Prospective 1-Year Outcomes Are Maintained at Short-Term Final Follow-Up After Superior Capsular Reconstruction Augmentation of Complete Rotator Cuff Repair

Growth Hormone-Releasing Peptide 2 May Be Associated With Decreased M1 Macrophage Production and Increased Histologic and Biomechanical Tendon-Bone Healing Properties in a Rat Rotator Cuff Tear Model

PURPOSE

To explore the potential of growth hormone-releasing peptide 2 (GHRP-2) for tendon-bone healing in a rat rotator cuff tear (RCT) model.

METHODS

The impact of GHRP-2 on M1 macrophage polarization in vitro was determined using real-time polymerase chain reaction, Western blot, and immunofluorescence staining. GHRP-2 was then applied in a rat RCT model, and the healing of the tendon-bone interface was systemically evaluated by histologic staining, radiologic assessments, gait analysis, and biomechanical tests. M1 macrophage polarization at the tendon-bone interface was assessed by immunofluorescence staining.

RESULTS

GHRP-2 was found to reduce the expression of Cd86, Nos2, and tnfa (all P < .01), suggesting inhibited M1 macrophage polarization in vitro. The in vivo experiments showed that the proportion of M1 macrophages was reduced both 2 and 4 weeks after surgery (P < .01), and the number of M1 was reduced 4 weeks after surgery (P < .01) at the tendon-bone interface. The in vivo experiments also showed that histologic scores and bone mineral density were increased by GHRP-2 at 8 weeks postsurgery (P < .01), suggesting improved healing of the tendon-bone interface. Furthermore, the GHRP-2 group showed a better biomechanical property at both 4 and 8 weeks postsurgery, including maximal failure load, stiffness, and tension (all P < .01), and better gait parameters at 8 weeks postsurgery, including mean area of the left front foot and mean intensity of the right front foot (all P < .05).

CONCLUSIONS

GHRP-2 may be associated with decreased M1 macrophage production and increased histologic and biomechanical tendon-bone healing properties in a rat RCT model.

CLINICAL RELEVANCE

The present study might be a transitional study to show the efficacy of GHRP-2 in enhancing bone-tendon healing and reduce retear rate after rotator cuff repair.

Improved restoration of biomechanical factors using a narrow-box shaped reconstruction compared to a wide one in superior capsular reconstruction for irreparable supraspinatus tendon tears: a biomechanical study using a static shoulder simulator

HYPOTHESIS AND/OR BACKGROUND

Extensive, irreparable rotator cuff tears remain a surgical challenge and multiple treatment options are proposed and currently in use. To biomechanically compare superior glenohumeral translation, subacromial contact pressures, and area in a box-shaped reconstruction using the long head of the biceps tendon (LHBT) in an irreparable supraspinatus tendon tear model.

METHODS

Seven cadaveric shoulders (mean age 61 years; range 32-84 years; standard deviation 22.3) were tested with a custom testing rig used to evaluate superior translation; subacromial contact pressures; and areas at 0°, 30°, and 60° of glenohumeral abduction. Conditions tested included the native state; a complete tear of the supraspinatus tendon; a wide box-shaped, double-bundle LHBT superior capsular reconstruction (BS-SCR); and a narrow BS-SCR.

RESULTS

Compared with the wide BS-SCR, the narrow BS-SCR had statistically significantly lower median contact pressure at 30° and 60°. The subacromial contact area showed a statistically significant difference at 0° (P = .001) and 30° (P = .004) for the narrow BS-SCR compared with the wide BS-SCR. At an abduction angle of 0°, the narrow BS-SCR could restore superior translation significantly better compared with the wide construct. For all angles, the wide and narrow BS-SCR increased the median subacromial distance statistically significantly. The contact areas in 30° and 60° of abduction were higher for all scenarios, both peaking in the intact state in 30° with approximately 600 mm2.

CONCLUSIONS

In comparison to a wide BS-SCR, a narrow BS-SCR using the LHBT has biomechanical advantages in regard to subacromial contact pressures, the subacromial contact areas, as well as the acromiohumeral distance. The width of the reconstruction, therefore, has a direct influence on the success of the technique.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

INTRODUCTION

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT).

METHODS

This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables.

RESULTS

Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, P = .021) and lower VAS scores (β = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (β = 3.0, P = .043).

CONCLUSION

Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Arthroscopic superior capsule reconstruction augmentation using a semitendinosus autograft in massive reparable rotator cuff tears

Background

Arthroscopic superior capsule reconstruction (SCR) augmentation is a viable treatment option for massive reparable cuff tears. This study aimed to retrospectively compare clinical and imaging outcomes of patients with reparable massive rotator cuff tears after arthroscopic rotator cuff repair (ARCR) with those after SCR augmentation using a semitendinosus autograft.

Methods

We retrospectively compared 50 patients with massive reparable rotator cuff tears who underwent ARCR and SCR augmentation (n = 25 each). Patients were clinically followed up for at least 2 years, and the American Shoulder and Elbow index, other patient-reported outcomes, active range of motion, and radiography and magnetic resonance imaging findings were assessed.

Results

At the final follow-up, both patient groups showed significant improvements in forward elevation in range of motion and visual analog scale scores. Improvements in the American Shoulder and Elbow scores in the SCR augmentation group were significantly superior to those in the ARCR group (48.3 and 28.9, P < .01). There was a significant difference in the retear rate between the SCR augmentation group and ARCR group (20% and 56%, respectively; P = .009).

Conclusion

Our study demonstrated that patient-reported outcomes and retear rates in patients who underwent SCR augmentation with rotator cuff repair for massive rotator cuff tears significantly improved compared with those in patients who underwent ARCR without augmentation. Augmentation with semitendinosus autografting during rotator cuff repair represents a solution for patients with massive reparable rotator cuff tears.

Time required to achieve clinically significant outcomes after arthroscopic superior capsular reconstruction

PURPOSE

To investigate the time-dependent nature of clinically significant outcomes, including the minimal clinically important difference (MCID), substantial clinical benefit, and Patient Acceptable Symptomatic State (PASS) after arthroscopic superior capsular reconstruction, and the factors contributing to the achievement of early clinically significant outcomes.

METHODS

Patients who underwent ASCR between March 2015 and September 2020 with complete preoperative and postoperative 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs) were retrospectively analysed. Threshold values for MCID, substantial clinical benefit, and PASS were obtained from the previous literature for the PROMs. The time required to achieve clinically significant outcomes was calculated using Kaplan-Meier analysis. Multivariate Cox regression was performed to evaluate the variables predictive of an earlier or delayed achievement of MCID.

RESULTS

Fifty-nine patients with a mean age of 64.5 ± 8.7 years old were included. The time of mean achievement of MCID, substantial clinical benefit, and PASS for VAS was 11.2 ± 0.9, 16.3 ± 1.1, and 16.6 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for ASES was 13.2 ± 1.0, 16.8 ± 1.0, and 18.3 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for the Constant score was 11.6 ± 0.9, 15.1 ± 1.0, and 14.7 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for SANE was 14.4 ± 1.0, 16.1 ± 1.0, and 15.5 ± 0.8 months, respectively. Patients with a higher preoperative VAS score achieved an earlier MCID for VAS (P = 0.014). However, patients with a higher preoperative ASES and SANE scores achieved delayed MCID for ASES and SANE (P = 0.026, and P < 0.001, respectively).

CONCLUSION

Most patients achieved MCIDs around 1 year after arthroscopic superior capsular reconstruction. A higher preoperative VAS score favours faster MCID achievement, while higher preoperative ASES and SANE scores contribute to delayed MCID achievement.

STUDY DESIGN

Cohort study LEVEL OF EVIDENCE: Level IV.

Arthroscopic Transosseous Superior Capsular Reconstruction

Superior capsular reconstruction is a common treatment option for irreparable rotator cuffs. Arthroscopic surgery procedures mostly use anchor-based methods. However, difficulty in preoperative graft measurement and intra-articular knot-tying present an obstacle for most sport surgeons. Complementing the known advantages of the transosseous technique in rotator cuff repair, a feasible, economical arthroscopic transosseous superior capsular reconstruction technique is described in this Technical Note. This procedure results not only in similar fixation strength and stability and greater bone stock but also in greater cost effectiveness due to using fewer anchors. This Technical Note describes the procedure in detail and compares it with conventional procedures.

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.

Compressed Biceps Autograft Augmentation of Arthroscopic Rotator Cuff Repair

Rotator cuff repair failure rates continue to be a challenging problem. Various methods of biological and structural augmentation of the rotator cuff have been explored to improve tendon healing after repair. We describe a technique in which biceps tendon autograft is harvested after tenodesis. The biceps tendon is then compressed into a patch that is placed over the repaired rotator cuff tendon. Repurposing the portion of the tendon that is otherwise discarded offers several advantages over other augmentations that have been used, including the biological potential of live autograft tenocytes in the patch, lower cost, and no donor-site morbidity.

Editorial Commentary: Shoulder Superior Capsule Reconstruction Leads to Good Outcomes Despite Ambiguous Graft Healing Suggesting a Spacer Effect

Massive, retracted rotator cuff tears with poor tissue quality continue to pose a problem for the shoulder surgeon. Augmentation of such repairs with grafts, patches, spacers, or biologics is being closely investigated to help improve clinical outcomes and healing rates. Specifically, superior capsule reconstruction augmentation of such rotator cuff tears may lead to good outcomes. However, we do not truly understand how much native cuff tissue or graft healing is actually taking place. Clinically, superior capsule reconstruction augmentation of rotator cuff repair may simply be serving as a spacer.