Biomechanical Comparison of Augmentation of Engineered Tendon-Fibrocartilage-Bone Composite With Acellular Dermal Graft Using Double Rip-Stop Technique for Canine Rotator Cuff Repair

Background

The retear rate after rotator cuff repair remains unacceptably high. Various biological engineered scaffolds have been proposed to reduce the retear rate. We have developed a double rip-stop repair with medial row knot (DRSK) technique to enhance suture-tendon strength and a novel engineered tendon-fibrocartilage-bone composite (TFBC) for rotator cuff repair.

Hypothesis

DRSK rotator cuff repair augmented with TFBC will have better biomechanical properties than that of DRSK repair with an acellular dermal graft (DG).

Study Design

Controlled laboratory study.

Methods

Fresh-frozen canine shoulders (n = 30) and knees (n = 10) were used. TFBCs were harvested from the patellar tendon-tibia complex and prepared for rotator cuff repair. The infraspinatus tendon was sharply detached from its bony attachment and randomly assigned to the (1) control group: DRSK repair alone, (2) TFBC group: DRSK repair with TFBC, and (3) DG group: DRSK repair with DG. All specimens were tested to failure, and videos were recorded. The footprint area, tendon thickness, load to create 3-mm gap formation, failure load, failure modes, and stiffness were recorded and compared. Data were recorded as mean ± SD.

Results

The mean load to create a 3-mm gap in both the control group (206.8 ± 55.7 N) and TFBC group (208.9 ± 39.1 N) was significantly higher than that in the DG group (157.7 ± 52.3 N) (P < .05 for all). The failure load of the control group (275.7 ± 75.0 N) and TFBC group (275.2 ± 52.5 N) was significantly higher compared with the DG group (201.5 ± 49.7 N) (P < .05 for both comparisons). The stiffness of the control group (26.4 ± 4.7 N/mm) was significantly higher than of the TFBC group (20.4 ± 4.4 N/mm) and the DG group (21.1 ± 4.8 N/mm) (P < .05 for both comparisons).

Conclusion

TFBC augmentation showed superior biomechanical performance to DG augmentation in rotator cuff tears repaired using the DRSK technique, while there was no difference between the TFBC and control groups.

Clinical Relevance

TFBC may help to reduce retear or gap formation after rotator cuff repair using the DRSK technique.

Concomitant rotator cuff repair and instability surgery provide good patient-reported functional outcomes in patients aged 40 years or older with shoulder dislocation

Background

Recurrent anterior shoulder dislocation in patients aged ≥ 40 years is not as rare as once thought. The mechanism of instability in this patient population is different—more likely to be attributed to rotator cuff pathology—compared with that in younger individuals. With an increasingly aging active population, surgical management has a rising role in preventing morbidity associated with recurrent instability. Our purpose was to evaluate outcomes of anterior shoulder instability repair (ie, Bankart or bony Bankart repair) with and without rotator cuff repair (RCR) in patients aged ≥ 40 years.

Methods

We conducted a retrospective chart review of all patients aged ≥ 40 years who underwent surgical repair for anterior shoulder instability from 2008-2016. Patients were categorized into 4 cohorts: Bankart repair only, bony Bankart repair only, Bankart repair with concomitant RCR, and bony Bankart repair with concomitant RCR. Demographic and history-of-instability data were collected. Clinical and functional outcomes assessed included the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons score, Penn Shoulder Score, visual analog scale score for pain, Western Ontario Shoulder Instability Index score, and patient satisfaction score.

Results

A total of 146 patients were included in this study, with 103 patients (71%) having ≥2-year outcome scores. Outcome scores were not significantly different among groups. For patients who underwent Bankart repair only, bony Bankart repair only, Bankart repair with RCR, and bony Bankart repair with RCR, the Single Assessment Numeric Evaluation scores were 80.8 ± 19.7, 90.0 ± 10.7, 79.3 ± 29.4, and 87.2 ± 10.6, respectively (P = .284); American Shoulder and Elbow Surgeons scores, 83.8 ± 19.7, 92.4 ± 17.4, 82.5 ± 25.6, and 85.6 ± 12.7, respectively (P = .114); Penn Shoulder Scores for function, 84.5 ± 17.9, 90.9 ± 15.3, 83.6 ± 25.1, and 95.7 ± 13.0, respectively (P = .286); and Western Ontario Shoulder Instability Index scores, 481.0 ± 519.5, 292.1 ± 414.3, 548.9 ± 690.5, and 320.6 ± 258.7, respectively (P = .713). Age at the time of surgery significantly differed between cohorts (P < .001). No patients had recurrence of instability during the study period.

Conclusion

Similar functional outcomes can be achieved in the surgical management of anterior instability in patients aged ≥ 40 years. Rotator cuff tears should be suspected and repaired in patients with anterior instability, especially those aged ≥ 50 years.

Does Having a Rotator Cuff Repair Before Total Shoulder Arthroplasty Influence Outcomes?

Background:

The number of rotator cuff repairs (RCRs) is increasing each year. Total shoulder arthroplasty (TSA) is a successful treatment option for patients with glenohumeral osteoarthritis with a functioning rotator cuff.

Purpose/Hypothesis:

The purposes of this study were to report the outcomes of TSA in patients with ipsilateral RCR and determine whether patients with a history of ipsilateral RCR who subsequently underwent TSA had differences in outcomes compared with matched controls who underwent TSA with no history of RCR. We hypothesized that patients with prior RCR will have significant improvements in clinical outcome scores, with no difference in outcomes after TSA compared with those with no prior RCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients eligible for inclusion were those with a history of prior RCR who underwent TSA at a single institution with a minimum 2-year follow-up between 2000 and 2015. Outcomes for this group, including American Shoulder and Elbow Surgeons (ASES) scores, were reported and then compared with a matched control group of patients who underwent TSA with no history of prior RCR. Controls were matched based on age, sex, and preoperative ASES score.

Results:

Overall, 14 patients (64% males; mean ± SD age, 65.1 ± 11.1 years) underwent prior ipsilateral RCR before TSA. ASES scores significantly improved from 42.9 to 78.5 at 2 years and to 86.6 at 5 years. When compared with 42 matched control patients (matched 1:3) who underwent TSA with no history of RCR, there was no significant difference in ASES scores at 2 years (78.5 vs 85.3; P = .19) and 5 years (86.6 vs 90.9; P = .72) between the prior RCR and no RCR groups.

Conclusion:

TSA in patients with a history of prior ipsilateral RCR led to significant improvements in clinical outcomes. No difference in clinical outcomes at 2 or 5 years after TSA was found between patients with and without a history of prior ipsilateral RCR.

Effects of a Thermosensitive Antiadhesive Agent on Single-Row Arthroscopic Rotator Cuff Repair

BACKGROUND

Postoperative stiffness after rotator cuff repair is a common complication that can lead to poor outcomes and patient discomfort. The application of an antiadhesive agent at the time of repair recently became an option for clinicians, but little information is available on its effects.

PURPOSE

To evaluate and compare retear rates, the incidence of postoperative stiffness, and the clinical outcomes of patients who underwent cuff repair with or without the application of an antiadhesive agent.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 296 patients who underwent arthroscopic rotator cuff repair surgery, we compared the outcomes of those injected with a thermosensitive gel antiadhesive agent into the subacromial space (112 cases) versus noninjected controls (184 cases). Retear rates in the 2 groups were determined by magnetic resonance imaging at 1 year after surgery. Shoulder joint range of motion and functional scores were evaluated serially.

RESULTS

The rate of retear was significantly lower in the injection group (20/112 cases; 17.9%) than the control group (53/184 cases; 28.8%) (P = .034). Postoperative stiffness was not significantly different between the 2 groups (P = .710). Among the data regarding range of motion, only forward flexion at 6 months after surgery showed superior results in the injection group. Functional scores showed conflicting results: The control group had better visual analog scale scores for pain (injection vs control: 2.17 vs 1.68 at 6 months; 1.82 vs 1.28 at 12 months), American Shoulder and Elbow Surgeons scores (79.89 vs 89.64 at 12 months), and simple shoulder test scores (8.70 vs 10.06 at 12 months), whereas the injection group had better Constant-Murley scores (injection vs control: 59.49 vs 55.60 at 3 months; 77.35 vs 71.98 at 6 months; 87.28 vs 81.56 at 12 months).

CONCLUSION

The tendon healing rate was significantly higher in the group receiving an antiadhesive agent than in the control group. No intergroup difference was seen in the occurrence of postoperative stiffness. However, the pain-related functional score showed inferior results in the injection group at 12 months. The biological action of antiadhesive agents in rotator cuff repair should be further evaluated.

Surgical repair of the supraspinatus: architectural changes in the muscle pre- and postoperatively

INTRODUCTION

Shortening of the tendon and muscle is recognised as a strong predictor for surgical failure of supraspinatus tendon tears. Changes in muscle architecture following repair have not been thoroughly investigated. We aimed to compare the architecture of the supraspinatus pre- and postoperatively.

METHODS

We recruited eight participants with full-thickness supraspinatus tears. Images of the supraspinatus were captured preoperatively (pre-op) and postoperatively at one (post-op1), three (post-op2) and six (post-op3) months in relaxed and contracted states (0° and 60° glenohumeral abduction). Fibre bundle length (FBL), pennation angle (PA) and muscle thickness (MT) were quantified. Self-reported function, and maximal isometric abduction and external rotation strengths were assessed.

RESULTS

Mean FBL increased from pre-op to post-op1 (p = 0.001) in the relaxed state and from pre-op to post-op2 (p = 0.002) in the contracted state. Decrease in FBL was observed from post-op2 to post-op3 in the relaxed state. Mean PA decreased from pre-op to post-op1 (p < 0.001) in the relaxed state, but increased from post-op2 to post-op3 in both relaxed (p = 0.006) and contracted (p = 0.004) states. At post-op3, external rotation (p = 0.009) and abduction (p = 0.005) strengths were greater than at post-op2. Overall function increased by 47.67% from pre-op to post-op3.

CONCLUSION

Lengthening of the supraspinatus occurs with surgery, altering the length-tension relationship of the muscle, which can compromise muscle function and lead to inferior surgical outcomes. These findings may guide clinicians to optimise loads, velocities and shoulder ranges for effective postoperative rehabilitation.

Comparison of 3 supraspinatus tendon repair techniques - a 3D computational finite element analysis

Considering that optimal contact area and pressure at the tendon-bone interface are associated with better footprint repair and outcomes, the aim of this study was to compare the performance of standard double-row, transosseous equivalent (TOE), and partial articular supraspinatus tendon avulsion (PASTA) techniques for the treatment of full-thickness tears of the supraspinatus tendon using 3D finite element models. Loading consisted, alternately, in a preloading of 10 N and 20 N of the sutures. The footprint coverage of the standard double-row, TOE, and PASTA techniques was estimated to represent 19%, 30%, and 35%, respectively, of the repair area. The average contact pressures followed an opposite trend, i.e., the largest was estimated for the standard double-row technique, whereas the lowest was estimated for the PASTA technique. Despite the present study advancing the computational modelling of rotator cuff repair, and the results being consistent with the literature, its findings must be evaluated cautiously, bearing in mind its limitations.

Shoulder arthroscopy: a bridge from the past to the future

This article constitutes the text of the Codman Lecture, delivered by the author to the attendees of the International Congress of Shoulder and Elbow Surgeons on September 19, 2019, in Buenos Aires, Argentina.

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes

Background:

Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs.

Purpose:

To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05.

Results:

A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up.

Conclusion:

Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

Synovial Fluid Volume at the Time of Arthroscopic Rotator Cuff Repair Correlates With Tear Size

Background

Inflammatory biomarkers are increased in the synovium and tendon of rotator cuff tears. Several studies demonstrate an associated increase in these markers and size of the tear, with implications of chondral destruction leading to rotator cuff tear arthropathy and glenohumeral arthritis.

Methods

This is a prospective study of 105 patients undergoing arthroscopic rotator cuff repair in which intra-articular synovial fluid was aspirated just prior to arthroscopy. Adult patients with a partial or full-thickness rotator cuff tear undergoing arthroscopic repair were included, and those with inflammatory arthritis, active infection, open cuff repair, intraoperative findings of osteoarthritis, or those undergoing revision cuff repair were excluded.

Results

The average patient age was 58 years (range 33-74 years), with 59 (56.2%) males. The mean aspirate volume of partial tears was 0.76 ± 0.43 mL, small tears 1.46 ± 1.88 mL, medium tears 3.04 ± 2.21 mL, and large tears 6.60 ± 3.23 mL. Full-thickness versus partial tears had significantly more synovial fluid (3.64 vs. 0.76 mL, respectively, p < 0.0001). An aspiration volume of 1.5 mL or greater resulted in 91.3% specificity and 96.8% positive predictive value for a full-thickness tear. Smoking (p = 0.017), tear size (p < 0.0001), and tears of the infraspinatus (p = 0.048) were significantly correlated with synovial fluid volume. Age, body mass index, chronicity of tear, sex, subscapularis involvement, supraspinatus involvement, and teres minor involvement had no association to synovial fluid volume.

Conclusion

Preoperative aspiration of the glenohumeral joint to identify the volume of synovial fluid can aid to identify full-thickness rotator cuff tears, and increased fluid volume should alert the clinician of a large tear.

Increased opioid use following rotator cuff repair associated with prior opioid use and surgeon prescription patterns

BACKGROUND

Prescription opioids are standard of care for postoperative pain management after musculoskeletal surgery, but there is no guideline or consensus on best practices. Variability in the intensity of opioids prescribed for postoperative recovery has been documented, but it is unclear whether this variability is clinically motivated or associated with provider practice patterns, or how this variation is associated with patient outcomes. This study described variation in the intensity of opioids prescribed for patients undergoing rotator cuff repair (RCR) and examined associations with provider prescribing patterns and patients' long-term opioid use outcomes.

METHODS

Medicare data from 2010 to 2012 were used to identify 16,043 RCRs for patients with new shoulder complaints in 2011. Two measures of perioperative opioid use were created: (1) any opioid fill occurring 3 days before to 7 days after RCR and (2) total morphine milligram equivalents (MMEs) of all opioid fills during that period. Patient outcomes for persistent opioid use after RCR included (1) any opioid fill from 90 to 180 days after RCR and (2) the lack of any 30-day gap in opioid availability during that period. Generalized linear regression models were used to estimate associations between provider characteristics and opioid use for RCR, and between opioid use and outcomes. All models adjusted for patient clinical and demographic characteristics. Separate analyses were done for patients with and without opioid use in the 180 days before RCR.

RESULTS

In this sample, 54% of patients undergoing RCR were opioid naive at the time of RCR. Relative to prior users, a greater proportion of opioid naive users had any opioid fill (85.7% vs. 75.4%), but prior users received more MMEs than naive users (565 vs. 451 MMEs). Providers' opioid prescribing for other patients was associated with the intensity of perioperative opioids received for RCR. Total MMEs received for RCR were associated with higher odds of persistent opioid use 90-180 days after RCR.

CONCLUSIONS

The intensity of opioids received by patients for postoperative pain appears to be partially determined by the prescribing habits of their providers. Greater intensity of opioids received is, in turn, associated with greater odds of patterns of chronic opioid use after surgery. More comprehensive, patient-centered guidance on opioid prescribing is needed to help surgeons provide optimal postoperative pain management plans, balancing needs for short-term symptom relief and risks for long-term outcomes.

Partial Rotator Cuff Repair With Superior Capsular Reconstruction Using the Biceps Tendon Is as Effective as Superior Capsular Reconstruction Using a Tensor Fasciae Latae Autograft in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Several treatment options are available for stable massive rotator cuff tears, including partial repair with or without tissue augmentation, tendon transfer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty.

Purpose/Hypothesis:

The purpose of this study was to compare the outcomes and effectiveness of partial rotator cuff repair with SCR using the long head of the biceps tendon (PRCR-SCRB) and SCR with a tensor fasciae latae autograft (SCRTF) for the treatment of rotator cuff tears with severe fatty degeneration. The hypothesis of this study was that SCRTF would be superior to PRCR-SCRB in functional and anatomic outcomes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 26 consecutive patients with massive and fatty degenerative rotator cuff tears were treated surgically. Patients were divided into either the PRCR-SCRB group (n = 14) or SCRTF group (n = 12). Functional outcomes were assessed at final follow-up, and the acromiohumeral distance (AHD) was measured.

Results:

All functional scores significantly improved in both groups at final follow-up. The PRCR-SCRB group showed better overall outcomes in terms of the visual analog scale for pain; American Shoulder and Elbow Surgeons score; and Quick Disabilities of the Arm, Shoulder and Hand, but these differences were not statistically significant. Better outcomes were found for only the AHD for the PRCR-SCRB group without statistical significance (P = .4). No statistical difference was found in terms of retear rate.

Conclusion:

PRCR-SCRB had comparable outcomes and improvement in AHD compared with SCRTF without the need for additional graft harvesting.

Does the Dog-Ear or Bird-Beak Deformity Remodel After Rotator Cuff Repair?

BACKGROUND

Dog-ear and bird-beak deformities are common after transosseous-equivalent repair (suture bridge technique). The natural course of deformities after rotator cuff (RC) repair using the suture bridge technique is unclear. The remodeling potential of these deformities has not been investigated.

PURPOSE

To evaluate remodeling and retear rates associated with deformities after RC repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between November 2011 and February 2012, we studied 99 consecutive shoulders. All patients underwent arthroscopic RC repair via the suture bridge technique with or without additional sutures. Two groups were formed: no deformity (n= 46) and deformity (n = 53). Deformity was defined as marginal detachment and protrusion of the RC after repair, involving inappropriate compression of the suture limbs from the anchors. Tendon height was measured from the highest point of the most protruding portion of the cuff to the cortex on semi-coronal magnetic resonance imaging (MRI) scan. Change in tendon height was evaluated on MRI scan at 1 week and 6 months postoperatively. Clinical assessment at every patient visit included the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and visual analog scale for pain (pVAS) score.

RESULTS

No significant differences were found in age, sex, symptom duration, tear size, and preoperative ASES, Constant, and pVAS scores (P > .05) between the 2 groups. The initial tendon height was 7.4 ± 1.5 mm in the no-deformity group and 9.3 ± 2.0 mm in the deformity group. Follow-up height was 6.3 ± 2.1 mm in the no-deformity group and 6.4 ± 1.6 mm in the deformity group. Mean postoperative tendon heights were 90.1% ± 23.8% of the initial height in the no-deformity group and 73.2% ± 15.1% in the deformity group. Clinical scores (ASES, Constant, and pVAS) were not significantly different between the groups at 6 months. There were 4 shoulders in each group that experienced retearing (types 4 and 5 according to the Sugaya classification) at 6 months postoperatively. There was no difference in retear rate (P > .999).

CONCLUSION

Most deformities after RC repair were remodeled with no effect on retears. Clinical outcomes were not affected by deformities.

Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques

BACKGROUND

Arthroscopic rotator cuff repair (RCR) with suture anchor-based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results.

PURPOSE

To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture-grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis.

RESULTS

A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant.

CONCLUSION

Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.

Acromioplasty during repair of rotator cuff tears removes only half of the impinging acromial bone

Background

To date, there is no consensus on when and how to perform acromioplasty during rotator cuff repair (RCR). We aimed to determine the volume of impinging bone removed during acromioplasty and whether it influences postoperative range of motion (ROM) and clinical scores after RCR.

Methods

Preoperative and postoperative computed tomography scans of 57 shoulders that underwent RCR were used to reconstruct scapula models to simulate volumes of impinging acromial bone preoperatively and then compare them to the volumes of bone resected postoperatively to calculate the proportions of desired (ideal) vs. unnecessary (excess) resections. All patients were evaluated preoperatively and at 6 months to assess ROM and functional scores.

Results

The volume of impinging bone identified was 3.5 ± 2.3 cm³, of which 1.6 ± 1.2 cm³ (50% ± 27%) was removed during acromioplasty. The volume of impinging bone identified was not correlated with preoperative critical shoulder angle (r = 0.025, P = .853), nor with glenoid inclination (r = -0.024, P = .857). The volume of bone removed was 3.7 ± 2.2 cm³, of which 2.1 ± 1.6 cm³ (53% ± 24%) were unnecessary resections. Multivariable analyses revealed that more extensive removal of impinging bone significantly improved internal rotation with the arm at 90° of abduction (beta, 27.5, P = .048) but did not affect other shoulder movements or clinical scores.

Conclusions

Acromioplasty removed only 50% of the estimated volume of impinging acromial bone. More extensive removal of impinging bone significantly improved internal rotation with the arm at 90° of abduction.

Optimizing the Double-Row Construct: An Untied Medial Row Demonstrates Equivalent Mean Contact Pressures in a Rotator Cuff Model

Background:

The merits of a double-row rotator cuff repair (RCR) construct are well-established for restoration of the footprint and lateral-row security. The theoretical benefit of leaving the medial row untied is to prevent damage to the rotator cuff by tissue strangulation, and the benefit of suture tape is a more even distribution of force across the repair site. These benefits, to our knowledge, have not been evaluated in the laboratory.

Hypothesis:

Leaving the medial row untied and using a suture bridge technique with suture tape will offer more even pressure distribution across the repair site without compromising total contact force.

Study Design:

Controlled laboratory study.

Methods:

A laboratory model of RCR was created using biomechanical research-grade composite humeri and human dermal allografts. The pressure distribution in a double-row suture bridge repair construct was analyzed using the following testing matrix: double-loaded suture anchors with the medial row tied (n = 15) versus untied (n = 15) compared with double-loaded suture tape and anchors with the medial row tied (n = 15) versus untied (n = 15). A digital pressure sensor was used to measure pressure over time after tensioning of the repair site. A multivariate analysis of variance was used for statistical analysis with post hoc testing.

Results:

The total contact force did not significantly differ between constructs. The contact force between double-loaded suture anchors and double-loaded suture tape and anchors was similar when tied (P = .15) and untied (P = .44). An untied medial row resulted in similar contact forces in both the double-loaded suture anchor (P = .16) and double-loaded suture tape and anchor (P = .25) constructs. Qualitative increases in focal contact pressure were seen when the medial row was tied.

Conclusion:

An untied medial row did not significantly affect the total contact force with double-loaded suture anchors and with double-loaded suture tape and anchors. Tying the medial row qualitatively increased crimping at the construct’s periphery, which may contribute to tissue strangulation and hinder clinical healing. Qualitative improvements in force distribution were seen with double-loaded suture tape and anchors.

Clinical Relevance:

Both tied and untied medial rows demonstrated similar pressures across the repair construct.

Retrospective review of open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement: a single surgeon's experience

BACKGROUND

There have been conflicting results when comparing outcomes of open vs. arthroscopic anterosuperior rotator cuff repairs with subscapularis involvement. The purpose of this study was to evaluate midterm outcome differences and complications following open vs. arthroscopic repair of rotator cuff tears involving the subscapularis by a single surgeon.

METHODS

This was a retrospective review of 57 rotator cuff repairs involving the subscapularis performed by a single surgeon over a 10-year period. During this time, the surgeon transitioned from open to arthroscopic repair. Preoperative and postoperative range of motion, lift-off test, belly press test, and American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment form scores were measured.

RESULTS

Eighteen patients had open procedures and 39 had arthroscopic repair. The mean preoperative ASES score for the open group was 39 and postoperatively was 79. The mean preoperative ASES score for the arthroscopic group was 44 and improved to 80 postoperatively. There was no significant difference in score or change in score between the 2 groups (P > .05). There was only 1 complication. It occurred in the open group and was a superficial wound dehiscence.

CONCLUSIONS

This study demonstrated no outcome differences between open and arthroscopic rotator cuff repair involving the subscapularis, even with large subscapularis tears. Both techniques significantly improved shoulder function. Arthroscopic and open rotator cuff repairs including the subscapularis are relatively safe procedures, and either technique is an acceptable option.

The effect of perioperative platelet-rich plasma injections on postoperative failure rates following rotator cuff repair: a systematic review with meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) has gained significant interest in recent years to potentially add biological augmentation of healing to surgical repairs of soft-tissue injuries. We sought to determine whether perioperative PRP injection influences the risk of failure following rotator cuff repair.

METHODS

A systematic search was performed in the Embase and PubMed databases and identified 16 randomized controlled trials or prospective cohort studies (1045 participants) reporting rates of failure, defined as a subsequent tear on postoperative imaging, after rotator cuff repair with or without perioperative PRP administration. A random-effects meta-analysis of the included studies was performed to determine the pooled effect of PRP administration on the postoperative failure risk.

RESULTS

Among the 16 studies investigating rotator cuff repairs, PRP augmentation resulted in a 25% reduction in the risk of repair failure, with low heterogeneity among the included studies. A significant protective effect was seen for studies of only small to medium tears (7 studies) (P = .007) and studies including large or massive tears (9 studies) (P < .001).

CONCLUSIONS

Intraoperative PRP reduces the failure risk following rotator cuff repair and has a consistent effect regardless of tear size. However, because of the variability in PRP preparations, a specific recommendation cannot be made.

Clinical and radiological outcomes of arthroscopic en bloc repair for delaminated rotator cuff tear versus non-delaminated tear

PURPOSE

The objective of the study is to determine clinical and radiological outcomes of arthroscopic repair for delaminated tears versus non-delaminated tears.

METHODS

Consecutive 138 patients with full-thickness rotator cuff tear were retrospectively enrolled. They were divided into two groups based on the presence of delamination. All delaminated tears were repaired by en bloc technique (suturing both layers by single stitch). Delaminated tears were categorized into two types: (1) posterior type, delamination involving mainly infraspinatus and (2) complete type, delamination involving both supraspinatus and infraspinatus. Clinical assessments were done using pain visual analog scale (PVAS), functional VAS, American Shoulder Elbow Surgeons score, the Constant score, and range of motion. Postoperative MRI was performed at 6 months after surgery to determine repair integrity.

RESULTS

Of the 138 patients, 78 (56.5%) had delaminated tears, including 30 cases of posterior type and 48 cases of complete type. The retear rate was 6.7% (4/60) in the non-delamination group and 5.1% (4/78) in the delamination group, showing no significant difference between the two groups. There was no significant difference in Sugaya classification between the two groups. Clinical scores were improved significantly in both delamination and non-delamination groups postoperatively, showing no significant difference between the two groups. Delamination subgroup (posterior or complete type) showed no significant correlation with retear rate, Sugaya classification, or clinical outcome.

CONCLUSIONS

Arthroscopic en bloc repair for delaminated rotator cuff tear showed no significant difference in clinical or radiological outcome from that for non-delaminated rotator cuff tear. The extent of delamination did not affect outcome either. Levels of Evidence: Level III, Retrospective comparative study.

Beige fibro-adipogenic progenitor transplantation reduces muscle degeneration and improves function in a mouse model of delayed repair of rotator cuff tears

BACKGROUND

Muscle atrophy and fatty infiltration (FI) are common occurrences following rotator cuff (RC) tears. Tears of all sizes are subject to muscle degeneration. The degree of muscle degeneration following RC tears is highly correlated with repair success and functional outcomes. We have recently discovered that muscle fibro-adipogenic progenitors (FAPs) can differentiate into uncoupling protein 1 (UCP-1)-expressing beige adipocytes and induce muscle regeneration. This study evaluated the potential of local cell transplantation of beige adipose FAPs (BAT-FAPs) to treat RC muscle degeneration in a murine model of RC repair.

METHODS

BAT-FAPs were isolated from muscle in UCP-1 reporter mice by flow cytometry as UCP-1⁺/Sca1⁺/PDGFR⁺/CD31^-/CD45^-/integrin α7^-. C57/BL6J mice underwent supraspinatus tendon tear with suprascapular nerve transection followed by repair 2 or 6 weeks after the initial injury. At the time of repair, mice received either no additional treatment, phosphate-buffered saline injection, or BAT-FAP injection. Functional outcomes were assessed by gait analysis. Mice were humanely killed at 6 weeks after cell transplantation. Supraspinatus muscle FI, fibrosis, muscle fiber size, and vascularity were analyzed and quantified via ImageJ. Analysis of variance with post hoc Tukey test and P <.05 was used to determine statistical significance.

RESULTS

Cell transplantation diminished fibrosis, FI, and atrophy and enhanced vascularization in both delayed repair models. Cell transplantation resulted in improved shoulder function as assessed with gait analysis in both the delayed repair models.

CONCLUSIONS

BAT-FAPs significantly reduced muscle degeneration and improved shoulder function after RC repair. BAT-FAPs hold significant promise as a therapeutic adjunct to repair for patients with advanced RC pathology.

Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial

BACKGROUND

Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears.

METHODS

We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy.

RESULTS

The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 4-21 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR]) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P = .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 6.5% of repaired patients and tear progression >5 mm in 29.2% of unrepaired patients.

CONCLUSIONS

We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm.

The clinical and radiologic outcome of microfracture on arthroscopic repair for full-thickness rotator cuff tear

BACKGROUND

The persistent incidence of retear despite improvements in techniques led orthopedic surgeons to the application of principles of tissue bioengineering to achieve enhanced repair and functional outcomes. The purpose of this study was to compare clinical and radiologic outcomes of arthroscopic single-row repair augmented with microfracture (SRM) at the greater tuberosity with single-row (SR) and double-row (DR) repair in the treatment of full-thickness rotator cuff tears.

MATERIALS AND METHODS

This is a retrospective comparative study. A total of 123 patients were enrolled for arthroscopic repair of full-thickness rotator cuff tears, with 40 patients treated by SR, 44 by SRM, and 39 by DR. The minimum follow-up was 2 years. The primary outcome was retear rate, which was detected by magnetic resonance imaging, and the secondary outcome was functional outcome.

RESULTS

The mean age of the patients was 59.2 years, 58.1 years, and 60.6 years in the SR, SRM, and DR groups, respectively. The retear rate was 33%, 14%, and 36% in the SR, SRM, and DR groups, respectively (P = .045). The SRM group had significantly improved functional outcomes compared with the SR and DR groups in terms of the postoperative Constant score and visual analog scale score (P = .001 and .002, respectively). Delta Constant scores were nonsignificant for retear and intact tendons (P = .137).

CONCLUSION

SRM has a significantly lower retear rate and better functional outcome than SR and DR repair.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs

BACKGROUND

Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood.

PURPOSE/HYPOTHESIS

This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores.

RESULTS

A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R² in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs.

CONCLUSION

Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation

BACKGROUND

The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct.

HYPOTHESIS

The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct.

RESULTS

The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures.

CONCLUSION

The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort.

CLINICAL RELEVANCE

The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

The arthroscopic triple-row modified suture bridge technique for rotator cuff repair: functional outcome and repair integrity

BACKGROUND

The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction.

METHODS

A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients.

RESULTS

The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05).

CONCLUSION

For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.