What Influence Does Progression of a Nonhealing Rotator Cuff Tear Have on Shoulder Pain and Function?

Efficacy of an Autologous Dermal Fibroblast Injection in Reducing the Retear Rate After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial

BACKGROUND

Interest in biological augmentation for improving bone-tendon interface (BTI) healing after arthroscopic rotator cuff repair (ARCR) is growing. Dermal fibroblasts, known for collagen synthesis similar to tenocytes, have shown effectiveness in BTI healing in chronic rotator cuff tear (RCT) models in rabbits. However, no human clinical trials have been conducted.

PURPOSE

To evaluate the clinical efficacy of autologous dermal fibroblasts (ADFs) for BTI healing after ARCR in patients with full-thickness RCTs >2 cm.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 86 patients were prospectively enrolled and randomized into 2 groups: an additional ADF injection between the bone and tendon during ARCR (ADF group) or ARCR alone (control group). A skin biopsy from the buttock was performed to obtain ADFs, which were cultured for approximately 4 weeks before surgery. ARCR was standardized to the double-row suture bridge technique to reduce the heterogeneity in different repair methods. The primary variable for evaluating ADF efficacy was the retear rate using magnetic resonance imaging at 6 months postoperatively. Secondary variables included range of motion, the American Shoulder and Elbow Surgeons score, the Constant score, and the Simple Shoulder Test score at baseline and at 6 and 12 months postoperatively.

RESULTS

Overall, 13 patients dropped out because of a subscapularis tendon tear, loss to follow-up, or the withdrawal of consent (7 in the ADF group and 6 in the control group). The retear rate was significantly lower in the ADF group (5.6% [2/36]) than in the control group (24.3% [9/37]) (P = .025). The American Shoulder and Elbow Surgeons, Constant, and Simple Shoulder Test scores showed significant improvement after surgery in both groups (all P values <.001). Functional scores and range of motion did not significantly differ between the 2 groups at 6 and 12 months (all P values >.05).

CONCLUSION

ADF application into the BTI during ARCR significantly decreased the retear rate in patients with full-thickness RCTs >2 cm. Therefore, an ADF injection could be a promising biological supplement to enhance BTI healing in these patients. However, clinical outcomes showed no significant difference between the 2 groups at 6 months and 1 year postoperatively.

Editorial Commentary: Partial Rotator Cuff Repair and Deltoid Retraining Shows Positive Outcomes for Large to Massive Rotator Cuff Tear

In terms of rotator cuff repair, there is a goal for complete repair and healing, as rotator cuff integrity correlates with clinical and functional results. Retear has been shown to have a significant influence on progression toward osteoarthritis, and patients with an intact supraspinatus show superior abduction and flexion strength. However, in cases where complete repair may not be possible and/or cost limitations may prohibit augmentation, partial repair can provide a respectable outcome. Furthermore, regardless of healing status, partial repair may provide satisfactory relief for patients to still achieve the minimally clinically important difference threshold based on patient-reported outcomes. As introduced by Burkhart, repairing the tear margin and the transverse force couple (subscapularis and/or infraspinatus tears, if present) establishes a "suspension bridge" mechanism for force transmission, effectively creating a "functional cuff tear" by minimizing the defect size and allowing for a balanced shoulder joint with a stable fulcrum. A deltoid retraining program following a partial rotator cuff repair can restore range of motion and strength to the shoulder as alternative muscle activation (latissimus dorsi and teres major) in unison with the deltoid can compensate for the partial tear to limit superior migration of the humeral head and generate a stable glenohumeral fulcrum in cases of large to massive rotator cuff tears. Ultimately, as the rates of shoulder arthroplasty increase in patients under 50 years of age, in terms of societal burden, surgeons should consider joint-sparing techniques such as partial repair.

Re-tear following rotator cuff repair: Do functional outcomes predict success?

Purpose

The purpose of this study is to compare functional outcomes between patients who were found to have a retear on ultrasound versus those with an intact repair following arthroscopic rotator cuff repair.

Methods

Retrospective cohort study comparing functional outcomes of 84 patients who underwent arthroscopic rotator cuff repair and were found to have a retear versus those who did not experience a retear. Functional outcomes included American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, strength and active range of motion (AROM) assessed preoperatively and postoperatively at 3 and 6 months.

Results

Patients without a retear by 6 months demonstrated greater improvements in internal rotation at 3 months (2.3° of mean change, p = 0.0356), as well as greater improvements in external rotation range of motion (8.8° of mean change, p = 0.0210) between 3 and 6 months as compared to those patients who did experience a retear. Both groups showed decreased pain scores and increased ASES scores at all points postoperatively.

Conclusions

Our study found statistically significant improvements in internal rotation at 3 months, and external rotation between 3 and 6 months in the non-retear group. No differences in functional outcomes existed between at final follow-up.

Leukocyte-Poor Platelet-Rich Plasma as an Adjuvant to Arthroscopic Rotator Cuff Repair Reduces the Retear Rate But Does Not Improve Functional Outcomes: A Double-Blind Randomized Controlled Trial

BACKGROUND

Whether the use of PRP as an adjuvant of rotator cuff repairs leads to improved tendon healing and better functional outcomes remains unclear in clinical evidence.

PURPOSE

The main purpose of this study was to assess whether the use of leukocyte-poor platelet-rich plasma (LP-PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) decreases the rate of retears compared with a control group. The secondary objective was to analyze whether LP-PRP improves patient-reported outcomes.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a double-blind randomized controlled trial at a single center. A consecutive series of 96 patients with rotator cuff tears <3 cm were enrolled and randomly allocated to the control group (double-row suture-bridge ARCR alone [n = 48]) and the PRP group (double-row suture-bridge repair, followed by 1 LP-PRP injection during surgery [n = 48]). The visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and the Pittsburgh Sleep Quality Index (PSQI) were administered preoperatively and at 6- and 12-month follow-up. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity at 6-month follow-up. Both patients and assessors were blinded to the intervention received during surgery.

RESULTS

The mean patient age was 56.1 ± 2.98 years. Of the 96 patients, 90 had MRI performed at 6 months after surgery (94% radiological follow-up). The retear rate in the PRP group was 15.2% (7/46 [95% CI, 6%-28%]), which was lower than that in the control group of 34.1% (15/44 [95% CI, 20%-49%]) (P = .037). Therefore, the risk ratio of ruptures in patients exposed to LP-PRP was 0.44 (95% CI, 0.2-0.9; P = .037). Overall, the ASES, VAS, SANE, and PSQI scores showed a statistical improvement after surgery (P < .001). There were no significant differences in functional scores between the groups. Most of the patients exceeded the minimal clinically important difference for the ASES, SANE, and VAS without significant differences between the groups.

CONCLUSION

In patients with rotator cuff tears <3 cm undergoing double-row suture-bridge repair, a 5-mL dose of LP-PRP injected at the tendon-bone interface significantly reduced the retear rate. However, the use of LP-PRP in terms of postoperative pain and patient-reported outcomes failed to show clinically meaningful effects.

REGISTRATION

NCT04703998 (ClinicalTrials.gov identifier).

Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair

Background

Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI.

Methods

An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05).

Results

There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05).

Conclusion

Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.

Editorial Commentary: A Biphasic (Calcified and Demineralized), Cancellous, Interpositional Allograft Augmenting Rotator Cuff Repair in an Ovine Model Does Not Show Harmful Inflammation or Foreign Body Reaction

To improve the outcomes of arthroscopic rotator cuff (RC) repair, it is important to achieve tendon-to-bone healing at the repair site. Healed repairs are more likely to restore shoulder strength and lead to higher magnitudes of satisfaction. Patches or grafts that can be either secured to the bursal surface of the RC or interposed between the RC tendon and greater tuberosity at the time of repair have been described as adjuncts to RC repair. A cancellous, biphasic allograft tissue composed of 2 layers (calcified to promote osseointegration and demineralized to support soft-tissue ingrowth) has been shown to be safe in an ovine model, without a harmful inflammatory or foreign body response. Human trials may be a reasonable next step.

Effect of Retear After Arthroscopic Rotator Cuff Repair on Return to Work and Sports in Nonathletes: A Retrospective Cohort Study

Background

The impact of retear after arthroscopic rotator cuff repair (ARCR) on clinical outcomes of patients remains controversial.

Purpose/Hypothesis

The purpose of this study was to determine the effects of retear on strength recovery, return to previous levels of work, and return to sports participation. It was hypothesized that retears (1) would not have a significant effect on patient-reported outcome measures (PROMs) and (2) would significantly inhibit strength recovery and return to previous work and sports.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors collected data from patients who underwent ARCR between January 2015 and December 2019. All included patients had undergone magnetic resonance imaging (MRI) and strength measurements 1 year postoperatively. Minimum 2-year postoperative PROMs (Constant score, pain visual analog scale, American Shoulder and Elbow Surgeons score, and Single Assessment Numeric Evaluation) and status on work and sports participation were collected, and PROM scores, strength recovery (percentage compared with the contralateral shoulder), return to work, and return to sports were compared between patients with versus without retear on 1-year postoperative MRI. Additionally, factors related to return to work and sports were identified through multivariable regression analysis.

Results

A total of 159 patients were included, of whom 19 (11.9%) had evidence of retear. Return-to-work and return-to-sports status was evaluated in 134 (84.3%) and 93 (58.5%) patients, respectively. There were no significant differences in PROM scores between patients with and without retears; however, patients with retears exhibited significantly worse supraspinatus strength recovery (73% vs 86%; P = .018) and external rotation strength recovery (78% vs 88%; P = .030) compared with patients with intact shoulders. There were no between-group differences in return to work or sports. Active workload was associated with unsuccessful return to work, whereas preoperative participation in shoulder sports was associated with successful return to work.

Conclusion

Patients with postoperative retears had significantly worse postoperative strength recovery than patients with intact shoulders. Active workload and preoperative shoulder sports participation were factors associated with ability to return to work.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.

METHODS

Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).

RESULTS

The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.

CONCLUSION

Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Patch augmentation does not provide better clinical outcomes than arthroscopic rotator cuff repair for large to massive rotator cuff tears

PURPOSE

Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes.

METHODS

Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed.

RESULTS

This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups.

CONCLUSION

The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR.

LEVEL OF EVIDENCE

III.

Retear After Arthroscopic Rotator Cuff Repair Results in Functional Outcome Deterioration Over Time

PURPOSE

This study aimed to evaluate the effect of retear on long-term functional outcomes and glenohumeral joint osteoarthritis (OA) progression after arthroscopic rotator cuff repair (ASRCR).

METHODS

We retrospectively reviewed 201 patients who underwent ASRCR and were followed up for at least 5 years. Rotator cuff tendon structural integrity was evaluated using magnetic resonance imaging and/or ultrasonography. Pain, active range of motion, and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) were evaluated for functional outcomes. To evaluate deterioration over time, the minimal clinically important difference value of pain and ASES were used.

RESULTS

The mean follow-up period was 8.6 ± 2.2 years and overall retear rate was 21.4%. OA progression was strongly associated with retear (odds ratio 5.1, P < .001). Functional outcomes at the 2-year postoperative follow-up significantly improved compared to the preoperative status (all P < .017), regardless of retear. However, the retear group presented worse functional outcomes at the final follow-up (pain: 3.1 ± 2.6; ASES: 72.0 ± 17.4) than at the 2-year postoperative follow-up (pain: 1.2 ± 2.3, P = .014; ASES: 91.1 ± 9.9, P= .015) than the healed tendon group at final follow-up (pain: .6 ± 1.7; P < .001; ASES 95.5 ± 11.8; P < .001). The time for deterioration of pain (healed group vs. retear group: 5.5 ± 0.5 vs. 10.6 ± 0.4 years; P < .001) and ASES (healed group vs. retear group: 7.5 ± 0.5 vs. 12.8 ± 0.2 years; P < .001) decreased in the retear group.

CONCLUSIONS

The functional status improved after ASRCR in short- and long-term follow-up, regardless of retear. However, retear was strongly associated with OA progression, and long-term functional outcomes deteriorated over time in retear cases, which was not observed during short-term follow-up.

STUDY DESIGN

III, retrospective cohort study.

Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective

PURPOSE

The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis.

METHODS

A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY.

RESULTS

On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921.

CONCLUSION

Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective.

LEVEL OF EVIDENCE

Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.

Functional results after oncological scapula resections

INTRODUCTION

Tumors of the scapula are rare representing only 1.6%-2.8% of all skeletal tumor localizations. Wide resection of these tumors is often necessary, and their anatomic location is the most decisive factor for the extent of the resection. Because of the importance of the shoulder girdle for all daily activities, such resections can have major functional consequences. However, only few reports with small numbers of cases are found in the literature.

PATIENTS AND METHODS

We retrospectively evaluated 31 consecutive patients with scapular tumors treated surgically for aggressive benign or malignant tumors of the scapula. Patients who had received curettage only were excluded. Four of these 31 patients were lost to follow-up. In 7 of the remaining 27 patients, a total scapulectomy had to be performed, whereas all others received a partial resection. In 1 case, a partial resection and replantation after irradiation was performed. Musculoskeletal Tumor Society Scoring System (MSTS) and Toronto Extremity Salvage Score (TESS) scores were evaluated postoperatively at the time of their follow-up.

RESULTS

In 16 men and 11 women, the median age was 46.2 years and the tumor entities were heterogeneous. The median follow-up time was 71 months. Three patients died during follow-up due to their tumor and 1 due to cardiac disease. We found significantly better functional results in the group with incomplete scapula resections as opposed to the scapulectomy group. We did not see a significant functional difference between the patients with benign and those with malignant lesions. Both the MSTS score with median 83.3% (range between 23% and 100%) and the TESS score with 81.6% (ranging from 20.4% to 100%) were at a satisfactory level. The preservation of the supraspinatus muscle was shown to be advantageous for better shoulder function, and younger patients also tended to have better postoperative results.

CONCLUSION

The resection of scapular tumors may lead to a significant functional disability of the shoulder girdle and the affected arm in many cases. However, this is represented neither in the MSTS or TESS score nor in the overall acceptance of the patients. Only 1 patient, an artisan, had to change his job. In total, the clinical results are quite good in short- and long-term follow-up. The score results were comparable to other studies.

Reverse Shoulder Arthroplasty After Prior Rotator Cuff Repair: A Matched Cohort Analysis

INTRODUCTION

Rotator cuff repair (RCR) is commonly performed before reverse shoulder arthroplasty (RSA) with conflicting evidence on the effect on arthroplasty outcomes. The purpose of this investigation was to evaluate the effect of a prior RCR on the outcomes and complications of primary RSA.

METHODS

Between 2007 and 2017, 438 RSAs performed in patients with a prior RCR and 876 case-matched controls were identified from a multicenter database. Patients were grouped based on a preoperative diagnosis of glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). Data collected included range of motion, strength, complications, and revisions. Additional clinical metrics included American Shoulder and Elbow Society score, Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test, and the University of California Los Angeles shoulder score.

RESULTS

Compared with controls, both GHOA and CTA study groups demonstrated lower postoperative forward elevation (FE) (133° versus 147°, P < 0.001; 133° versus 139°, P = 0.048) and FE trength (6.5 versus 8.2, P = 0.004; 6.1 versus 7.3, P = 0.014). In addition, inferior improvements were observed in the GHOA and CTA study groups with respect to abduction (38° versus 52°, P = 0.001; 36° versus 49°, P = 0.001), FE (41° versus 60°, P < 0.001; 38° versus 52°, P = 0.001), ER (16° versus 25°, P < 0.001; 10° versus 17°, P = 0.001), and Constant score (28.4 versus 37.1, P < 0.001; 26.2 versus 30.9, P = 0.016). Compared with controls, no differences were observed in the GHOA and CTA study groups with respect to notching (11.2% versus 5.6%, P = 0.115; 5.8% versus 7.9%, P = 0.967), complications (4.3% versus 1.6%, P = 0.073; 2.5% versus 2.7%, P = 0.878), and revision surgery (3.1% versus 0.9%, P = 0.089; 1.1% versus 1.3%, P = 0.822).

CONCLUSION

RSA after a prior RCR improves both pain and function, without increasing scapular notching, complications, or revision surgery. However, compared with patients without a prior RCR, postoperative shoulder function may be slightly decreased.

LEVEL OF EVIDENCE

III; Retrospective Cohort Study.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

CONTEXT

There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making.

OBJECTIVE

To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology.

DATA SOURCES

PubMed, MEDLINE, Ovid, and Cochrane Reviews databases.

STUDY SELECTION

Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities.

RESULTS

A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21).

CONCLUSION

The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

Factors Related to Symptomatic Failed Rotator Cuff Repair Leading to Revision Surgeries After Primary Arthroscopic Surgery

PURPOSE

To evaluate the clinical characteristics of patients with symptomatic failed rotator cuff repair who required revision surgeries and to identify clinical and radiologic factors related to the need for revision surgery.

METHODS

Ninety-eight patients who were diagnosed with rotator cuff retear within 2 years after primary arthroscopic surgery were included. Patients were divided into 2 groups: patients who underwent revision surgery within 2 years postoperatively (44 patients, group I) and patients who did not require additional treatment due to minimal discomfort during the same period (54 patients, group II). Demographic and radiographic factors related to cuff healing were analyzed. Univariate and multivariate analyses were performed to evaluate factors related to revision surgery.

RESULTS

Group I showed significantly inferior clinical outcomes at the time of revision compared to group II (American Shoulder and Elbow Surgeons score; 54.0 ± 12.1 vs 86.5 ± 12.2, Constant score; 65.2 ± 10.8 vs 84.0 ± 11.4, P < .001). Total cholesterol level (210.2 ± 40.0 vs 189.7 ± 39.1, P = .012), low-density lipoprotein level (130.7 ± 28.7 vs 115.5 ± 26.9, P = .008), and fatty infiltration of the infraspinatus (20.5% vs 3.7%, P = .011) were significantly greater in group I than in group II. On postoperative magnetic resonance imaging, retear of the infraspinatus tendon occurred significantly more frequently in group I (81.8%) than in group II (37.0%, P < .001). In group I, relative changes in anteroposterior (AP) (19.2 ± 37.8) and mediolateral retear size (29.6 ± 90.7) were significantly greater than in group II (AP; -39.5 ± 19.2, mediolateral; -29.2 ± 26.8, P < .001). Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair (odds ratio 1.19, confidence interval 1.08-1.31, P < .001).

CONCLUSIONS

Preoperative serum total cholesterol level, low-density lipoprotein levels, and fatty infiltration of the infraspinatus were significantly related to symptomatic failed rotator cuff repair. Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair.

LEVEL OF EVIDENCE

Level III, Case-control study.

Degenerative rotator cuff tear, repair or not repair? A review of current evidence

INTRODUCTION

We review the literature and highlight the important factors to consider when counselling patients with non-traumatic rotator cuff tears on which route to take. Factors include the clinical outcomes of surgical and non-surgical routes, tendon healing rates with surgery (radiological outcome) and natural history of the tears if treated non-operatively.

METHODS

A PRISMA-compliant search was carried out, including the online databases PubMed and Embase™ from 1960 to the end of June 2018.

FINDINGS

A total of 49 of the 743 (579 PubMed and 164 Embase™) results yielded by the preliminary search were included in the review. There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Effectiveness of supervised early exercise program in patients with arthroscopic rotator cuff repair: Study protocol clinical trial

BACKGROUND

Based on the available evidence, it is difficult to make a clinical decision about the best exercise program and to establish the most favorable time to start postoperative treatment after rotator cuff (RC) repair. The aim of this trial is to evaluate the effects of adding a supervised early exercise program to standard treatment for functional improvement and pain relief compared with standard treatment alone in patients with arthroscopic RC repair.

METHOD/DESIGN

A total of 118 patients between the ages of 18 and 50 years with arthroscopic RC repair will be randomized to 2 treatment arms. The control group will receive a standard exercise program based on a consensus statement on shoulder rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The intervention group will receive a supervised early exercise program in combination with standard treatment. This supervised exercise program will be based on electromyographic evidence. Three evaluations will be performed: before surgery, at 6 weeks, and at 12 weeks. The primary outcome measure will be the shoulder function by the Constant-Murley questionnaire, and the secondary outcome measures will be the upper limb function by the disabilities of the arm, shoulder, and hand questionnaire; pain by the visual analog scale; and the shoulder range of motion by a goniometer.

DISCUSSION

We hypothesize that patients who receive a supervised early exercise program in combination with standard treatment will benefit more in respect to shoulder function, pain reduction, and range of motion than those who receive a standard exercise program. If this is confirmed, our study can be used clinically to enhance the recovery of patients with arthroscopic RC repair.

TRIAL REGISTRATION

Brazilian registry of clinical trials UTN number U1111-1224-4143. Registered December 18, 2018.

Postoperative residual pain is associated with a high magnetic resonance imaging (MRI)-based signal intensity of the repaired supraspinatus tendon

PURPOSE

To assess patients with and without postoperative residual pain and to compare clinical function and magnetic resonance imaging (MRI) appearance of the repaired supraspinatus tendon between patients with and without pain.

METHODS

One-hundred and seventeen patients with supraspinatus tear were included in this study. Visual Analog Scale (VAS) scores for pain were assessed at a follow-up of at least 1 year. Patients with residual shoulder pain were enrolled in the residual pain group (RP group) and patients without pain enrolled in the no pain group (NP group). The American Shoulder and Elbow Surgeons (ASES) shoulder evaluation form, the modified University of California at Los Angeles (UCLA) score and the Fudan University Shoulder Score (FUSS) were also used to evaluate shoulder function. MRI examinations were performed to evaluate rotator cuff integrity according to the Sugaya method, and muscular hypotrophy, fatty infiltration, and signal/noise quotient (SNQ) of the rotator cuff tendon.

RESULTS

Thirty-five patients had residual pain (RP group) and 82 patients had no pain (NR group). At the final follow-up, there was a significant difference in ASES (92 ± 8 points vs 76 ± 10 points; p < 0.001), UCLA (32 ± 3 points vs 28 ± 3 points; p < 0.001), FUSS (90 ± 7 points vs 80 ± 9 points; p < 0.001) and strength (9 ± 3 kg vs 6 ± 2 kg; p < 0.001) between the NP group and the RP group, respectively. Postoperative MRI revealed that there was no significant difference in the retear rate (9.8% vs 8.6%; ns), the muscular hypotrophy (ns), and the fatty infiltration index (0.9 ± 0.2 vs 0.9 ± 0.2; ns) between the NP and the RP groups, respectively. The postoperative tendon SNQ of the RP group was significantly higher than that of the NP group (4.6 ± 2.5 vs 3 ± 1.7; p < 0.001). There was a significant association between tendon SNQ and VAS for this cohort ([Formula: see text] = 0.29; p = 0.003).

CONCLUSION

Postoperative residual pain is associated with a high MRI signal intensity of the repaired supraspinatus tendon. Since high signal intensity of tendon tissue indicates degenerated tendon tissue quality, it highlighted the necessity of debriding the degenerated rotator cuff tendon tissue.

LEVEL OF EVIDENCE

III.

Current Concepts in Rotator Cuff Repair Techniques: Biomechanical, Functional, and Structural Outcomes

There is substantial evidence indicating that double-row (DR) repair restores more of the anatomic rotator cuff footprint and is biomechanically superior to single-row (SR) repair. Transosseous-equivalent (TOE) techniques have shown biomechanical advantages when compared with traditional DR, including increased contact at the rotator cuff footprint, higher pressure at the tendon-bone interface, and increased failure strength. Several meta-analyses of evidence level 1 and 2 studies have shown a lower rate of failed/incomplete healing when DR repair was compared with SR repair types. There is some limited evidence that TOE techniques improve healing rates in large and massive tears as compared with SR and DR. Overall, most level 1 and 2 studies have failed to prove a significant difference between SR and DR repairs in terms of clinical outcomes. However, most studies include only short-term follow-up, minimizing the impact that the higher rate of retears/failed healing seen with SR repairs can have in the long term. There are no high-quality clinical studies comparing different DR configurations, and there are currently not enough clinical data to determine the functional advantages of various DR technique modifications over one another. Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance. It is essential for the orthopaedic surgeon to know in detail the available literature to be able to apply the most appropriate and cost-effective technique in terms of healing and functional outcomes. This review provides a critical analysis of the comparative biomechanical and clinical studies among SR, DR, and TOE techniques reported in the literature in the past decade.

Arthroscopic Rotator Cuff Repair in 2019: Linked, Double Row Repair for Achieving Higher Healing Rates and Optimal Clinical Outcomes

The primary aim of rotator cuff repair surgery is to restore the musculotendinous units by creating a complete, tension-free repair construct that optimizes conditions for tendon-to-bone healing. There are many factors outside the control of the surgeon that are capable of affecting the healing process; however, there are also a number of important technical considerations that the surgeon can control, including familiarity with methods to deal with immobile tissues and techniques to perform novel repair constructs. It is clear that linked double row repairs are more likely to heal, and healed rotator cuff repairs best restore shoulder strength, improve patients' satisfaction, and maximize functional outcomes.

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.

Rotator Cuff Repair: Single Row Repair Versus Double Row Repair and Superior Capsular Reconstruction

The surgical management of rotator cuff (RC) tears has progressed considerably in recent decades. Arthroscopic procedures now represent the mainstay of contemporary treatment approaches. The success of repair is predicated upon the achievement of a secure, durable repair that promotes tendon-to-bone healing. Both single and double row (DR) suture anchor configurations have been described to achieve stable fixation. Although consensus is lacking with regard to the clinical superiority of one configuration over another, trends in the literature suggest that DR repairs may optimize the likelihood of tendon healing and restoration of shoulder strength. In cases of truly irreparable RC tears, superior capsular reconstruction is a promising alternative to open tendon transfer and arthroplasty procedures. The purposes of this concise review are to: (1) explain our preference for a DR repair configuration in almost all circumstances; and (2) advocate superior capsular reconstruction as a viable treatment tactic for truly irreparable RC tears in the absence of significant glenohumeral arthritis.

Risk Factors for Short-term Complications After Rotator Cuff Repair in the United States

PURPOSE

To use a population-level dataset to evaluate the rate of 30-day complications after rotator cuff repair, and to evaluate the risk factors for complication and unplanned hospital readmission.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2015 to identify patients who underwent rotator cuff repair and concomitant procedures using Current Procedural Terminology codes. Postoperative complications and unplanned hospital readmissions were identified. Patient demographics, medical comorbidities, and perioperative variables were used in a multivariate logistic regression model to identify the risk factors for infection, any complication, and unplanned hospital readmission.

RESULTS

A total of 23,741 patients were identified who underwent rotator cuff repair. Overall, 1.39% of patients experienced at least 1 complication, with 0.66% minor complications and 0.85% major complications. Unplanned readmission occurred in 1.16% of patients. Infection was the most common complication, occurring in 0.3% of patients (n = 72), and was the most common reason for return to the operating room. Open rotator cuff repair and male gender were independent risk factors for all outcomes. Increased age and numerous medical comorbidities were associated with the risk of any complication or unplanned hospital readmission.

CONCLUSIONS

Rotator cuff repair has a low incidence of short-term complications. Infection was the most common complication. Open repair, male gender, increased age, and medical comorbidities all significantly increased the risk of complications and hospital readmission.

LEVEL OF EVIDENCE

Level IV, case series.