Trends in rotator cuff surgery: Research through the decades

Trends in shoulder arthroplasty research over the decades

Introduction

The aim of this study is to analyse the most cited articles in shoulder arthroplasty surgery and identify trends in topics by decade.

Methods

Journal Citation Index Web of Science (WoS) was searched to find articles using the search terms "shoulder arthroplasty", "shoulder hemiarthroplasty", "shoulder replacement" and "shoulder prosthesis". All articles were ranked according to most cited overall and most cited between 2022 and 2023, and then further analysed to find the most cited articles per decade. Articles were studies for topic, study type, evidence level and number of subjects. A second search was performed using Google Scholar (GS) with the same search terms.

Results

All the most cited articles were published in 4 orthopaedic journals. Citation counts were higher for GS searches than WoS for every article, by an average of 1.92 times. Each decade's most cited articles seemed to fit into a few broad topics, showing trends in that decade. The highest cited papers were generally low-level evidence studies.

Conclusion

Shoulder arthroplasty literature appears to follow trends throughout the decade. High quality evidence is lacking in the highest cited papers, but this study highlights the importance and value of these lower-evidence breakthrough studies, which have shaped shoulder arthroplasty surgery.

The continuous fragility index of outcomes in rotator cuff repair augmentation randomized trials: a systematic review

BACKGROUND

Symptomatic rotator cuff tears often undergo surgical repair, which may be paired with various augmentation strategies to enhance structural healing rates. While many randomized controlled trials (RCTs) evaluate augmentation techniques, the statistical robustness of many findings in these studies is unknown. This systematic review aims to evaluate the continuous fragility index (CFI) of RCTs on augmentation techniques for rotator cuff repairs.

METHODS

MEDLINE, Embase, and CENTRAL databases were comprehensively searched from inception to September 2023 for RCTs assessing the efficacy of at least 1 augmentation strategy during rotator cuff repair. Eligible studies reported at least 1 statistically significant finding for a continuous outcome. The CFI for eligible outcomes was calculated, with median CFI presented by type of augmentation and outcome. Multivariable regression was performed to identify associations between CFI and other outcome variables.

RESULTS

Nineteen RCTs (1305 patients) were included in the final analysis. The median CFI for the 86 outcomes analyzed was 5.85 (interquartile range [IQR]: 2.3-14.4). Augmentation-specific analysis demonstrated variability in CFIs, with the most robust outcomes found in platelet-rich plasma studies (median: 10.95; IQR: 3.3-19.0) and suture-spanning augmentation studies (median: 11.90; IQR: 11.45-14.35). Outcome-specific analysis demonstrated range of motion outcomes as most robust (median: 9.85; IQR: 7.58-14.0) and strength-related outcomes as most fragile (median: 2.00; IQR: 1.0-16.3). Multivariable regression identified larger sample size as a statistically significant predictor of greater CFI. Notably, loss to follow-up exceeded the CFI in 31.4% of outcomes.

CONCLUSION

The observed median CFI of 5.85 in augmentation trials is consistent with the CFI reported in orthopedic and sports medicine literature. However, almost a third of outcomes had a loss to follow-up exceeding their CFI, risking the reversal of study findings with more robust follow-up and outcomes. Clinicians and researchers should consider fragility in addition to P values when assessing study results, especially in the context of high loss to follow-up. Future trials should report the fragility of their findings.

Causal relationship between sarcopenia and rotator cuff tears: a Mendelian randomization study

Background

Sarcopenia and rotator cuff tears are common among elderly patients. However, the role of sarcopenia in the management of rotator cuff tears has been often overlooked. This study aimed to elucidate the effects of sarcopenia-related traits on rotator cuff tears.

Methods

Two-sample Mendelian randomization (MR) analyses based on genome-wide association study data were used to evaluate the causal relationships among appendicular lean mass (ALM), usual walking pace, low hand grip strength, and rotator cuff tears. Multivariate Mendelian randomization (MVMR) analyses were used to evaluate the direct effects of each muscle trait on the causal relationship.

Results

Univariate MR analysis showed that ALM and usual walking pace were causally related to rotator cuff tears (odds ratio (OR) = 0.895; 95% confidence interval (CI), 0.758-0.966, P<0.001 and OR = 0.458, 95% CI, 0.276-0.762, P = 0.003, respectively), and there was no evidence of causality between low hand grip strength and rotator cuff tears (OR = 1.132, 95% CI, 0.913-1.404, P = 0.26). MVMR analysis confirmed the causal effects of ALM and walking pace on rotator cuff tears (OR = 0.918, 95% CI, 0.851-0.990, P = 0.03 and OR = 0.476, 95% CI, 0.304-0.746, P = 0.001, respectively).

Conclusion

A causal genetic relationship exists between sarcopenia and rotator cuff tears. Sarcopenia-related traits including low muscle mass and physical function, increase the risk of rotator cuff tears. These findings provide new clinical insights and evidence-based medicine to optimize management of rotator cuff tears.

Orthopedic surgeon-scientist representation is low among National Institutes of Health grants for rotator cuff research

Background

The purpose of this study is to characterize National Institutes of Health (NIH) funding for rotator cuff research and evaluate the impact of orthopedic surgeons on this portfolio.

Methods

The NIH's Research Portfolio Online Reporting Tools Expenditures and Results database was queried for "rotator cuff repair" or "rotator cuff tear" from the 2011 to 2021 fiscal years. Compound annual growth rates were calculated and grants were categorized by basic, clinical, or translational research. Funding totals were compared by Principal Investigator (PI) and grant characteristics.

Results

A total of 52 grants were awarded to 38 PIs between 2011 and 2021, totaling $40,156,859. Annual NIH funding for rotator cuff tear and rotator cuff repair increased by a Compound annual growth rate of 11.0% from 2011 to 2021, compared to 3.4% for the total NIH budget. Orthopedic surgeon-scientists received $9,208,212 (22.9%), most commonly through R01 (80.5%) and K08 (7.1%) mechanisms. No significant difference in funding was found by PI sex (P = .332), degree (P = .460), academic rank (P = .118), or researcher type (P = .227). Professors had a higher h-index than associate and assistant professors (P = .001). Orthopedic surgeon-scientists had a higher h-index (mean 36.3 ± 9.4) compared to clinician-scientists (mean 8.0 ± 1.4) and research-scientists (35.5 ± 40.7) (P = .044). Clinical topics receiving the highest funding were rehabilitation (23.9%), diagnosis, (22.3%) and surgical technique (14.8%). Orthopedic surgeon-scientists acquired funding for diagnosis (57.1%), rehabilitation (17.0%), and surgical technique (14.5%).

Discussion

While NIH funding for rotator cuff research is growing, orthopedic surgeon representation is low. Future studies should evaluate barriers to obtaining funding for orthopedic surgeon-scientists.

Arthroscopic Repair of a High-Grade Partial Articular-Sided Subscapularis Tendon Tear Without Bursal-Sided Tendon Overtension

The subscapularis tendon is one of the shoulder's primary anterior stabilizers along with capsulolabral tissues to prevent anterior dislocation and attaches to the lesser tuberosity. Subscapularis tendon ruptures can cause anterior shoulder pain and weakness of internal rotation. Patients with partial-thickness tears of subscapularis tendons who do not respond to conservative treatment may be candidates for surgical repair. The transtendon repair of a partial articular-sided subscapularis tendon tear, like the transtendon repair of a PASTA (partial articular supraspinatus tendon avulsion), can result in overtension and bunching of the bursal-sided subscapularis tendon. We propose an all-inside arthroscopic transtendon repair technique of a high-grade partial articular-sided subscapularis tendon tear without bursal-sided tendon overtension or bunching.

Magnetic resonance imaging evaluation of the correlation between calcific tendinitis and rotator cuff injury

BACKGROUND

This study aims to evaluate the incidence of calcific tendinitis (CaT) in rotator cuff tears (RCTs) and to assess the correlation between CaT and RCTs with magnetic resonance imaging (MRI).

METHODS

The MRI of 108 patients with rotator cuff CaT admitted to our hospital from January 2019 to January 2021 were retrospectively analyzed. Another retrospective analysis was made of 108 patients with similar age, gender, occupation, and shoulder injury side to those in the first group. The incidence of RCTs and their correlation with CaT were assessed based on an MRI of shoulder joints.

RESULTS

There was a statistical difference (p < 0.05) in the incidence of RCTs between the CaT group (23.4%) and the control group (37.2%). No significant difference was observed in the size of the RCTs between the two groups (P = 0.422). In the CaT group, 17.4% of patients had complete tears, compared with 26.3% in the control group. There was no significant correlation between the calcification site and RCTs in the CaT group, and only 3.7% of patients suffered calcification and a tear in the exact location of the same tendon (P > 0.05, r = 0.03).

CONCLUSIONS

Compared with patients with shoulder pain without CaT, patients with rotator cuff CaT suffered no increased risk of RCTs on MRI, so CaT and RCTs may have different pathological causes, and there is no significant correlation between the two.