillars of radiological diagnostics. Each modality has specific advantages and limitations in the visualization and assessment of pathologies of the rotator cuff and biceps tendon.

METHODOLOGICAL INNOVATIONS

The MR arthrography offers additional insights in unclear cases by enhancing the differentiation between complete and partial tears.

PERFORMANCE

The MRI provides detailed information on tendon quality and associated damages, such as muscle atrophy and fat infiltration, making it the preferred method. The use of MR arthrography can identify defects through increased intra-articular pressure or contrast medium leakage.

EVALUATION

Muscle damage, as induced by edema in acute injuries or fatty degeneration in chronic conditions, can be evaluated using imaging techniques. Special attention is warranted for the infraspinatus, subscapularis and teres minor muscles due to their unique injury patterns and prevalences.

Supraspinatus extraction from MRI based on attention-dense spatial pyramid UNet network

BACKGROUND

With potential of deep learning in musculoskeletal image interpretation being explored, this paper focuses on the common site of rotator cuff tears, the supraspinatus. It aims to propose and validate a deep learning model to automatically extract the supraspinatus, verifying its superiority through comparison with several classical image segmentation models.

METHOD

Imaging data were retrospectively collected from 60 patients who underwent inpatient treatment for rotator cuff tears at a hospital between March 2021 and May 2023. A dataset of the supraspinatus from MRI was constructed after collecting, filtering, and manually annotating at the pixel level. This paper proposes a novel A-DAsppUnet network that can automatically extract the supraspinatus after training and optimization. The analysis of model performance is based on three evaluation metrics: precision, intersection over union, and Dice coefficient.

RESULTS

The experimental results demonstrate that the precision, intersection over union, and Dice coefficients of the proposed model are 99.20%, 83.38%, and 90.94%, respectively. Furthermore, the proposed model exhibited significant advantages over the compared models.

CONCLUSION

The designed model in this paper accurately extracts the supraspinatus from MRI, and the extraction results are complete and continuous with clear boundaries. The feasibility of using deep learning methods for musculoskeletal extraction and assisting in clinical decision-making was verified. This research holds practical significance and application value in the field of utilizing artificial intelligence for assisting medical decision-making.

Outcome of reverse shoulder arthroplasty secondary to rotator cuff arthropathy in a low-income population

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a valuable treatment for rotator cuff arthropathy (RCA) in developed regions. Socioeconomic issues impact access to specialized care and there is a lack of data on RSA outcomes in developing regions. We present our 24-month follow-up on RSA surgeries to treat RCA in our low-income population.

METHODS

Prospective evaluation of 26 patients subjected to RSA at Hospital Geral de Fortaleza-CE, Brazil, between January 2018 and December 2020. Literacy [>/≤ 8 school years(SY)] and income were documented. Outcomes considered pain (visual analogue scale; VAS) as well as SSV, SPADI, ASES, and UCLA scoring, and range of motion [forward flexion (FF); external rotation (ER)].

RESULTS

Patients were 68.5 ± 7.6 years-old with 16(61.5%) females; 65% had hypertension and 7 (26.9%) had diabetes. Over 90% declared < 900.00 US$ monthly family earnings and 10 (38.4%) patients declared ≤8 SY with > 80% exerting blue-collar jobs. Pain showed a significant reduction from baseline (8 ± 2) to 24 months (2.1 ± 2.3; p < 0.001). UCLA (10.3 ± 5.6 and 28.6 ± 7.2), ASES (16.7 ± 10.8 and 63.1 ± 28.4), SSV (326 ± 311 and 760 ± 234), and SPADI (98.3 ± 26.5) scores significantly improved from baseline to 24 months, achieving minimal clinically important difference. FF (89.2° ± 51.2° to 140.6 ± 38.3°) and ER (19.2° ± 22.5 to 33.4° ± 20.6°) significantly improved from baseline to 24 months (p = 0.004 and 0.027, respectively). There were 5 non-serious adverse events with one surgical revision. All patients returned to daily life activities.

CONCLUSION

This is the first outcome report 2 years following RSA in a low-income population. Data indicate this procedure is justifiable regardless of socioeconomic issues.

Editorial Commentary: Patients May Have Posterior Glenoid Labral Tears in the Absence of Instability or Magnetic Resonance Imaging Findings

Posterior labral tears occur more often than imagined 25 years ago. Although such tears are generally identified in patients with posterior shoulder instability, the spectrum of labral tears in patients without instability creates a challenging diagnosis. Both physical examination and magnetic resonance imaging interpretation are difficult. Pathology encompassing posterior labral tears without instability notably reveals differences compared with throwers with posterior labral tears and patients with posterior instability. Recent research has identified 3 tear types: occult (type 1), incomplete (type 2), and complete (type 3). Attention to diagnosis deserves critical attention, in addition to tailoring of repair techniques to address the appropriate conditions in the shoulder. Even in patients without posterior instability and with ambiguous magnetic resonance imaging or magnetic resonance arthrography findings, posterior shoulder pain during daily activities or sports may indicate a posterior labral tear. Arthroscopic posterior labral repair without capsular plication provides good clinical outcomes and high rates of return to sport and labral healing.

Evaluation of the Relationship between Acromiohumeral Distance and Supraspinatus Tendon Thickness Measured by Ultrasonography and Rotator Cuff Pathologies, Pain, and Function

PURPOSE OF THE STUDY

In this study, we aimed to evaluate acromiohumeral distance (AHD) and supraspinatus tendon (ST) thickness measurements and their relationship with pain and function in ST pathologies.

MATERIAL AND METHODS

The study included 111 patients and 25 healthy controls (HC). Patients were divided into 3 groups according to their diagnosis: non-tear tendinopathy (NTT), partial thickness tear (PTT), and full thickness tear (FTT). The AHD and ST thickness of the participants were measured with ultrasound. The pain and functional status of the patients were evaluated with the Numeric Rating Scale (NRS), The QuickDASH shortened version of the DASH Outcome Measure - Disabilities of the Arm Shoulder and Hand (QDASH), and Simple Shoulder Test (SST).

RESULTS

The AHD value was significantly higher in the NTT group (p=0.000). The AHD value was significantly lower in the FTT group (p=0.000). ST thickness value was significantly lower in the PTT group compared to the NTT group (p=0.000). There was a positive correlation between ST thickness and BMI (r=0.553,p<0.01). There was a negative correlation between ST thickness and SST and a positive correlation between ST thickness (r=-0.223,p<0.05) and QDASH (r=0.276,p<0.05).

CONCLUSIONS

We found that AHD and SST thicknesses significantly differed in the NTT, PTT, FTT, and HC groups. This difference may be important for diagnosis. In addition, the effect of obesity on ST thickness and the relationship between ST thickness and functional scores may be considered. Weight control may be effective at this point.

KEY WORDS

acromiohumeral distance, supraspinatus tendon thickness, ultrasound.

Does Morphology of the Shoulder Joint Play a Role in the Etiology of Rotator Cuff Tear?

BACKGROUND

The etiology of rotator cuff tears (RCTs) have been investigated for years and many underlying causes have been identified. Shoulder joint morphology is one of the extrinsic causes of RCTs.

AIM

Morphometric measurements on MRI sections determined which parameters are an important indicator of RCT in patients with shoulder pain. The aim of this study was to determine the risk factors in the etiology of RCTs by evaluating the shoulder joint morphology with the help of previously defined radiological parameters.

METHOD

Between January 2019-December 2020, 408 patients (40-70 years old) who underwent shoulder MRI and met the criteria were included in the study. There were 202 patients in the RCT group and 206 patients in the control group. Acromion type, acromial index (AI), critical shoulder angle (CSA), acromiohumeral distance (AHD), lateral acromial angle (LAA), acromial angulation (AA), acromion-greater tuberosity impingement index (ATI), and glenoid version angle (GVA) were measured from the MRI images of the patients.

RESULTS

AI (0.64 vs. 0.60, p = 0.003) CSA (35.3° vs. 32.4°, p = 0.004), ATI (0.91 vs. 0.83, P < 0.001), and AA (13.6° vs. 11.9°, p = 0.011) values were higher in the RCT group than in the control group and the difference was significant. AHD (8.1 mm vs. 9.9 mm, P < 0.001), LAA (77.2° vs. 80.9°, p = 0.004) and GVA (-3.9° vs. -2.5°, P < 0.001) values were lower in the RCT group than in the control group, and again the difference was significant. According to the receiver operating characteristic curve analysis, the cutoff values were 0.623 for AI and 0.860 for ATI.

CONCLUSION

Acromion type, AI, CSA, AHD, LAA, AA, ATI, and GVA are suitable radiological parameters to evaluate shoulder joint morphology. High AI, CSA, AA, ATI, GVA and low AHD and LAA are risk factors for RCT.

Risk Factors Analysis and Prediction of Rotator Cuff Tears: A Retrospective Study

AIM

Rotator cuff tears (RCTs) are a major cause of shoulder pain and disability, affecting millions worldwide. Understanding the risk factors and developing reliable predictive measures for RCTs is essential for early diagnosis, targeted prevention, and effective treatment of this patient population. This study seeks to enhance our understanding by analyzing the acromiohumeral distance (AHD) and Constant-Murley Score (CMS) in patients with and without RCTs, thereby aiding the development of a predictive model aimed at improving clinical outcomes and prevention strategies in rotator cuff pathology.

METHODS

This retrospective analysis involved 201 patients with shoulder pain, categorized into RCT (n = 72) and no RCTs (N-RCTs, n = 129) groups based on Magnetic Resonance Imaging (MRI) findings. We compared demographics, AHD, CMS, and rotator cuff status between groups and utilized logistic regression for identifying RCT predictors, leading to the development of a multifactorial predictive model.

RESULTS

The mean AHD was 6.60 ± 1.12 mm. The RCT group showed a marginally higher AHD than the N-RCT group (p = 0.669). CMS scores were significantly lower in the RCT group (p < 0.001). Dominant side involvement (Odds Ratio (OR) 2.244), type III acromion (OR 6.106), and lower CMS (OR 0.938) significantly correlated with RCTs. The predictive model demonstrated an area under the curve (AUC) of 0.701 for RCT diagnosis.

CONCLUSIONS

Reduced CMS, dominance of the affected side, and type III acromion emerged as key risk factors for RCTs. Our predictive model, incorporating these factors, holds promise for RCT diagnosis, with future studies needed for further validation.

The effect of shear wave elastography in the diagnosis of delaminated partial-thickness rotator cuff tears

AIM

To assess the effectiveness of shear wave elastography (SWE) in diagnosing delaminated partial-thickness rotator cuff tears (DPT-RCT).

MATERIAL AND METHODS

A retrospective study was carried out on 137 patients with DPT-RCT. The study included complete clinical data, including the images of conventional ultrasound (US), SWE, Magnetic Resonance Imaging (MRI) and shoulder arthroscopic surgery. The features of US, SWE, and MRI were evaluated. The study analysed the Shear-Wave Velocity (SWV) among three types of DPT-RCT, and between the regions of tears, normal contralateral, and affected unilateral supraspinatus tendon. Furthermore, receiver operating characteristic (ROC) curves were evaluated.

RESULTS

 The SWE detection rate was significantly higher (91.2%) compared to US (73.7%) and MRI (87.6%) for the overall diagnosis of DPT-RCT. Similarly, SWE yielded higher rates of detection for types 1 (89.5%) and 2 (92.3%) of DPT-RCT as compared to US (71.7%, 69.2%) and MRI (81.6%, 94.9%), respectively. However, there was no significant difference in the accuracy of diagnosing type 3 among the three methods. The SWV of the 137 supraspinatus tendon tears was 3.64±0.60 m/s, which was higher than that of the normal supraspinatus tendon (2.43±0.47 m/s, p<0.01) as well as the region of tears (1.61±0.54 m/s, p<0.01). Nevertheless, there was no significant difference in SWV among the three types of DPT-RCT. The cutoff thresholds of SWV for identifying normal tendon from DPT-RCT and for identifying DPT-RCT from the region of tears were 2.96m/s and 2.39m/s, respectively.

CONCLUSIONS

SWE with SWV can provide both quantitative and qualitative diagnostic information for DPT-RCT, which can be used as a crucial supplement imaging method.

Associations of normal fasting glucose levels and of insulin resistance with degenerative rotator cuff tear : Normoglycemia and rotator cuff tear

BACKGROUND

The upper normoglycemic range has been proposed as a risk factor for degenerative rotator cuff tendon tear (RCT), and insulin resistance has been suggested as a risk factor for tendinopathy. However, no research has established their association with degenerative RCT in the general population. This study aimed to determine whether fasting glucose levels and insulin resistance are risk factors for degenerative RCT in the normoglycemic population and identify the risk range for fasting glucose.

METHODS

This study included 418 normoglycemic participants from a rural cohort. Participants completed questionnaires, physical exams, blood tests, and MRI evaluations of both shoulders. Insulin resistance was assessed using a triglyceride/high-density-lipoprotein (TG/HDL) ≥ 3.5. Logistic regression analysis was used to determine the association between fasting glucose level, TG/HDL ≥ 3.5, and other factors and degenerative RCT. The study calculated the areas under the receiver operating characteristic curve (AUC) to determine the more appropriate predicting value between the scale and categorical values of fasting glucose levels, and compared the AUCs using the DeLong method.

RESULTS

In the multivariable analyses, both scale and categorical values of fasting glucose levels, and TG/HDL ≥ 3.5 were significantly associated with degenerative RCT. Fasting glucose levels ≥ 90.5 mg/dL (OR: 3.87, 95% CI: 2.10-7.06) in scale value and 90-99 mg/dL (OR: 4.13, 95% CI: 2.87-8.12) in categorical value were significantly associated with degenerative RCT (P < .001). The AUC of the scale value of fasting glucose levels ≥ 90.5 mg/dL was 0.68. The AUC of the categorical value of fasting glucose levels of 90-99 mg/dL was 0.70. Because of the significantly larger AUC of the categorical value of fasting glucose levels of 90-99 mg/dL, those fasting glucose levels were determined to be independently associated with degenerative RCT (P < .001).

CONCLUSIONS

High fasting glucose levels within the normal range may link to increase insulin resistance and risk of degenerative RCT. Normoglycemic levels of 90-99 mg/dL and insulin resistance may be risk factors for degenerative RCT.

LEVEL OF EVIDENCE

Level III, prognostic study.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.