Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome

M2 Macrophage-Derived Exosomes Promote Tendon-to-Bone Healing by Alleviating Cellular Senescence in Aged Rats

PURPOSE

To explore the potential of M2 macrophage-derived exosomes (M2-Exos) in enhancing tendon-to-bone healing in aged rats by mitigating cellular senescence of bone marrow-derived stem cells (BMSCs).

METHODS

In vitro, the effects of M2-Exos on alleviating cellular senescence and improving chondrogenic potential of senescent BMSCs were evaluated. Rats (24 young and 48 aged) with chronic rotator cuff tear (RCT) were repaired and assigned into 3 groups: young group (young rats injected with fibrin at the enthesis), aged group (aged rats injected with fibrin at the enthesis), and aged + M2-Exos group (aged rats injected with fibrin containing M2-Exos at the enthesis). At 6 and 12 weeks after repair, enthesis regeneration was evaluated. Proteomic analysis was conducted to explore the mechanism through which M2-Exos mitigated cellular senescence.

RESULTS

In senescent BMSCs treated with M2-Exos, there was a reduction in senescence biomarkers including senescence-associated β-galactosidase, p53, p21, and senescence-associated secretory phenotype (P < .001). M2-Exos also enhanced chondrogenic potential of senescent BMSCs, reflected in greater Bern score (P < .001) and increased expression of Sox9 (P = .013), Col2a1 (P < .001), and Acan (P < .001). Histologically, aged rats treated with M2-Exos demonstrated significantly greater histologic scores (P < .001 at both 6 and 12 weeks) and increased fibrocartilage regeneration at the enthesis. Biomechanically, these rats exhibited greater failure load, stiffness, and stress (all P < .001) at 12 weeks. Mechanistically, proteomic analysis suggested that M2-Exos might alleviate cellular senescence by potentially regulating DNA replication and repair.

CONCLUSIONS

M2-Exos can significantly alleviate BMSC senescence and thereby enhance tendon-to-bone healing in an aged rat RCT model.

CLINICAL RELEVANCE

This study suggests the potential utility of M2-Exos as a therapy for RCT in the older population.

Fatty infiltration predicts retear and functional impairment following rotator cuff repair: systematic review and meta-analysis

INTRODUCTION

Fatty infiltration (FI) in rotator cuff (RC) is detected in many patients with complete RC tears. But there remains controversy on the prognostic effects of FI in RC tears, especially for patients with moderate and severe FI. This study aims to systematically review the relationship between the severity of preoperative FI and risk of retear, and the association between preoperative FI and functional outcomes.

MATERIALS AND METHODS

We searched PubMed, Embase and Web of Science for studies on association between preoperative FI and retear or functional outcomes following complete RC repair. FI was assessed using Goutallier classification and global fatty degeneration index (GFDI). Meta-analysis was performed to determine odds ratios (ORs) for retear among patients with mild (grade 0-1), moderate (grade 2) and severe (grade 3-4) FI in RC tears. We delivered qualitative synthesis on association between FI and functional outcomes.

RESULTS

Eighteen studies with 1997 patients were included in the systematic review and ten studies were included in the meta-analysis. Patients with GFDI ≤ 1 had lower retear odds (OR = 0.08, 95%CI 0.02-0.29, p < 0.01). Moderate FI in supraspinatus muscle (SSP) was associated with higher retear odds compared with mild FI (OR = 1.95, 95%CI 1.09-3.48, p = 0.02) and severe FI was associated with more retear compared with moderate FI (OR = 3.37, 95%CI 1.08-10.53, p = 0.04). Similar effects were observed in FI in infraspinatus muscle (ISP) (moderate vs. mild: OR = 2.22, 95%CI 1.07-4.62, p = 0.03; severe vs. moderate: OR = 2.06, 95%CI 1.02-4.16, p = 0.04). The severity of FI in subscapularis muscle and teres minor muscle was not observed to be associated with the retear rates. In functional outcomes, lower grade of FI in GFDI was associated with better prognosis. FI in single muscles failed to present prognostic effects on functional outcomes.

CONCLUSIONS

The severity of FI in SSP and ISP showed effects on retear following complete RC repair. The GFDI was a compatible predictor for risk of anatomic and functional impairment.

Imaging of Reparable and Irreparable Rotator Cuff Tears

This review offers a comprehensive discussion of magnetic resonance imaging (MRI) for the assessment of rotator cuff tendon repair and joint-preserving surgical options for patients with irreparable rotator cuff tears. Deciding to proceed with arthroscopic repair of a rotator cuff tendon tear is impacted both by clinical factors and morphological imaging features. Preoperative clinical and imaging features also predict the likelihood of success of a rotator cuff tendon repair and are important to recognize. In patients with irreparable rotator cuff tears and relatively preserved glenohumeral cartilage, various joint-preserving surgical options are available and seen increasingly in clinical practice.The acceptable range of postoperative imaging findings correlating with a functionally intact rotator cuff repaired tendon, and MRI findings that are either suggestive of or definitive for rotator cuff tendon repair failure are discussed in detail, with attention to the Sugaya classification. Ancillary features, such as progressive retraction of the myotendinous junction and the degree of muscle fatty atrophy, can be used as problem-solving tools in cases equivocal for rotator cuff retear. Finally, this review discusses in detail the most common joint-preserving treatment options for patients with irreparable rotator cuff tears, including an in-depth focus on superior capsular reconstruction.

Does surgical intervention alter the natural history of degenerative rotator cuff tears? Comparative analysis from a prospective longitudinal study

BACKGROUND

The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short- to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively.

METHODS

This comparative study consists of 2 separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included visual analog scale pain, American Shoulder and Elbow Surgeons, active range of motion, strength, and ultrasonography.

RESULTS

There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9 ± 5.3 yr vs. 61.2 ± 7.8 yr, P = .04). The median follow-up for control subjects after pain development was 5.1 years (interquartile range [IQR] 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; P = .45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; P = .06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (P = .43 and P = .58, respectively). At final follow-up, the surgical group demonstrated significantly lower visual analog scale pain (0 [IQR 2] vs. 3.5 [IQR 4], P = .0002), higher composite American Shoulder and Elbow Surgeons (95 [IQR 13] vs. 65.8 [IQR 32], P = .0002), and activities of daily living scores (29 [IQR 4] vs. 22 [IQR 8], P = .0002), greater abduction strength (69.6 N [standard deviation {SD} 29] vs. 35.9 N [SD 29], P = .0002), greater active forward elevation (155° [SD 8] vs. 142° [SD 28], P = .002), greater active external rotation in abduction (mean 98.5°, SD 12 vs. mean 78.2°, SD 20; P = .0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, P = .05; 17% vs. 34%, P = .03; respectively).

CONCLUSION

This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment.

Collagen Injections for Rotator Cuff Diseases: A Systematic Review

BACKGROUND

Because of its anatomy and function, the rotator cuff (RC) is vulnerable to considerable morbidity. The prevalence of RC diseases (RCDs) among the general population is 5-39%, reaching over 30% in patients older than 60. The aim of the present systematic review is to investigate the effects of the use of collagen injections in the treatment of RCDs.

METHODS

A systematic search of scientific electronic databases (such as PubMed, Scopus and Web of Science) was performed up to November 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent authors conducted the search and assessed the articles. The inter-rater reliability for the quality assessment was measured using Cohen's kappa coefficient, while the Modified Coleman Methodology Score (CMS) was applied to evaluate the methodological quality of the articles included in this systematic review.

RESULTS

A total of eight articles were included, with the overall quality of the included articles being evaluated as fair. Despite the use of different types of collagen and injection protocols, as well as the different scores applied, each included study showed clinically relevant improvements. However, given the high degree of heterogeneity of the included studies, we cannot draw conclusions regarding which type of collagen and injection protocol are best for RCD treatment.

DISCUSSION

Collagen administration for RCDs seems to be effective at reducing pain and improving function, as well as the tendon structure, especially in partial tears and RC tendinopathy. High-quality, prospective studies with long-term follow-up are necessary to validate the findings of the articles included in this systematic review.

Sling Is Not Inferior to Brace Immobilization After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To compare the safety and efficacy of immobilizing the upper limb with a brace versus a less-constrained sling in the rehabilitation after arthroscopic rotator cuff repair (ARCR), by documenting clinical and radiologic results.

METHODS

ARCR was performed in 110 patients (54.9 ± 8.3 years) randomized in group A, using a brace for 6 weeks after surgery (3 weeks day and night then 3 weeks only at night), and group B, using a simple sling for 2 weeks only. Patients were evaluated at baseline, 6 weeks, and 3 and 6 months. Functional outcomes were range of motion, strength, Disabilities of the Arm, Shoulder and Hand score, and Constant-Murley Score (CMS). Pain was assessed with a visual analog scale and quality of life with the SF-36 questionnaire. The primary outcome was the CMS at 6 months. At 6 months, 3-Tesla magnetic resonance imaging was performed to document the status of the rotator cuff repair. The minimal clinically important difference was also analyzed.

RESULTS

Both groups A and B showed a worsening at 6 weeks and an improvement at 3 and 6 months of Disabilities of the Arm, Shoulder and Hand and CMS, as well as a significant visual analog scale decrease at every follow-up (P < .005). SF-36 showed a different trend: General health improved at 6 weeks, then decreased at 3 months, and increased again at 6 months. No difference was retrieved between the 2 groups at any follow-up in terms of pain, functional, and general health scores. The minimal clinically important difference for the primary outcome was 14.5 points and was reached in 56.5% and 61.2% of patients in the sling and brace group, respectively. The evaluation of magnetic resonance imaging scans identified 5 patients in each group with a supraspinatus tendon re-rupture, with no statistical difference in the re-rupture rate between the 2 groups.

CONCLUSIONS

This randomized controlled trial demonstrated that ARCR postoperative sling immobilization was not inferior to immobilization with a brace, having no differences in terms of functional scores, pain levels, general health, and risk of tendon re-rupture.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial (designed as a therapeutic study investigating the results of treatment) with statistically significant difference.

Disparities in Rotator Cuff Tear Progression Definitions and Rates: A Systematic Review

Background

While rotator cuff tears are prevalent in the general population, the natural history of this disease is unclear. Understanding rotator cuff tear progression is crucial for refining surgical indications and evaluating the necessity of early interventions. This study presents an in-depth analysis of the existing literature on the definitions and progression rates of rotator cuff tears, aiming to enhance clinical decision making and patient outcomes.

Methods

A systematic literature search was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Medline (PubMed), Embase (Elsevier), and Web of Science databases on January 12, 2023. Articles were identified as relevant to the natural history and progression of asymptomatic and symptomatic partial-thickness (PT) and full-thickness (FT) rotator cuff tears. Those written in English reporting rotator cuff progression rates of tears in adults, based on magnetic resonance imaging (MRI) or ultrasound, were included. After reviewing the articles, the data on the rates of tear progression and associated risk factors were extracted, compiled, and analyzed. The risk of bias was determined using the Newcastle-Ottawa Scale.

Results

Twenty-one articles met the inclusion criteria, with 1,831 tears included. The progression rate for all partial thickness tears was 26.7% ± 12.8% at an average follow-up of 2.2 ± 0.9 years, with 5 definitions for tear progression. For FT tears, the progression rate was 54.9% ± 18.6% at a follow-up time of 3.0 ± 2.0 years, with 8 definitions for tear enlargement. A significant difference (p < 0.0001) was found between the progression rates of PT and FT tears. Patients who were initially asymptomatic and became symptomatic had higher progression rates (33%-63%) than those who remained asymptomatic (4%-38%).

Conclusion

Further research would benefit by identifying a clinically relevant and standardized definition of rotator cuff tear progression, to describe the natural history of rotator cuff disease, making results more comparable and optimizing treatment planning.

Level of Evidence

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

Arthroscopic Margin Convergence Repair Without Suture Anchors Improves Clinical Outcomes for Full- and Partial-Thickness Rotator Cuff Tears

Purpose

To evaluate the clinical outcome scores of an arthroscopic margin convergence technique without the use of suture anchors to repair different types of rotator cuff tears and to determine whether the type or extent of the tear has an effect on clinical outcome scores after this procedure.

Methods

Patients receiving arthroscopic margin convergence repair without suture anchors for rotator cuff tears from 2013 to 2018 were retrospectively analyzed. Arthroscopically determined partial- or full-thickness rotator cuff tears with a minimum follow-up period of 20 months were included. Outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) shoulder score; University of California, Los Angeles (UCLA) shoulder score; and visual analog scale (VAS) score. A 2-tailed distribution paired t test was used to determine statistical significance (P < .05) between preoperative scores and scores at final follow-up. Correlation tests and linear regression analysis were used to determine the correlation between various clinical variables and outcomes. A cohort-specific minimal clinically important difference analysis was performed for each outcome score, calculated as one-half of the standard deviation of the delta score.

Results

A total of 38 patients were included for analysis: 12 with partial-thickness tears and 26 with full-thickness tears. The mean postoperative follow-up period was 33.9 months (range, 22.2-94.5 months), with a minimum follow-up period of 22 months. The mean age of the patients was 62 ± 15.1 years. The minimal clinically important difference values for the ASES, UCLA, and VAS scores were 9.68, 2.92, and 1.13, respectively. There were significant improvements in the ASES (from 29.3 ± 18.3 preoperatively to 93.7 ± 8.3 postoperatively, P = .001), UCLA (from 14.3 ± 6.2 to 32.8 ± 2.6, P = .001), and VAS (from 7.37 ± 1.8 to 0.63 ± 1.02, P = .001) clinical outcome scores. However, patients with either Patte stage 3 retraction (P = .033 for ASES score and P = .020 for UCLA score) or U-shaped tears (P = .047 for ASES score and P = .050 for UCLA score) had significantly lower clinical outcome scores than patients with less severe retraction or differently shaped tears.

Conclusions

The arthroscopic margin convergence technique without the use of suture anchors may be a suitable option in patients with partial- or full-thickness rotator cuff tears.

Level of Evidence

Level IV, therapeutic case series.

The Suprascapular Artery as a Reference for the Evaluation of Supraspinatus Fatty Infiltration on Magnetic Resonance Imaging

Background

Fatty infiltration (FI) of the supraspinatus is commonly seen in chronic large-to-massive rotator cuff tears. Evaluating FI in patients with severe muscle atrophy can be confusing.

Purpose/Hypothesis

The purpose of this study was to investigate the anatomic relationship between the suprascapular artery and supraspinatus muscle on magnetic resonance imaging (MRI) to provide a method for defining the border of the supraspinatus muscle on Y-view MRI. It was hypothesized that the branches of the suprascapular artery would encircle the supraspinatus muscle on Y-view and adjacent MRI slices and could be used for defining the supraspinatus outline on oblique sagittal images.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

A total of 172 shoulders that had undergone arthroscopic repair for large-to-massive rotator cuff tears were retrospectively included. Two methods, one based on the supraspinous fossa and trapezius (SF method) and the other based on the region bounded by the branches of the suprascapular artery (SA method), were used for defining the supraspinatus outline on Y-view MRI for the assessment of FI. Preoperative supraspinatus FI grade and tangent sign and postoperative tendon integrity were evaluated. Shoulder function was assessed using the American Shoulder and Elbow Surgeons (ASES) score and active range of motion.

Results

The branches of the suprascapular artery encircled the supraspinatus in all shoulders, with the diameter of the branches ranging from 0.5 to 3 mm. The agreement in supraspinatus FI grading between the SF and SA methods was 65.12%. When limited to the 61 shoulders with a positive tangent sign, the agreement dropped to 22.95% (κ = 0.032). The group (FI grade 2 by SA method and ≥3 by SF method) showed no significant difference in postoperative outcomes compared with the 2-vs-2 group but had significantly better postoperative ASES scores (P = .001) and active range of motion in forward elevation (P = .020) compared with the ≥3-vs-≥3 group. The tangent sign was positive in 92.16% of the 2-vs-≥3 group.

Conclusion

The suprascapular artery is a reliable reference for the evaluation of supraspinatus FI. When a positive tangent sign presents, supraspinatus FI is likely to be overestimated if the hyperintensity outside the region bounded by the branches of the suprascapular artery is mistaken as FI.

Effect of polydeoxyribonucleotide and polynucleotide on rotator cuff healing and fatty infiltration in a diabetic rat model

Failure rate after chronic rotator cuff repair is considerably high. Moreover, diabetes mellitus is known as a compromising factor of rotator cuff tear. The effect of Polydeoxyribonucleotide (PDRN) and polynucleotide (PN) on tendon healing and fatty infiltration is unclear as tissue regeneration activator in diabetic state. Therefore, a diabetic rat model with chronic rotator cuff tear was made for mechanical, histologic and blood tests. In the animal study using a diabetic rat cuff repair model, the administration of PDRN and PN increased the load to failure of repaired cuffs and improved tendon healing and decreased fatty infiltration. Also, the plasma levels of vascular endothelial growth factor and fibroblast growth factor were elevated in PDRN and PN administrated groups. We concluded that PDRN and PN appear to boost tendon recovery and reduce the presence of fatty infiltration following cuff repair in diabetic state. Also, PN showed a later onset and a longer duration than PDRN associated with the mean plasma growth factors.

Factors associated with patient satisfaction after arthroscopic rotator cuff repair: do they differ by age?

BACKGROUND

Several studies have investigated factors affecting patient satisfaction after arthroscopic rotator cuff repair (ARCR); however, it is unknown if these factors vary according to age. Therefore, this study aimed to evaluate the factors associated with satisfaction of ARCR in individuals 70 years and older versus younger patients.

METHODS

Among 319 consecutive patients who underwent ARCR, 173 were included. Patients were divided into an old age group (≥70 years) and a young age group (<70 years), and the two age groups were further divided into satisfied and unsatisfied subgroups. Patient satisfaction was evaluated at the final follow-up visit using a binary question (yes or no). Clinical outcomes were assessed preoperatively and at the final follow-up.

RESULTS

Satisfaction rates in the older and younger age groups were 75.41% and 79.47%, respectively. Mean changes in Constant and American Shoulder and Elbow Surgeons scores were significantly different between the satisfied and unsatisfied subgroups (P=0.031 and P=0.012, respectively) in the young patients. In the old patients, there was a significant difference in the mean change in depression subscale of the Hospital Anxiety and Depression Scale (P=0.031) and anxiety subscale of the Hospital Anxiety and Depression Scale (P=0.044) scores between the satisfied and unsatisfied subgroups.

CONCLUSIONS

Factors affecting patient satisfaction after ARCR differed according to age. Psychological improvement was more important to elderly patients, whereas restoration of function was more important to younger patients. Pain relief was important for both age groups. Level of evidence: III.

Supraspinatus Tendon Reconstruction Versus the Bridging Technique in a Rat Model: Histological, Biomechanical, and Functional Outcomes

BACKGROUND

Massive irreparable rotator cuff tears (MIRCTs) are among the most challenging shoulder conditions to treat surgically. Supraspinatus tendon reconstruction (STR) is a recently introduced technique for MIRCTs based on fascia lata-muscle interface healing, which completely differs from the classic bridging technique with fascia lata-tendon interface healing. However, histological and biomechanical comparisons of the fascia-muscle and fascia-tendon interfaces have not been performed.

PURPOSE

To investigate the histological and biomechanical healing of the fascia-bone interface and fascia-muscle interface after chronic MIRCTs in a rat model using different surgical methods.

STUDY DESIGN

Controlled laboratory study.

METHODS

The authors established a chronic MIRCT model in the right shoulder of rats and then repaired it using the STR or bridging repair technique. Evaluations were performed at 2, 4, 8, and 12 weeks, including histological, imaging, biomechanical, and functional analyses.

RESULTS

Both techniques resulted in good fascia-bone interface healing based on the histological results. The STR group had significantly more cartilage formation at 8 and 12 weeks and higher Modified Tendon Maturity Score after 12 weeks at the fascia-bone interface compared with the bridging repair group and formed the typical 4-layered structure. Collagen fibers in the fascia-muscle and fascia-tendon interfaces exhibited normal muscle-tendon interface characteristics at 12 weeks. However, the STR group had more improvement in fatty infiltration compared with the bridging repair group. The ultimate failure load and stiffness did not differ between the STR and bridging repair groups 4 weeks postoperatively in both the fascia-bone interface and supraspinatus muscle-fascia-bone integrity. Movement distance and grasp time were significantly longer in the STR group than in the bridging repair group at 12 weeks and attached the level in the normal control groups.

CONCLUSION

These results suggest that the fascia-muscle interface from the STR technique is histologically and functionally better than the fascia-tendon interface. Moreover, this study provides a theoretical basis for the clinical use of the STR technique.

CLINICAL RELEVANCE

The fascia-muscle interface and fascia-tendon interface were the key points of the STR and bridging techniques, respectively. The fascia-muscle interface is histologically and functionally superior to the bridging technique, and the STR technique might be a better choice for the treatment of MIRCTs.

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair

BACKGROUND

Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking.

PURPOSE

To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs).

RESULTS

Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC.

CONCLUSION

The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Obesity is associated with muscle atrophy in rotator cuff tear

Objective

The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears.

Methods

This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis.

Results

A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear.

Conclusions

Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients.

Level of Evidence

III.

A systematic review on sonoelastography for rotator-cuff post-repair assessment

Surgical repair of rotator cuff tears is performed routinely; however, the risks of re-tears and the associated consequences are significant. Sonoelastography, an imaging modality that evaluates the mechanical properties of tissues, can examine the dynamic transitions in rotator cuff stiffness following retear and investigate the relationship between these changes and the occurrences of retears. This systematic review aimed to summarize the role of perioperative sonoelastography in repaired rotator cuffs. A comprehensive search of the PubMed, Embase, and Cochrane databases was conducted, covering studies published until June 19, 2023. The Newcastle-Ottawa scale was used for quality assessment. The key information extracted from each study included the injury/surgery type, follow-up duration, sonoelastography mode, and main sonoelastographic findings. Eleven eligible studies comprising 355 patients were included. All studies focused on supraspinatus muscles and tendons with previous arthroscopic repairs. During the postoperative 1st - 6th months, muscle stiffness increased in the supraspinatus and decreased in the ipsilateral deltoid. Failure to recover supraspinatus muscle elasticity might be indicative of potential tendon re-tear; however, it is imperative to first establish correlations with other imaging modalities. Conflicting findings have been observed regarding stiffening or softening of the supraspinatus tendon after surgical repair. The preoperative stiffness of the supraspinatus tendon did not correlate with postoperative tendon integrity or function.

Aging-Related Rotator Cuff Tears: Molecular Mechanisms and Implications for Clinical Management

Shoulder pain and disabilities are prevalent issues among the elderly population, with rotator cuff tear (RCT) being one of the leading causes. Although surgical treatment has shown some success, high postoperative retear rates remain a great challenge, particularly in elderly patients. Aging-related degeneration of muscle, tendon, tendon-to-bone enthesis, and bone plays a critical role in the development and prognosis of RCT. Studies have demonstrated that aging worsens muscle atrophy and fatty infiltration, alters tendon structure and biomechanical properties, exacerbates enthesis degeneration, and reduces bone density. Although recent researches have contributed to understanding the pathophysiological mechanisms of aging-related RCT, a comprehensive systematic review of this topic is still lacking. Therefore, this article aims to present a review of the pathophysiological changes and their clinical significance, as well as the molecular mechanisms underlying aging-related RCT, with the goal of shedding light on new therapeutic approaches to reduce the occurrence of aging-related RCT and improve postoperative prognosis in elderly patients.

Patient Sex Is a Significant Factor in Arm Function Recovery After Arthroscopic Rotator Cuff Repair

Purpose

The purpose of this study was to investigate the impact of patient sex on arm functional recovery after arthroscopic rotator cuff repair (ARCR).

Methods

We retrospectively reviewed the clinical records of patients who underwent rehabilitation after ARCR at two affiliated hospitals between January 2014 and December 2019. Patient characteristics included age, sex, type of muscle tear, tear location, muscle strength, Japanese Orthopedic Association (JOA) score, and patient responses to the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We used mixed-effects regression models with random intercepts to evaluate the QuickDASH scores, JOA scores, and muscle strength relative to the nonoperated side.

Results

Of the 124 patients, 82 (66.1%) were 65-year-old men and 42 (33.9%) were 67-year-old women. The preoperative JOA scores (P = .03) and those at 6 months (P < .001) and 12 months (P = .04) after ARCR were significantly greater for men than for women. QuickDASH scores of men were significantly lower at 24 months (P = .02) and all other time points (P < .001) than those of women. The improvement in QuickDASH scores was significantly higher for women than for men (P < .01). The results of the multiple regression analysis showed that patient sex (95% confidence interval, 0.01-0.45; P < .05) had an impact on QuickDASH scores at 24 months after ARCR.

Conclusion

In this study, patient sex was a significant factor affecting the recovery and QuickDASH scores of patients who underwent ARCR. Level of Evidence: Level IV, prognostic case series.

Local Injection of Rapamycin-Loaded Pcl-Peg Nanoparticles for Enhanced Tendon Healing in Rotator Cuff Tears via Simultaneously Reducing Fatty Infiltration and Drug Toxicity

As a common cause of shoulder pain, rotator cuff tears (RCTs) are difficult to treat clinically because of their unsatisfactory prognosis due to the fatty infiltration caused by muscle-derived stem cells (MDSCs). Previous studies have found that rapamycin (RAPA) can inhibit fatty infiltration. However, systemic administration of RAPA may cause complications such as infection and nausea, while local administration of RAPA may lead to the cytotoxicity of tendon cells, affecting the healing of rotator cuffs. In this study, biocompatible and clinically approved polycaprolactone-polyethylene glycol (PCL-PEG) is formulated into an injectable nanoparticle for the sustained release of RAPA. The results indicate that the RAPA/PCL-PEG nanoparticles (NPs) can efficiently prolong the release of RAPA and significantly reduce the cytotoxicity of tendon cells caused by RAPA. The study of the fatty infiltration model in rats with delayed rotator cuff repair shows that weekly intraarticular injection of RAPA/PCL-PEG NPs can more effectively reduce the fatty infiltration and muscle atrophy of rat rotator cuffs and leads to better mechanical properties and gait improvements than a daily intraarticular injection of RAPA. These findings imply that local injection of RAPA/PCL-PEG NPs in the shoulder joints can be a potential clinical option for RCTs patients with fatty infiltration.

Influence of Pain Sensitivity on Surgical Outcomes of Arthroscopic Rotator Cuff Repair: A Prospective Cohort Study

BACKGROUND

The Pain Sensitivity Questionnaire (PSQ) has been found to be a valid tool, and PSQ scores have been shown to be predictive of outcomes after surgery for lumbar stenosis. The effect of pain sensitivity on outcomes of rotator cuff repair (RCR) surgery has not been examined.

HYPOTHESIS

PSQ scores would be associated with surgical outcomes after arthroscopic RCR surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients 18 to 80 years old scheduled for RCR were consecutively enrolled. Patients with glenohumeral arthritis grade ≥2 or RCR revision surgery were excluded. PSQ was completed preoperatively. The Disabilities of the Arm, Shoulder and Hand score and American Shoulder and Elbow Surgeons score were used as patient-reported outcome measurements (PROMs), and visual analog scale pain score was documented as well. Active shoulder external rotation (ER), internal rotation, and anterior forward elevation range of motion (ROM) were recorded. PROMs and ROM measurements were recorded preoperatively and at 3 months, 6 months, and 1 year after surgery. Rotator cuff tear size, type of repair, and concomitant procedures were documented. Patients were classified as having high or normal pain sensitivity based on PSQ scores.

RESULTS

Of 100 enrolled patients, 38 patients were classified as having high pain sensitivity. Patients with high pain sensitivity had worse American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder and Hand scores preoperatively, 6 months postoperatively, and 1 year postoperatively (P < .01). From the preoperative assessment to 3 months postoperatively, PROMs improved more in patients with high versus normal pain sensitivity. However, for patients with high pain sensitivity, PROMs plateaued after 3 months but continued to improve for patients with normal pain sensitivity (P < .01). Visual analog scale pain scores were higher at all time points for patients with high pain sensitivity (P < .05). Preoperatively, patients with high pain sensitivity had restricted active ROM compared with patients who had normal pain sensitivity for anterior forward elevation, ER, and internal rotation (P = .009, P = .012, and P = .006, respectively). By 1 year after surgery, ER ROM was still restricted in patients with high pain sensitivity.

CONCLUSION

Pain sensitivity is an important factor influencing RCR outcomes. Patients with high pain sensitivity undergoing RCR showed less improvement in active ROM and worse PROMs after surgery compared with patients who had normal pain sensitivity. Preoperative PSQ may predict postoperative improvements.

The Posterosuperior Tetralogy Scoring System as a Practical Tool to Predict Shoulder Function After Posterosuperior Large-to-Massive Rotator Cuff Repairs

Background

Fatty infiltration (FI) or atrophy alone has been found to be inaccurate in predicting shoulder function after repair of large-to-massive rotator cuff tears (L/MRCTs), especially when a diverse extent of FI and atrophy presents in multiple rotator cuff muscles.

Purpose/Hypothesis

The Posterosuperior Tetralogy Scoring System (PS-Tetra Score), which integrates FI and atrophy, was proposed to predict shoulder function after surgery. It was hypothesized was that a PS-Tetra Score ≥3 would be a risk factor for poor shoulder function after repair of posterosuperior L/MRCTs and would possess greater diagnostic value than using isolated FI or atrophy of the supraspinatus (SSP) or infraspinatus (ISP).

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 187 arthroscopic repairs of posterosuperior L/MRCTs were reviewed. Magnetic resonance imaging evaluations were performed of FI and atrophy of the SSP and ISP, teres minor hypertrophy, tendon retraction, and acromiohumeral distance. A postoperative American Shoulder and Elbow Surgeons (ASES) score of 70 was used to subgroup patients according to shoulder function. Univariate and multivariate analyses were performed to determine the risk factors of poor shoulder function (ASES ≤70). The diagnostic values of different indicators for predicting shoulder function were evaluated.

Results

In univariate analysis, female sex, higher Goutallier grade of the SSP and ISP, positive SSP tangent sign, and PS-Tetra Score ≥3 was significantly associated with ASES score ≤70, whereas in binary logistic regression analysis, a PS-Tetra Score ≥3 was the only significant risk factor for poor shoulder function. The occurrence rate of poor function in shoulders with a PS-Tetra Score of 0, 1, 2, 3, and 4 was 0% (0/52), 0% (0/52), 19.57% (9/46), 58.06% (18/31), and 83.33% (5/6), respectively. PS-Tetra Score ≥3 possessed higher crude agreement (87.70%), specificity (90.97%), positive predictive value (62.16%), and area under the receiver operating characteristic curve (0.814) than the other 3 indicators, with relatively high negative predictive value (94.00%) and moderate sensitivity (71.88%).

Conclusion

PS-Tetra Score ≥3 was a risk factor of poor shoulder function after repair of posterosuperior L/MRCTs and possessed greater diagnostic value than using isolated FI or atrophy of SSP or ISP alone for predicting shoulder function.

Fat quantification of the rotator cuff muscles using CT histogram analysis in comparison with Dixon MRI sequence

OBJECTIVES

To quantify the proportion of fat within the rotator cuff muscles using CT histogram analysis (HA) and to compare fat fraction (FF) values obtained from CT and T2*-corrected 6-echo three-dimensional gradient-echo Dixon sequences.

METHODS

Twenty-six patients who underwent both shoulder CT and MRI were enrolled. The FF of rotator cuff muscles was measured on FF maps of the Dixon technique. Using CT, the FF values were obtained in two ways: 1) CT mean Hounsfield Unit (HU) measurement-based fat quantification using subcutaneous fat and the teres major muscle as internal standards; and 2) CT HA-based fat quantification in which pixels from -190 to -30 HU were arbitrarily classified as fat, and those from -30 to 150 HU as muscle. Afterward, the relationship between FF values from MRI (FF-MR), CT mean HU-based analysis (FF-HU), and CT HA (FF-HA) was assessed.

RESULTS

There were strong positive correlations (p < 0.001) between FF-MR and FF-HA, which were higher when compared with FF-HU (r = 0.90 vs. 0.77 for total). For a total of 104 rotator cuff muscles, the intraclass correlation between FF-MR and FF-HA was excellent (ICC, 0.90), which was higher than that between FF-MR and FF-HU (ICC, 0.76). The ICCs showed excellent interobserver agreement between FF-MR, FF-HU, and FF-HA (ICCs, 0.93-0.96).

CONCLUSIONS

Fat quantification within the rotator cuff muscles using CT HA is both feasible and reliable.

ADVANCES IN KNOWLEDGE

CT HA provides reliable quantification of intramuscular fat and has strengths regarding its retrospective applicability to conventional CT studies without additional radiation dose to subjecting patients.

Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears

BACKGROUND

Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.

METHODS

This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.

RESULTS

Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).

CONCLUSION

Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

Rotator Cuff Repair with Knotless All-Suture Medial Row Anchors and Biceps Autograft Augmentation

Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.

Postoperative graft integrity affects clinical outcomes after superior capsule reconstruction using fascia lata autograft in posterior-superior rotator cuff tears: a multicenter study

BACKGROUND

Previous studies have postulated that graft thickness and graft healing may be important factors for optimizing clinical outcomes of superior capsule reconstruction (SCR) for patients with irreparable rotator cuff tears (RCTs). However, the relationship between postoperative graft integrity and clinical outcomes after SCR remains unclear. We aimed to assess the relationship between postoperative graft integrity, including graft thickness and size of graft tear, and clinical outcomes after SCR in patients with irreparable RCTs.

METHODS

This retrospective multicenter study included 188 patients (86 women, 102 men; mean age, 69.2 years; range, 49-87 years) with irreparable RCTs who underwent arthroscopic SCR using fascia lata autografts. Using magnetic resonance imaging, the graft integrity was evaluated postoperatively at or after 1 year and was classified, according to Hasegawa's classification, into 4 categories: type I-II, intact graft of sufficient thickness; type III, thinned graft without discontinuity; type IV, presence of a minor discontinuity; and type V, presence of a major discontinuity. We compared (1) baseline characteristics, (2) visual analog scale (VAS) for pain, (3) American Shoulder and Elbow Surgeons (ASES) score, (4) active shoulder range of motion, and (5) acromiohumeral distance (AHD) among 4 groups based on postoperative graft integrity.

RESULTS

Magnetic resonance imaging scans revealed 152 shoulders (80.9%) with type I-II graft, 13 (6.9%) with type III graft, 13 (6.9%) with type IV graft, and 10 (5.3%) with type V graft. VAS and ASES scores significantly improved after SCR in all graft types (P < .0001 to P = .02). However, shoulders with type V grafts had significantly inferior postoperative VAS and ASES scores compared to those with type I-II grafts (P = .001 and P < .0001, respectively). Shoulders without graft tears (types I-II and III) showed significant improvements in shoulder elevation and internal rotation after SCR (P < .0001 to P = .02). In contrast, shoulders with large graft tears (type V) showed no significant improvement in shoulder range of motion. Postoperative acromiohumeral distance significantly increased only in shoulders with type I-II grafts (P < .0001).

CONCLUSION

Postoperative graft thickness and size of graft tear affected clinical and radiographic outcomes after SCR using a fascia lata autograft. Patients with large graft tears had significantly inferior postoperative clinical scores compared to those with intact grafts of sufficient thickness, although arthroscopic SCR provided pain relief even in patients with graft tears. Shoulders with intact grafts of sufficient thickness restored glenohumeral stability and showed better clinical outcomes than those with graft thinning or tears.

Association Between Supraspinatus Tendon Retraction, Histologic Myofiber Size, and Supraspinatus Muscle Atrophy on MRI

BACKGROUND

Atrophy of the rotator cuff is a negative prognostic indicator after rotator cuff repair. Although full-thickness rotator cuff tears accompanied by tendon retraction are commonly associated with decreased muscle cross-sectional area (CSA) on magnetic resonance imaging (MRI), it is unclear whether this is accompanied by histologic atrophy of rotator cuff myofibers.

PURPOSE

To evaluate the effect of supraspinatus tendon retraction and myofiber size on supraspinatus atrophy on MRI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Supraspinatus muscle biopsy specimens were obtained from consecutive patients undergoing arthroscopic shoulder surgery. Rotator cuff tears were classified according to size. Preoperative MRI was used to measure tendon retraction and CSA of the supraspinatus muscle in the Y-shaped view. The occupation ratio of the supraspinatus was calculated by dividing the supraspinatus CSA by the supraspinatus fossa CSA. Muscle biopsy specimens were examined using laminin to quantify myofiber CSA. The association between supraspinatus tear size and measures of histologic and MRI muscle atrophy were compared using standard statistical tests. Multivariable logistic regression analysis was used to identify independent predictors of muscle atrophy on MRI.

RESULTS

A total of 38 patients were included: 8 with no tear, 14 with a partial-thickness tear, and 16 with a full-thickness tear. Increasing tear size was associated with greater distance of tendon retraction (P < .001), smaller mean histologic myofiber size (P = .004), lower mean supraspinatus CSA on MRI (P < .001), and lower occupation ratio: 0.73 (control), 0.66 (partial tear), 0.53 (small to medium full-thickness tear), and 0.38 (large to massive full-thickness) (P < .001). On Pearson correlation analysis, tendon retraction demonstrated strong correlation with occupation ratio (-0.725; P < .001) and weak correlation with myofiber size (-0.437; P = .006), while occupation ratio showed moderate correlation with myofiber size (0.593; P < .001). Multivariable linear regression analysis demonstrated that increasing tendon retraction (P < .001), age (P = .034), and smaller histologic myofiber CSA (P = .047) were independently associated with greater supraspinatus atrophy on MRI.

CONCLUSION

Supraspinatus muscle atrophy appreciated on MRI is independently associated with patient age, tendon retraction, and atrophy of the supraspinatus myofibers at the histologic level.

Factors affecting satisfaction in patients with a rotator cuff retear: CT arthrography-based study

PURPOSE

The relationship between retear that may occur after rotator cuff repair and patient satisfaction is not well established. This study aimed to determine whether the types and size of the retear evaluated by computed tomography arthrography (CTA) influenced patient satisfaction. We also analyzed the patient factors that could affect patient satisfaction.

PATIENTS AND METHODS

A total of 50 patients who were diagnosed with rotator cuff retear after undergoing arthroscopic rotator cuff repair were included in this study. All the patients were dichotomously classified into the satisfactory or dissatisfactory groups according to the patients' self-classifications. CTA was used to assess the attachment status of the footprint, detect retear on the medial side of the footprint of the repaired cuff, and determine the retear size. Demographic factors, including sex, age, occupation, dominant upper extremity, duration of pain, presence of diabetes mellitus, trauma history, history of ipsilateral shoulder surgery, repair technique, worker's compensation status, and functional shoulder score, were investigated.

RESULTS

Thirty-nine patients were classified into the satisfactory group and 11 patients were classified into the dissatisfactory group. There were no differences in age, sex, occupation, dominant hand, duration of pain, presence of diabetes mellitus, trauma history, history of ipsilateral shoulder surgery, repair technique, worker's compensation, and duration of follow-up between the two groups. However, the postoperative American Shoulder and Elbow Surgeon (ASES) score (P < 0.01), visual analog scale (VAS) pain level (P < 0.01), anteroposterior (AP) length (P < 0.01), and area of the retear site (P < 0.01) were significantly different.

CONCLUSION

The AP length and area of the retear site estimated using CTA were confirmed as the significant risk factors for dissatisfaction. However, the type of repaired rotator cuff judged by the attachment status of the footprint did not correlate with patient satisfaction. In addition, the postoperative VAS pain scale and ASES score was correlated with patient satisfaction.

Traumatic rotator cuff tears with concomitant shoulder dislocation: tear characteristics and postsurgical outcomes

BACKGROUND

Arthroscopic rotator cuff repair has been shown to have favorable outcomes following traumatic rotator cuff tear with concomitant shoulder dislocation. The aim of this study was to compare outcomes and tear characteristics between patients who underwent arthroscopic rotator cuff repair following traumatic tear with shoulder dislocation to those without dislocation.

METHODS

A retrospective review of 226 consecutive patients with traumatic rotator cuff tears who underwent arthroscopic repair between 2013 and 2017 with a minimum of 1-year follow-up was performed. Patients with traumatic dislocations and concomitant rotator cuff tears were placed in the Dislocation & Tear cohort (DT cohort) and were matched 1:2 with a second cohort sustaining traumatic cuff tears without dislocation (T cohort). Primary outcomes were injury characteristics including tendon involvement and atrophy and tear size and thickness. Secondary outcomes were postoperative strength and range of motion (ROM) in forward flexion (FF), external rotation (ER), and internal rotation (IR); patient-reported outcomes including Subjective Shoulder Value, visual analog scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; complications including repair failure (defined as symptomatic retear confirmed on postoperative magnetic resonance imaging), infection, adhesive capsulitis, and impingement; and rates of revision surgery.

RESULTS

There were 18 patients in the DT Cohort and 36 patients in the T Cohort with no significant differences in time to final follow-up (50.4 ± 24.5 months vs. 49.0 ± 30.4 months, P = .73). The DT cohort displayed a larger mean tear size (34 ± 12 mm vs. 19 ± 12 mm, P = .01) and had greater infraspinatus involvement (78% vs. 36%, P = .004) and subscapularis involvement (72% vs. 39%, P = .02) than the T cohort. With regard to strength, postoperative ER strength was less likely to be 5/5 in the DT Cohort (53% vs. 94% of patients with 5/5 strength, P = .002) compared with the T cohort. With regard to ROM, the DT cohort had significantly lower preoperative FF (90° ± 55° vs. 149° ± 33°, P < .001), ER (36 ± 21° vs. 52° ± 14°, P = .02), and IR (5.4 ± 2.1 vs. 7.5 ± 1.2, P = .002) compared with the T cohort but had similar FF, ER, and IR outcomes postoperatively. There were no differences between the groups for complications and postoperative patient-reported outcomes.

CONCLUSION

Traumatic rotator cuff tears with concomitant dislocations are associated with larger tear size and greater infraspinatus and subscapularis involvement than traumatic tears without dislocation. Arthroscopic repair of this injury is associated with lower preoperative ROM in FF, ER, and IR, as well as lower postoperative ER strength compared with traumatic tears without dislocation. Nonetheless, excellent patient-reported outcomes can be achieved following arthroscopic repair similar to patients without dislocation.

Prognostic Factors for Clinical Outcomes After Arthroscopic Rotator Cuff Repair

Background

Limited knowledge exists regarding prognostic factors after rotator cuff repair.

Purpose

To identify pre- and perioperative predictors for functional outcomes after arthroscopic rotator cuff repair.

Study Design

Case-control study; Level of evidence, 3.

Methods

This study included patients who underwent arthroscopic rotator cuff repair between January 2013 and April 2019 and who had preoperative magnetic resonance imaging scans. The procedures were performed by 4 shoulder surgeons at a single institution. Excluded were patients who had previous surgeries, those who underwent open surgery, and those without 12- and 24-month follow-up clinical data. Patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] Standardized Shoulder Assessment Form and University of California, Los Angeles [UCLA] Shoulder Rating Scale scores) were assessed preoperatively and at 6, 12, and 24 months postoperatively. Using multiple linear regression analysis, the authors evaluated the influence of 29 variables relating to patient, lesion, and procedure characteristics on postoperative outcomes, with the 24-month ASES score as the dependent variable.

Results

The study sample consisted of 474 patients (500 shoulders). The median ASES score increased from 41.6 preoperatively to 88.3 at 24 months (P < .001), and the median UCLA score increased from 14 preoperatively to 32 in the same period (P < .001). The following variables were found to be independent predictors for higher 24-month postoperative ASES score: male sex, absence of rheumatologic disease, older age, lower degree of supraspinatus muscle fatty degeneration, acromioplasty, and a higher preoperative ASES score.

Conclusion

The prognostic factors for better clinical results at 24 months after arthroscopic rotator cuff repair were male sex, absence of rheumatologic disease, older age, lower degree of fatty degeneration of the supraspinatus muscle, concomitant acromioplasty, and higher preoperative ASES score.

Outcomes of Isolated Biceps Tenodesis/Tenotomy or Partial Rotator Cuff Repair Associated with Biceps Tenodesis/Tenotomy for Massive Irreparable Tears: A Systematic Review

Irreparable large to massive rotator cuff tears (MIRCTs) are a prevalent cause of shoulder pain and dysfunction, and nonoperative treatment may not always be effective. Various surgical options exist, with isolated biceps tenotomy/tenodesis (BT) or arthroscopic partial repair with associated biceps tenotomy/tenodesis (PCR-BT) being the most common. The aim of this study was to systematically review the available data on the clinical and functional outcomes of BT and PCR-BT in patients with MIRCTs.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched for studies on the treatment of MIRCT. We included studies with BT or PCR-BT with a minimum follow-up of 24 months. The MINORS (Methodological Index for Nonrandomized Studies) score was used to assess study quality. Outcomes included were the visual analog scale for pain, functional scores such as Constant-Murley and American Shoulder and Elbow Surgeons, range of motion, radiological measurements, and complications.

RESULTS

A total of 1101 patients (506 had a BT and 595 had a PCR-BT) from 22 studies were included (cases series = 13, case-control = 7, randomized control trial = 1, prospective cohort study = 1). The mean MINORS score was 13.2 ± 3.2. The mean age and follow-up were 67 ± 6.8 years and 4.58 ± 1.1 years (range, 2, 12), respectively. The VAS improvement showed at the last follow-up for PCR-BT (range, 1.97, 5.8) and BT (range, 4, 6.1). CMS was improved at the final follow-up for PCR-BT (range, 13, 47.6) and BT (range, 10.8, 28). Regarding the ASES, it has demonstrated significant improvements for PCR-BT (range, 31.81, 44.8) and BT (range, 30,45.8). For forward flexion, PCR-BT showed improvement (range, -14°, 59.4°), as well as the BT group (range, 2°, 27.9°).

CONCLUSIONS

This systematic review demonstrated that both BT and PCR-BT improve functional outcomes and reduce pain at midterm follow-up for MIRCT. Since we know that a failed cuff repair would worsen the shoulder, it might be beneficial in terms of the risk-benefit ratio to not repair in certain patients with MIRCT.

Arthroscopic rotator cuff repair: patients with physically demanding work have significantly worse time to return to work, level of employment, and job loss

PURPOSE

The purpose of this study was to determine the results of arthroscopic rotator cuff repair (ARCR) in terms of return to work (RTW).

METHODS

Inclusion criteria were working patients who underwent ARCR for rotator cuff rupture at the study site between 2008 and 2020 and minimum 12 months of follow-up. Patients were stratified based on the physical demand of their work according to the Canadian Classification and Dictionary of Occupations. The primary outcomes were time to RTW, level of employment (LoE), change of tasks, and work loss. Secondary outcomes included the return to sports activities, EQ-VAS, EQ-5D-5L, DASH, and Oxford Shoulder Score.

RESULTS

Three-hundred and eighty-three patients were enrolled; at the follow-up evaluation, fifty-three patients (13.8%) lost their job, with a percentage of 34.4% (eleven patients) in the heavy-work category, and five patients (1.3%) chose early retirement. Other twenty-six patients (6.8%) had to lower their level of employment, and twenty patients (5.2%) changing their tasks, with 279 patients (72.9%) returning to their previous work activity. RTW was obtained at a mean time of 4.7 ± 4.6 months, ranging from 3.8 ± 3.1 months in the sedentary work vs 5.8 ± 2.8 months in the very heavy-work category (p = 0.015). The mean EQ-VAS score was 77.3 ± 18 points, the mean Oxford Shoulder Score was 43.4 ± 7.2 points, and the mean DASH score was 9.9 ± 14.5 points; 75.3% returned to their previous level of sport activity.

CONCLUSIONS

The success of ARCR in terms of RTW is not always complete and varies significantly based on the physical demand of the patient's job. Patients with physically demanding work have a significantly higher time to RTW, reduction of the LoE, and job loss rate, thus affecting the possibility to have a satisfactory return to their previous life. The findings are of clinical relevance since they can help the surgeons to give their patients reliable expectations and to correctly plan the post-operative management.

LEVEL OF EVIDENCE

IV.

Effect of Quality of Repair on Clinical and Structural Outcomes of Rotator Cuff Repair

BACKGROUND

Anatomic repair of a torn rotator cuff tendon on the greater tuberosity (GT) is an important surgical goal in rotator cuff repair. However, few studies have investigated whether the efforts made to maximize coverage of the GT are associated with the clinical and structural outcomes after rotator cuff repair surgery.

PURPOSE

To investigate whether the quality of repair at the time of surgery is associated with clinical and structural outcomes after surgery and to identify factors influencing the quality of repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively collected from 141 patients who underwent arthroscopic rotator cuff repair between 2008 and 2016. All repairs were classified according to the amount of postoperative GT coverage: A, complete coverage of the GT (n = 96); B, incomplete coverage, comprising more than half of GT (n = 27); C, incomplete coverage, comprising less than half of the GT (n = 16); and D, exposure of the glenohumeral joint (n = 2). All patients underwent magnetic resonance imaging 1 year after surgery. Clinical outcomes and structural integrity based on Sugaya classification were assessed 2 years and 1 year after surgery, respectively. Preoperative factors associated with the postoperative GT coverage (measured at the close of surgery) were identified using a multivariable proportional odds cumulative logit model.

RESULTS

The forward flexion strength in group A (10.3 ± 4.6 lb) was significantly greater than that in group C (6.5 ± 3.7 lb) (P = .003) 2 years after surgery. The postoperative Constant score in group A (76.6 ± 11.5) was greater than that in group C (66.7 ± 15.6) (P = .018). The number of cases that showed retearing of the repaired tendon was as follows: group A (5/96; 5.2%), group B (7/27; 25.9%), and group C (10/16; 62.5%). There was no significant difference in the changes of pain visual analog scale scores among groups 2 years after surgery (all P > .05). Also, there was no significant difference in the changes of range of motion in all directions among groups 2 years after surgery (all P > .05). Patients with preoperative GT coverage B included in the postoperative GT coverage groups through surgery were as follows: group A (23/45; 51.1%), group B (17/45; 37.8%), and group C (5/45; 11.1%). Preoperative GT coverage was the only independent factor that was associated with GT coverage in multivariable analysis.

CONCLUSION

Quality of repair, measured as the extent of postoperative GT coverage at the time of surgery, was associated with clinical and structural outcomes after rotator cuff repair surgery.

Evolution of functional tissue engineering for tendon and ligament repair

This review paper is motivated by a Back-to-Basics presentation given by the author at the 2022 Orthopaedic Research Society meeting in Tampa, Florida. I was tasked with providing a brief history of research leading up to the introduction of functional tissue engineering (FTE) for tendon and ligament repair. Beginning in the 1970s, this timeline focused on two common orthopedic soft tissue problems, anterior cruciate ligament ruptures in the knee and supraspinatus tendon injuries in the shoulder. Historic changes in the field over the next 5 decades revealed a transformation from a focus more on mechanics (called "bioMECHANICS") on a larger (tissue) scale to a more recent focus on biology (called "mechanoBIOLOGY") on a smaller (cellular and molecular) scale. Early studies by surgeons and engineers revealed the importance of testing conditions for ligaments and tendons (e.g., high strain rates while avoiding subject disuse and immobility) and the need to measure in vivo forces in these tissues. But any true tissue engineering and regeneration in these early decades was limited more to the use of auto-, allo- and xenografts than actual generation of stimulated cell-scaffold constructs in culture. It was only after the discovery of tissue engineering in 1988 and the recognition of frequent rotator cuff injuries in the early 1990s, that biologists joined surgeons and engineers to discover mechanical and biological testing criteria for FTE. This review emphasizes the need for broader and more inclusive collaborations by surgeons, biologists and engineers in the short term with involvement of those in biomaterials, manufacturing, and regulation of new products in the longer term.

Rotator cuff repair in patients with inflammatory arthritis: satisfactory midterm outcomes

Background

We aimed to evaluate midterm patient-reported outcomes and reoperation rates following rotator cuff repair in patients with either rheumatoid arthritis (RA) or other inflammatory arthritis (nonRA-IA) diagnoses.

Methods

We identified all patients with either RA or nonRA-IA who underwent a rotator cuff repair at our institution between 2008 and 2018. IA diagnoses included RA, systemic lupus erythematosus, psoriatic arthritis, and other unspecified inflammatory arthritis. We compiled a cohort of 51 shoulders, with an average follow-up time of 7.0 years. The average age was 60 years (range 39-81), and 55% of patients were female. Patients were contacted via phone to obtain patient-reported outcomes surveys. Univariate linear regression was used to evaluate associations between patient characteristics and outcomes.

Results

A review of preoperative radiographs demonstrated that 50% of patients presented with some degree of glenohumeral joint inflammatory degeneration. At the final follow-up, the mean visual analog score for pain was 2 (range 0-8), and the mean American Shoulder and Elbow Surgeons score (ASES) was 77 (standard deviation [SD] = 19). The mean subjective shoulder value was 75% (SD = 22%), and the average satisfaction was 9 (SD 1.9). The mean Patient-Reported Outcomes Measurement Information System upper extremity score was 41 (SD = 10.6). Female sex and a complete tear (vs. partial) were both associated with lower ASES scores, whereas no other characteristics were associated with postoperative ASES scores. The 5-year Kaplan-Meier survival estimate free of reoperation was 91.8% (95% confidence interval 83.0-99.8).

Conclusions

Rotator cuff repair in patients with RA or other inflammatory arthritis diagnoses resulted in satisfactory patient-reported outcomes that seem comparable to rotator cuff repair when performed in the general population. Furthermore, reoperations were rare, with a 5-year survival rate free of reoperation for any reason of over 90%. Altogether, an inflammatory arthritis diagnosis should not preclude by itself attempted rotator cuff repair surgery in these patients.

Effectiveness of combined extracorporeal shock-wave therapy and hyaluronic acid injections for patients with shoulder pain due to rotator cuff tendinopathy: a person-centered approach with a focus on gender differences to treatment response

BACKGROUND

Rotator cuff (RC) tendinopathy is a common shoulder pain condition. Extracorporeal shockwave therapy (ESWT) and hyaluronic acid peritendinous injection are viable treatment options for RC tendinopathy. The aim of this study is to evaluate the response in two different therapeutic rehabilitative approaches, the combined treatment ESWT plus hyaluronic acid injections (E + Hy) compared to ESWT alone (ESWT-al), in a cohort of patients with RC tendinopathy according to gender differences.

METHODS

This is a retrospective longitudinal cohort study of patients with painful RC tendinopathy. Patients that had received a clinical evaluation, a shoulder ultra sound examination, as well as the Shoulder Pain and Disability Index (SPADI) questionnaire, and the Numerical Rating Scale (NRS) for pain at baseline, 1-month (T1) and 2-month follow-ups (T2) were included.

RESULTS

Medical records of 53 patients were analyzed. In the comparison between baseline to T1 and similarly from baseline to T2, a statistically significant reduction has been reported in the NRS (p < 0.001) and in the SPADI (p < 0.001) in the entire study group. At T1, patients in the E + Hy compared to ESWT-al group, showed a slight but statistically significant reductions in both NRS and SPADI score, while these changes were more evident at T2 (p < 0.001). Interestingly, a gender dimorphism in NRS and in SPADI was found, with female patients that apparently responded better to the combined E + Hy compared to ESWT-al approach.

CONCLUSION

This retrospective cohort study suggests that the combination of ESWT plus HyA injections seems to be more effective than ESWT alone in RC tendinopathy in both genders. Moreover, in ESWT alone treatment, male patients reported better outcomes compared to females. However, further randomized controlled trials should be structured to confirm and enforce these conclusions.

VEGFA-Enriched Exosomes from Tendon-Derived Stem Cells Facilitate Tenocyte Differentiation, Migration, and Transition to a Fibroblastic Phenotype

Tendon-derived stem cells (TDSCs) play a vital role in repair of rotator cuff tear injuries by secreting paracrine proteins that regulate resident cell functions. Secreted exosomes may play a role in tendon injury repair by mediating intercellular communication; however, the detailed mechanisms by which TDSC-derived exosomes affect tenocyte development remain unknown. Here, we examined the effects of exosomes isolated from conditioned medium of TDSCs on tenocyte differentiation, migration, and transition to a fibroblastic phenotype in vitro. Successful isolation of exosomes from TDSCs was confirmed by high expression levels of CD81, CD63, CD9, and TSG101. Treatment with TDSC-derived exosomes promoted the growth and migration of cultured rat tenocytes, and increased the levels of the fibrosis markers collagen I, collagen III, scleraxis, tenascin C, and α-smooth muscle actin. Furthermore, vascular endothelial growth factor A (VEGFA) expression was higher in TDSC-derived exosomes than in TDSCs, and genetic knockdown of VEGFA suppressed the stimulatory effect of TDSC-derived exosomes on tenocyte development. Overall, these results demonstrate that VEGFA-enriched exosomes isolated from TDSCs promote differentiation and migration of cultured tenocytes and their transition to a fibroblastic phenotype. These data provide a new potential clinical treatment strategy for tendon injury.

Significant radiologic factors related to clinical outcomes after arthroscopic rotator cuff retear repair

Background

Healing of the tendon itself is not always related to successful clinical outcomes after rotator cuff repair. It was hypothesized that certain radiologic factors affecting clinical outcomes could exist in case of the retear after arthroscopic rotator cuff repair (ARCR) and the radiologic factors could help predict clinical process. The purpose of this study was to identify the radiologic factors associated with clinical outcomes of the retear after ARCR.

Methods

Between January 2012 and December 2019, among patients with sufficient footprint coverage for ARCR, 96 patients with Sugaya classification 4 or higher retear on follow-up magnetic resonance imaging were included. The association between clinical outcomes such as American Shoulder and Elbow Surgeons (ASES) score, Constant score and range of motion and radiologic variables such as initial tear dimension, retear dimension, variance of tear dimension, critical shoulder angle, acromial index, and acromiohumeral distance was analyzed.

Results

Preoperatively, the ASES and Constant scores were 59.81±17.02 and 64.30±15.27, respectively. And at the last follow-up, they improved to 81.56±16.29 and 78.62±14.16, respectively (p<0.01 and p<0.01). In multiple linear regression analysis, the variance of the mediolateral dimension of tear had statistically significant association with the ASES and Constant scores (p<0.01 and p=0.01).

Conclusions

In patients with the retear after ARCR, the variance in the mediolateral dimension of tear had significantly negative association with the clinical outcomes. This could be considered to be reference as relative criteria and needed more sample and mechanical study.

In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months

Background:

Rotator cuff repair is a common orthopaedic procedure that provides pain relief for many patients, but unfortunately, an estimated 20% to 70% of repair procedures will fail. Previous research has shown that elongation (ie, retraction) of a repaired tendon is common even in patients with a repair construct that appears intact on magnetic resonance imaging. However, it is unknown how this repair tissue functions under dynamic conditions.

Purpose:

To quantify static retraction and maximum dynamic elongation of repair tissue after rotator cuff repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Data from 9 patients were analyzed for this study. During surgery, a 3.1-mm tantalum bead was sutured to the supraspinatus tendon, medial to the repair site. Glenohumeral kinematics were assessed at 1 week (static) and 3 months (static and during scapular-plane abduction) after surgery using a biplanar videoradiographic system. The 3-dimensional position of the bead was calculated relative to the tendon’s insertion on the humerus (ie, bead-to-insertion distance). Static retraction was calculated as the change in the bead-to-insertion distance under static conditions between 1 week and 3 months after surgery, and maximum dynamic elongation was calculated as the maximal positive change in the bead-to-insertion distance during dynamic motion relative to the start of motion. The magnitudes of static retraction and maximum dynamic elongation were assessed with 1-sample t tests.

Results:

At 3 months after surgery, static retraction occurred in all patients by a mean of 10.0 ± 9.1 mm (P = .01 compared with no elongation). During scapular-plane abduction, maximum dynamic elongation averaged 1.4 ± 1.0 mm (P < .01 compared with no elongation). Descriptively, dynamic elongation consistently took 1 of 2 forms: an initial increase in the bead-to-insertion distance (mean, 2.0 ± 0.6 mm) before decreasing until the end of motion or an immediate and substantial decrease in the bead-to-insertion distance at the onset of motion.

Conclusion:

Repair tissue elongation (static retraction and maximum dynamic elongation) appeared to be a common and significant finding at 3 months after arthroscopic rotator cuff repair. Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function.

Posterior decentering of the humeral head in patients with arthroscopic rotator cuff repair

Background: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). Methods: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2 mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. Results: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 33.8, which was greater than that for tear size ≥3 cm and FD grade ≥3. Conclusions: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

Effect of human dermal allograft thickness on glenohumeral stability for superior capsular reconstruction in irreparable supraspinatus tears: A biomechanical analysis of the superior capsular reconstruction - A cadaveric study

PURPOSE

The objective of this study was to compare the biomechanics of using a double layered human dermal allograft to a single layered human dermal allograft in superior capsular reconstruction.

METHODS

Five cadaveric shoulders were tested. The superior translation of the humerus and the subacromial contact pressure were measured at 0°, 30° and 60° of glenohumeral abduction in the following six conditions: (1) intact rotator cuff, (2) irreparable supraspinatus tear, (3) superior capsular reconstruction using a double layered human dermal allograft with and (4) without posterior suturing, (5) superior capsular reconstruction using a single human dermal allograft with and (6) without posterior suturing.

RESULTS

There was a significant increase in superior translation of the humerus and subacromial contact pressure when comparing torn supraspinatus to intact shoulder. All superior capsular reconstruction repairs lead to a reduction in superior translation and subacromial contact pressures compared to after the supraspinatus tear except for single layered superior capsular reconstruction repair without posterior suturing. There was no difference in superior translation and subacromial contact pressures comparing the intact shoulder to any of the superior capsular reconstruction constructs.

CONCLUSION

Superior capsular reconstruction using a single or double layered human dermal allograft improves superior translation after supraspinatus repair. There is some biomechanical benefit of a double layered human dermal allograft technique over a single layered graft technique in superior capsular reconstruction.

LEVEL OF EVIDENCE

IV.

Quantitative magnetic resonance imaging assessment of the infraspinatus and teres minor in massive rotator cuff tear and its significance in clinical outcome after rotator cuff repair

BACKGROUND

Teres minor (TM) muscle hypertrophy in large to massive rotator cuff tears (RCTs) has been considered a compensatory change to atrophy of the infraspinatus (ISP). However, few reports have assessed its relation to the prognosis after rotator cuff repair.

METHODS

A total of 139 patients who underwent arthroscopic repair of large to massive RCTs involving the ISP between January 2013 and December 2015 were retrospectively investigated. Occupational ratios of the ISP (OR_ISP) and TM (OR_TM) were measured by sagittal magnetic resonance imaging (MRI). Rotator cuff healing was evaluated by MRI 1 year postoperatively, and functional outcomes using the Simple Shoulder Test (SST) and Constant score and external rotator (ER) strength by isokinetic muscle performance test (IMPT) were measured.

RESULTS

A total of 116 patients completed the MRI and IMPT at 1 year postoperatively, and functional scores were measured at least 2 years postoperatively. Of these, the repaired tendon had not healed in 34 patients (29%). There was a highly negative correlation between OR_ISP and OR_TM both pre- and postoperatively (Pearson correlation = -0.52 and -0.54, respectively). Preoperative OR_ISP was significantly higher in the healed than in the healing failure group (0.47 ± 0.10 vs. 0.41 ± 0.12, P = .02); however, postoperative OR_ISP and pre- and postoperative OR_TM were not. The preoperative OR_ISP cutoff value for healing was 0.46. For functional outcomes, only postoperative OR_ISP showed a statistical correlation with SST, Constant score (P = .04 and .03, respectively), and ER strength (P = .02).

CONCLUSION

TM muscle hypertrophy in large to massive RCT appears to be a compensatory change in the progression of atrophy of the ISP muscle and was not a significant indicator of either better healing of the repaired rotator cuff tendon or better function. Only preoperative OR_ISP was an independent prognostic factor affecting rotator cuff healing after repair of large to massive RCTs.

Arthroscopic Rotator Cuff Repair Results in Lower Two-Year Reoperation Rates Compared With Open Rotator Cuff Repair in a Large Cross-sectional Cohort

PURPOSE

To use a large, contemporary database to perform a cross-sectional analysis of current practice trends in rotator cuff repair (RCR) for the treatment of full-thickness rotator cuff tear (RCT) and determine outcomes of arthroscopic and open RCR, including hospital readmissions and 2-year reoperation rates with accurate laterality tracking using International Classification of Diseases, Tenth Revision (ICD-10) codes.

METHODS

The PearlDiver Mariner dataset was used to query patients with full-thickness RCTs from 2010 to 2017. Propensity-score matching was performed to account for differences in age and comorbidities and allow for comparison between those undergoing open RCR and arthroscopic RCR. Subsequent procedures were tracked using ICD-10 codes to identify ipsilateral surgery within 2 years of index surgery. Hospital and emergency department admission within 30 days of surgery were investigated.

RESULTS

Of 534,076 patients diagnosed with full-thickness RCT, 37% underwent RCR; 73% of which were arthroscopic. From 2010 to 2017, arthroscopic RCRs increased from 65% to 80%, whereas open RCRs decreased from 35% to 20% (P < .0001). Younger patients underwent arthroscopic RCR more frequently, and patients who underwent open RCR had greater rates of 30-day emergency department (7.0%) and hospital readmission (2.0%) compared with arthroscopic RCR (6.3%, 1.0%, respectively) (P < .0001). For 24,392 patients with ICD-10 coding and 2-year follow-up, 10.4% of patients required reoperation, with the most common procedure being revision RCR, and 1.3% required conversion to arthroplasty. Open RCRs were more likely to require subsequent surgery (11.3%) compared with arthroscopic RCR (9.5%) (P < .0001). Patients aged 50 to 59 had the greatest rate of reoperation (14.0%), but no patients younger than age 40 years required reoperation, and no patients younger than age 50 years required conversion to arthroplasty.

CONCLUSIONS

The frequency of arthroscopic RCR has continued to increase compared to open RCR. In this large cross-sectional analysis, arthroscopic RCR demonstrated lower 2-year reoperation rates and 30-day readmission rates compared to open RCR.

LEVEL OF EVIDENCE

III, cross-sectional study.

Clinical differences between patients with early and late revision surgery for symptomatic failed arthroscopic rotator cuff repair

PURPOSE

Time ranges of revision rotator cuff surgeries after arthroscopic repair are highly variable. However, the cause and clinical relevance of the different timings of revision surgeries have not been analyzed. The purpose of this study was to evaluate the clinical manifestations of patients who required revision surgeries at early and late periods after failed arthroscopic rotator cuff repair, and to identify clinical and radiological differences related to the timing of revision surgery.

METHODS

Sixty patients who underwent revision surgery due to symptomatic failed rotator cuff repair after arthroscopic repair were included. Patients were divided into two groups: patients who underwent revision surgeries within 1 year postoperatively (21 patients, group I) and patients who underwent revision surgeries more than 1 year postoperatively (39 patients, group II). Clinical and radiological characteristics were compared between the two groups before primary and revision surgery.

RESULTS

VAS for pain (5.9 ± 1.9 in group I, 3.9 ± 1.4 in group II, P < 0.001) and Constant score (50.7 ± 9.9 in group I, 60.4 ± 8.9 in group II, P < 0.001) at the time of revision surgery were significantly different between the two groups. In group II, isometric muscle strength of forward flexion (74.1 ± 21.1 to 63.9 ± 15.1, P = 0.020) and external rotation (73.0 ± 23.5 to 61.2 ± 15.0, P = 0.032) were significantly deteriorated after primary surgery, even with significant improvement of pain and shoulder function (VAS: 5.7 ± 1.9 to 3.9 ± 1.4, P < 0.001; Constant score: 50.3 ± 11.0 to 60.4 ± 8.9, P < 0.001). On postoperative MRI, re-tear at the tendon-bone interface on the greater tuberosity occurred significantly more in group I (81.0%) than group II (51.3%, P = 0.024). Incidence of full-thickness tear of the subscapularis tendon was significantly different between the two groups (42.9% in group I, 12.8% in group II, P = 0.012).

CONCLUSION

Patients who had early revision surgeries had significantly worse clinical outcomes after primary surgery than patients who had late revision surgeries. Healing failure at the tendon-bone interface on the greater tuberosity and re-tear combined with full-thickness tear of subscapularis tendon were related to early revision. Conversely, patients of the late revision group had muscle weakness that considerably impacted daily activities, even with improved pain and shoulder function.

LEVEL OF EVIDENCE

III.

Diagnostic Ultrasound Shows Reversal of Supraspinatus Muscle Atrophy Following Arthroscopic Rotator Cuff Repair

PURPOSE

Prospective study to assess ultrasonography (US) utility as an imaging tool for supraspinatus muscle atrophy diagnosis, establishing if there is any relationship between repairing supraspinatus tears and its eventual muscular recovery.

METHODS

Observational study.

SELECTION CRITERIA

adults with a full-thickness reparable supraspinatus tear confirmed arthroscopically. Clinical and imaging data pre- and postoperatively with 12 months of follow-up were recorded, including demographic data, Constant scale, Patte classification, repair type, and supraspinatus muscle belly US images in both shoulders, recording height, diameter, echogenicity (mean number of pixels between 0-black and 255-white), and central tendon pennate angle (PA).

RESULTS

In total, 110 supraspinatus tears underwent arthroscopic repair (2015-2018). Mean age was 61 ± 8 years (46-77). We detected a correlation between atrophy and age in terms of echogenicity and PA (P = .01). Echogenicity improved from 54.5 to 51.0 (P = .365) and slightly deteriorated on the contralateral side from 51.6 to 52.9 (P = .351). Supraspinatus echogenicity compared to trapezius muscle reduced from 0.43 to 0.36 (P < .001). PA augmented from 5.8 to 8.6 (P < .001). Mean PA on the contralateral side was 8.6 preoperatively. Patte II cases showed the most significant improvement in terms of imaging evaluation of atrophy. Although Patte III cases almost did not improve in terms of atrophy, they improved clinically. We observed improvement after surgery in Constant score from 35 to 85 (P < .001). Minimal clinically important differences for Constant and visual analog scale were 44.45 ± 12.87 and 6.54 ± 1.41, respectively. Recurrence of symptoms was 13%, related to worse results of PA and echogenicity compared to nonrecurrences.

CONCLUSIONS

Supraspinatus atrophic muscle changes after repair can be reversed. It can be quantified using US imaging (histogram, histogram ratio and echogenicity reduction, pennate pattern, and PA augmentation). Patte II cases showed the best results after repair, demonstrated by US. The faster the repair, the better the results without being influenced by repair type. The bigger the tear and retraction, the more echogenicity and less PA, with worse clinical and US results.

LEVEL OF EVIDENCE

Level III, prospective therapeutic study.

Presurgical tear characteristics and estimated shear modulus as predictors of repair integrity and shoulder function one year after rotator cuff repair

Background

Rotator cuff repair provides pain relief for many patients; however, retears are relatively common and affect approximately 20%-70% of patients after repair. Although magnetic resonance imaging (MRI) offers the ability to assess tissue characteristics such as tear size, retraction, and fatty infiltration, it provides little insight into the quality of the musculotendinous tissues the surgeon will encounter during surgery. However, shear wave elastography (SWE) could provide an indirect assessment of quality (ie, stiffness) by measuring the speed of shear waves propagating through tissue. The objective of this study was to determine the extent to which estimated shear modulus predicts repair integrity and functional outcomes 1 year after rotator cuff repair.

Methods

Thirty-three individuals scheduled to undergo arthroscopic rotator cuff repair were enrolled in this study. Before surgery, shear modulus of the supraspinatus tendon and muscle was estimated using ultrasound SWE. MRIs were obtained before and 1 year after surgery to assess tear characteristics and repair integrity, respectively. Shoulder strength, range of motion, and patient-reported pain and function were assessed before and after surgery. Functional outcomes were compared between groups and across time using a two-factor mixed model analysis of variance. Stepwise regression with model comparison was used to investigate the extent to which MRI and shear modulus predicted repair integrity and function at 1 year after surgery.

Results

At 1 year after surgery, 56.5% of patients had an intact repair. No significant differences were found in any demographic variable, presurgical tear characteristic, or shear modulus between patients with an intact repair and those with a recurrent tear. Compared with presurgical measures, patients in both groups demonstrated significant improvements at 1 year after surgery in pain (P < .01), self-reported function (P < .01), range of motion (P < .01), and shoulder strength (P < .01). In addition, neither presurgical MRI variables (P > .16) nor shear modulus (P > .52) was significantly different between groups at 1 year after surgery. Finally, presurgical shear modulus generally did not improve the prediction of functional outcomes above and beyond that provided by MRI variables alone (P > .22).

Conclusion

Although SWE remains a promising modality for many clinical applications, this study found that SWE-estimated shear modulus did not predict repair integrity or functional outcomes at 1 year after surgery, nor did it add to the prediction of outcomes above and beyond that provided by traditional presurgical MRI measures of tear characteristics. Therefore, it appears that further research is needed to fully understand the clinical utility of SWE for musculoskeletal tissue and its potential use for predicting outcomes after surgical rotator cuff repair.

Distinct Gene Expression Profile in Patients With Poor Postoperative Outcomes After Rotator Cuff Repair: A Case-Control Study

BACKGROUND

Impaired healing after rotator cuff repair is a major concern, with retear rates as high as 94%. A method to predict whether patients are likely to experience poor surgical outcomes would change clinical practice. While various patient factors, such as age and tear size, have been linked to poor functional outcomes, it is currently very challenging to predict outcomes before surgery.

PURPOSE

To evaluate gene expression differences in tissue collected during surgery between patients who ultimately went on to have good outcomes and those who experienced a retear, in an effort to determine if surgical outcomes can be predicted.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Rotator cuff tissue was collected at the time of surgery from 140 patients. Patients were tracked for a minimum of 6 months to identify those with good or poor outcomes, using clinical functional scores and follow-up magnetic resonance imaging to confirm failure to heal or retear. Gene expression differences between 8 patients with poor outcomes and 28 patients with good outcomes were assessed using a multiplex gene expression analysis via NanoString and a custom-curated panel of 145 genes related to various stages of rotator cuff healing.

RESULTS

Although significant differences in the expression of individual genes were not observed, gene set enrichment analysis highlighted major differences in gene sets. Patients who had poor healing outcomes showed greater expression of gene sets related to extracellular matrix production (P < .0001) and cellular biosynthetic pathways (P < .001), while patients who had good healing outcomes showed greater expression of genes associated with the proinflammatory (M1) macrophage phenotype (P < .05).

CONCLUSION

These results suggest that a more proinflammatory, fibrotic environment before repair may play a role in poor healing outcome. With validation in a larger cohort, these results may ultimately lead to diagnostic methods to preoperatively predict those at risk for poor surgical outcomes.

Significance of the acromiohumeral distance on stress radiography for predicting healing and function after arthroscopic repair of massive rotator cuff tears

BACKGROUND

A decreased acromiohumeral distance (AHD) is commonly detected in patients with massive rotator cuff tears (mRCTs). Most studies evaluating fixed humeral elevation have used preoperative or postoperative standardized radiography and not stress radiography. This study aimed to evaluate the predictive role of the preoperative AHD measured using stress radiography (AHD_stress) in rotator cuff healing and function after arthroscopic repair of mRCTs.

METHODS

The data of 113 patients who underwent arthroscopic repair of mRCTs were analyzed. Postoperative cuff integrity was evaluated using magnetic resonance imaging at 1 year, and shoulder function was evaluated at a mean of 34.9 ± 17.8 months (range, 24-92 months) postoperatively. Forty-seven patients showed healing failure. Propensity score matching (1-1) was performed between the healed group and healing failure group. Thirty-eight patients in each group were matched in the final analysis. The AHD and AHD_stress were defined as the shortest distances from the inferior acromion to the superior humerus on standard anteroposterior radiography and stress radiography (5.4-kg weight applied inferiorly in a neutral position), respectively. The AHD difference (AHD_diff) was defined as the difference between the AHD and AHD_stress values. Receiver operating characteristic curve analysis was performed to determine cutoff values for significant variables.

RESULTS

No difference in the mean preoperative AHD was found between the healed group (7.5 ± 2.0 mm) and healing failure group (6.9 ± 2.2 mm, P = .234). The AHD_diff value was significantly higher in the healed group (4.4 ± 2.1 mm) than in the healing failure group (3.0 ± 2.0 mm, P = .002; cutoff, 3.2 mm). Patients with an AHD_diff value ≥ 3.2 mm showed a lower healing failure rate (28.9% vs. 71.1%, P < .001) and higher functional scores than patients with an AHD_diff value < 3.2 mm. The AHD_diff value was higher in patients with an American Shoulder and Elbow Surgeons (ASES) score ≥ 80 (4.9 ± 1.9 mm) than in those with an ASES score < 80 (3.1 ± 2.1 mm, P = .024). Among patients with healing failure, only the postoperative AHD showed a significant difference between those with an ASES score ≥ 80 (7.0 ± 2.5 mm) and those with an ASES score < 80 (4.8 ± 2.1 mm, P = .009; cutoff, 4.8 mm).

CONCLUSION

A reducible AHD, which increased by ≥ 3.2 mm under stress radiography, can be a favorable predictor of rotator cuff healing and function after arthroscopic repair of mRCTs. Our findings suggest that this new and simple radiologic parameter should be considered preoperatively and would be helpful to determine appropriate treatment strategies.

Comparing the Predictors of Functional Outcomes After Arthroscopic Rotator Cuff Repair Modified Frailty Index, Clinical Frailty Scale, and Charlson Comorbidity Index

Background:

The incidence of rotator cuff tears increases with age, and operative management is usually required in patients with persistent symptoms. Although several studies have analyzed the effect of age and comorbidities on outcomes after rotator cuff repair, no study has specifically examined the consequence of frailty.

Purpose:

To determine the best frailty/comorbidity index for predicting functional outcomes after arthroscopic rotator cuff repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors conducted a retrospective cohort study of 340 consecutive patients who underwent unilateral arthroscopic rotator cuff repair at a tertiary hospital between April 2016 and April 2018. All patients had undergone arthroscopic double-row rotator cuff repair with subacromial decompression by a single fellowship-trained shoulder surgeon. Patient frailty was measured using the Modified Frailty Index (MFI), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI), calculated through retrospective chart review based on case notes made just before surgery; patient age and sex were also noted preoperatively. Functional outcomes using the Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California Los Angeles (UCLA) Shoulder Score, and visual analog scale for pain were measured preoperatively and at 3, 6, 12, and 24 months postoperatively.

Results:

The MFI was a consistent significant predictor in all functional outcome scores up to 24 months postoperatively (P < .05), unlike the CFS and CCI. Sex was also a significant predictor of postoperative OSS, CSS, and UCLA Shoulder Score, with male sex being associated with better functional outcomes. Patients with higher MFI scores had slower functional improvement postoperatively, but they eventually attained functional outcome scores comparable with those of their counterparts with lower MFI scores at 24 months postoperatively.

Conclusion:

The MFI was found to be a better tool for predicting postoperative function than was the CFS or CCI in patients undergoing arthroscopic rotator cuff repair. The study findings suggest that a multidimensional assessment of frailty (including both functional status and comorbidities) is important in determining functional outcomes after arthroscopic rotator cuff repair.

Trends in rotator cuff surgery: Research through the decades

INTRODUCTION

The aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigation.

METHODS

Journal Citation Index was searched to find articles using the search terms pertaining to "rotator cuff repair". All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade.

RESULTS

All the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade's most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade.

CONCLUSION

There are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.

Efficacy of Intraoperative Platelet-Rich Plasma Augmentation and Postoperative Platelet-Rich Plasma Booster Injection for Rotator Cuff Healing: A Randomized Controlled Clinical Trial

Background:

Platelet-rich plasma (PRP) has been applied as an adjuvant treatment for arthroscopic rotator cuff repair (ARCR) to enhance rotator cuff healing. However, it remains debatable whether PRP enhances tendon-to-bone healing.

Purpose:

To assess the efficacy of intraoperative augmentation and postoperative injection of PRP that was prepared using the double-spin method and calcium activation without thrombin in patients with ARCR.

Study Design:

Randomized controlled trial; Level of evidence, 1; and cohort study; Level of evidence, 3.

Methods:

A total of 58 patients underwent ARCR using intraoperative PRP augmentation. Half of the patients were randomly assigned to receive an additional ultrasound-guided PRP injection at the repair site at 2 weeks postoperatively (PRP-booster group); the other half did not receive the booster injection (PRP-only group). A control group that did not receive any PRP treatment was retrospectively matched using propensity score matching. Structural integrity was assessed using magnetic resonance imaging at 1 year postoperatively, and healing rates were compared between patients with tear sizes ≤2 cm versus >2 cm. Functional outcomes were assessed using the visual analog scale (VAS) for pain; VAS for satisfaction; shoulder range of motion; and Constant, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores at minimum 2-year follow-up.

Results:

In patients with tears >2 cm, the rate of healing failure at 1-year follow-up was significantly less in the overall PRP group than in the control group (12.9% vs 35.7%, respectively; P = .040), however, the PRP-booster group did not present a better healing rate than did the PRP-only group. The overall PRP group had lower VAS for pain scores compared with the control group (0.5 ± 1.1 vs 1.3 ± 1.8, respectively; P = .016) and higher VAS for satisfaction scores (9.2 ± 1.2 vs 8.6 ± 1.7; P = .023) at the final follow-up, whereas no statistical difference was found between the PRP-only and PRP-booster groups in functional outcomes.

Conclusion:

Intraoperative PRP augmentation during ARCR demonstrated superior anatomic healing results in patients with rotator cuff tears >2 cm as well as reduced pain and increased subjective satisfaction. PRP booster injection provided no additional benefit to tendon integrity or functional recovery.

Atrophy patterns in isolated subscapularis lesions

BACKGROUND

While supraspinatus atrophy can be described according to the system of Zanetti or Thomazeau there is still a lack of characterization of isolated subscapularis muscle atrophy. The aim of this study was to describe patterns of muscle atrophy following repair of isolated subscapularis (SSC) tendon.

METHODS

Forty-nine control shoulder MRI scans, without rotator cuff pathology, atrophy or fatty infiltration, were prospectively evaluated and subscapularis diameters as well as cross sectional areas (complete and upper half) were assessed in a standardized oblique sagittal plane. Calculation of the ratio between the upper half of the cross sectional area (CSA) and the total CSA was performed. Eleven MRI scans of patients with subscapularis atrophy following isolated subscapularis tendon tears were analysed and cross sectional area ratio (upper half /total) determined. To guarantee reliable measurement of the CSA and its ratio, bony landmarks were also defined. All parameters were statistically compared for inter-rater reliability, reproducibility and capacity to quantify subscapularis atrophy.

RESULTS

The mean age in the control group was 49.7 years (± 15.0). The mean cross sectional area (CSA) was 2367.0 mm² (± 741.4) for the complete subscapularis muscle and 1048.2 mm² (± 313.3) for the upper half, giving a mean ratio of 0.446 (± 0.046). In the subscapularis repair group the mean age was 56.7 years (± 9.3). With a mean cross sectional area of 1554.7 mm² (± 419.9) for the complete and of 422.9 mm² (± 173.6) for the upper half of the subscapularis muscle, giving a mean CSA ratio of 0.269 (± 0.065) which was seen to be significantly lower than that of the control group (p < 0.05).

CONCLUSION

Analysis of typical atrophy patterns of the subscapularis muscle demonstrates that the CSA ratio represents a reliable and reproducible assessment tool in quantifying subscapularis atrophy. We propose the classification of subscapularis atrophy as Stage I (mild atrophy) in case of reduction of the cross sectional area ratio < 0.4, Stage II (moderate atrophy) in case of < 0.35 and Stage III (severe atrophy) if < 0.3.