Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study

The impact of bone marrow stimulation on arthroscopic rotator cuff repair for small to large rotator cuff tears: a randomized controlled trial

BACKGROUND

Bone marrow stimulation (BMS), a procedure involving the creation of multiple channels in the greater tuberosity, is often performed alongside arthroscopic rotator cuff repair (ARCR). This study evaluated the effect of BMS on clinical and structural outcomes following ARCR.

METHOD

This study involved 204 patients with small, medium, and large full-thickness rotator cuff tears. In all, 103 patients who underwent BMS and ARCR made up the BMS group, while the 101 patients who only had ARCR made up the control group with randomization. Clinical and functional outcomes were assessed before and at 3 months, 6 months, 1 year, and 2 years after surgery, using parameters such as range of motion, functional scores (American Shoulder and Elbow Surgeons and Constant score), and clinical scores (Visual Analogue Scale). Tendon integrity was also examined postoperatively via ultrasound at 6 months and 2 years.

RESULTS

There were no significant differences between the two groups concerning range of motion, functional scores (American Shoulder and Elbow Surgeons score and Constant score), and clinical score (Visual Analogue Scale) during the 2-year postsurgery period (all P > .05). Similarly, the rotator cuff retear rate, as assessed using ultrasonographic tendon integrity checks over 2 years postsurgery, did not significantly vary between the groups (all P > .05).

CONCLUSION

There were no significant disparities in functional scores and clinical outcomes between the BMS and control groups. Further, no significant differences were observed in tendon integrity postsurgery. Therefore, the inclusion or exclusion of BMS is not anticipated to influence the postoperative outcome in ARCR for patients with small, medium, or large rotator cuff tears.

Biologic augmentation of rotator cuff repair with microfragmented autologous subacromial bursal tissue enveloped in a patch of compressed autologous long head of biceps tendon tissue: the Bio-Ravioli technique

Background

Rotator cuff repair is one of the most frequently performed procedures in orthopedic surgery. However, considering the limited healing potential of rotator cuff tendons, several augmentation strategies have evolved to enhance tendon healing. The purpose of this article was to present a new surgical technique called Bio-Ravioli.

Methods

Patients with repairable full-thickness posterosuperior rotator cuff tear and a moderate-to-high risk of healing failure were chosen as candidates for the Bio-Ravioli procedure. It is a biologic augmentation strategy to increase healing potential of arthroscopic rotator cuff repair by use of a biologic graft fixed at the bone-tendon interface. The Bio-Ravioli consists of microfragmented autologous subacromial bursal tissue enveloped in a patch of compressed autologous long head of biceps tendon tissue. The rotator cuff is then repaired to the bone and over the graft using a transosseus equivalent configuration.

Conclusion

The Bio-Ravioli technique represents an easy and reliable way to increase the healing potential at the bone-tendon interface by using autologous mesenchymal stem cells from different sources: subacromial bursa and long head of the biceps tendon.

Similar Healing Rates of Arthroscopic Rotator Cuff Repair With and Without Bone Marrow Stimulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) techniques such as microfracture, nanofracture, and the crimson duvet procedure expose the bone marrow of the proximal humerus to the rotator cuff tendon footprint. The effect of performing BMS on tendon healing is a subject of interest.

PURPOSE

To compare studies on arthroscopic rotator cuff repair with BMS versus without BMS for rotator cuff tears according to healing rates and clinical and radiological outcomes.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 2.

METHODS

The 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in conducting a search. Studies that compared arthroscopic rotator cuff repair with and without BMS were included if they provided postoperative patient-reported outcomes and healing rates. Dichotomous outcomes were expressed as mean differences (MDs), while continuous outcomes were expressed as odds ratio.

RESULTS

Included were 5 studies (N = 499 shoulders); 4 studies had level 1 evidence, and 1 study had level 2 evidence. The healing rate of rotator cuff repair was similar between the 2 groups (ie, with and without BMS) (odds ratio, 1.58 [95% CI, 0.63 to 4.00]; P = .33). Furthermore, there were no significant differences in the postoperative Constant score (MD, 1.41 [95% CI, -0.58 to 3.39]; P = .16), American Shoulder and Elbow Surgeons score (MD, 0.77 [95% CI, -1.43 to 2.96]; P = .49), or range of motion for forward flexion (MD, 2.45 [95% CI, -0.66 to 5.57]; P = .12) and external rotation (MD, 0.81 [95% CI, -2.35 to 3.97]; P = .62) at the final follow-up between the 2 groups.

CONCLUSION

The healing rate of rotator cuff repair was similar, regardless of whether BMS was performed or not. Additionally, there was no significant difference in postoperative patient-reported outcome scores, range of motion, and complications.

REGISTRATION

CRD42023388427 (PROSPERO).

Bone Marrow Stimulation Does Not Lead to Lower Retear Rates, Better Functional Outcomes, or Higher Complication Rates at Short-Term Follow-Up for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine the effect of bone marrow stimulation (BMS) on retear rates, functional outcomes, and complication rates in patients who underwent arthroscopic rotator cuff repair (RCR) through a meta-analysis of randomized controlled trials.

METHODS

PubMed, EMBASE, Web of Science, and The Cochrane Library were searched on March 25, 2023. Two evaluators independently screened the literature, extracted data, and assessed the methodologic quality of the enrolled studies. Meta-analysis was conducted using RevMan software, version 5.4.

RESULTS

A total of 7 randomized controlled trials with 638 patients were included. The evaluation of rotator cuff tendon integrity was conducted using distinct imaging modalities. Specifically, 259 patients underwent magnetic resonance imaging whereas 208 patients underwent ultrasound. Additionally, a subset of 95 patients underwent either of these modalities; however, the precise distribution between these 2 modalities was not explicitly delineated. Compared with RCR alone, RCR combined with BMS provided similar retear rates (P = .51, I2 = 46%), Constant-Murley scores (P = .14, I2 = 0%), American Shoulder and Elbow Surgeons (standardized shoulder assessment form) scores (P = .56, I2 = 0%), Western Ontario Rotator Cuff Index scores (P = .20, I2 = 0%), visual analog scale scores (P = .19, I2 = 0%), forward flexion (P = .18, I2 = 0%), external rotation (P = .62, I2 = 0%), severe complication rates (P = .56, I2 = 0%), and mild complication rates (P = .10, I2 = 0%).

CONCLUSIONS

Compared with the outcomes observed after isolated arthroscopic RCR, arthroscopic RCR with BMS showed comparable results in terms of retear rate, functional outcomes, and incidence of complications.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears

BACKGROUND

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

METHODS

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

RESULTS

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

CONCLUSION

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Bone Marrow Stimulation for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) has been proposed to augment healing at the time of arthroscopic rotator cuff repair (ARCR) by creating several bone marrow vents in the footprint of the rotator cuff, allowing mesenchymal stem cells, platelets, and growth factors to cover the area as a "crimson duvet."

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes after BMS and a control for those undergoing ARCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

A literature search of 3 databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing BMS and a control for ARCR were included. Clinical outcomes were compared, and a P value <.05 was considered to be statistically significant.

RESULTS

A total of 7 RCTs with 576 patients were included. Overall, 18.8% of patients treated with BMS and 21.0% of patients treated with a control had a retear (I2 = 43%; P = .61). With BMS, the mean Constant score was 88.2, and with the control, the mean Constant score was 86.7 (P = .12). Additionally, there was no significant difference in the American Shoulder and Elbow Surgeons score (94.3 vs 93.2, respectively; P = .31) or visual analog scale score (0.9 vs 0.9, respectively; P = .89).

CONCLUSION

The level 1 evidence in the literature did not support BMS as a modality to improve retear rates or clinical outcomes after ARCR.

Revision rotator cuff repair: can a Sugaya III tendon considered to be healed or not

BACKGROUND

Sugaya et al described a classification system to assess postoperative rotator cuff tendon healing. Although Sugaya I and II tendons can be considered as healed and Sugaya type IV and V can be considered as retorn, the exact status of Sugaya III tendons remains unclear. The objective of this study was to evaluate the impact of Sugaya III tendons on postoperative functional scores in a population of patients undergoing revision rotator cuff repair.

METHODS

We retrospectively studied the records of all patients who underwent revision rotator cuff repair in one of 12 different institutions between July 2001 and December 2020. A total of 203 shoulders were included (59% males, mean age: 51 ± 8 years old, mean follow-up 11.5 years [range: 2-28.8 yr]). Fifty-four patients (61% males, mean age 52 ± 6 years old, mean follow-up 14.1 years [range: 10.4-28.8 yr]) had a follow-up ≥10 years (mean 14.1 years [range: 10.4-28.8 yr]) and were included in a long-term follow-up subgroup analysis. Structural integrity of the repaired tendon was evaluated on magnetic resonance imaging at last follow-up. Functional scores, acromiohumeral index (AHI), and progression of fatty infiltration and of osteoarthritis were compared according to Sugaya type.

RESULTS

Mean Constant score and mean strength were significantly higher in Sugaya I and II tendons than in Sugaya III (P = .021 and .003) and Sugaya IV and V tendons (P = .07 and .038), but did not differ between Sugaya III and Sugaya IV and V tendons. Mean Subjective Shoulder Value, pain, AHI were significantly higher and fatty infiltration and progression in the Hamada classification were significantly lower in Sugaya I and II tendons and in Sugaya III than in Sugaya IV and V tendons (P < .05), but did not differ between Sugaya I and II and Sugaya III tendons. Similar characteristics could also be observed in the long-term follow-up subgroup.

CONCLUSION

Sugaya III tendons after revision rotator cuff repair do not allow restoration of strength thereby impacting the Constant score. However, there seems to be a protective effect of Sugaya III tendons with regard to pain, progression of proximal migration of the humeral head, osteoarthritis, and fatty infiltration, which seems to last at long-term follow-up.

Effect of Bone Marrow Stimulation on Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background

Arthroscopic rotator cuff repair (RCR) is a common orthopaedic procedure, but it has a high rate of retears that can negatively affect the functional outcomes. Bone marrow stimulation (BMS) has been suggested as an additional treatment to improve the outcomes of RCR.

Purpose

To compare the effectiveness of the BMS procedure during RCR with conventional RCR.

Study Design

Systematic review; Level of evidence, 2.

Methods

A systematic literature search was conducted in MEDLINE/PubMed, Embase, Cochrane Library, and Scopus, on March 1, 2023, for studies comparing postoperative retear rates and functional outcomes between patients who underwent primary arthroscopic RCR with and without the BMS procedure. Only level 1 and 2 randomized controlled trials with a minimum 12-month follow-up were included. The primary outcomes were retear rates and functional outcomes as measured by the Constant; American Shoulder and Elbow Surgeons (ASES); and University of California, Los Angeles (UCLA) scores and by postoperative range of motion. Subgroup analyses were performed based on repair technique (single-row repair vs double-row or suture-bridge repair). The standardized mean difference (SMD) and odds ratio (OR) were utilized to synthesize continuous and dichotomous outcomes, respectively. Homogeneity was evaluated using the chi-square test and I2 statistic.

Results

The literature search yielded 661 articles, of which 6 studies (522 patients; 261 with BMS, 261 without BMS) met the eligibility criteria. The combined analysis showed no significant decrease in retear rates with the utilization of the BMS procedure during RCR (OR, 0.60; 95% CI, 0.35 to 1.03; P = .07; I2 = 24%). There was no significant intergroup difference in functional outcomes (Constant score: SMD, 0.13; 95% CI, -0.04 to 0.31; P = .13; I2 = 0%; ASES score: SMD, 0.04; 95% CI, -0.20 to 0.28; P = .73; I2 = 0%; UCLA score: SMD, -0.13; 95% CI, -0.50 to 0.23; P = .47; I2 = 0%). Subgroup analyses revealed no significant differences in postoperative retear risk or total Constant score according to the repair technique.

Conclusion

Based on the available evidence, this systematic review did not find a significant benefit of the BMS procedure at the footprint during arthroscopic RCR compared with conventional RCR in terms of retear rates and functional outcomes at short-term follow-up.

Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies

BACKGROUND

There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling.

METHODS

A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates).

CONCLUSION

The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.

Editorial Commentary: Bone Marrow Stimulation and Losartan Augmentation of Shoulder Rotator Cuff Repair

Rotator cuff retear rates after repair have been variously reported as ranging from 5% to 40% for small to mediums tears and as high as 40% to 94% for large to massive tears. Thus strategies to enhance structural healing are relevant. In rabbits, combining oral losartan (which has antifibrotic effects by downregulating transforming growth factor-β1) and bone marrow stimulation (BMS) of the greater tuberosity, showed improved rotator cuff repair pull-out strength and highly organized tendon matrix in a chronic injury model, whereas BMS alone did not improve the mechanical properties. However, clinical studies show that BMS techniques have a positive impact on healing and retear rates. BMS stimulates migration of mesenchymal stem cells from bone marrow to the lesion, and this approach has been widely used to fill cartilage defects by fibrocartilage metaplasia. BMS is a straightforward and cost-effective technique; the use of multiple deeper bone tunnels is recommended.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Microfracture Lateral to the Greater Tuberosity of the Humerus Enhances Tendon-to-Bone Healing in a Rat Rotator Cuff Model

BACKGROUND

Microfracture at the rotator cuff insertion is an established surgical marrow-stimulation technique for enhancing rotator cuff healing. However, the effect of lateralized or medialized microfracture on the insertion is unknown.

PURPOSE

To compare the biomechanical and histologic effects of microfracture at 3 different regions for rotator cuff repair in a rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 72 Sprague-Dawley rats with bilateral supraspinatus tendon insertion detachment were allocated into 4 groups with 4 different interventions: no microfracture at the humeral head as a control group (Con), traditional microfracture at the footprint area (MFA), and medialized microfracture to the footprint area (MMFA) on the articular surface of the humerus or lateralized microfracture to the footprint area at the greater tuberosity (LMFA). All underwent immediate repair. Tendon-to-bone healing was assessed by biomechanical and histologic tests 4 and 8 weeks postoperation.

RESULTS

At 4 weeks, the LMFA group showed a significantly superior failure load compared with the other groups (all P < .05). The LMFA and MFA groups showed significantly superior stiffness compared with the Con and MMFA groups (all P < .01). At 8 weeks, superior failure load and stiffness were observed in the LMFA group compared with the control group (all P < .05). Histologic examination revealed that the LMFA group had superior collagen composition and tendon-to-bone maturation at the interface at 4 and 8 weeks compared with the Con group (all P < .05).

CONCLUSION

Lateralized microfracture at the greater tuberosity improved the histologic quality of repair tissue and biomechanical strength at the tendon-to-bone insertion after rotator cuff repair in a rat model.

CLINICAL RELEVANCE

Microfracture lateral to the footprint area might be a better way to enhance rotator cuff healing clinically.

Combined Biologic Augmentation Strategies with Collagen Patch Graft, Microfractures, and Platelet Concentrate Injections Improve Functional and Structural Outcomes of Arthroscopic Revision Rotator Cuff Repair

BACKGROUND

Arthroscopic revision rotator cuff repair (ARRCR) is challenging. Biologic strategies seem to be promising. The aim was to evaluate the effectiveness of the combination of microfractures of the greater tuberosity, augmentation with collagen patch graft, and platelet concentrate injections in ARRCR.

METHODS

A retrospective comparative study was conducted on patients that underwent ARRCR with a minimum follow-up of two years. Patients in the augmentation group underwent ARRCR combined with microfractures, collagen patch graft, and postoperative subacromial injections of platelet concentrate. A standard rotator cuff repair was performed in the control group.

PRIMARY OUTCOME

Constant-Murley score (CMS).

SECONDARY OUTCOMES

disease-specific, health-related quality of life using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; assessment of tendon integrity with magnetic resonance at least six months after surgery. Significance was set at p < 0.05.

RESULTS

Forty patients were included. Mean follow-up was 36.2 ± 8.7 months. The mean CMS was greater in the augmentation group (p = 0.022). No differences could be found for DASH score. Healing failure rate was higher in the control group (p = 0.002).

CONCLUSION

Biologic augmentation of ARRCR using a combination of microfractures, collagen patch graft, and subacromial injections of platelet concentrate is an effective strategy in improving tendon healing rate.

LEVEL OF EVIDENCE

retrospective cohort study, level III.

A network meta-analysis of arthroscopic rotator cuff repair

OBJECTIVE

Rotator cuff tear is a common shoulder injury that often leads to serious limitations in daily life. Herein, a network Meta-analysis using frequency theory was performed to evaluate the clinical outcomes of five rotator cuff repair techniques, including single-row repair, double-row repair, suture bridge repair, platelet-rich plasma therapy, and bone marrow stimulation, thus guiding clinical decision-making on rotator cuff repair.

METHODS

PubMed, EMbase, The Cochrane Library, and Web of Science were searched for randomized controlled trials and cohort studies comparing rotator cuff repair techniques published from inception to May 2022. Combined analysis and quality assessment were performed using software STATA15.1 and Review Manager5.3.

RESULTS

A total of 51 articles were finally included, including 27 randomized controlled trials and 24 cohort studies. Results from the network Meta-analysis showed that: (1) In terms of the American Shoulder and Elbow Surgeons score, platelet-rich plasma therapy, double-row repair, bone marrow stimulation, and single-row repair were significantly better than suture bridge repair. (2) In terms of Constant score, bone marrow stimulation was significantly better than double-row repair, single-row repair, and suture bridge repair. (3) In terms of visual analog scale score, platelet-rich plasma therapy was significantly better than double-row repair and suture bridge repair. (4) In terms of the Shoulder Rating Scale of the University of California at Los Angeles score, platelet-rich plasma therapy and double-row repair were relatively better but not significantly different from the other treatments. (5) In terms of the risk of re-tear, the re-tear rate of platelet-rich plasma therapy and double-row repair was significantly lower than that of single-row repair and suture bridge repair.

CONCLUSION

Based on the results of network Meta-analysis and surface under the cumulative ranking, platelet-rich plasma therapy, bone marrow stimulation, and double-row repair have good overall rehabilitation effects. It is recommended to choose appropriate repair techniques as per the actual clinical situation.

A Comparison of Clinical Outcomes in Rotator Cuff Re-Tear Patients Who Had Either an Arthroscopic Primary Repair or Arthroscopic Patch Augmentation for Large-to-Massive Rotator Cuff Tears

BACKGROUND AND PURPOSE

Despite the prevalent incidence of re-tear following rotator cuff repair, there is a notable lack of comparative studies investigating the outcomes between patients with re-tear who underwent primary repair versus those who received patch augmentation for large-to-massive tears. We assessed clinical outcomes of these techniques through a retrospective, randomized controlled trial.

METHODS

134 patients diagnosed with large-to-massive rotator cuff tears from 2018 to 2021 underwent surgery; 65 had primary repair and 69 had patch augmentation. A total of 31 patients with re-tears were included, split into two groups; Group A (primary repair, 12 patients) and Group B (patch augmentation, 19 patients). Outcomes were evaluated using several clinical scales and MRI imaging.

RESULTS

Most clinical scores improved postoperatively in both groups. No significant difference in clinical outcomes was observed between groups, except for pain visual analog scale (P-VAS) scores. P-VAS scores showed greater decrease in the patch-augmentation group, a statistically significant difference.

CONCLUSIONS

for large-to-massive rotator cuff tears, patch augmentation led to greater decreases in pain than primary repair, despite similar radiographic and clinical results. Greater tuberosity coverage of the supraspinatus tendon footprint may impact P-VAS scores.

The role of bone marrow stimulation in rotator cuff repair: a systematic review and meta-analysis

PURPOSE

The objective of this study was to investigate whether RCR (rotator cuff repair) with BMS (bone marrow stimulation) can provide a lower retear rate and better shoulder function than arthroscopic RCR alone in rotator cuff tear (RCT) patients.

METHOD

The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched until Feb 2022. Risk of bias for randomized controlled trials was evaluated by two independent reviewers with Cochrane collaboration risk bias of tool, and that for cohort studies was evaluated with the Newcastle-Ottawa Scale (NOS). The primary outcome was the retear rate. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles Shoulder Scale (UCLA) score, Constant-Murley score (CMS) and visual analogue scale (VAS) score. Subgroup analysis was performed to explore the effect of suture method and tear size on BMS procedure.

RESULT

Five randomized controlled trials and four cohort studies with a total of 827 patients were included. The pooled retear rate between the RCR with BMS group and the RCR alone group was significantly different (17.5% vs. 28.9%; P < 0.0001). There were no differences in the ASES score, UCLA score and VAS score. The CMS was significantly higher in RCR with BMS group than the RCR alone groups (P = 0.02), while the difference was well below the MCID. RCR with BMS resulted in a significantly lower retear rate than RCR alone for large and massive RCTs (19.7% vs. 32.5%; P = 0.01).

CONCLUSION

Compared with RCR alone, RCR with BMS can significantly reduce the retear rate in arthroscopic RCT patients while not clinically relevant differences were found. BMS may further reduce the retear rate of large and massive RCTs.

LEVEL OF EVIDENCE

Level III; Systematic Review and Meta-analysis.

Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique

Background

We have tried to create hematoma over the footprint site at the end of arthroscopic rotator cuff repair (ARCR) surgery, expecting to apply biochemical effects of the platelet-related factors. The purpose of this study was to investigate the presence of hematoma-like tissue (HLT) on postoperative magnetic resonance imaging, and to evaluate the relationship between the HLT and the structural outcomes of ARCR.

Materials and methods

Twenty-five patients were reviewed with a mean age at surgery of 69.8 years (range, 52-85 years). Postoperative magnetic resonance imaging was performed at 1 week, 6-8 weeks, and >6 months postoperatively. Structural outcomes for the repaired cuff and thickness of HLT were evaluated on coronal T2-weighted images. Signal intensity of HLT was evaluated on coronal T2-weighted fat-suppressed images as the ratio compared to supraspinatus tendon intensity (HLT/SSP ratio).

Results

Structural outcomes showed Sugaya type 1 in 12 shoulders, type 2 in 4, and type 3 in 9. HLT thickness was significantly thicker at 1 week and 6-8 weeks postoperatively in Sugaya type 1 patients than in type 3 patients (1 week; P = .014, 6-8 weeks; P < .001). HLT/SSP ratio gradually decreased (at 1 week; 1.9 ± 0.7, 6-8 weeks; 1.6 ± 0.6, >6 months; 1.2 ± 0.5), and differed significantly between >6 months and both 1 week and 6-8 weeks (P < .001 each).

Local Intraoperative Marrow-Derived Augmentation for Primary Rotator Cuff Repair: An Updated Systematic Review and Meta-analysis of Studies From 2010 to 2022

Background

Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair.

Purpose

To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I ².

Results

A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I ² = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I ² = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls.

Conclusion

Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.

Prospective Randomized Trial of Biologic Augmentation With Bone Marrow Aspirate Concentrate in Patients Undergoing Arthroscopic Rotator Cuff Repair

BACKGROUND

Although initial studies have demonstrated that concentrated bone marrow aspirate (cBMA) injections promote rotator cuff repair (RCR) healing, there are no randomized prospective studies investigating clinical efficacy.

HYPOTHESIS/PURPOSE

To compare outcomes after arthroscopic RCR (aRCR) with and without cBMA augmentation. It was hypothesized that cBMA augmentation would result in statistically significant improvements in clinical outcomes and rotator cuff structural integrity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients indicated for aRCR of isolated 1- to 3-cm supraspinatus tendon tears were randomized to receive adjunctive cBMA injection or sham incision. Bone marrow was aspirated from the iliac crest, concentrated using a commercially available system, and injected at the aRCR site after repair. Patients were assessed preoperatively and serially until 2 years postoperatively via the following functional indices: American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, 12-Item Short Form Health Survey, and Veterans RAND 12-Item Health Survey. Magnetic resonance imaging (MRI) was performed at 1 year to assess rotator cuff structural integrity according to Sugaya classification. Treatment failure was defined as decreased 1- or 2-year ASES or SANE scores as compared with preoperative baseline, the need for revision RCR, or conversion to total shoulder arthroplasty.

RESULTS

An overall 91 patients were enrolled (control, n = 45; cBMA, n = 46): 82 (90%) completed 2-year clinical follow-up and 75 (82%) completed 1-year MRI. Functional indices significantly improved in both groups by 6 months and were sustained at 1 and 2 years (all P < .05). The control group showed significantly greater evidence of rotator cuff retear according to Sugaya classification on 1-year MRI (57% vs 18%; P < .001). Treatment failed for 7 patients in each group (control, 16%; cBMA, 15%).

CONCLUSION

cBMA-augmented aRCR of isolated supraspinatus tendon tears may result in a structurally superior repair but largely fails to significantly improve treatment failure rates and patient-reported clinical outcomes when compared with aRCR alone. Additional study is warranted to investigate the long-term benefits of improved repair quality on clinical outcomes and repair failure rates.

REGISTRATION

NCT02484950 (ClinicalTrials.gov identifier).

Intraoperative Channeling in Arthroscopic Rotator Cuff Repair: A Multicenter Randomized Controlled Trial

BACKGROUND

Despite recent advances in arthroscopic rotator cuff repair, the retear rate remains high. New methods to optimize healing rates must be sought. Bone channeling may create a quicker and more vigorous healing response by attracting autologous mesenchymal stem cells, cytokines, and growth factors to the repair site.

HYPOTHESIS

Arthroscopic rotator cuff repair with bone channeling would result in a higher healing rate compared with arthroscopic rotator cuff repair without adjuvant channeling.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Secondary objectives included comparisons of the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Constant strength subscore, and visual analog scale (VAS) for pain score between groups. Patients undergoing arthroscopic rotator cuff repair were recruited at 3 sites and were randomized to receive either bone channeling augmentation or standard repair. Healing was determined via ultrasound at 24 months postoperatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12, and 24 months postoperatively.

RESULTS

A total of 168 patients were enrolled between 2013 and 2018. Intention-to-treat analysis revealed no statistical differences in healing rates between the 2 interventions at 24 months postoperatively. Statistically significant improvements occurred in both groups from preoperatively to all time points for the WORC, the ASES score, the Constant score or Constant strength subscore, and the VAS for pain (P < .0001). No differences were observed between the bone channeling and control groups in WORC, ASES, Constant, and VAS pain scores at any time point.

CONCLUSION

This trial did not demonstrate the superiority of intraoperative bone channeling in rotator cuff repair over standard rotator cuff repair at 24 months postoperatively. Healing rates, patient-reported function, and quality-of-life outcomes were similar between groups.

REGISTRATION

NCT01877772 (ClinicalTrials.gov identifier).

Bone marrow stimulation in arthroscopic rotator cuff repair is a cost-effective and straightforward technique to reduce retear rates: A systematic review and meta-analysis

Background

Bone marrow stimulation (BMS) has been considered a well-established method for treating knee and ankle osteochondral lesions. Some studies have also shown that BMS can promote healing of the repaired tendon and enhance biomechanical properties during rotator cuff repair. Our purpose was to compare the clinical outcomes of arthroscopic repair rotator cuff (ARCR) with and without BMS.

Methods

A systematic review with meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, Embase, Web of Science, Google scholar, ScienceDirect, and the Cochrane Library were searched from inception to March 20, 2022. Data on retear rates, shoulder functional outcomes, visual analog score and range of motion were pooled and analyzed. Dichotomous variables were presented as odds ratios (OR), and continuous variables were presented as mean differences (MD). Meta-analyses were conducted with Review Manager 5.3.

Results

Eight studies involving 674 patients were included, with mean follow-up period ranging from 12 to 36.8 months. Compared to ARCR alone, the intraoperative combination of the BMS resulted in lower retear rates (P < 0.0001), but showed similar results in Constant score (P = 0.10), University of California at Los Angeles (UCLA) score (P = 0.57), American Shoulder and Elbow Surgeons (ASES) score (P = 0.23), Disabilities of the Arm, Shoulder and Hand (DASH) score (P = 0.31), VAS (visual analog score) score (P = 0.34), and range of motion (ROM) (forward flexion, P = 0.42; external rotation, P = 0.21). After sensitivity analyses and subgroup analyses, no significant changes in statistical results were observed.

Conclusion

Compared to ARCR alone, the combination of intraoperative BMS can significantly reduce the retear rates, but showed similar short-term results in functional outcomes, ROM and pain. Better clinical outcomes are anticipated in the BMS group by improving structural integrity during long-term follow-up. Currently, BMS may be a viable option in ARCR based on its straightforward and cost-effective advantages.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022323379.

Effect of Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Augmentation on the Rate of Revision Rotator Cuff Repair

Background

The application of orthobiologics at the time of arthroscopic rotator cuff repair (RCR) has received an increasing amount of clinical interest despite a relative scarcity of human clinical studies on their efficacy.

Purpose

To utilize a national administrative database to determine the association of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) applied at the time of RCR with revision surgery rates.

Study Design

Cohort study; Level of evidence, 3.

Methods

The Mariner data set from the PearlDiver patient records repository was utilized to identify patients undergoing RCR using Current Procedural Terminology (CPT) code 29827. Patients receiving BMAC or PRP at the time of RCR were then identified using CPT coding. For comparison purposes, a matched cohort was created consisting of patients who underwent RCR without biologic augmentation in a 5:1 fashion for each biologic separately. Cases were matched according to age, sex, tobacco use, biceps tenodesis, distal clavicle excision, and subacromial decompression. All groups were then queried for revision RCR or conversion to reverse shoulder arthroplasty. Revision rates were compared utilizing a multivariate binomial logistic regression analysis. Adjusted odds ratios (ORs) and 95% CIs were calculated.

Results

A total of 760 patients who underwent biologic augmentation during RCR were identified, including 646 patients in the PRP group and 114 patients in the BMAC group. They were compared with 3800 matched controls without documented biologic application at the time of surgery. Compared with matched controls, patients who received BMAC at the time of surgery experienced a significantly lower incidence of revision surgery at 2 years (OR, 0.36; 95% CI, 0.15-0.82; P = .015). There was no significant difference in revision rates between PRP and matched controls (OR, 0.87; 95% CI, 0.62-1.23; P = .183).

Conclusion

The application of BMAC at the time of RCR was associated with a significant decrease in the incidence of revision surgery. There was no apparent effect of PRP on the incidence of revision surgery after primary RCR. Higher-level clinical studies considering surgical factors are needed to more clearly define the role of biologic adjuvants in RCR.

Management of Failed Rotator Cuff Repairs: A Review

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Double-Row Repair With Platelet-Rich Plasma Optimizes Retear Rates After Small to Medium Full-Thickness Rotator Cuff Repair: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To compare the different interventions described in the literature for the surgical treatment of small and medium complete rotator cuff tears.

METHODS

A systematic review of randomized controlled trials of small-medium, full-thickness rotator cuff tears published since 2000 was performed. Clinical characteristics, re-tear rates, range of motion (ROM), and patient-reported outcomes (PRO) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model. Interventions were ranked for each domain (re-tear risk, pain, ROM, and PROs) via surface under the cumulative ranking curves.

RESULTS

A total of 18 studies comprising 2046 shoulders (47% females, mean age 61 ± 3 years, mean follow-up 21 ± 5 months) were included. Interventions that ranked highest for minimizing re-tear risk included arthroscopic single-row repair (A+SR) or double-row repair (A+DR) with or without platelet-rich plasma (PRP). Open repair and A+SR repair with acromioplasty (ACP) ranked highest for pain relief. Interventions that ranked highest for ROM improvement included open repair, PT, and A+DR with or without ACP. Interventions that ranked highest for PROs included arthroscopic footprint microfracture with or without SR, open repair, and A+SR with or without ACP.

CONCLUSIONS

Based on a network meta-analysis of level 1 studies, arthroscopic rotator cuff repair with a SR or DR construct demonstrates similar retear rates, PROs, and clinical outcomes. The highest-ranking treatment for minimizing retears was arthroscopic repair with DR constructs and PRP augmentation, although open repair and arthroscopic SR remain reliable options with excellent clinical outcomes. Addition of PRP to DR constructs trended toward a 56% decreased risk of retear as compared to DR repair alone. Although no single treatment emerged superior, several interventions offered excellent clinical improvements in pain, ROM, and PROs that exceeded minimal clinically important difference thresholds.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis of level I studies.

Does Complete Footprint Coverage Affect Outcomes After Conventional Arthroscopic Repair of Large-Sized Rotator Cuff Tears?

Background:

In large-sized rotator cuff tears, tendon repair with incomplete footprint coverage is performed frequently as a way of tension-free or low-tension repair.

Purpose:

To compare clinical outcomes after arthroscopic repair of large-sized rotator cuff tears between patients with complete versus incomplete footprint coverage.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among 297 patients who underwent arthroscopic surgery for a large-sized rotator cuff tear, we selected 58 patients (<50% coverage; mean age, 63.34 ± 6.8 years; 34 men and 24 women) with incomplete footprint coverage. Using propensity score matching, another 58 patients with complete footprint coverage (mean age, 63.4 ± 8.03 years; 34 men and 24 women) were selected after 1:1 matching for age, sex, and tear size—the main demographic and prognostic factors of outcomes after rotator cuff repair. Clinical outcomes were compared on magnetic resonance imaging or ultrasonography at minimum of 6 months postoperatively, and functional outcomes were compared using range of motion and pain visual analog scale; American Shoulder and Elbow Surgeons; Constant; University of California, Los Angeles; and Simple Shoulder Test scores at a minimum of 2 years postoperatively.

Results:

A total of 18 patients in the incomplete footprint coverage group (31.0%) and 20 patients in the complete footprint coverage group (34.5%) showed healing failure, with no significant difference between groups (P = .843). In addition, there were no differences in functional outcomes between groups (P > .05 for all).

Conclusion:

Whether the rotator cuff footprint was completely covered did not affect clinical outcomes in conventional arthroscopic repair of large-sized rotator cuff tears.

Functional and radiologic results of the crimson duvet procedure in rotator cuff treatment: a randomized controlled clinical trial

BACKGROUND

Rotator cuff tears are one of the more frequent pathologies of the shoulder. Arthroscopic techniques and biologic augmentation have been developed to improve the rate and quality of healing. The crimson duvet procedure (CDP) theoretically provides mesenchymal stem cells through microfracture treatment of the footprint. The aim of this research was to evaluate the effect of CDP in patients who had undergone arthroscopic surgery for complete rotator cuff repair.

METHODS

A prospective randomized clinical trial was performed in a total of 123 patients, consisting of 59 women and 64 men, with a mean age of 58 years. We included patients with a clinical and radiologic diagnosis of a complete rotator cuff tear. All patients were treated with arthroscopic rotator cuff repair. In group 1, the surface of the footprint was débrided; in group 2, the footprint underwent microfracture. The primary outcome was the nonhealing rate, which was detected by magnetic resonance imaging (MRI) or ultrasonography, and the secondary outcome was the functional result. A Sugaya classification of I to III was considered to indicate healing. For clinical evaluation, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Constant scores were evaluated, along with the range of motion. The functional evaluation was performed preoperatively and at 6 months and 1 year postoperatively. The radiologic (MRI or ultrasonography) evaluation was performed at 6 months. Neither the patients nor the radiologists and physical therapists who performed the postoperative evaluations were informed of the random selection.

RESULTS

We observed a healing rate of 85.11% in the control group and 93.7% in the CDP group, which was not significant (P = .19). However, a significant improvement in function was observed in all patients. The ASES score improved from 68.9 (SD 13.8) preoperatively to 92.2 at 6 months and to 96.4 (SD 6.2) at 12 months (P < .05), but no difference was observed between the groups. A similar level of improvement was observed in the Constant score.

CONCLUSION

The arthroscopic repair of complete rotator cuff tears presents good and excellent clinical results in most patients. Nevertheless, nonhealing occurs at a rate that depends mainly on the age of the patient and the size of the tear. The addition of CDP did not improve the functional results or the healing rate.

Significant Improvement in Shoulder Function and Pain in Patients Following Biologic Augmentation of Revision Arthroscopic Rotator Cuff Repair Using an Autologous Fibrin Scaffold and Bone Marrow Aspirate Derived From the Proximal Humerus

Purpose

To clinically evaluate patients who underwent a biologic augmentation technique in revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated stem cells isolated from bone marrow aspirate (BMA) obtained from the proximal humerus.

Methods

This is a retrospective review of prospectively collected data from patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and BMA obtained from the proximal humerus between 2014 and 2015. Minimum follow-up was 12 months. Outcome measures were collected preoperatively and postoperatively including range of motion as well as American Shoulder and Elbow Surgeons Shoulder Form, Simple Shoulder Test, single assessment numeric evaluation, and visual analog score. In addition, BMA samples of each patient were assessed for the number of nucleated cells and colony-forming units. Regression analysis was performed to investigate whether the number of nucleated cells and colony-forming units had an influence on outcome and failure.

Results

Ten patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA obtained from the proximal humerus between 2014 and 2015 were included. The mean follow-up time was 30.7 (range: 12-49) months. Four patients were revised at final follow-up. Postoperative clinical scores improved significantly: American Shoulder and Elbow Surgeons (28.1 ± 5.4 to 60.9 ± 9.0; P < .01), single assessment numeric evaluation (6.6 ± 2.3 to 65.1 ± 10.9; P < .01), visual analog scale (7.2 ± 0.9 to 3.1 ± 0.9; P < .01), and Simple Shoulder Test (1.6 ± 0.5 to 10.3 ± 5.7; P < .01). Postoperative range of motion increased significantly with regard to flexion (97.0 ± 13.6 to 151.0 ± 12.2; P < .01) and abduction (88.0 ± 14.0 to 134.0 ± 15.1; P = .038) but not with external rotation (38.0 ± 5.7 to 50.5 ± 6.5; P = .16). Less pain was correlated to an increased number of nucleated cells (P = .026); however, there was no correlation between failure rate and number of nucleated cells (P = .430).

Conclusions

Patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA demonstrated a significant improvement in shoulder function along with reduction of pain. However, the overall revision rate for this procedure was 40%.

Level of Evidence

Level IV, therapeutic case series.

Anatomic based microfracture technique of insertion for rotator cuff repair in Vietnamese people: Case series study

Abstract

Postoperative tendon healing is still a matter of concern after rotator cuff repair. Several techniques have been introduced to help improve this healing process. Among them, the bone marrow is commonly used source and a research subject for methods using stem cells to promote wound healing process. A number of studies have shown that bone marrow stem cells can travel up through the holes on the rotator cuff insertion sites, contributing into the rotator cuff repair process, increasing the efficiency of tendon healing and improving clinical results.

Patients and methods

Cross-sectional descriptive study was performed on 41 rotator cuff tear patients. The microfractures for these patients were calculated beforehand, which have great depth but small diameter, based on the anatomical characteristic of the rotator cuff tear insertions of Vietnamese people. Patients' rotator cuff tendon healing processes were evaluated using ultrasound after surgery. Final tendon healing and clinical results ultimately rely on MRI assessments, classified according to Sugaya's classification, UCLA and ASES scale.

Results

No cases of rupture and fracture of the greater tubercle was recorded. There was a clear progression of tendon healing on ultrasound according to postoperative follow-up time-stamps (1 month, 3 months). MRI images evaluation also reveals at the latest follow-up time, according to Sugaya classification, the ratio of tendon healing was 87.8%, while the percentage of re-rupture was 12.2%. ASES and average UCLA scale were collected at the end of the study, respectively as 95.41 ± 5.45 and 32.36 ± 2.53.

Conclusion

The technique's microfractures characteristics based on the rotator cuff tear insertion anatomy ensures a secure, straightforward approach along with promising results in terms of tendon healing rate and postoperative functional outcomes.

Healing Effect of Subcutaneous Administration of Granulocyte Colony-Stimulating Factor on Acute Rotator Cuff Injury in a Rat Model

Granulocyte colony-stimulating factor (G-CSF) is a cytokine that mobilizes bone marrow-derived cells (BMDCs) to peripheral blood and has been clinically used to treat neutropenia. Previously, we reported that BMDCs migrated into the rotator cuff repair site via peripheral blood in the healing process. However, techniques to accelerate the healing process using the peripheral blood pathway have not been established. We evaluated whether G-CSF has a noteworthy effect on improving rotator cuff healing by enhancing the influx of BMDCs into the peripheral blood. We used Sprague-Dawley rats and chimeric rats, selectively expressing green fluorescent protein (GFP) in BMDCs. Their bilateral supraspinatus tendons were resected and sutured to the greater tuberosity of the humerus using the Masson-Allen technique, and G-CSF was subcutaneously injected for 5 days after surgery. Several GFP-positive cells were observed around the enthesis in the G-CSF-treated group compared with that in the Control group. Histological analysis revealed that the tendon-to-bone maturing scores and the Safranin O-stained cartilaginous areas were significantly higher in G-CSF-injected rats than in the control rats at weeks 4 and 8 after surgery. Consistently, the ultimate force to failure in the G-CSF-treated group significantly increased compared with the Control group at weeks 4 and 8 after surgery. These results suggest that BMDCs mobilized into the peripheral blood after G-CSF administration migrated to the rotator cuff repair area and effectively enhanced rotator cuff healing by promoting tenocyte and cartilage matrix production. In conclusion, the BMDC mobilization technique by G-CSF treatment via peripheral blood will provide a potential therapeutic approach for rotator cuff healing with clinically relevant applications. Impact statement As the retear rate following rotator cuff repair is high, new methods to aid its healing are required. Granulocyte colony-stimulating factor (G-CSF) has been used clinically and may represent a novel approach to treating rotator cuff tear. Herein, using a rat model, we elucidate the kinetics of bone marrow-derived mesenchymal stem cells at the repair site following G-CSF administration and describe the underlying mechanism by which G-CSF can help promote the repair of the rotator cuff.

Footprint preparation with nanofractures in a supraspinatus repair cuts in half the retear rate at 1-year follow-up. A randomized controlled trial

PURPOSE

To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up.

METHODS

Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes.

RESULTS

Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p = 0.014). Clinically both groups had significant improvements, but no differences were found between groups.

CONCLUSION

Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint.

LEVEL OF EVIDENCE

Level I.

Tendon-to-bone healing after repairing full-thickness rotator cuff tear with a triple-loaded single-row method in young patients

Background

Arthroscopic repair is recommended for young patients with full-thickness rotator cuff tears (RCTs), but the healing rates have raised concerns. The Southern California Orthopedic Institute (SCOI) row method has been developed based on greater than 3 decades of experience with excellent clinical outcomes; however, studies with a focus on the younger patient population are limited in number. The current study assessed the short-term clinical outcome and the initial tendon-to-bone healing in a young cohort after repair of a full-thickness RCT using the SCOI row method.

Methods

A retrospective cohort study was performed. Patients < 55 years of age who had a full-thickness RCT and underwent an arthroscopic repair using the SCOI row method were reviewed. Clinical outcomes were assessed at baseline, and 3 and 6 months post-operatively. The visual analog scale (VAS), University of California at Los Angeles (UCLA) scale, and Constant-Murley score were completed to assess pain and function. Active range of motion was also examined, including abduction and flexion of the involved shoulder. A preoperative MRI was obtained to assess the condition of the torn tendon, while 3- and 6-month postoperative MRIs were obtained to assess tendon-to-bone healing. Repeated measurement ANOVA and chi-square tests were used as indicated.

Results

Eighty-nine patients (57 males and 32 females) with a mean age of 44.1 ± 8.6 years who met the criteria were included in the study. Compared with baseline, clinical outcomes were significantly improved 3 and 6 months postoperatively based on improvement in the VAS, UCLA score, and Constant-Murley score, as well as range of motion. Greater improvement was also noted at the 6-month postoperative assessment compared to the 3-month postoperative assessment. Three- and six-month postoperative MRIs demonstrated intact repairs in all shoulders and footprint regeneration, which supported satisfactory tendon-to-bone healing. The mean thickness of regeneration tissue was 7.35 ± 0.76 and 7.75 ± 0.79 mm as measured from the 3- and 6-month MRI (P = 0.002). The total satisfactory rate was 93.3 %.

Conclusions

Arthroscopic primary rotator cuff repair of a full-thickness RCT using the SCOI row method in patients < 55 years of age yields favorable clinical outcomes and early footprint regeneration.

Effect of kartogenin-loaded gelatin methacryloyl hydrogel scaffold with bone marrow stimulation for enthesis healing in rotator cuff repair

BACKGROUND

Strategies involving microfracture, biomaterials, growth factors, and chemical agents have been evaluated for improving enthesis healing. Kartogenin (KGN) promotes selective differentiation of bone marrow mesenchymal stem cells (BMSCs) into chondrocytes. Gelatin methacryloyl (GelMA) is a promising biomaterial for engineering scaffolds and drug carriers. Herein, we investigated KGN-loaded GelMA hydrogel scaffolds with a bone marrow-stimulating technique for the repair of rotator cuff tear.

METHODS

KGN-loaded GelMA hydrogel scaffolds were obtained by ultraviolet GelMA crosslinking and vacuum freeze-drying. Fifty-four New Zealand rabbits were randomly divided into (1) repair only (control), (2) microfracture + repair (BMS), and (3) microfracture + repair augmentation with a KGN-loaded GelMA hydrogel scaffold (combined) groups. Tendons were repaired by transosseous sutures. The structure, degradation, and in vitro KGN release of the scaffolds were characterized. Animals were euthanized 4, 8, and 12 weeks after repair. Enthesis healing was evaluated by macroscopy, microcomputed tomography, histology, and biomechanical tests.

RESULTS

The KGN-loaded GelMA hydrogel scaffolds are porous with a 60.4 ± 28.2-μm average pore size, and they degrade quickly in 2.5 units/mL collagenase solution. Nearly 81% of KGN was released into phosphate-buffered saline within 12 hours, whereas the remaining KGN was released in 7 days. Macroscopically, the repaired tendons were attached to the footprint. No differences were detected postoperatively in microcomputed tomography analysis among groups. Fibrous scar tissue was the main component at the tendon-to-bone interface in the control group. Disorderly arranged cartilage formation was observed at the tendon-to-bone interface in the BMS and combined groups 4 weeks after repair; the combined group exhibited relatively more cartilage. The combined group showed improved cartilage regeneration 8 and 12 weeks after repair. Similar results were found in tendon maturation scores. The ultimate load to failure and stiffness of the repaired tendon increased in all 3 groups. At 4 weeks after repair, the BMS and combined groups exhibited greater ultimate load to failure than the control group, although there was no difference in stiffness among groups. The BMS and combined groups exhibited greater ultimate load to failure and stiffness than the control group, and the combined group exhibited better values than the BMS group at 8 and 12 weeks after repair.

CONCLUSION

Compared with the bone marrow-stimulating technique, the KGN-loaded GelMA hydrogel scaffold with bone marrow stimulation improved enthesis healing by promoting fibrocartilage formation and improving the mechanical properties.

Prognostische Faktoren der arthroskopischen Rotatorenmanschettenrekonstruktion

Hintergrund

Rupturen der Rotatorenmanschette sind eine der häufigsten Erkrankungen des Bewegungsapparats. Die klinischen und strukturellen Ergebnisse nach einer arthroskopischen Rotatorenmanschettenrekonstruktion (ARCR) sind im Allgemeinen gut, aber hinsichtlich der großen Schwankungsbreite der postoperativen Resultate noch verbesserungsfähig.

Fragestellung

Ziel dieser Literaturübersicht ist es, einen Überblick über prognostische Faktoren zu geben, die das postoperative Ergebnis nach ARCR beeinflussen.

Material und Methoden

Systematische Reviews, welche prognostische Faktoren für das Outcome nach ARCR analysieren, wurden in diese Übersichtsarbeit eingeschlossen. Die Literatursuche erfolgte in den Datenbanken Embase, Medline (Ovid) und Scopus. In die Auswertung wurden nur prognostischen Faktoren eingeschlossen, welche in mindestens zwei Übersichtsarbeiten beschrieben wurden.

Ergebnisse

Sieben systematische Reviews mit insgesamt 332 eingeschlossenen Artikeln wurden ausgewertet. Postoperative Ergebnisse waren Patientenzufriedenheit, Lebensqualität sowie funktionelle und strukturelle Ergebnisse. Sechzehn prognostische Faktoren wurden identifiziert und in patientenbezogene, rupturbezogene und behandlungsbezogene prognostische Faktoren untergliedert.

Schlussfolgerung

Anhand von patienten-, ruptur- und behandlungsbezogenen prognostischen Faktoren soll in Zukunft ein Vorhersagemodell erstellt werden können, um die individuellen Heilungschancen nach ARCR vorherzusagen und dem Patienten eine präzise Therapieempfehlung abgeben zu können.

Preoperative bone marrow stimulation does not improve functional outcomes in arthroscopic cuff repair: a prospective randomized controlled trial

AIMS

Despite recent advances in arthroscopic rotator cuff repair, re-tear rates remain high. New methods to improve healing rates following rotator cuff repair must be sought. Our primary objective was to determine if adjunctive bone marrow stimulation with channelling five to seven days prior to arthroscopic cuff repair would lead to higher Western Ontario Rotator Cuff (WORC) scores at 24 months postoperatively compared with no channelling.

METHODS

A prospective, randomized controlled trial was conducted in patients undergoing arthroscopic rotator cuff repair. Patients were randomized to receive either a percutaneous bone channelling of the rotator cuff footprint or a sham procedure under ultrasound guidance five to seven days prior to index surgery. Outcome measures included the WORC, American Shoulder and Elbow Surgeons (ASES), and Constant scores, strength, ultrasound-determined healing rates, and adverse events.

RESULTS

Overall, 94 patients were randomized to either bone channelling or a sham procedure. Statistically significant improvements in all clinical outcome scores occurred in both groups from preoperative to all timepoints (p < 0.001). Intention-to-treat analysis revealed no statistical differences in WORC scores between the two interventions at 24 months postoperatively (p = 0.690). No differences were observed in secondary outcomes at any timepoint and healing rates did not differ between groups (p = 0.186).

CONCLUSION

Preoperative bone channelling one week prior to arthroscopic rotator cuff repair was not associated with significant improvements in WORC, ASES, Constant scores, strength, or ultrasound-determined healing rates. Cite this article: Bone Joint J 2021;103-B(1):123-130.

Mid-Term Outcomes after Arthroscopic "Tear Completion Repair" of Partial Thickness Rotator Cuff Tears

Background and Objectives: Different arthroscopic procedures are used for partial-thickness rotator cuff tears (PT-RCTs), but there is still no evidence on the superiority of one procedure over the other. The aim of this study was to evaluate the clinical outcomes and the rate of complications of a tear completion repair (TCR) technique. Materials and Methods: Patients who had undergone arthroscopic TCR technique for PT-RCTs with a follow-up of at least 2-years after surgery were included. The TCR technique involved the removal of the "critical zone" and creating microfractures to biologically support tendon healing. Functional outcomes were assessed prospectively by the Constant score (CS) and active and passive range of movement (ROM). Pain and patient satisfaction were measured using a visual analog scale (VAS). Complication rates were recorded, and tendon integrity was assessed with magnetic resonance imaging (MRI) or ultrasound performed at least 2-years after surgery. Results: Eighty-seven patients with a median age of 57 years were followed-up for a median of 5 years. The CS score improved from 53.5 preoperatively to 94.0 postoperatively (p < 0.001). Median VAS score decreased from 8.6 to 1.0 (p < 0.0001). Median patient satisfaction was 9.3. The overall complication rate was 14.9%. Conclusions: Patients with PT-RCTs of the supraspinatus tendon treated by the TCR technique with "critical zone" removal and biological stimulation by microfractures showed good functional results with excellent strength recovery, a high degree of patient satisfaction, and resolution of painful symptoms at mid-term follow-up.

Novel and reproducible technique coping with intraoperative anchor pullout during arthroscopic rotator cuff repair

PURPOSE

To evaluate the incidence of intraoperative anchor pullout during arthroscopic rotator cuff repair, to compare the outcomes of different methods of managing anchor pullout, and to introduce a new technique for anchor pullout.

METHODS

1076 patients who underwent arthroscopic rotator cuff repair using a single-row repair technique were included. In 483 patients, rotator cuff repair was performed using a screw-in type anchor, and in 593 patients, soft anchors were used. When intraoperative anchor pullout occurred, it was managed by buddy screwing, anchor insertion in a different location, cement augmentation, or by bar anchoring using a threaded Steinmann pin. Plain radiography and sonography were used to check anchor locations and healing.

RESULTS

Fifty-two patients experienced anchor pullout intra- or postoperatively (48 and four patients, respectively). Anchor pullouts were more frequently observed for larger tears, women, older patients, and in patients with preoperative stiffness (limitations of both active and passive movements of the affected shoulder joint). For screw-in type anchors, pullout during surgery occurred in 16 patients (3.3%, 16/483), and all were managed using the buddy screwing technique. For soft anchor cases, pullout occurred in 32 patients (5.4%, 32/593) and was managed by anchor insertion in a different location (17 patients), cement augmentation (two patients), or bar anchoring using a threaded Steinmann pin (13 patients). Three patients managed by buddy screwing and two patients managed by anchor insertion in a different location had anchor failure after repair. Tendon healing at 6 months was observed in 12/16 patients treated by buddy screwing, 11/17 treated by anchor insertion in a different location, 2/2 treated by cement augmentation, and 12/13 treated by bar anchoring with a threaded Steinmann pin.

CONCLUSION

Intraoperative anchor pullout during arthroscopic rotator cuff repair is an uncommon but cumbersome complication. There are some techniques already introduced to deal with this complication. In comparison, not one technique is overwhelmingly superior to others; however, our new technique which is bar anchoring with a threaded Steinmann pin could be another solution, since it could utilize primary anchor sites and results appear to be acceptable. Level of evidence III.

Postoperative rotator cuff integrity: can we consider type 3 Sugaya classification as retear?

BACKGROUND

Sugaya classification is a widely accepted classification system that is used to analyze postoperative rotator cuff tendon integrity. However, there are inconsistencies in the literature as to whether type 3 Sugaya should be considered as a retear or healed tendon.

PURPOSE

We aimed to show that type 3 Sugaya is not a retear by comparing the long-term supraspinatus and infraspinatus muscle degeneration and the functional outcomes of type 3 with those of type 4 and 5 Sugaya. We hypothesized that the clinical course of type 3 Sugaya would be different from type 4 or 5 Sugaya.

METHOD

The study was a retrospective multicenter review of all the rotator cuff repair done in 2003-2004. We included all the patients who had undergone supraspinatus repair with 10-year follow-up (magnetic resonance imaging done with full functional assessment). Data collection included pre- and postoperative supraspinatus and infraspinatus fatty infiltration, supraspinatus muscle atrophy, and Constant score with a separate analysis of its Strength subsection. Supraspinatus tendon integrity at 10-year follow-up was determined according to Sugaya classification. The patients were divided into 2 groups: type 3 Sugaya and type 4 and 5 Sugaya. Statistical comparison was done between the groups.

RESULTS

There was no significant difference in the preoperative fatty infiltration of the supraspinatus and infraspinatus, supraspinatus muscle atrophy, and Constant score between the 2 groups. However, type 3 Sugaya patients had significantly better scores in the preoperative Strength subsection. Postoperatively, type 3 Sugaya patients showed significantly lesser fatty infiltration of the supraspinatus and infraspinatus, lesser supraspinatus muscle atrophy, and higher Constant score compared with type 4 and 5 Sugaya (P < .001).

CONCLUSION

Patients with type 3 Sugaya supraspinatus tendon exhibited lesser muscle degeneration in the supraspinatus and infraspinatus and performed better in functional assessment compared with type 4 and 5 Sugaya patients. We inferred that type 3 Sugaya should not be considered as a retear.

Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents

PURPOSE

The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents.

METHODS

This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity.

RESULTS

A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon.

CONCLUSIONS

Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series.

Bone Marrow Stimulation in Arthroscopic Repair for Large to Massive Rotator Cuff Tears With Incomplete Footprint Coverage

BACKGROUND

There is no research on incomplete footprint coverage with single-row repair related to bone marrow stimulation (BMS) in large to massive rotator cuff tears (RCTs).

PURPOSE/HYPOTHESIS

The purpose was to compare the clinical results and structural integrity between BMS and non-BMS groups that underwent arthroscopic repair of large to massive rotator cuff tears with <50% footprint coverage. It was hypothesized that both groups would exhibit improved clinical outcomes at 2 years after surgery but the BMS group would have significantly better clinical outcomes and structural integrity.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 98 patients who underwent arthroscopic repair with <50% footprint coverage for large to massive RCTs with (BMS group; n = 56) or without (non-BMS group; n = 42) BMS. Functional outcomes at the 2-year follow-up were assessed using the visual analog scale for pain score, subjective shoulder value; American Shoulder and Elbow Surgeons score; University of California, Los Angeles, shoulder score; and active range of motion. Structural integrity was evaluated using magnetic resonance arthrography or computed tomography arthrography results at 6 months postoperatively.

RESULTS

At the 2-year follow-up, all functional outcomes significantly improved in both groups compared with preoperative values (P < .001). However, there were no significant postoperative differences between groups. On follow-up magnetic resonance arthrography or computed tomography arthrography, the overall retear rate was not significantly different between the BMS group (30.3%; 17/56) and the non-BMS group (35.7%; 15/42).

CONCLUSION

While both groups exhibited functional improvement after single-row repair with <50% footprint coverage for large to massive RCTs, BMS did not produce better clinical outcomes or structural integrity.

Preliminary Clinical Outcomes Following Biologic Augmentation of Arthroscopic Rotator Cuff Repair Using Subacromial Bursa, Concentrated Bone Marrow Aspirate, and Platelet-Rich Plasma

Purpose

To evaluate the clinical outcomes of patients who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma.

Methods

Sixteen patients were included in the study who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, cBMA, and platelet-rich plasma from January 2018 to July 2018 and had a minimum 1-year follow-up. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, Constant-Murley, and Single Assessment Numerical Evaluation (SANE) scores were collected preoperatively and at terminal follow-up. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit, and the patient acceptable symptomatic state thresholds were used. In vitro cellular proliferation of subacromial bursa (nucleated cells/gram) and cBMA (nucleated cells and colony-forming units/cc) samples was evaluated and correlated to clinical outcomes scores.

Results

Mean follow-up was 12.6 ± 1.8 months (range 12-19 months). Patients achieved significant improvement in ASES (45.8±22.5_pre vs 88.5 ± 14.6_post, Δ44.7 ± 20.7; P = .001), Simple Shoulder Test (4.3 ± 3.2_pre vs 10.4 ± 1.6_post, Δ5.7 ± 3.9, P = .002), Constant-Murley (44.3 ± 18.2_pre vs 83.6 ± 17.5_post, Δ37.2 ± 21.8; P = .001), SANE (13.3 ± 10.7_pre vs 86.3 ± 17.5_post, Δ71.9 ± 22.9; P = .001), and pain scores (5.0±2.8_pre vs 1.1 ± 1.6_post, Δ3.5±2.5, P = .001) at final follow-up. With regards to ASES score, 93.8% of patients achieved the minimal clinically important difference, 93.8% the substantial clinical benefit, and 62.5% reached or exceeded the patient acceptable symptomatic state criteria. There was a significant positive correlation of nucleated cell count of cBMA with postoperative SANE score (r = 0.707; P = .015) and delta in ASES score (r = 0.727; P = .011). All other correlations were found to be nonsignificant (P > .05, respectively).

Conclusions

Patients undergoing arthroscopic rotator cuff repair augmented using the Mega-Clot with bursa technique achieved significant improvement in functional outcomes at a minimum 1-year follow-up, with 93.8% of patients reaching substantial clinical benefit.

Level of Evidence

Level IV, therapeutic case series.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

[Effect of microfracture combined with biomimetic hydrogel scaffold on rotator cuff tendon-to-bone healing in rabbits]

OBJECTIVE

To assess the effect of microfracture and biomimetic hydrogel scaffold on tendon-to-bone healing in a rabbit rotator cuff tear model.

METHODS

Gelatin and methacrylic anhydride were used to synthesize gelatin methacryloyl (GelMA). Then the GelMA were treated with ultraviolet rays and vacuum freeze-drying method to obtain a biomimetic hydrogel scaffold. The morphology of the scaffold was observed by gross observation and scanning electron microscope. Degradation of the scaffold was determined at different time points. Twenty-four adult New Zealand rabbits, weighting 2.8-3.5 kg and male or female, were surgically created the bilateral acute rotator cuff tear models. One shoulder was treated with microfractures on the footprint and transosseous suture (control group, n=24). The other shoulder was treated with the same way, except for putting the scaffold on the footprint before transosseous suture (experimental group, n=24). The general conditions of rabbits were observed postoperatively. Tendon-to-bone healing was evaluated by gross observation, Micro-CT, HE staining, and bio-mechanical testing at 4 and 8 weeks after operation.

RESULTS

The scaffold was white and has a porous structure with pore size of 31.7-89.9 μm, which degraded slowly in PBS solution. The degradation rate was about 95% at 18 days. All the rabbits survived to the completion of the experiment. Micro-CT showed that there was no obvious defect and re-tear at the tendon-to-bone interface in both groups. No difference was found in bone mineral density (BMD), tissue mineral density (TMD), and bone volume/total volume (BV/TV) between the two groups at 4 and 8 weeks postoperatively ( P>0.05). HE staining showed that the fibrous scar tissue was the main component at the tendon-to-bone interface in the control group at 4 and 8 weeks postoperatively; the disorderly arranged mineralized cartilage and fibrocartilage formation were observed at the tendon-to-bone interface in the experimental group at 4 weeks, and the orderly arranged cartilage formation was observed at 8 weeks. Besides, the tendon maturation scores of the experimental group were significantly higher than those of the control group at 4 and 8 weeks ( P<0.05). There was no significant difference in the ultimate load to failure and stiffness between the two groups at 4 weeks ( P>0.05); the ultimate load to failure at 8 weeks was significantly higher in the experiment group than in the control group ( t=4.162, P=0.009), and no significant difference was found in stiffness between the two groups at 8 weeks ( t=2.286, P=0.071).

CONCLUSION

Compared with microfracture alone, microfracture combined with biomimetic hydrogel scaffold can enhance tendon-to-bone healing and improve the ultimate load to failure in rabbits.

Hip abductor tendon tears: where are we now?

Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilising the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic injury during arthroplasty and chronic degenerative tendinopathy. Ultrasound and magnetic resonance imaging have provided limited clues regarding the pattern of disease and further work is required to clarify both the macro and microscopic pattern of disease. While surgery has been attempted over the last 2 decades, the outcomes are variable and the lack of high-quality studies have limited the uptake of surgical repair. Hip abductor tendon tears share many features with rotator cuff tears, hence, innovations in surgical techniques, materials and biologics may apply to both pathologies.

Clinical and functional outcomes of a novel transosseous device to treat rotator cuff tears: A minimum 2-year follow-up

PURPOSE

Despite the improvements in the repair equipment techniques of rotator cuff, a gold standard method has not been defined yet and transosseous fixation through deltoid-splitting (mini-open) approach is still regarded as a good option. The primary purpose of this study is to present satisfactory clinical and functional outcomes with a novel transosseous device in full-thickness rotator cuff tear through deltoid-splitting.

MATERIALS AND METHODS

This retrospective study was performed on 70 consecutive patients who underwent surgery by a single surgeon from June 2014 to June 2016 for a full-thickness rotator cuff tear and was managed with a novel transosseous device. Total number of patients, mean age, percentage of male and female patients, mean duration of follow-up, percentage of involvement of the dominant extremity, affected shoulder, and tear size were recorded. Functional and clinical outcomes were assessed baseline and postoperatively at 3 and 6 months and final follow-up using Disabilities of the Arm, Shoulder and Hand (Q-DASH) and Constant-Murley scores.

RESULTS

A total of 70 (49 (70%) female, 21 (30%) male) patients whose mean age was 58.66 ± 9.19 (38-77) years were included. The mean surgery time was 35.33 ± 5.34 (28-55) min. The mean follow-up time was 28.31 ± 3.03 (24-36) months. According to the DeOrio and Cofield classification, 15 (21.43%) tears were small, 33 (47.14%) medium, 16 (22.86%) large, and 6 (8.57%) massive. By the final follow-up, the mean Constant-Murley score had significantly improved from 27.67 ± 7.46 (13-41) to 81.25 ± 3.77 (74-87; p = 0.0001) and the Q-DASH score had decreased from 82.34 ± 10.37 (65.91-100) to 10.28 ± 6.88 (0-23.45; p = 0.0001). There were no significant differences in the Constant-Murley or Q-DASH score at baseline-final follow-up between the small, medium, large, and massive tear groups (p > 0.05).

CONCLUSIONS

Treatment of full-thickness rotator cuff tear using this novel transosseous device significantly improved functional and clinical scores. However, further long-term prospective randomized multicenter trials involving comparative studies are necessary to confirm these findings.

Clinical Outcomes Following Biologically Enhanced Patch Augmentation Repair as a Salvage Procedure for Revision Massive Rotator Cuff Tears

PURPOSE

To evaluate the clinical outcomes of patients who underwent biologically enhanced patch augmentation repair for the treatment of revision massive rotator cuff tears.

METHODS

Twenty-two patients who underwent arthroscopic and mini-open rotator cuff repair using a patch augmented with platelet-rich plasma and concentrated bone marrow aspirate (cBMA) for revision massive (≥2 tendons) rotator cuff tears from 2009 to 2014, with a minimum 1-year follow-up, were included in the study. In this procedure the medial side of the graft is secured to the rotator cuff tendon remaining medially. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, and postoperative Single Assessment Numerical Evaluation scores were evaluated. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit (SCB), and the patient-acceptable symptomatic state (PASS) thresholds were used. Clinical success or failure was defined based on whether the patient reached the SCB threshold. In the laboratory, cellular counting along with the concentration of connective tissue progenitor cells were performed on patch samples from the day of surgery. Scaffolds were processed histologically at days 0, 7,14, and 21 of culture.

RESULTS

Patients had significant improvement in the Simple Shoulder Test (2.6 ± 3.0_pre vs 5.2 ± 4.2_post, P = .01), whereas improvement in pain scores was found to be nonsignificant (5.6 ± 2.5_pre vs 4.2 ± 3.4_post,P = .11) at final follow-up. Mean ASES improved by Δ14.6 ± 33.4 points; however, this did not reach statistical significance (40.2 ± 21.6_pre vs 53.9 ± 31.4_post,P = .10). With regards to ASES score, 45% of patients achieved the minimal clinically important difference, 41% the SCB, and 32% reached or exceeded the PASS criteria. At 21 days, there was a significantly greater cell count in scaffolds from patients who had clinical success than those who were failures (P = .02).

CONCLUSIONS

Only 41% of patients undergoing biologically enhanced patch augmentation repair reached substantial clinical benefit, whereas 32% reached or exceeded the PASS criteria.

LEVEL OF EVIDENCE

Case Series: Level IV.

Editorial Commentary: Rotator Cuff Tendon Healing May Be Enhanced With a Blanket

After rotator cuff repair, the regeneration of the anatomic enthesis may be beneficial. Although many cell and growth factor studies have been performed, none have shown a consistent regeneration of this structure. The use of bone marrow vents in the greater tuberosity has been associated with improved healing. The resultant clot has been dubbed a "crimson duvet" or blanket. The use of this readily available-and inexpensive-modality should be maximized in patients undergoing rotator cuff repair. In the end, a goal could be to enhance tendon-to-bone healing via a scaffold, cells, and growth factors. Pending inevitable reliable advances in biological augmentation, mesenchymal stem cells and growth factors from the greater tuberosity are just a marrow-stimulating pick away.

Small Subchondral Drill Holes Improve Marrow Stimulation of Rotator Cuff Repair in a Rabbit Model of Chronic Rotator Cuff Tear

BACKGROUND

Microfracture of the greater tuberosity has been proved effective for enhancing tendon-to-bone healing after rotator cuff repair. However, no standard diameter for the microfracture has been established.

PURPOSE/HYPOTHESIS

This study aimed to assess treatment with large- and small-diameter microfractures to enhance healing during rotator cuff repair surgery in a rabbit model of chronic rotator cuff tear. It was hypothesized that a small-diameter microfracture had advantages in terms of tendon-to-bone integration, bone-tendon interface maturity, microfracture healing, and biomechanical properties compared with a large-diameter microfracture.

STUDY DESIGN

Controlled laboratory study.

METHODS

Bilateral supraspinatus tenotomy from the greater tuberosity was performed on 21 New Zealand White rabbits. Bilateral supraspinatus repair was performed 6 weeks later. Small-diameter (0.5 mm) microfracture and large-diameter microfracture (1 mm) were performed on the left side and right side, respectively, in 14 rabbits as a study group, and simple repair without microfracture was performed in 7 rabbits as a control group. At 12 weeks later, 7 of 14 rabbits in the study group were sacrificed for micro-computed tomography evaluation and biomechanical testing. Another 6 rabbits were sacrificed for histological evaluation. In the control group, 3 of the 7 rabbits were sacrificed for histological evaluation and the remaining rabbits were sacrificed for biomechanical testing.

RESULTS

Significantly better bone-to-tendon integration was observed in the small-diameter microfracture group. Better histological formation and maturity of the bone-tendon interface corresponding to better biomechanical results (maximum load to failure and stiffness) were obtained on the small-diameter microfracture side compared with the large-diameter side and the control group. The large-diameter microfracture showed worse radiographic and histological properties for healing of the microfracture holes on the greater tuberosity. Additionally, the large-diameter microfracture showed inferior biomechanical properties but similar histological results compared with the control group.

CONCLUSION

Small-diameter microfracture showed advantages with enhanced rotator cuff healing for biomechanical, histological, and radiographic outcomes compared with large-diameter microfracture, and large-diameter microfracture may worsen the rotator cuff healing.

CLINICAL RELEVANCE

This animal study suggested that a smaller diameter microfracture may be a better choice to enhance healing in clinical rotator cuff repair surgery in humans.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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