Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair

No difference in 2-year outcomes of arthroscopic rotator cuff repair in patients with osteoporosis

BACKGROUND

Many prognostic factors associated with healing after arthroscopic rotator cuff repair have been evaluated. It has been shown from previous literature that osteoporosis is an independent risk factor for poor healing and increased need for revision surgery. To our knowledge, there has not been a study reporting patient reported outcomes (PROs) for arthroscopic rotator cuff repair in patients with osteoporosis. The purpose of this study was to compare PROs of arthroscopic rotator cuff repair (RCR) in patients with decreased bone mineral density to those with normal bone mineral density. We hypothesized that patients with decreased bone mineral density would have worse outcomes.

METHODS

A retrospective chart review identified patients who had arthroscopic RCR with preoperative and minimum 2-year postoperative PROs. Demographic data and rotator cuff tear size were recorded, and the PROs included American Shoulder and Elbow Surgeons (ASES), visual analog scale pain score, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (VR-12) physical component score (PCS), and VR-12 mental component score (MCS). Each patient record was queried for an osteoporosis, osteopenia, or osteoporotic fracture diagnosis within a year before or after RCR. Patients with one of these diagnoses comprised the decreased bone mineral density group; whereas, patients without these diagnoses comprised the control group. An analysis of covariance was used to compare 2-year PROs while controlling for age, sex, tear size, preop ASES, preop VR-12 MCS, preop VR-12 PCS, and Charlson Comorbidity Index. Significance was set at α = 0.05.

RESULTS

Three-hundred fifty-seven patients were included. The mean age was 59.8 ± 10.0 years, and 191 (53.5%) were male. There were 30 patients (8.4%) in the decreased bone mineral density group and 327 patients (91.6%) in the control group. One hundred eighty-two (51.0%) patients had large or massive tears, and 175 patients (49.0%) had small or medium tears. There were no baseline differences between groups based on Charlson Comorbidity Index (P = .092), VR-12 MCS mean scores (P = .924), and initial ASES mean scores (P = .183). A small baseline difference existed in VR-12 PCS mean scores (P = .032). As expected, the decreased bone mineral density group had more females (28 of 30, P < .001) and older patients (67.6 ± 7.6 years vs. 59.1 ± 10.0 years, P < .001). Analysis of covariance identified no significant difference in 2-year ASES scores between groups (P = .216).

CONCLUSION

Despite previous literature showing the negative effect of osteoporosis on rotator cuff healing, our data showed no relationship between decreased bone mineral density and 2-year clinical outcomes following RCR. Patients with decreased bone mineral density can still achieve excellent 2-year outcomes.

Osteoporosis Management for Shoulder Surgeons

PURPOSE OF REVIEW

The aim of this review is to aggregate currently available literature as it pertains to treating surgical shoulder pathology in patients with osteoporosis.

RECENT FINDINGS

Emerging data surrounding perioperative use of anti-osteoporosis medications for patients undergoing shoulder surgery have not shown definitively favorable or unfavorable outcomes. Similar evaluations in animal studies have shown promising results as a biologic augment to tendon and bone healing, especially with newer, anabolic agents. The mainstay of bone health management remains pre-operative evaluation, using opportunistic radiographic and CT based validated measurements, along with optimization of risk factors. Surgical techniques continue to incorporate implants that perform well in osteopenic bone. Promising pre-clinical studies have identified anabolic anti-osteoporosis medications as viable biologic augments to shoulder surgery, which has not been borne out in any clinical studies at this time.

The Relationship Among Probable SARCopenia, Osteoporosis and SuprasPinatus Tendon Tears in Postmenopausal Women: The SARCOSP Study

We aimed to investigate the relationship among probable sarcopenia, osteoporosis (OP) and supraspinatus tendon (SSP) tears in postmenopausal women. Postmenopausal women screened/followed for OP were recruited. Demographic data, comorbidities, exercise/smoking status, and handgrip strength values were recorded. Probable sarcopenia was diagnosed as handgrip strength values < 20 kg. Achilles and SSP thicknesses were measured using ultrasound. Among 1443 postmenopausal women, 268 (18.6%) subjects had SSP tears. Unilateral tears were on the dominant side in 146 (10.1%) and on the non-dominant side in 55 women (3.8%). In contrast to those without, women with SSP tears had older age, lower level of education, thinner SSP and lower grip strength (all p < 0.05). In addition, they had higher frequencies of hypertension, hyperlipidemia, DM, OP and probable sarcopenia, but lower exercise frequency (all p < 0.05). Binary logistic regression modeling revealed that age [odds ratio (OR): 1.046 (1.024-1.067 95% CI)], hypertension [OR: 1.560 (1.145-2.124 95% CI)], OP [OR: 1.371 (1.022-1.839 95% CI)] and probable sarcopenia [OR: 1.386 (1.031-1.861 95% CI)] were significant predictors for SSP tears (all p < 0.05). This study showed that age, presence of hypertension, probable sarcopenia and OP were related with SSP tears in postmenopausal women. To this end, although OP appeared to be related to SSP tears, SSP tear/thickness evaluation can be recommended for OP patients, especially those who have other risk factors such as older age, higher BMI, hypertension, and probable sarcopenia.

Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis

Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.

Macroporous Granular Hydrogels Functionalized with Aligned Architecture and Small Extracellular Vesicles Stimulate Osteoporotic Tendon-To-Bone Healing

Osteoporotic tendon-to-bone healing (TBH) after rotator cuff repair (RCR) is a significant orthopedic challenge. Considering the aligned architecture of the tendon, inflammatory microenvironment at the injury site, and the need for endogenous cell/tissue infiltration, there is an imminent need for an ideal scaffold to promote TBH that has aligned architecture, ability to modulate inflammation, and macroporous structure. Herein, a novel macroporous hydrogel comprising sodium alginate/hyaluronic acid/small extracellular vesicles from adipose-derived stem cells (sEVs) (MHA-sEVs) with aligned architecture and immunomodulatory ability is fabricated. When implanted subcutaneously, MHA-sEVs significantly improve cell infiltration and tissue integration through its macroporous structure. When applied to the osteoporotic RCR model, MHA-sEVs promote TBH by improving tendon repair through macroporous aligned architecture while enhancing bone regeneration by modulating inflammation. Notably, the biomechanical strength of MHA-sEVs is approximately two times higher than the control group, indicating great potential in reducing postoperative retear rates. Further cell-hydrogel interaction studies reveal that the alignment of microfiber gels in MHA-sEVs induces tenogenic differentiation of tendon-derived stem cells, while sEVs improve mitochondrial dysfunction in M1 macrophages (Mφ) and inhibit Mφ polarization toward M1 via nuclear factor-kappaB (NF-κb) signaling pathway. Taken together, MHA-sEVs provide a promising strategy for future clinical application in promoting osteoporotic TBH.

Tendon Disorders in Chronic Liver Disease: A Retrospective Cohort Study in Taiwan

To investigate the relationship between chronic liver disease and tendon disorder, a retrospective cohort study was conducted using the Kaohsiung Veterans General Hospital database. Patients >18 years with newly diagnosed liver disease and with at least a two-year follow-up in the hospital were included. An equal number of 20,479 cases were enrolled in both the liver-disease and non-liver-disease groups using a propensity score matching method. Disease was defined using ICD-9 or ICD-10 codes. The primary outcome was the development of tendon disorder. Demographic characteristics, comorbidities, use of tendon-toxic drugs, and status of HBV/HCV infection were included for analysis. The results showed 348 (1.7%) and 219 (1.1%) individuals developed tendon disorder in the chronic liver disease group and non-liver-disease group. Concomitant use of glucocorticoids and statins may have further raised the risk of tendon disorder in the liver disease group. The co-existence of HBV/HCV infection did not increase the risk of tendon disorder in the patients with liver disease. Considering these findings, physicians should be more aware of tendon issues in advance, and a prophylactic strategy should be adopted in patients with chronic liver disease.

The role of vitamin D on rotator cuff tear with osteoporosis

BACKGROUNDS

Osteoporosis (OP) is an important risk factor for rotator cuff tears (RCTs). However, the relationship and mechanism between rotator cuff injury and osteoporosis are unclear. Therefore, to investigate association between rotator cuff injury and osteoporosis, and find clinical characteristics, bone mineral density, bone metabolism markers, and nutrient levels in rotator cuff injury patients with or without osteoporosis.

METHODS

One hundred and four cases of patients (RCTs, n=32; RCTs-OP, n=72) who underwent rotator cuff injury and need arthroscopic rotator cuff repair between June 2021 and February 2022, along with the diagnosis of osteoporosis were identified from the dual-energy X-ray bone density screening(DXA). The outcome measure includes clinical characteristics, bone mineral density, bone metabolism markers, vitamins, and amino acids. Multivariable logistic regression analysis was applied to build a predicting model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predicting model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was assessed using bootstrapping validation.

RESULTS

OP with RCTs has a lower level of in 25-vitD, osteocalcin (OCN), serum Ca2+, ornithine, diaminocaproic_acid but the high level of Vitamin_B12, PTH, Vitamin_D3,γ_aminobutyric_acid, Vitamin_C and Vitamin_E than RCTs patients without OP. Predictors contained in the prediction nomogram included lumber T score, femur T score, Niacin_B3, and vitamin D, reflecting the combined effect of vitamins on RCTs-related OP progression. The model has good discriminative ability with a C-index of 0.938(95% CI:-1.83-1.39) and good scaling ability. The high C-index value of 0.95 is still achievable with range validation. Analysis of decision curves showed that non-adherence is clinically useful when intervention decisions are at the 14% probability limit of non-adherence.

CONCLUSION

This study supports the hypothesis that lumber T score, femur T score, Niacin_B3, and Vitamin D are valuable prognostic biomarkers on RCTs related OP progression.

WHAT IS KNOWN ABOUT THE SUBJECT

It is found that vitamin D are valuable prognostic biomarkers, reflecting the combined effect of vitamins on RCTs related OP progression.

WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE

These findings also highlight that nutrients condition such as vitamins and amino acids of patients provide a new understanding of the development of RCTs.

Trabecular Bone Score Could Not Predict the Bone Mineral Density of Proximal Humerus

Background

Osteoporosis is an important clinical factor for tendon healing after arthroscopic rotator cuff repair (ARCR). Conventional dual energy X-ray absorptiometry (DXA) of the hip and lumbar spine (LS) does not represent proximal humeral bone mineral density (BMD). Theoretically, direct measurement of the BMD of the proximal humerus is the best method; however, it is not popular and is non-standardized. Therefore, we evaluate whether the trabecular bone score (TBS) using LS DXA would represent proximal humeral BMD.

Methods

Conventional hip and LS DXA and proximal humeral BMD were measured in 212 consecutive ARCR patients, and TBS was calculated using LS DXA. Comparative analysis between the affected and contralateral asymptomatic shoulders was done; moreover, correlation analysis was conducted to evaluate the representativity of TBS for proximal humeral BMD. Regression analysis was performed to elucidate the risk factor of intraoperative suture anchor failure (ISAF).

Results

BMDs of the affected shoulder were significantly lower than those of the contralateral side (all P<0.05). TBS failed to present a strong correlation with proximal humeral BMD (correlation coefficients 0.155–0.506, all P<0.05), and the BMD of the greater tuberosity (GT) of the proximal humerus was revealed to be a sole risk factor for ISAF (odds ratio, 0.01, P=0.020).

Conclusions

TBS and conventional hip and LS DXA did not represent proximal humeral BMD. Furthermore, among the various radiological measurements, the BMD of the GT was a sole risk factor of ISAF. Therefore, further research for the direct measurement of proximal humeral BMD is mandatory to predict proximal humeral focal osteoporosis.