Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

The WORC Index and Predicting Treatment Failure in Patients Undergoing Primary Arthroscopic Rotator Cuff Repair

Background:

Rotator cuff tears are common injuries that are reliably treated with arthroscopic repair, producing good to excellent results. The Western Ontario Rotator Cuff (WORC) index is a validated disease-specific instrument used to assess patient outcomes; however, no study to date has correlated WORC index with treatment failure.

Purpose:

To evaluate the WORC index as a predictor for successful treatment in arthroscopic rotator cuff repair. An additional purpose was to identify patient and tear characteristics associated with risk of treatment failure.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

This study reviewed a total of 500 patients who underwent arthroscopic rotator cuff repair with a minimum of 2-year follow-up. Patient charts were reviewed for treatment failures, defined as persistent or recurrent shoulder pain or weakness, leading to further workup and identification of a failure to heal or recurrent tear by magnetic resonance imaging. Patient demographic and comorbidity data were gathered and correlated with risk of failure. All patients completed WORC questionnaires, and scores were correlated with risk of treatment failure.

Results:

There were 28 (5.6%) treatment failures at a median 28 weeks (SD, 42 weeks) postoperatively. Patients claiming workers’ compensation were 3.21 times more likely (odds ratio; P = .018) to fail treatment. Posterior interval tears (those including infraspinatus) were 3.14 times more likely (P = .01) to fail than anterior interval tears. Tear size was associated with treatment failure; the odds of failure was 3.24 for a 2-tendon tear and 5.83 for a 3-tendon tear (P = .03). Tears involving the nondominant arm were associated with an increased risk of failure by a factor of 3.04 (95% CI, 1.01-9.11; P = .047). A WORC score ≥80 was associated with a 95% probability of treatment success at 1 year.

Conclusion:

After arthroscopic rotator cuff repair, patients with WORC scores ≥80 at 1 year have a 95% probability of successful treatment and likely do not benefit from continued follow-up visits. Furthermore, several risk factors were identified that may influence outcomes after rotator cuff repair, including workers’ compensation, location of tear, tear size, and hand dominance.

Clinical efficacy and safety of platelet-rich plasma in arthroscopic full-thickness rotator cuff repair: A meta-analysis

BACKGROUND

Arthroscopic repair of rotator cuff tears, although commonly performed, carries the risk of retears. Therefore, bioremediation techniques such as platelet-rich plasma injections have been used as adjuvant therapies. The clinical efficacy of platelet-rich plasma in the arthroscopic repair of full-thickness rotator cuff injury is controversial. We performed a meta-analysis to evaluate the clinical effectiveness and safety of platelet-rich plasma and provide evidence-based medical recommendations for selecting the proper clinical treatment plan for full-thickness rotator cuff injuries.

METHODS

A search for the terms "platelet-rich plasma" and "rotator cuff" was performed in the PubMed, EMBASE, and Cochrane Library databases using a computer. After conducting quality evaluations and data extraction, RevMan 5.3 software was used to combine the effect sizes, and the GRADEpro Guideline Development Tool was used to rate the level of evidence from aspects of functional score, pain score and retear rate.

RESULTS

Eight randomized controlled trials involving 566 patients were included. The long-term retear rate(RR = 0.96, 95% CI [0.52, 1.78], P = .89), Constant score(RR = 0.96, 95% CI [0.52, 1.78], P = .89), and Visual Analog Scale score for pain (SMD = -0.28, 95% CI [-0.60, 0.04], P = .08), as well as both the long-term and short-term Disabilities of the Arm, Shoulder, and Hand scores(SMD = -0.13, 95% CI [-0.44, 0.18], P = .41;SMD = -0.02, 95% CI [-0.40, 0.36], P = .93), were not significantly different between the platelet-rich plasma and control groups. However, the short-term retear rate(RR = 0.29, 95% CI [0.13, 0.65], P = .003) and Visual Analog Scale score (SMD = -0.41, 95% CI [-0.62, -0.19], P = .0002) were significantly lower, while the short-term Constant score(SMD = 0.37, 95% CI [0.19, 0.55], P < .0001) and short-term and long-term University of California at Los Angeles activity scores (SMD = 0.38, 95% CI [0.16, 0.60], P = .0008;SMD = 0.85, 95% CI [0.48, 1.22], P < .00001) were significantly higher, in the platelet-rich plasma group than in the control group.

CONCLUSION

Platelet-rich plasma injection can effectively improve the short-term outcomes following arthroscopic repair of full-thickness rotator cuff tears, thus reducing the rate of retears, alleviating pain, and improving patients' shoulder function. Specifically, the clinical outcomes are better with the use of platelet-rich plasma in single-row fixation than in other fixation techniques. Therefore, platelet-rich plasma injection can be recommended as an adjuvant therapy in single-row repair for improved short-term results.

A comparison of continuous interscalene block versus general anesthesia alone on the functional outcomes of the patients undergoing arthroscopic rotator cuff repair

PURPOSE

The aim of this prospective and randomized study was to compare the effects of general anesthesia to the combination of general anesthesia and continuous interscalene block on postoperative pain and functional outcomes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included a total of 85 patients aged 45-74 years, who were scheduled for elective arthroscopic rotator cuff repair. One group consists of patients who underwent only general anesthesia (GA, N = 43), and the other group consists of patients who underwent a combination of continuous interscalene brachial plexus block and general anesthesia (CISB + GA, N = 42). Pain levels of the patients were evaluated postoperatively by a visual analog scale. Shoulder function was evaluated preoperatively and postoperatively using the Constant score.

RESULTS

Patients in the CISB + GA group had lower postoperative visual analog scores and less additional analgesic needs during the early postoperative period than those in the GA group. Constant scores of the patients in the CISB + GA group at postoperative week 6 were higher than those in the GA group. Evaluation of the functional outcomes at 6 months postoperatively showed that there were no significant differences between the two groups.

CONCLUSION

Although CISB significantly improved postoperative pain control and early (in the first 6 weeks) functional outcomes following arthroscopic rotator cuff repair, there was no significant difference between the CISB group and CISB + GA group at 6 months.

LEVEL OF EVIDENCE

Level II, Randomized Controlled Trial, Treatment Study.

Group format rehabilitation is equally effective as individual therapy in patients with surgically repaired rotator cuff tears

OBJECTIVE

Does group physiotherapy methods produce different results when compared with individual physiotherapy in persons with surgically repaired rotator cuff tears? No studies to date have examined the feasibility or effectiveness of such therapy formats. Given the prevalence of rotator cuff tears, a study examining group format therapy is warranted and can produce evidence to transform care for rotator cuff tear rehabilitation.

METHODS

We analyzed the electronic medical records of persons that underwent rotator cuff repair surgery followed by the prescribedpost-surgical physiotherapy at Southlake Regional Health Centre. Both groups were provided standard physiotherapy intervention protocol for post-operative rotator cuff tear. Active range of motion (AROM), quick disabilities of the arm, shoulder and hand (Q-DASH) measures, and efficiency measures were examined for differences between groups.

RESULTS

No significant differences between AROM (abduction p = .92, lateral rotation p = .64, and flexion p = 1.00) and Q-DASH (p = .62) measures between groups were observed at discharge. Overall, group therapy participants required a greater number of visits (p = .000); however, when separated by age groups, only the 60- to 69-year-old participants significantly differed in number of visits between groups (p = .000), whereas no difference was observed in the 50- to 59-year-old participants (p = .14).

CONCLUSION

Group format physiotherapy may be equally effective as individual formats in improving AROM and functional outcomes of participants with surgically repaired rotator cuff tears. Further research is needed to determine the optimal age range for group therapy interventions in this population.

Post-operative non-steroidal anti-inflammatory drugs do not affect clinical outcomes of rotator cuff repair

Background

The administration of non-steroidal anti-inflammatory drugs (NSAIDs) to patients is thought to impair rotator cuff healing and clinical outcomes.

Methods

36 patients who underwent rotator cuff repair were divided into 3 groups based on their post-operative analgesia regimes.

Results

At 4.4 years postoperative, there was significant improvement in SST and UCLA scores (p < 0.001). There were no significant differences in post-operative clinical outcome scores between the groups (p > 0.05). Administration of NSAIDs and duration of their use did not influence outcomes of rotator cuff repair (p = 0.151).

Conclusion

NSAIDs has no significant influence on clinical outcomes of rotator cuff repair.

The operative treatment of shoulder pain in patients with a concurrent diagnosis of cervical spondylosis and shoulder dysfunction

Background

Etiology of neck and shoulder pain may be multifactorial. When surgical intervention is indicated, the choice of whether to start with spine or shoulder surgery is an important clinical decision to make based on severity of pathologies, comorbidities, and patient preference. The literature includes with very few studies exploring the incidence or results of the surgical treatment paths followed in this clinical situation. This study compares patient-reported outcomes of patients with both cervical spine and shoulder pathology who underwent intervention for cervical, shoulder, or both pathologies.

Methods

The authors retrospectively reviewed 154 charts at a single institution between 2009-2017 who had both cervical spine and shoulder pathology while undergoing operative intervention of one or both pathologies. For each patient, demographics, patient-perceived success, NRS pain scores, functional outcomes (Focus on Therapeutic Outcome scores and neck disability index scores), and post-operative opioid use were reported.

Results

Patient-reported success (P=0.85), NRS pain score decreases (P=0.45), all functional outcomes except for final external rotation range of motion (P=0.02), and post-operative opioid use (P=0.30) were similar when comparing only cervical spine to shoulder intervention. Success (P=1.00), NRS pain score decreases (P=0.37), both functional outcomes, and post-operative opioid use (P=0.08) were all similar when comparing patients who underwent cervical then shoulder intervention to shoulder then cervical intervention. Finally, statistical significance was found when comparing reported success (P=0.0004) but not NRS decreases (P=0.18), functional outcomes, or post-operative opioid use (P=0.43) in patients who underwent both operation types versus only one.

Conclusions

Similar outcomes are seen when comparing isolated surgical intervention types and order of surgeries when undergoing both interventions. Multiple surgical intervention types, regardless of order, tends to result in higher rates of patient-reported success but similar post-operative outcomes compared to one.

In vivo analysis of vascularization and biocompatibility of electrospun polycaprolactone fibre mats in the rat femur chamber

In orthopaedic medicine, connective tissues are often affected by traumatic or degenerative injuries, and surgical intervention is required. Rotator cuff tears are a common cause of shoulder pain and disability among adults. The development of graft materials for bridging the gap between tendon and bone after chronic rotator cuff tears is essentially required. The limiting factor for the clinical success of a tissue engineering construct is a fast and complete vascularization of the construct. Otherwise, immigrating cells are not able to survive for a longer period of time, resulting in the failure of the graft material. The femur chamber allows the observation of microhaemodynamic parameters inside implants located in close vicinity to the femur in repeated measurements in vivo. We compared a porous polymer patch (a commercially available porous polyurethane‐based scaffold from Biomerix™) with electrospun polycaprolactone (PCL) fibre mats and chitosan (CS)‐graft‐PCL modified electrospun PCL (CS‐g‐PCL) fibre mats in vivo. By means of intravital fluorescence microscopy, microhaemodynamic parameters were analysed repetitively over 20 days at intervals of 3 to 4 days. CS‐g‐PCL modified fibre mats showed a significantly increased vascularization at Day 10 compared with Day 6 and at Day 14 compared with the porous polymer patch and the unmodified PCL fibre mats at the same day. These results could be verified by histology. In conclusion, a clear improvement in terms of vascularization and biocompatibility is achieved by graft‐copolymer modification compared with the unmodified material.

Acute Cuff Tear Repair Trial (ACCURATE): protocol for a multicentre, randomised, placebo-controlled trial on the efficacy of arthroscopic rotator cuff repair

INTRODUCTION

Rotator cuff tear is a very common and disabling condition that can be related to acute trauma. Rotator cuff tear surgery is a well-established form of treatment in acute rotator cuff tears. Despite its widespread use and almost a gold standard position, the efficacy of an arthroscopic rotator cuff repair is still unknown. The objective of this trial is to investigate the difference in outcome between arthroscopic rotator cuff repair and inspection of the shoulder joint defined as placebo surgery in patients 45-70 years of age with an acute rotator tear related to trauma.

METHODS AND ANALYSIS

Acute Cuff Tear Repair Trial (ACCURATE) is a randomised, placebo-controlled, multicentre efficacy trial with sample size of 180 patients. Concealed allocation is done in 1:1 ratio. The randomisation is stratified according to participating hospital, gender and baseline Western Ontario Rotator Cuff Index (WORC). Both groups receive the same standardised postoperative treatment and physiotherapy. The primary outcome measure is the change in WORC score from baseline to 2-year follow-up. Secondary outcome measures include Constant-Murley Score, the Numerical Rating Scale for pain, subjective patient satisfaction and the health-related quality of life instrument 15 dimensions (15D). Patients and outcome assessors are blinded from the allocated intervention. The primary analysis of results will be conducted according to intention-to-treat analysis.

ETHICS AND DISSEMINATION

The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and Regional Ethics Committee in Linköping Sweden and Regional Committees for Medical and Health Research Ethics South East in Norway. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02885714; Pre-results.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

Background:

Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique.

Hypothesis:

Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

Results:

The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative).

Conclusion:

Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.

Inferior outcome of rotator cuff repair in chronic hemodialytic patients

BACKGROUND

Repair of rotator cuff tears has yielded excellent functional outcomes in recent decades; however, poor outcomes and dissatisfaction have been noted in specific groups. Spontaneous tendon rupture has been reported in patients receiving long-term hemodialysis owing to alteration of tendon structure, which might impede functional recovery after rotator cuff repair. The purpose of the present study was to compare the clinical outcomes between hemodialysis and non-hemodialysis patients after rotator cuff repair.

METHODS

We retrospectively reviewed patients who underwent mini-open rotator cuff repair from Jan 2013 to Jan 2017. A total of 14 patients under chronic hemodialysis (HD) were matched to non-hemodialysis (NHD) patients at a 1:2 ratio according to age, gender, tear size, severity of fatty infiltration and history of diabetes. Pre- and post-operative functional outcome was assessed using the simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES), Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and visual analog scale (VAS) scores. Clinical functional outcome at the last follow-up was adopted for comparison of the HD and NHD groups.

RESULTS

A total of 42 patients were enrolled in this comparative study, with a mean age of 66.64 ± 1.68 years in the HD group and 65.71 ± 5.40 years in the NHD group. At the final clinical assessment, the post-operative functional outcome was significantly improved in both groups (p < 0.001). However, the functional outcome of the HD group was significantly inferior to that of the NHD group in terms of the SST score (6.50 ± 2.24 vs 9.39 ± 1.87, p < 0.001), ASES score (63.17 ± 15.93 vs 86.96 ± 11.43, p < 0.001), UCLA score (20.14 ± 7.71 vs 29.82 ± 5.08, p < 0.001) and VAS score (3.00 ± 0.96 vs 1.21 ± 1.03, p < 0.001).

CONCLUSION

The improvement of pain and functional improvement of long-term hemodialysis patients were inferior to those of patients without hemodialysis after mini-open rotator cuff repair.

Do we really allow patient decision-making in rotator cuff surgery? A prospective randomized study

BACKGROUND

There is a growing patient interest in being involved in the decision-making process. However, little information is provided on how this information should be structured. Does it make a difference, in patient treatment decision-making, whether information is given based on the benefits or on the side effects in rotator cuff disorders?

METHODS

It is a prospective randomized study that includes patients diagnosed with rotator cuff tears. Patients were randomly allocated to either group A (benefit-inform) or group B (side effect-inform) and were asked to answer the following questions based on their assigned group: Group A: Your doctor informs you that you have a rotator cuff tear and states that if he/she surgically repairs your cuff tear you will improve and that the cuff remains healed at the 2-year follow-up in 71% of the cases where surgery is done. Would you choose surgery? Yes or No Group B: Your doctor informs you that you have a rotator cuff tear and that if he/she surgically repairs your cuff tear you will improve and that the cuff is torn again at 2-year follow-up in 29% of the cases where surgery is done. Would you choose surgery? Yes or No Age, gender, the shoulder affected and the functional status assessed through the Constant score were also recorded.

RESULTS

80 patients were randomized (43 to group A and 37 to group B). The patients assigned to group A (benefit) accepted surgery significantly more frequently than those assigned to group B (complication) (P = 0.000). In group A, 36 of 43 (84%) accepted surgery, compared to 17 of 37 (46%) in group B.

CONCLUSIONS

The way that information on rotator cuff disorders is provided strongly influences patients' treatment decisions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03205852 . Registered 29 June 2017. Retrospectively registered.

Clinical and Radiographic Outcomes After Arthroscopic Lamina-Specific Double-Row Repair of Large Delaminated Rotator Cuff Tears in Active Patients

Background:

The presence of delamination and a larger rotator cuff tear (RCT) size have been associated with poorer outcomes in rotator cuff repair. Therefore, we developed a new surgical procedure, arthroscopic lamina-specific double-row fixation (ALSDR), for the repair of large delaminated RCTs.

Purpose:

To investigate the clinical outcomes, magnetic resonance imaging findings, and satisfaction with several variables after ALSDR for large delaminated RCTs.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 30 active patients (mean age, 59.1 years) undergoing ALSDR were assessed by a numeric rating scale (NRS; 0-10) for pain, surgery, work, and exercise as well as American Shoulder and Elbow Surgeons (ASES), Constant, and Simple Shoulder Test (SST) scores at a mean of 65.9 months postoperatively. Rotator cuff integrity was determined by magnetic resonance imaging. The Spearman correlation coefficient (ρ) was used to determine the correlation between clinical and NRS scores.

Results:

Five patients (16.7%) had a retear. Each of the postoperative functional and NRS scores except the NRS work score was significantly better in the healed shoulders than in the shoulders with a retear (P < .001). The NRS pain score showed a significant negative correlation with ASES, Constant, and SST scores (ρ = −0.775, −0.668, and −0.742, respectively; P < .001 for all). The NRS surgery score had a positive correlation with Constant and SST scores (ρ = 0.393 [P = .032] and ρ = 0.456 [P = .011], respectively). The NRS work score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.382 [P = .037], ρ = 0.386 [P = .035], and ρ = 0.414 [P = .023], respectively). The NRS exercise score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.567 [P = .001], ρ = 0.511 [P = .004], and ρ = 0.639 [P < .001], respectively).

Conclusion:

Our results showed that there was a significant correlation between clinical and NRS scores. The results indicate that ALSDR can provide a high degree of functionality and can be a useful alternative treatment for active patients with large delaminated RCTs.

Greater tuberosity angle and critical shoulder angle according to the delamination patterns of rotator cuff tear

The purpose was to evaluate the relationship between GTA, CSA, and the delamination patterns of RCTs. This study included 315 patients with RCTs from 2014 to 2018, retrospectively. The subjects were divided into 5 groups: Group A, control group; Group B, non-delaminated tear; Group C, delaminated tear with equally retraction of articular and bursal layer; Group D, articular layer more retracted delaminated tear, and Group E, bursal layer more retracted delaminated tear. In conclusion, large GTA and CSA were associated with rotator cuff tears. However, there was no difference of GTA and CSA according to the delamination patterns.

Are we getting any better? A study on repair integrity in 1600 consecutive arthroscopic rotator cuff repairs

Background

Postoperative retear is the most common surgical complication after rotator cuff repair. This study aimed to determine whether there had been any improvements in rotator cuff repair integrity in our center and to identify any changes in the management of rotator cuff tears that may have impacted postoperative retear rate.

Methods

This retrospective observational single cohort study used running average analysis to examine 1600 consecutive patients over 8 years, who underwent primary arthroscopic rotator cuff repair by a single surgeon, and had cuff integrity assessed by ultrasound 6 months after operation.

Results

Retear rates ranged from 3% to 34%, with a mean of 15%. Over our study retear rates decreased from 18% to 5%. Reductions in retear rates were associated with less aggressive rehabilitation, postoperative abduction sling use, and increased surgical experience. Increases in retear rates were associated with increased false positives with a more sensitive ultrasound machine and learning curves with new equipment for a surgeon and sonographer.

Conclusion

A decrease in retear rate after arthroscopic rotator cuff repair occurred during our study. Although the study design prevents us from directly attributing changes in retear rate to changes in management, our results suggest that rehabilitation optimization and increased surgeon experience decrease postoperative retear.

EFFECT OF SUBSCAPULARIS TEARS ON FUNCTIONAL SCORES OF PATIENTS UNDERGOING ROTATOR CUFF REPAIR

OBJECTIVE

To evaluate the influence of partial- and full-thickness upper third subscapularis tendon tears on the functional scores of patients undergoing arthroscopic rotator cuff repair.

METHODS

Patients who underwent arthroscopic rotator cuff repair were divided into three groups according to the subscapularis tendon condition: intact, partial-thickness tear, or full-thickness upper third tear. Functional scores were compared among groups. Second, the influence of biceps and infraspinatus tears on the scores was tested using multivariate regression analysis.

RESULTS

We evaluated 307 shoulders in 297 patients. Full-thickness upper third subscapularis tears presented significantly worse scores than intact tendons. Partial-thickness tears had scores that did not differ significantly from those of the other groups. Patients with full-thickness upper third tears presented a greater rate of injured and unstable biceps tendons. The multivariate analysis showed that biceps and infraspinatus tendon tears did not influence the scores or the intergroup comparison.

CONCLUSION

Full-thickness upper third subscapularis tendon tears presented worse functional scores than intact subscapularis tendons among patients undergoing posterosuperior rotator cuff repair. Patients with full-thickness subscapularis tears were more likely to suffer biceps tears, but this fact did not influence functional scores. Level of Evidence I; Clinical randomized trial.

Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

Degenerative rotator cuff tears are the most common cause of shoulder pain and have a strong association with advanced aging. Considerable variation exists in surgeons' perceptions on the recommended treatment of patients with painful rotator cuff tears. Natural history studies have better outlined the risks of tear enlargement, progression of muscle degeneration, and decline in the function over time. This information combined with the known factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes can be used to better refine appropriate surgical indications. Although conservative treatment can be successful in the management of many of these tears, risks to nonsurgical treatment also exist. The application of natural history data can stratify atraumatic degenerative tears according to the risk of nonsurgical treatment and better identify tears where early surgical intervention should be considered.

Structural integrity of rotator cuff at 16 years following repair: good long-term outcomes despite recurrent tears

BACKGROUND

There are few studies reporting long-term rotator cuff integrity following repair. The present study reports a case series of surgically repaired supraspinatus tendons followed up with clinical outcomes and ultrasound imaging after an average of 16 years.

METHODS

The prospectively studied clinical outcomes at short-, medium- and long-term follow-up in 27 shoulders in 25 patients treated with arthroscopic subacromial decompression and mini-open rotator cuff repair have been reported previously. The functional outcomes scores recorded were the University of California Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) measures. These patients then underwent an ultrasound scan with respect to the long-term assessment of the shoulder and the integrity of the repair.

RESULTS

A recurrent tear was noted in 37% of patients at 16.25 years after surgery, of which 50% were small. Two patients required repeat surgery. Patients had a mean UCLA score of 30, an ASES score of 91.3 and a SST score of 9.5 with a 85% level of satisfaction with surgery. Patients with a recurrent tear had outcome scores equivalent to those with an intact cuff with no significant pain. No independent risk factors were identified as predictors for recurrent tear.

CONCLUSIONS

Patients showed sustained benefit and satisfaction at long-term follow-up despite a 37% recurrence of full-thickness supraspinatus tear.

Efficacy of bone marrow stimulation in arthroscopic repair of full thickness rotator cuff tears: a meta-analysis

Background

To conduct a meta-analysis to compare the curative effect of treating the full thickness tear of the rotator cuff using the arthroscopic bone marrow stimulation (BMS) technology and provide the evidence for its extensive clinical application.

Methods

A systematic literature search was conducted to evaluate the studies on comparison of the curative effect of routine surgery with or without BMS on rotator cuff tear in the major medical databases. The literature was screened according to the inclusion and exclusion standards, and the quality assessment was conducted, then Review Manager 5.3 software was used for meta-analysis.

Results

Eight articles were eligible for inclusion. There were no statistically significant differences between BMS and control groups for overall outcome scores (P > 0.05). Except the Constant score of BMS group was significantly higher than that of the control group at the third follow-up month (P = 0.007). However, the postoperative re-tear rate of the BMS group was significantly lower than that of the control group (P < 0.001). Furthermore, we made a subgroup analysis and found that the postoperative Constant and UCLA score had no significant differences among all groups (P > 0.05), and the re-tear rates of the BMS groups were lower than those of the control groups (P = 0.001, P = 0.0002).

Conclusions

BMS technology has no significant influence on the postoperative clinical result of patients. However, it can obviously promote the tendon-to-bone healing of the rotator cuff and decrease the re-tear rate, which provides evidence for the clinical treatment.

Enhancement of rotator cuff tendon-bone healing using bone marrow-stimulating technique along with hyaluronic acid

Objective

The purpose of this study was to investigate the effect of hyaluronic acid (HA) in the tendon–bone healing process after rotator cuff repair in a rabbit model.

Methods

In vitro, rat bone marrow stromal cells (rBMSCs) were cultured in media for cartilage-related and inflammation-related gene expression levels examination at 1.0 mg/mL of HA. In vivo, 48 New Zealand white rabbits underwent rotator cuff repair surgery, and they were randomly divided into three groups: (1) control group (n = 16), (2) microfracture (MF) group accepting MF treatment (n = 16) and (3) MF/HA group accepting MF with HA treatment (n = 16). Four rabbits from each group were sacrificed at 6 and 12 weeks postoperatively for histological evaluation and biomechanical testing.

Results

In vitro experiments reveal that HA significantly decreased inflammation-related mRNA expression (IL-1, TNFα) compared with the control group. At 6 weeks after surgery, there was no significant difference of load-to-failure between groups. At 12 weeks after surgery, the mean failure load of the MF/HA group was significantly higher than that of the control group (100.5 ± 10.1 N vs. 68.0 ± 6.2 N; p = 0.0115). The mean failure load of the MF group appeared higher than that of the control group, whereas there was no significant difference (p > 0.05). Histologically, more chondrocytes were clustered at the tendon–bone interface, and more extracellular matrixes were produced in the MF/HA group. The interface of the MF/HA group appeared similar with the normal tendon–bone interface.

Conclusion

HA may play a crucial role in the acceleration of tendon-to-bone healing which might be through inhibiting inflammation. Rotator cuff repair using MF along with HA led to better tendon–bone healing and a subsequent increase of biomechanical strength at the repair site.

The translational potential of this article

HA injection is very common for patients with rotator cuff disease because of its antiinflammatory action and adhesion prevention preoperatively. The HA injection during surgery provides an antiinflammatory effect during tendon–bone healing process and leads to better tendon–bone healing postoperatively.

Real-Time Monitoring of Ascorbic Acid-Mediated Reduction of Cytotoxic Effects of Analgesics and NSAIDs on Tenocytes Proliferation

Tendinopathy is a common painful musculoskeletal disorder treated by injection of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), which are believed to have cytotoxicity toward tenocytes. Ascorbic acid is an antioxidant that promotes collagen biosynthesis and prevents free radical formation. It is believed to protect tenocytes from oxidative stress. The optimal concentration of ascorbic acid, especially when used in conjunction with anesthetics and NSAIDs injection, to treat different stages of tendinopathies is unknown. Human tenocytes were isolated from a torn edge of the supraspinatus tendon of a 51-year-old male patient during arthroscopic repair. We monitored real-time changes in human tenocyte proliferation upon exposure to different concentrations of ascorbic acid, bupivacaine, and ketorolac tromethamine using the xCELLigence system. No significant changes in cell index were observed between the control group and tenocytes treated with the 3 concentrations of ascorbic acid. Tenocytes exposed to 0.5% bupivacaine and 30 or 15 mg/mL ketorolac tromethamine revealed significant reduction in tenocytes proliferation. Bupivacaine 0.5% with 250 μg/mL ascorbic acid and 15 mg/mL ketorolac tromethamine with 250 μg/mL ascorbic acid showed the least cytotoxicity against tenocytes. The optimal ascorbic acid concentration required to reduce the cytotoxic effects of bupivacaine and ketorolac tromethamine was demonstrated using this platform.

Patterns of tendon retraction in full-thickness rotator cuff tear: comparison of delaminated and nondelaminated tendons

OBJECTIVE

To analyze full-thickness rotator cuff tears, compare retraction patterns in delaminated and nondelaminated tendons, and correlate retraction distances with anteroposterior tear lengths.

MATERIALS AND METHODS

In 483 MR examinations reported as showing full-thickness cuff tear, two musculoskeletal radiologists independently characterized tendons as delaminated or nondelaminated. Tendon delamination was defined as either horizontal intra-substance splitting of bursal and articular layers by an intervening plane of fluid, or differential retraction of bursal and articular layers. In a subset of 144 shoulders with surgically proven full-thickness cuff tears (45 delaminated, 99 nondelaminated tendons), matched cohorts (n = 45) were further analyzed to compare tendon retraction distance, anteroposterior tear length and retraction ratios (retraction distance/anteroposterior length).

RESULTS

Delamination was present in 13% of 483 total tears, and 31% of 144 operated tears (p = 0.001). In nondelamination and delamination cohorts, mean anteroposterior tear length measured 30.0 and 31.5 mm respectively (p = 0.6). Although nondelaminated tendons showed mean retraction 31.5 mm, articular and bursal layers of delaminated tendons showed mean retractions 36.3 mm and 21 mm respectively (p < 0.0001). Anteroposterior tear length and retraction distance were significantly associated in all cuff tears (p < 0.0001). Retraction ratio for nondelaminated tendons (1.05) was significantly different from retraction ratios for articular (1.21) and bursal (0.70) layers of delaminated tendons (p < 0.0001).

CONCLUSION

In full-thickness rotator cuff tear, delaminated and nondelaminated tendons show significant differences in retraction distances, despite similarities in anteroposterior dimensions. Delaminated tendons are important to identify and report because they are more likely to fail conservative treatments and undergo operative repairs.

Clinical and Structural Outcomes after Arthroscopic Repair of Medium- to Massive-Sized Delaminated and Nondelaminated Rotator Cuff Tears

INTRODUCTION

Current evidence is controversial about the outcomes after the repair of the delaminated versus nondelaminated rotator cuff tears. The objective of this study was to evaluate the factors affecting delamination of the cuff and clinical and structural outcomes after en masse arthroscopic repair of delaminated versus nondelaminated cuff of varying sizes.

MATERIALS AND METHODS

A total of 233 patients with full-thickness posterosuperior cuff tears were divided in two groups: Group 1: Delaminated tears (n = 131) and Group 2: Nondelaminated tears (n = 102) of medium, large, and massive sizes. Both groups were evaluated by clinical scores (Constant-Murley [CM], American shoulder and elbow score [ASES]) and ultrasonography (USG), at a minimum followup of 2 years.

RESULTS

The mean followup was 45.47 months. There was a weak but statistically significant linear correlation (P = 0.02) between the increasing size of tear and delamination, whereas increasing age and duration of symptoms did not correlate with increasing tendency of delamination. Final followup USG analysis revealed that there was no significant difference (P = 0.55) between healing rates of Group 1 and Group 2. Further taking various tear sizes into account, USG revealed no significant difference between the healing rates of two groups. The mean overall final postoperative CM and ASES scores of two groups did not show any significant difference (CM; P = 0.36, ASES; P = 0.4). However, the clinical outcome was significantly better in the completely healed group as compared to partially healed or retear group.

CONCLUSIONS

A weak linear correlation between delamination and increasing size of the tear was noted. Although overall structural and clinical outcome is no different between two groups, the clinical outcomes of completely healed tear are better than partially healed ones.

LEVEL OF EVIDENCE

Level III, Retrospective comparative.

Patch-augmented rotator cuff surgery (PARCS) study-protocol for a feasibility study

BACKGROUND

A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery and the use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Patches have been made using different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh). However, clinical evidence on their use is limited. The aim of the patch-augmented rotator cuff surgery (PARCS) feasibility study is to determine, using a mixed method approach, the design of a definitive randomised trial assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

METHODS

The objectives of this six-stage mixed methods feasibility study are to determine current practice, evidence and views about patch use; achieve consensus on the design of a randomised trial to evaluate patch-augmented rotator cuff surgery; and assess the acceptability and feasibility of the proposed design. The six stages will involve a systematic review of clinical evidence, two surveys of surgeons, focus groups and interviews with stakeholders, a Delphi study and a consensus meeting. The various stakeholders (including patients, surgeons, and representatives from industry, the NHS and regulatory bodies) will be involved across the six stages.

DISCUSSION

The PARCS feasibility study will inform the feasibility and acceptability of a randomised trial of the effectiveness and cost-effectiveness of a patch-augmented rotator cuff surgery. Consensus opinion on the basic design of a randomised trial will be sought.

TRIAL REGISTRATION

Not applicable.

Arthroscopic double-row rotator cuff repair: a comprehensive review of the literature

Rotator cuff repairs seek to achieve adequate tendon fixation and to secure the fixation during the process of biological healing. Currently, arthroscopic rotator cuff repair has become the gold standard. One of the earliest defined techniques is single-row repair but the inadequacy of single-row repair to precisely restore the anatomical footprint as well as the significant rates of retear especially in large tears have led surgeons to seek other techniques. Double-row repair techniques, which have been developed in response to these concerns, have various modifications like the number and placement of anchors and suture configurations.

When the literature is reviewed, it is possible to say that double-row repairs demonstrate superior biomechanical properties. In regard to retear rates, both double row and transosseous equivalent (TOE) techniques have also yielded more favorable outcomes compared to single-row repair. But the clinical results are conflicting and more studies have to be conducted. However, it is more probable that superior structural integrity will yield better structural and functional results in the long run. TOE repair technique is regarded as promising in terms of better biomechanics and healing since it provides better footprint contact. Knotless TOE structures are believed to reduce impingement on the medial side of tendons and thus aid in tendon nutrition; however, there are not enough studies about its effectiveness.

It is important to optimize the costs without endangering the treatment of the patients. We believe that the arthroscopic TOE repair technique will yield superior results in regard to both repair integrity and functionality, especially with tears larger than 3 cm. Although defining the pattern of the tear is one of the most important guiding steps when selecting the repair technique, the surgeon should not forget to evaluate every patient individually for tendon healing capacity and functional expectations.

Comparison of Clinical and Anatomical Outcomes between Delaminated Rotator Cuff Tear and Single Layer Rotator Cuff Tear

Background

Delaminated rotator cuff tear is known to be a degenerative tear having a negative prognostic effect. This study undertook to compare the anatomical and clinical outcomes of delaminated tears and single layer tears.

Methods

Totally, 175 patients with medium to large rotator cuff tears enrolled for the study were divided into 2 groups, based on the tear pathology: single layer tear (group 1) and delaminated tear (group 2). Preoperatively, length of the remnant tendon, muscle atrophy of supraspinatus (SS), and fatty degeneration of SS and infraspinatus (IS) muscles were assessed on magnetic resonance imaging (MRI). For follow-up, the repair integrity of the rotator cuff was evaluated by ultrasonography. Clinical outcomes were assessed by evaluating the Constant score (CS) and Korean Shoulder Score (KSS).

Results

Retears were detected in 6 cases of group 1 (6.5%) and 11 cases of group 2 (13.3%). Although higher in group 2, the retear rate was significantly not different (p=0.133). Preoperative MRI revealed length of remnant tendon to be 15.46 ± 3.60 mm and 14.17 ± 3.16 mm (p=0.013), and muscle atrophy of SS (occupation ratio) was 60.54 ± 13.15 and 56.55 ± 12.88 (p=0.045), in group 1 and group 2, respectively. Fatty degeneration of SS and IS in both groups had no significant differences. Postoperatively, no significant differences were observed for CS and KSS values between the groups.

Conclusions

Delaminated rotator cuff tears showed shorter remnant tendon length and higher muscle atrophy that correlate to a negative prognosis. These prognostic effects should be considered during delaminated rotator cuff tear treatment.

Arthroscopic treatment for intratendinous rotator cuff tear results in satisfactory clinical outcomes and structural integrity

PURPOSE

This study aimed to evaluate the clinical outcomes and structural integrity of arthroscopic repair of intratendinous rotator cuff tear.

METHODS

Patients who were diagnosed with an intratendinous tear but in whom conservative treatment failed were selected and underwent arthroscopic repair. Between 2008 and 2014, a total of 30 patients (6 men, 24 women; mean age, 59 ± 3.7 years) met the inclusion criteria and were followed up. The mean follow-up period was 26.3 ± 0.7 months. The results were evaluated using the University of California at Los Angeles (UCLA) score, the Society of the American Shoulder and Elbow Surgeons rating scale (ASES) questionnaire, and the visual analog scale (VAS) and range of motion (ROM) were measured preoperatively and at final follow-up. Magnetic resonance imaging (MRI) was performed preoperatively and at 6.7 ± 0.2 months postoperatively. Postoperative MRI was performed on 27 out of 30 patients and analysed using the Sugaya classification.

RESULTS

Corresponding to the preoperative MRI findings, arthroscopic findings of intratendinous tears were observed in all 30 patients. The mean active forward elevation ROM was 137.3° ± 15.4° before surgery and 168.8° ± 15.2° at the final follow-up. The internal and external rotations at abduction were 31.7° ± 5.1° and 63.0° ± 11.6° before surgery, respectively, and 60.5° ± 8.0° and 75.2° ± 10.8° after surgery, respectively. The UCLA score improved from of 20.1 ± 7.4 points preoperative to 28.4 ± 5.5 points at the final follow-up. The ASES score improved from 55.7 ± 15.3 points preoperative to 82.6 ± 9.7 points postoperatively. The VAS for pain score decreased from 6.4 ± 1.2 points preoperative to 1.6 ± 0.9 points postoperative. Satisfactory outcomes (excellent/good) in terms of UCLA and ASES scores were observed in 29 of 30 patients. Based on Sugaya classification, grades I, II, and III structural integrities were observed in 9, 14, and 4 patients, respectively.

CONCLUSIONS

Successful clinical outcomes and structural integrity can be achieved with arthroscopic repair of intratendinous rotator cuff tears involving more than half thickness (> 50%). Therefore, arthroscopic repair is a practical next treatment option for patients with intratendinous rotator cuff tears in whom conservative treatment fails.

LEVEL OF EVIDENCE

IV.

The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff

Background

Platelet rich plasma (PRP) is widely used in rotator cuff repairs but its effect on the healing process is unclear. Several cell culture studies on the effect of allogenic PRP have reported promising results but are not transferable to clinical practice.

The aim of the present study is to assess the possible effect of autologous PRP on rotator cuff tendon cells. The amount of growth factors involved with tendon-bone healing (PDGF-AB, IGF-1, TGF-β1, BMP-7 and -12) is quantified.

Methods

Rotator cuff tissue samples were obtained from (n = 24) patients grouped by age (>/< 65 years) and sex into four groups and cells were isolated and characterized. Later, autologous PRP preparations were obtained and the effect was analyzed by means of cell proliferation, collagen I synthesis and expression of collagen I and III. Furthermore, the PRPs were quantified for growth factor content by means of platelet-derived growth factor (PDGF-AB), insulin-like growth factor (IGF-1), transforming growth factor (TGF-β1), as well as bone morphogenetic protein (BMP) -7 and − 12.

Results

Cell proliferation and absolute synthesis of collagen I were positively affected by PRP exposure compared to controls (p < 0.05), but expression and relative synthesis of collagen I (normalized to cell proliferation) were significantly reduced.

PRP contained high amounts of IGF-1 and lower levels of TGF-β1 and PDGF-AB. The amounts of BMP-7 and -12 were below the detection limits.

Conclusions

PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect on the human rotator cuff tenocytes of the same individual in vitro by means of cell proliferation and absolute, but not relative collagen I synthesis.

These results encourage further studies on clinical outcomes with more comparable standards in terms of preparation and application methods.

Level of evidence

Controlled laboratory study.

Arthroscopic Superior Capsular Reconstruction With a Minimally Invasive Harvested Fascia Lata Autograft Produces Good Clinical Results

Background:

Painful dysfunctional shoulders with irreparable rotator cuff tears (IRCTs) in active patients are a challenge. Arthroscopic superior capsular reconstruction (ASCR) is a new treatment option originally described using a fascia lata autograft harvested through an open approach. However, concerns about donor site morbidity have discouraged surgeons from using this type of graft.

Hypothesis:

ASCR using a minimally invasive harvested fascia lata autograft produces good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

From 2015 to 2016, a total of 22 consecutive patients (mean age, 64.8 ± 8.6 years) with chronic IRCTs (Hamada grade 1-2; Goutallier cumulative grade ≥3; Patte stage 1: 2 patients; Patte stage 2: 6 patients; Patte stage 3: 14 patients) underwent ASCR using a minimally invasive harvested fascia lata autograft. All patients completed preoperative and 6-month evaluations consisting of the Simple Shoulder Test (SST), subjective shoulder value (SSV), Constant score (CS), range of motion (ROM), acromiohumeral interval (AHI), and magnetic resonance imaging. Twenty-one patients completed the 2-year shoulder and donor site morbidity assessments.

Results:

The mean active ROMs improved significantly (P < .001): elevation, from 74.8° ± 55.5° to 104.5° ± 41.9° (6 months) and 143.8° ± 31.7° (2 years); abduction, from 53.2° ± 43.3° to 86.6° ± 32.9° (6 months) and 120.7° ± 37.7° (2 years); external rotation, from 13.2° ± 18.4° to 27.0° ± 16.1° (6 months) and 35.6° ± 17.3° (2 years); and internal rotation, from 1.2 ± 1.5 points to 2.6 ± 1.5 points (6 months) and 3.8 ± 1.2 points (2 years). The mean functional shoulder scores improved significantly (P < .001): SST, from 2.1 ± 2.9 to 6.8 ± 3.5 (6 months) and 8.6 ± 3.5 (2 years); SSV, from 33.0% ± 17.4% to 55.7% ± 25.6% (6 months) and 70.0% ± 23.0% (2 years); CS, from 17.5 ± 13.4 to 42.5 ± 14.9 (6 months) and 64.9 ± 18.0 (2 years). The mean shoulder abduction strength improved significantly (P < .001) from 0.0 to 1.1 ± 1.4 kg (6 months) and 2.8 ± 2.6 kg (2 years). The mean AHI improved from 6.4 ± 3.3 mm to 8.0 ± 2.5 mm (6 months) and decreased to 7.1 ± 2.5 mm (2 years). This 0.7 ± 1.5–mm overall decrease was statistically significant (P = .042). At 6 months, 20 of 22 patients (90.9%) had no graft tears. At 2 years, 12 of 21 patients (57.1%) were bothered by their harvested thigh, 16 (76.2%) noticed donor site changes, 16 (76.2%) considered that the shoulder surgery’s end result compensated for the thigh’s changes, and 18 (85.7%) would undergo the same surgery again.

Conclusion:

ASCR using a minimally invasive harvested fascia lata autograft produced good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.

Systematic review of the surgical management of rotator cuff repair with an augmentative patch: a feasibility study protocol

BACKGROUND

Shoulder pain is a common problem in the general population and is responsible for prolonged periods of disability, loss of productivity, absence from work and inability to carry out household activities. Rotator cuff problems account for up to 70% of shoulder pain problems and are the third most prevalent musculoskeletal disorder after those occurring in the lower back and neck. Rotator cuff surgery has high failure rates (25-50% within 12 months), and as a result, there is a pressing need to improve the outcome of rotator cuff surgery. Patch augmented surgery for rotator cuff repairs has recently been developed and is increasingly being used within the UK National Health Service. Patch augmented surgery could lead to a dramatic improvement in patient and surgical outcomes, but its clinical and cost effectiveness needs rigorous evaluation. The existing evidence on the use of patches may be at risk of bias as currently only a small number of single-centre comparative studies appear to have been carried out. Additionally, it is unclear for which patches a clinical study (comparative and non-comparative) has been conducted. This paper outlines the protocol for a systematic review intended to summarise the best available clinical evidence and will indicate what further research is required.

METHODS

Electronic databases (Medline, Embase and Cochrane) will be systematically searched between April 2006 and the present day for relevant publications using a specified search strategy, which can be adapted for the use in multiple electronic databases, and inclusion criteria. Screening of both titles and abstracts will be done by two independent reviewers with any discrepancies resolved by a third independent reviewer. Data extraction will include information regarding the type of participants, type of intervention and outcomes including but not limited to shoulder-specific function and pain scores, patch-related adverse events and type of study. The results will be summarised in a narrative review where qualitative analysis is not possible.

DISCUSSION

This review aims to collate the current evidence base regarding the use of patches to augment rotator cuff repair. The results of this review will help to develop, using consensus methods, the design of a definitive randomised trial assessing the clinical and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and is feasible.

SYSTEMATIC REVIEW REGISTRATION

CRD42017057908.

Altmetric Versus Bibliometric Perspective Regarding Publication Impact and Force

BACKGROUND

Bibliometric and Altmetric analyses highlight key publications, which have been considered to be the most influential in their field. The hypothesis was that highly cited articles would correlate positively with levels of evidence and Altmetric scores (AS) and rank.

METHODS

Surgery as a search term was entered into Thomson Reuter's Web of Science database to identify all English-language full articles. The 100 most cited articles were analysed by topic, journal, author, year, institution, and AS.

RESULTS

By bibliometric criteria, eligible articles numbered 286,122 and the median (range) citation number was 574 (446-5746). The most cited article (Dindo et al.) classified surgical complications by severity score (5746 citations). Annals of Surgery published most articles and received most citations (26,457). The country and year with most publications were the USA (n = 50) and 1999 (n = 11). By Altmetric criteria, the article with the highest AS was by Bigelow et al. (AS = 53, hypothermia's role in cardiac surgery); Annals of Surgery published most articles, and the country and year with most publications were USA (n = 4) and 2007 (n = 3). Level-1-evidence articles numbered 13, but no correlation was found between evidence level and citation number (SCC 0.094, p = 0.352) or AS (SCC = 0.149, p = 0.244). Median AS was 0 (0-53), and in articles published after the year 2000, AS was associated with citation number (r = 0.461, p = 0.001) and citation rate index (r = 0.455, p = 0.002). AS was not associated with journal impact factor (r = 0.160, p = 0.118).

CONCLUSION

Bibliometric and Altmetric analyses provide important but different perspectives regarding article impact, which are unrelated to evidence level.

Healing Rates and Functional Outcomes After Triple-Loaded Single-Row Versus Transosseous-Equivalent Double-Row Rotator Cuff Tendon Repair

Background:

Although healing rates and outcomes of arthroscopic single-row rotator cuff repairs have been compared with double-row repairs, none have utilized triple-loaded anchors.

Purpose:

To compare healing and function after single-row repairs with triple-loaded anchors versus double-row repairs with a suture-bridge technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A single surgeon performed arthroscopic rotator cuff repair on 47 consecutive patients with an easily reducible full-thickness rotator cuff tear of medium size (1-3 cm). A retrospective cohort study was performed in which the first 25 patients underwent repair with a double-row suture-bridge (DRSB) technique. The next 22 patients underwent repair with a single-row technique with triple-loaded anchors and simple stitches (SRTL) after a change in technique by the surgeon. Twenty-one DRSB and 18 SRTL repairs were evaluated preoperatively and at a minimum of 12 months postoperatively with a visual analog scale for pain, the American Shoulder and Elbow Surgeons form, and the Simple Shoulder Test. Healing was evaluated with magnetic resonance imaging at a minimum of 12 months.

Results:

When DRSB repairs were compared with SRTL repairs, there were no significant differences in patient age (61 vs 65 years), tear size (2.3 vs 2.1 in the sagittal plane; 2.0 vs 1.8 cm in the coronal plane), Goutallier fatty infiltration (supraspinatus grade: stage 0, 38%; stage 1, 38%; stage 2, 19%; stage 3, 5%; vs stage 0, 56%; stage 1, 39%; stage 2, 5%; stage 3, 0%), tendon healing (71% vs 78%), improvement in visual analog scale pain score (3.7 vs 3.2), or improvement in American Shoulder and Elbow Surgeons scores (34.6 vs 36.9), with P > .05 in all cases. SRTL repairs had significantly greater improvement in Simple Shoulder Test scores versus DRSB repairs (6.6 vs 4.5; P = .03).

Conclusion:

DRSB and SRTL repairs have similar improvements in pain and function with equivalent healing rates for arthroscopic repair of mobile full-thickness rotator cuff tears of medium size (1-3 cm).

Bone marrow-stimulating techniques in arthroscopic rotator cuff repair: a systematic review protocol

INTRODUCTION

Bone marrow-stimulating (BMS) techniques during arthroscopic rotator cuff repair surgery theoretically enhance the biological component for healing and hence improve tendon healing, but their efficacy remains unproven. The purpose of this review is to determine the effects and associated harms of BMS in arthroscopic rotator cuff repair surgery.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis of randomised-controlled trials (RCTs) and retrospective cohort studies (RCS) that compare outcomes following BMS use against no use of BMS during arthroscopic rotator cuff repair surgery. We will search the databases including the Cochrane Central Register of Controlled Trials, Medline and Embase, and clinical trial registries for relevant studies. We will include studies published from start of indexing until 23 August 2018. Two reviewers will independently assess the eligibility for studies. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will use the Cochrane Collaboration tool to assess the risk of bias of included RCTs, while we will use the Risk Of Bias In Non-randomised Studies - of Interventions tool to evaluate the risk of bias of RCS. We will perform a random-effects meta-analysis in calculating the pooled risk estimates when appropriate. We will assess the overall quality of the data for each individual outcome using the Grading of Recommendations, Assessments, Development and Evaluation approach. The primary outcomes are tendon healing rate, overall pain and shoulder functions. The secondary outcomes are the proportion of participants with adverse events related to interventions, the range of motion and the proportion of participants with return to previous activities.

ETHICS AND DISSEMINATION

We will report this review according to the guidance of the PRISMA statement. The results of this review will be disseminated through conference presentations and publications in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42018087161.

Partial-width injuries of the rat rotator cuff heal with fibrosis

PURPOSE

Identify the healing outcomes following a partial-width, full-thickness injury to the rotator cuff tendon-bone attachment and establish if the adult attachment can regenerate the morphology of the healthy attachment.

HYPOTHESIS

We hypothesized that a partial-width injury to the attachment would heal via fibrosis and bone remodeling, resulting in increased cellularity and extra-cellular matrix deposition, reduced bone volume (BV), osteoclast presence, and decreased collagen organization compared to shams.

MATERIALS AND METHODS

A partial-width injury was made using a biopsy punch at the center one-third of the rat infraspinatus attachment. Contralateral limbs underwent a sham operation. Rats were sacrificed at 3 and 8 weeks after injury for analyses. Analyses performed at each time point included cellularity (Hematoxylin & Eosin), ECM deposition (Masson's Trichrome), BV (micro-computed tomography; microCT), osteoclast activity (Tartrate Resistant Acid Phosphatase; TRAP), and collagen fibril organization (Picrosirius Red). Injured and sham shoulders were compared at both 3 and 8 weeks using paired, two-way ANOVAs with repeated measures (Sidak's correction for multiple comparisons).

RESULTS

Cellularity and ECM deposition increased at both 3 and 8 weeks compared to sham contralateral attachments. BV decreased and osteoclast presence increased at both 3 and 8 weeks compared to sham contralateral limbs. Collagen fibril organization was reduced at 3 weeks after injury compared to 3-week sham attachments.

CONCLUSIONS

These findings suggest that a partial-width injury to the rotator cuff attachment does not fully regenerate the native structure of the healthy attachment. The injury model healed via scar-like fibrosis and did not propagate into a full-width tear after 8 weeks of healing.

Biomechanical evaluation of an arthroscopic transosseous repair as a revision option for failed rotator cuff surgery

Background

The number of revision rotator cuff cases is increasing. The literature is lacking guidance or biomechanical evaluation for fixation strength in a revision case scenario. Therefore, the aim of the study was to provide biomechanical data investigating primary fixation strength of a transosseous technique after anchor pullout failure of a single row reconstruction. It was hypothesized that an arthroscopic transosseous repair system as a procedure for rotator cuff revisions is providing equivalent stability compared to a primary single row suture anchor fixation due to change of fixation site.

Methods

Eight matched pairs (n = 16) of fresh frozen human shoulders were tested. The paired specimen shoulders were randomly divided into two repair groups (A single row and B primary transosseous repair). The potted specimens were mounted onto the Servohydraulic test system. Both groups were tested under cyclic loading followed by load to failure testing. Suture anchor repair shoulders (group A) that were tested to failure underwent a revision transosseous repair and were subsequently tested again using the same setup and protocol (group C).

Results

The mean native footprint areas did not show a significant difference between groups. The reconstructed footprint area showed a significantly greater coverage in favor of the transosseous repair. Ultimate load to failure of reconstructions with the primary anchor fixation (344.73 N ± 63.19) and the primary transosseous device (375.36 N ± 70.27) was not significantly higher compared to the revision repair (332.19 N ± 119.01 p = 0.45, p = 0.53).

Conclusion

The tested transosseous anchor device is a suitable option to widely used suture anchors, providing equivalent fixation properties even in a revision case scenario.

Level of evidence

Basic Science Study, Biomechanics.

Characteristics of the patients with delaminated rotator cuff tear

Purpose: The purpose of this study was to analyze factors relating to delamination in full-thickness rotator cuff tears.

Methods: 126 patients with full-thickness rotator cuff tears treated by arthroscopic rotator cuff repair were the subjects of this study. There were 52 females and 74 males whose average age was 64.2 years. Fifty-three patients had history of trauma. The average duration of disorder was 29.5 weeks. Nineteen patients were diagnosed with diabetes. On types of the tears, small tear was observed in 59 patients, medium tear in 47 patients, large tear in 6 patients, and massive tear in 14 patients. The average size of tear was 1.98 cm. Delamination of the torn cuff was observed in 45 patients. Factors compared between the patients without delamination and those with delamination were as follows: gender and age of the patients, history of trauma, duration of disorder, diabetes, smoking, size and number of rotator cuff tears.

Results: The delamination rate of the smoking patients was significantly higher than non-smoking patients. The delamination rate of patients with more than two tendon tears was significantly higher than those with only one tendon tear. The average size of tear with delamination was significantly larger than that of tear without delamination. The other factors were not related to delamination.

Conclusions: This study suggests that smoking, size of tear and number of torn cuffs are associated with delamination. The progression of torn cuff, anatomical features and nicotine of smoking affect the causes of delaminated tear of rotator cuff.

Recurrent tears of the rotator cuff: Effect of repair technique and management options

Retears of the rotator cuff, following operative repair, is not an uncommon event. Various factors have been shown to influence recurrence including the technique of repair. Multiple techniques have been performed with varying results and complications. The repair technique significantly affects the rate and pattern of retears. Although risk of retears with double row and suture bridge techniques is relatively low, medial cuff failure is a potential complication which poses significant challenges when revision repair is undertaken. Modifications in surgical techniques in, both, double row and suture bridge repairs can help decrease the risk of medial cuff failure. Thorough analysis of retear rates and patterns reported, and their relation with the repair technique, provides new insights about the pathogenesis of rotator cuff retears, their future prevention and appropriate management.

Does structural integrity following rotator cuff repair affect functional outcomes and pain scores? A meta-analysis

BACKGROUND

To assess whether the integrity of rotator cuff repairs has an impact on functional outcomes, as well as pain scores, after surgery.

METHODS

Systematic review and meta-analyses performed for Level Ι, ΙΙ and ΙΙΙ studies that presented functional outcome scores and radiological assessment of integrity following rotator cuff repair. Extracted data included patient demographics, functional outcome scores [Constant Score, University of California at Los Angeles (UCLA) shoulder score, American Shoulder and Elbow Surgeons (ASES) shoulder score, visual analogue scale (VAS) Pain score], as well as assessment of repair integrity on radiological investigations. A meta-analysis was performed using weighted means and a random effects model.

RESULTS

Twelve studies were included in the final analysis. Average re-tear rate for the 800 included patients was 22% at a mean follow-up of 27.5 months after surgery. Patients with intact repairs had a significantly higher Constant Score (8.61 points, p < 0.00001), UCLA shoulder score (2.96 points, p < 0.0001) and ASES shoulder score (9.49 points, p < 0.0006). Patients with intact repairs also reported lower pain VAS Pain scores by 0.62 points (p < 0.0004).

CONCLUSIONS

Our results show better functional outcome and pain scores in patients with intact rotator cuffs at follow-up when compared to those that have re-torn. This difference is equivalent to the published Minimal Clinically Important Difference for the ASES but not Constant Scores. This review has also highlighted that shoulder strength in patients with intact cuff repairs is likely to be greater than in patients with a failed repair.

Bone marrow mesenchymal stem cells do not enhance intra-synovial tendon healing despite engraftment and homing to niches within the synovium

Background

Intra-synovial tendon injuries display poor healing, which often results in reduced functionality and pain. A lack of effective therapeutic options has led to experimental approaches to augment natural tendon repair with autologous mesenchymal stem cells (MSCs) although the effects of the intra-synovial environment on the distribution, engraftment and functionality of implanted MSCs is not known. This study utilised a novel sheep model which, although in an anatomically different location, more accurately mimics the mechanical and synovial environment of the human rotator cuff, to determine the effects of intra-synovial implantation of MSCs.

Methods

A lesion was made in the lateral border of the lateral branch of the ovine deep digital flexor tendon within the digital sheath and 2 weeks later 5 million autologous bone marrow MSCs were injected under ultrasound guidance into the digital sheath. Tendons were recovered post mortem at 1 day, and 1–2, 4, 12 and 24 weeks after MSC injection. For the 1-day and 1–2-week groups, MSCs labelled with fluorescent-conjugated magnetic iron-oxide nanoparticles (MIONs) were tracked with MRI, histology and flow cytometry. The 4, 12 and 24-week groups were implanted with non-labelled cells and compared with saline-injected controls for healing.

Results

The MSCs displayed no reduced viability in vitro to an uptake of 20.0 ± 4.6 pg MIONs per cell, which was detectable by MRI at minimal density of ~ 3 × 10⁴ cells. Treated limbs indicated cellular distribution throughout the tendon synovial sheath but restricted to the synovial tissues, with no MSCs detected in the tendon or surgical lesion.

The lesion was associated with negligible morbidity with minimal inflammation post surgery. Evaluation of both treated and control lesions showed no evidence of healing of the lesion at 4, 12 and 24 weeks on gross and histological examination.

Conclusions

Unlike other laboratory animal models of tendon injury, this novel model mimics the failed tendon healing seen clinically intra-synovially. Importantly, however, implanted stem cells exhibited homing to synovium niches where they survived for at least 14 days. This phenomenon could be utilised in the development of novel physical or biological approaches to enhance localisation of cells in augmenting intra-synovial tendon repair.

Complications of the Fingers and Hand After Arthroscopic Rotator Cuff Repair

Background

Complications of the fingers and hand that occur after Arthroscopic Rotator Cuff Repair (ARCR) have not been examined in detail.

Objective

The aim of our study was to evaluate the diagnosis and treatment of complications of the fingers and hand that occur after ARCR and to examine treatment outcomes.

Methods

The case records of 40 patients (41 shoulders) who underwent ARCR using suture anchors were retrospectively reviewed to investigate complications of the fingers and hand after ARCR.

Results

Twelve patients (29%) experienced numbness, pain, edema, and movement limitations of the fingers and hand. These symptoms occurred on average 1.1 months (range, 0.1-2.5 months) after ARCR. The diagnoses were cubital tunnel syndrome in 2 hands, carpal tunnel syndrome in 3 hands, and flexor tenosynovitis (TS) in 10 hands. None of the 10 hands with TS exhibited triggering of the fingers. The mean interval between treatment initiation and symptom resolution was 2.2 months for the 5 hands treated by corticosteroid injection or surgery and 5.9 months for the 7 hands treated by alternating warm and cold baths alone. None of the hands exhibited Complex Regional Pain Syndrome (CRPS).

Conclusion

Complications of the fingers and hand after ARCR were observed in 29%. TS was the most frequent complication. When symptoms in the fingers and hand occur after ARCR, rather than immediately suspecting CRPS, TS should be primarily suspected, including when TS symptoms such as triggering are not present, and these patients should be treated proactively using corticosteroid injections or surgery.

Supraspinatus tendon repair using anchors: a biomechanical evaluation in the rabbit

Background

Arthroscopic rotator cuff repairs are mostly secured with suture anchors and often supplemented by footprint decortication. The objectives of this study were to characterize the strength of bone–tendon healing following anchor repair and assess the effect of channeling the supraspinatus (SSP) humeral footprint 1 week ahead of reattachment surgery.

Methods

One hundred twelve rabbits underwent unilateral detachment of one SSP tendon and were randomly assigned to two groups: channeling the footprint at time of detachment and no channeling. One week later, reattachment was performed using an anchor. The repaired and contralateral shoulders were harvested at 0, 1, 2, or 4 weeks after repair and mechanically tested to failure. Outcome measures included load at failure, stiffness, and site of failure.

Results

Anchor fixation had a mean load at failure of 81 ± 32 N and a stiffness of 27 ± 9 N/mm immediately after repair compared to 166 ± 47 N and 66 ± 13 N/mm in the contralateral (both p < 0.05). Mechanical recovery of the reattached SSP tendon was achieved after 4 weeks (221 ± 73 N, 206 ± 59 N, and 198 ± 49 N in the channeling, no channeling, and contralateral groups, respectively, p > 0.05). The dominant site of failure shifted from the footprint at 0/1 week to bone avulsion/mid-substance tear at 4 weeks (p < 0.05). There were no differences in outcomes between the channeling and no channeling groups.

Conclusions

This study is the first of its kind to provide quantitative data on the mechanical properties of the enthesis following anchor repair in a rabbit model. Anchor repair led to rapid and complete restoration of SSP mechanical properties. Further evidence is needed before recommending channeling ahead of repair surgery.

Clinical outcomes and structural integrity of arthroscopic double-row versus suture-bridge repair for rotator cuff tears

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.

Location and thickness of delaminated rotator cuff tears: cross-sectional analysis with surgery record review

Background

To facilitate better treatment, we analyzed morphologic features of delamination from the viewpoint of the location of delamination and the thickness of each layer.

Materials and Methods

Of 270 shoulders that consecutively underwent arthroscopic rotator cuff repair, 210 were included. During the operation, the surgeon assessed the size of the rotator cuff tear, determined the presence and location of delamination, and compared the thickness between superficial and deep layers if delamination was present. Immediately after the operation, the surgeon wrote down the data in the record form. The authors retrospectively referred to these surgical records to investigate those items.

Results

Delamination was found in 111 of 210 shoulders. The overall preoperative Constant score did not significantly differ between the 2 groups. In terms of the location, 7.2% cases had delamination in the anterior part, 74.8% in the posterior part, and 18.0% in both parts (Fleiss κ = 0.9). The larger the rotator cuff tear, the more frequently the delamination was limited to the posterior part (trend P = .001). As for layer thickness comparison, 40.0% of the shoulders with small tears, 38.8% with medium tears, 66.0% with large tears, and 80.0% with massive tears had a thicker deep layer than superficial layer (Fleiss κ = 0.9). The larger the size of the rotator cuff tear, the more frequently the deep layer was thicker than the superficial layer (trend P = .001).

Conclusions

The larger the rotator cuff tear, the more carefully shoulder surgeons should observe and treat the posterior and deep part of delamination.

Massive Rotator Cuff Tear: When to Consider Reverse Shoulder Arthroplasty

PURPOSE OF REVIEW

The purpose of this review is to discuss the indications for reverse shoulder arthroplasty (RSA) in the treatment of massive rotator cuff tear (MCT), review the reported outcomes in the literature, and outline our approach and surgical technique for treating these patients.

RECENT FINDINGS

While RSA remains a successful and well-accepted treatment for cuff tear arthropathy (CTA), management of MCT in the absence of arthritis is controversial. In this particular setting, patients best suited for RSA are elderly, lower-demand individuals with chronic, irreparable MCT, and pseudoparalysis. Age < 60, better pre-operative function and upper extremity neurologic dysfunction are potential risk factors for poor outcome with RSA in this population. Long-term follow-up studies of RSA for CTA and MCT show good functional outcomes and implant survival > 90% at 10 years. Treatment of MCT must be individualized for each patient. When patient selection is optimized, RSA is a reliable means of relieving pain and improving function with excellent success. Further investigation is necessary to better define its indications and assess the role of alternative, joint-salvaging procedures.

Preoperative Korean Shoulder Scoring System Correlates with Preoperative Factors of Rotator Cuff Tears

Background

The Korean Shoulder Scoring System (KSS) is a reliable and valid procedure for discriminative assessment of the clinical status of patients with rotator cuff tears. This study evaluates the correlation between the preoperative KSS and factors in patients with rotator cuff tears.

Methods

From November 2009 to June 2016, 970 patients who underwent arthroscopic rotator cuff repair were retrospectively evaluated. A total of 490 patients met the study criteria. Preoperative factors included age, sex, symptom duration, mediolateral (ML) and anteroposterior (AP) tear size, acromiohumeral distance (AHD), tangent sign, tendon involvement (type I, supraspinatus; type II, supraspinatus and subscapularis; type III, supraspinatus and infraspinatus; type IV, all 3 tendons), fatty infiltration of rotator cuff muscles (group I, Goutallier stages 0 and 1; group II, Goutallier stages 2, 3, and 4), and KSS.

Results

Old age, ML tear size, and AP tear size negatively correlated with the preoperative KSS (p<0.001). AHD showed a positive correlation with the preoperative KSS (p<0.001). A significantly inferior preoperative KSS was found in females and type III tendon involvement (p<0.001). For supraspinatus and infraspinatus, the preoperative KSS of group II fatty infiltration showed a significantly lower score than group I fatty infiltration (p<0.05).

Conclusions

A relatively lower preoperative KSS was associated with old age, large tear size, narrow AHD, female, type III tendon involvement, and group II fatty infiltration of the supraspinatus and infraspinatus. Our study indicates that preoperative KSS can be a good measurement for the preoperative status of patients with rotator cuff tears.

Partial and Full-Thickness RCT: Modern Repair Techniques

PURPOSE OF REVIEW

The purpose of this article is to review the recent literature concerning modern repair techniques related to partial- and full-thickness rotator cuff tears.

RECENT FINDINGS

The understanding of rotator cuff pathology and healing continues to evolve, beginning with emerging descriptions of the anatomic footprint and natural history of rotator cuff tears. Significant controversy remains in treatment indications for partial-thickness rotator cuff lesions as well as optimal surgical repair techniques for both partial- and full-thickness tears. Techniques such as margin convergence and reduction of the so-called "comma" tissue have improved the ability to anatomically reduce large and retracted tears. Repair strength and contact pressures are improved with double-row repairs and transosseus-equivalent techniques compared to traditional single-row repairs. Future work is directed towards obtaining reliable radiographic healing and demonstrating clinical superiority and cost-effectiveness of a single technique. Much recent work regarding rotator cuff anatomy and pathology has been reported. Newer techniques improve repair strength. Despite these advances, significant questions remain concerning surgical indications and clinical outcomes.

The Effect of Rotator Cuff Repair on Natural History: A Systematic Review of Intermediate to Long-Term Outcomes

Background:

Rotator cuff disease can have a progressive natural history of increasing tear size and worsening function. It remains unknown whether rotator cuff repair alters this natural history.

Methods:

A systematic review of the intermediate to long-term (minimum 5-year) results of operative rotator cuff repair and no repair of rotator cuff injuries was performed to compare (1) patient-based outcomes, (2) future surgical intervention, (3) future tear progression or recurrence, and (4) tear size. The no-repair group included both conservative treatment and surgical treatment without repair. After the application of selection criteria, 29 studies with 1,583 patients remained. Meta-regression was conducted to adjust for baseline age, sex, tear size, and duration of follow-up.

Results:

Comparison of the repair and no-repair groups revealed no significant differences in terms of age (p = 0.36), sex (p = 0.88), study level of evidence (p = 0.86), or Coleman methodology score (p = 0.8). The duration of follow-up was significantly longer for the no-repair group (p = 0.004), whereas baseline tear size was significantly larger in the repair group (p = 0.014). The percentage of patients requiring additional surgery was significantly higher in the no-repair group after adjustment for age, sex, duration of follow-up, and tear size (9.5% higher in estimated means between groups [95% confidence interval, 2.1% to 17%]; p = 0.012). The likelihood of a recurrent defect (repair group) or extension of the prior tear (no-repair group) was not different between groups after adjustment for age, sex, duration of follow-up, and tear size (p = 0.4). There were no differences between the repair and no-repair groups in terms of the Constant score after adjustment for age, sex, duration of follow-up, and tear size (p = 0.31). The final tear size was significantly larger in the no-repair group than the repair group (967 mm² higher in estimated means between groups [95% confidence interval, 771 to 1,164 mm²]; p < 0.001).

Conclusions:

At intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased need for future surgery after adjusting for age, sex, duration of follow-up, and tear size. The likelihood of a recurrent defect after rotator cuff repair did not differ from that of tear extension after nonoperative treatment. Thus, rotator cuff repair may not alter natural history.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of rotator cuff malreduction on tendon tension: an evaluation of a custom-made digital tensiometer clamp

INTRODUCTION

Rotator cuff tears are common and good-to-excellent clinical outcome is reported after subsequent repair. However, the retear rate of rotator cuff repairs has been shown to be as high as 20%. The reasons for retear seem to be multifactorial, mainly comprised by mechanical and biological aspects. Regarding mechanical causes, the role of the tendon tension and malreduction is so far unknown. First, we hypothesized that the tendon tension depends on the technique of tendon reposition and that malreduction of the tendon results in an increased tendon tension. Second, we aimed to demonstrate the inter- and intraobserver reliability of a novel custom-made digital tensiometer clamp.

MATERIALS AND METHODS

A tendon defect of posterosuperior rotator cuff (reverse L-shaped) was simulated in seven cadaveric human shoulder specimens. By use of a custom-made tensiometer clamp, the supraspinatus tendon was reduced by pulling it in (1) an anterolateral direction (anatomical reduction) and (2) in a straight lateral direction (malreduction) until the footprint was completely covered. The reduction procedure was consecutively repeated to evaluate the inter- and intraobserver reliability.

RESULTS

The mean traction forces for anatomical reduction and malreduction were 16.02 N (SD 8.06) and 19.52 N (SD 9.95), respectively. The difference between the two groups was statistically significant (p = 0.028). The interobserver reliability showed a correlation of r = 0.757 [95% confidence interval (CI) 0.092-0.955]. The intraobserver reliability of the three surgeons was observed to be between r = 0.905 and 0.986.

CONCLUSIONS

The malreduction of the rotator cuff has a significant influence on the tendon tension and may therefore affect the healing rate of the tendon after the repair, so that a tension-balanced repair could improve the clinical results. Furthermore, the application of a novel custom-made tensiometer clamp showed good interobserver and excellent intraobserver reliabilities.

Enhancement of tendon‑bone healing following rotator cuff repair using hydroxyapatite with TGFβ1

The formation of fibrocartilage at the healing site following a rotator cuff tear repair is a major problem in the field of tendon-bone healing. The present study aimed to enhance the healing of the tendon-bone interface following rotator-cuff tear repair by the interposition of hydroxyapatite (HA) encapsulated with transforming growth factor β1 (TGFβ1). Using an acute rotator cuff repair model, rats were divided into three groups: i) Repair only (control); ii) HA group; and iii) HA-TGFβ1 group. Animals were sacrificed at 2, 4 and 8 weeks following surgery. Micro-computed tomography (CT), histomorphometric analyses and biomechanical tests were used to evaluate the supraspinatus tendon-bone complex. The micro-CT images revealed notable novel bone formation in the groups treated with HA-TGFβ1. The histomorphometric analyses demonstrated improved fibrocartilage formation and collagen organization at the tendon-bone interface. The HA-TGFβ1 combination significantly improved the area of fibrocartilage, particularly at early time points (2 and 4 weeks). There was a significantly greater load-to-failure force achieved in the HA and HA-TGFβ1 groups compared with the control group at 4 and 8 weeks. Augmentation of the ceramic powder with HA-TGFβ1 at the tendon-bone interface was demonstrated to strengthen the healing entheses, increase bone and fibrocartilage formation and improve collagen organization compared with surgical repair alone. Local application of HA-TGFβ1 demonstrates potential in improving tendon-bone healing following rotator cuff repair.

[Arthroscopic rotator cuff surgery : New and established methods]

This present article summarizes established and current developments and aspects of rotator cuff surgery. Achieved milestones as well as current approaches are presented and assessed with respect to their clinical and radiographic impact. Despite biomechanical and technical improvements in modern rotator cuff repair techniques, re-defect and re-tearing rates could not be fully eliminated. Meanwhile, the importance of biological processes around successful tendon-bone reintegration has been increasingly recognized. Hence, this article presents the current scientific standing regarding biological growth factors, platelet-rich plasma and rotator cuff augmentation techniques (with allogenic/autologous grafts). In summary, there are clear biomechanical advantages as well as many promising approaches to biological augmentation; however, the latter have not yet been transferred into regular clinical application.