Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol

Influence of Critical Shoulder Angle and Rotator Cuff Tear Type on Load-Induced Glenohumeral Biomechanics: A Sawbone Simulator Study

Glenohumeral (GH) biomechanics after rotator cuff (RC) tears are not fully understood. The purpose of our study was to determine if the critical shoulder angle (CSA), type of RC tears, and level of weight bearing increase GH translation, instability based on the instability ratio, muscle forces and joint reaction force (JRF), and shifts the center of force (CoF) superiorly. A GH simulator with muscle-mimicking cable systems was used to simulate 30° abduction in the scapular plane. A Sawbone humerus and five specimen-specific scapular anthropometries were used to test six types of RC tears, three weight-bearing loads, and the native and adjusted (to different CSAs) deltoid origin sites. Linear mixed effects models (CSA, RC tear type, and weight bearing) with random effects (specimen and sex) were used to assess differences in GH biomechanics. With increasing CSA, GH translation increased, JRF decreased, and the CoF position was more inferior. RC tears did not significantly alter GH translation but shifted the CoF position superiorly, close to where glenoid erosion occurs in patients with RC tears with secondary osteoarthritis. Weight bearing significantly increased GH translation and JRF. RC and deltoid muscle forces increased with the presence of RC tears and increased weight bearing. The remaining RC muscles of intact tendons compensated for the torn RC tendons but not for the altered CoF position. GH translation remained comparable to shoulders with intact RC. These findings highlight the importance of early detection, clinical management, and targeted rehabilitation strategies for patients with RC tears.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Clinical results of arthroscopically-assisted lower trapezius transfer using fascia lata autograft for posterior superior irreparable rotator cuff tear

Background

Different interpositional grafts have been proposed to connect between the lower trapezius tendon (LTT) to the humerus during LTT transfer. While studies often mention the successful use of Achilles tendon allograft, there is currently no literature reporting the clinical outcomes of utilizing fascia lata autograft (FLA) in LTT transfer. Therefore, the current study aims to evaluate the clinical and radiologic results of LTT using FLA for posterior superior irreparable rotator cuff tears (PSIRCTs) without arthritis.

Patient and methods

The present study constitutes a retrospective case series involving 22 patients, with a mean follow-up of 35.9 ± 15.9 months. Pain levels were gauged using the Visual Analog Scale (VAS), while shoulder function was comprehensively assessed through the Constant and ASES (American Shoulder and Elbow Society) scores. The evaluation of shoulder activities in daily living employed the ADLER (Activities of Daily Living Requiring Active External Rotation) score. Active ROM (Range of Motion) of all directions were obtained, radiologic assessments included key parameters such as AHD (Acromion Humeral Distance) and the Hamada grade. Finally, the integrity of the transferred LTT was evaluated, and a subgroup analysis was undertaken based on Tm trophicity.

Results

By the final follow-up period, VAS, Constant, ASES, and ALDER demonstrated significant improvement. Active ROM significantly improved in (FE) forward elevation to 155° ± 29°, abduction (Abd) to 140° ± 32°, external rotation (ER) at 90° Abd to 68° ± 19°, and ER at the side to 39° ± 17°. AHD and Hamada grade showed no significant arthritic progression. Tm hypertrophy group experienced superior improvements in ER compared to that of the non-hypertrophy group. Complications included re-tear (n = 2), infection (n = 1) and donor-site morbidity (n = 1).

Conclusion

The study highlighted promising clinical outcomes of LTT transfer using FLA, with no significant complications. Along with Achilles tendon allograft, FLA can be a safe and viable alternative interpositional graft choice.

Which is better? Early versus delayed rehabilitation after arthroscopic rotator cuff repair

PURPOSE

This study aimed to compare the 5-year clinical and functional outcomes, including repaired tendon healing status, between early and delayed rehabilitation after arthroscopic rotator cuff repair METHODS: A total of 75 patients with rotator cuff tears (less than 5 cm) underwent arthroscopic repairs over a 60-month period. Participants were randomly assigned to early and delayed postoperative rehabilitation groups with distinct protocols. Clinical and functional outcome measures included Constant score, University of California at Los Angeles (UCLA) score, visual analogue scale for pain and isokinetic dynamometer test for muscle strength recovery. Clinical and functional scores were compared between baseline and 5 years postoperatively. Radiologic assessment via magnetic resonance imaging was performed at a minimum of 12 months postoperatively for evaluations of tendon integrity and recurrent tears.

RESULTS

Baseline characteristics showed no statistically significant differences between groups. Both groups demonstrated equivalent improvement in range of motion and pain scores with no statistical differences. Clinical scores improved significantly in both groups by postoperative 12 months and plateaued. At the postoperative 5-year mark, the early group showed better improvement in the visual analogue scale and UCLA score, while the delayed group had superior Constant scores. Postoperative magnetic resonance imaging revealed six recurrent tears, two in the early group and four in the delayed group, with no statistical differences. Muscle strength recovery showed no differences between the two groups.

CONCLUSION

Both the early and the delayed rehabilitation groups showed similar outcomes in postoperative range of motion, functional scores, muscle strength recovery and tendon healing in the short- and mid-term follow-ups.

LEVEL OF EVIDENCE

Level III.

The influence of rotator cuff tear type and weight bearing on shoulder biomechanics in an ex vivo simulator experiment

Glenohumeral biomechanics after rotator cuff (RC) tears have not been fully elucidated. This study aimed to investigate the muscle compensatory mechanism in weight-bearing shoulders with RC tears and asses the induced pathomechanics (i.e., glenohumeral translation, joint instability, center of force (CoF), joint reaction force). An experimental, glenohumeral simulator with muscle-mimicking cable system was used to simulate 30° scaption motion. Eight fresh-frozen shoulders were prepared and mounted in the simulator. Specimen-specific scapular anthropometry was used to test six RC tear types, with intact RC serving as the control, and three weight-bearing loads, with the non-weight-bearing condition serving as the control. Glenohumeral translation was calculated using instantaneous helical axis. CoF, muscle forces, and joint reaction forces were measured using force sensors integrated into the simulator. Linear mixed effects models (RC tear type and weight-bearing) with random effects (specimen and sex) were used to assess differences in glenohumeral biomechanics. RC tears did not change the glenohumeral translation (p > 0.05) but shifted the CoF superiorly (p ≤ 0.005). Glenohumeral translation and joint reaction forces increased with increasing weight bearing (p < 0.001). RC and deltoid muscle forces increased with the presence of RC tears (p ≤ 0.046) and increased weight bearing (p ≤ 0.042). The synergistic muscles compensated for the torn RC tendons, and the glenohumeral translation remained comparable to that for the intact RC tendons. However, in RC tears, the more superior CoF was close to where glenoid erosion occurs in RC tear patients with secondary osteoarthritis. These findings underscore the importance of early detection and precise management of RC tears.

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

Background

Efficacy of nonoperative treatment for rotator cuff tears has been debated, especially for full-thickness tears. The purpose of this study was to a) define the minimal clinically important difference (MCID) of nonoperative treatment with regard to Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) and upper extremity (UE), and b) determine the proportion of patients with both partial and full-thickness tears (PTRCT, FTRCT) who achieve this improvement following initial nonoperative treatment. We hypothesized that >75% of PTRCT and FTRTC patients would achieve MCID for PROMIS PI and UE.

Methods

We performed a retrospective cohort study evaluating nonoperatively managed patients with image-confirmed PTRCT and FTRCT. Treatment modalities and follow-up PROMIS scores at least 6 months after their initial visit were recorded. Using a distribution technique, MCID was calculated.

Results

A total of 111 FTRCT and 68 PTRCT patients were included with at least 6 months of follow-up. At 6 months from initial presentation, the MCID for PROMIS UE was 3.75 and 3.95 for FTRCT and PTRCT patients, respectively. For PROMIS PI, the MCID was 3.35 and 3.90 for FTRCT and PTRCT, respectively. In total, 41% of FTRCT and 41% of PTRCT achieved MCID for PROMIS UE. Thirty-four percent of FTRCT and 35% of PTRCT achieved MCID for PROMIS PI.

Conclusion

The majority of patients undergoing nonoperative treatment for supraspinatus/infraspinatus rotator cuff tears did not achieve MCID at 6 months for PROMIS PI (34% for FTRCT and 35% for PTRCT) or UE (41% for FTRCT and 41% for PTRCT).

Content reporting and effectiveness of therapeutic exercise in the management of massive rotator cuff tears: A systematic review with 490 patients

Background

Massive rotator cuff tears (MRCT) account for a substantial fraction of tears above the age of 60 years. However, there are no clear criteria for prescription parameters within therapeutic exercise treatments. The aim of this study was to evaluate the effects and characteristics of therapeutic exercise treatments in patients with MRCT.

Methods

A systematic search was conducted in MEDLINE/PubMed, Web of Science, SPORTDiscus, SciELO, Scopus and EMBASE from inception to August 2022. Studies were included if they evaluated the effects of exercise on patients with MRCT. The risk of bias was evaluated and the Consensus on Exercise Reporting Template (CERT) was also used. A narrative synthesis without meta-analysis was performed.

Results

One randomized controlled trial, two non-randomized studies, six non-controlled studies, one case series and four retrospective studies were included. They ranged from serious to moderate risk of bias. The CERT reflected a poor description of the exercise programmes. Studies showed a pattern of improvements in most patient-reported outcome measures (PROM) surpassing the MCID, and active elevation range of motion.

Conclusions

There is limited evidence that exercise and co-interventions are effective in the management of some patients with MRCT, based on a systematic review without meta-analysis. Future research should improve content reporting.

Level of evidence

IV.

Nonoperative Treatment of Rotator Cuff Tears

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Massive Irreparable Rotator Cuff Tears: Which Patients Will Benefit from Physiotherapy Exercise Programs? A Narrative Review

Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32-96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.

Dynamic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tears: Histologic Analysis in a Rat Model and Short-term Clinical Evaluation

BACKGROUND

Superior capsular reconstruction (SCR) has been demonstrated to be a valuable treatment for patients with irreparable massive rotator cuff tears (IMRCTs). However, the torn medial supraspinatus (SSP) tendons, which acted as dynamic stabilizers, were left untreated in conventional SCR, and the dynamic force from the SSP tendon was not restored.

PURPOSE

To evaluate the effect of dynamic SCR (dSCR) on fascia-to-bone healing in a rat model, and to compare the short-term clinical effectiveness of dSCR and SCR using autologous fascia lata (FL) in patients with IMRCTs.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

A total of 50 rats were divided randomly into 2 groups: the dSCR group and the SCR group (25 rats per group). First, chronic IMRCTs were created, and then the torn tendons in both groups were subjected to SCR using autologous thoracolumbar fascial (TLF) grafts. The remnant of the SSP tendon was sutured to the medial part of the TLF graft in the dSCR group but not in the SCR group. Histologic sections were assessed at 1, 2, 4, 8, and 16 weeks postoperatively. In the clinical study, 22 patients (9 SCR, 13 dSCR) were analyzed. The recovery of shoulder function, including the active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons score, Constant score, and University of California Los Angeles score, acromiohumeral distance (AHD), and fatty infiltration, was evaluated before surgery and at the last follow-up.

RESULTS

Histologic analysis of the fascia-to-bone junction in the rat model showed that the TLF gradually migrated into tendon-like tissue over the rotator cuff defects in both groups, and the modified tendon maturation score of the fascia-to-bone interface in the dSCR group was higher than that in the SCR group at 4 weeks (12.20 ± 1.30 vs 14.60 ± 1.52; P = .004), 8 weeks (19.60 ± 1.14 vs 22.20 ± 1.10; P = .019), and 16 weeks (23.80 ± 0.84 vs 26.20 ± 0.84 P = .024). The dSCR group showed earlier fibrocartilage cell formation and angiogenesis. In the clinical study, all 22 patients completed a minimum of 12 months of follow-up after surgery, and the mean follow-up duration was 22.89 ± 7.59 months in the SCR group and 25.62 ± 7.32 months in the dSCR group. The patients in both groups showed significant improvements in terms of ROM, shoulder function scores, and AHD. At the last follow-up, abduction (56.67°± 27.39° vs 86.54°± 30.37°; P = .029), external rotation (25.00°± 9.35° vs 33.08°± 8.55°; P = .049), internal rotation cone rank (-2.78 ± 2.44 vs -4.38 ± 1.12; P = .049), VAS (-3.00 ± 0.87 vs -3.92 ± 0.95; P = .031) and Constant (47.89 ± 15.39 vs 59.15 ± 9.74; P = .048) scores, and the AHD improvement degree (3.06 ± 1.41 mm vs 4.38 ± 1.35 mm; P = .039) in the dSCR group were significantly improved compared with those in the SCR group. The results of fatty infiltration at the last follow-up showed that there was significant improvement compared with the preoperative results in both the conventional SCR (P = .036) and the dSCR (P = .001) groups. However, there were no significant differences between the 2 groups (P = .511).

CONCLUSION

dSCR can promote faster fascia-to-bone healing in a rat model, and the dSCR technique could provide a preferable treatment option for patients with IMRCTs.

CLINICAL RELEVANCE

dSCR might restore the dynamic of SSP in some sense and then improve the fatty infiltration in the SSP.

Arthroscopic Superior Capsule Reconstruction with Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum Two-Year Follow-Up

PURPOSE

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs).

METHODS

The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely reparable massive RCT (dimension > 5 cm and two tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up).. Clinical outcomes were evaluated pre-operatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI).

RESULTS

A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range 24 to 64). All clinical scores also improved at the two-year follow-up (mean VAS 0.7 [SD 0.7] vs. 5.4 [SD 1.1], P < 0.001; mean ASES 92.6 [SD 8.0] vs. 34.8 [SD 13.4], P < 0.001; mean UCLA 31.5 [SD 3.9] vs. 11.0 [SD 3.2], P < 0.001; and mean CMS 86.6 [SD 7.2] vs. 40.0 [SD 11.6], P < 0.001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%).

CONCLUSIONS

ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the two-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences (MCID)) on ASES, UCLA, and VAS with improved abduction strength restoration.

No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study

PURPOSE

Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years.

METHODS

In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma.

RESULTS

Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups.

CONCLUSION

In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic.

LEVEL OF EVIDENCE

III.

Bioprinted living tissue constructs with layer-specific, growth factor-loaded microspheres for improved enthesis healing of a rotator cuff

Substantial challenges remain in constructing the native tendon-to-bone interface for rotator cuff healing owing to the enthesis tissues' highly organized structural and compositional gradients. Herein, we propose to bioprint living tissue constructs with layer-specific growth factors (GFs) to promote enthesis regeneration by guiding the zonal differentiation of the loaded stem cells in situ. The sustained release of tenogenic, chondrogenic, and osteogenic GFs was achieved via microsphere-based delivery carriers embedded in the bioprinted constructs. Compared to the basal construct without GFs, the layer-specific tissue analogs realized region-specific differentiation of stem cells in vitro. More importantly, bioprinted living tissue constructs with layer-specific GFs rapidly enhanced the enthesis regeneration in a rabbit rotator cuff tear model in terms of biomechanical restoration, collagen deposition, and alignment, showing gradient interface of fibrocartilage structures with aligned collagen fibrils and an ultimate load failure of 154.3 ± 9.5 N resembling those of native enthesis tissues in 12 weeks. This exploration provides a feasible strategy to engineer living tissue constructions with region-specific differentiation potentials for the functional repair of gradient enthesis tissues. STATEMENT OF SIGNIFICANCE: Previous studies that employed acellular layer-specific scaffolds or stem cells for the reconstruction of the rotator cuff faced challenges due to their insufficient capability to rebuild the anisotropic compositional and structural gradients of native enthesis tissues. This manuscript proposed a living tissue construct with layer-specific, GFs-loaded µS, which can direct in situ and region-specific differentiation of the embedded stem cells to tenogenic, chondrogenic, and osteogenic lineages for functional regeneration of the enthesis tissues. This bioprinted living tissue construct with the unique capability to reduce fibrovascular scar tissue formation and simultaneously facilitate enthesis tissue remodeling might provide a promising strategy to repair complex and gradient tissues in the future.

Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis

QUESTIONS

To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).

DESIGN

Systematic review with meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.

INTERVENTION

Exercise as an intervention for L-MRCTTs.

OUTCOME MEASURES

Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes.

CONCLUSION

A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

Arthroscopic therapy of rotator cuff diseases: A bibliometric study of the past 2 decades (2002–2021)

Purpose

Rotator cuff diseases, as a common cause of shoulder pain and disability, have seriously affected the patients' daily life. Rotator cuff repair techniques have been a hot topic in the arthroscopic therapy field. Our study was to use bibliometrics analysis to clarify the current status and research trends in the field of arthroscopic therapy of rotator cuff diseases.

Methods

The publications relating to arthroscopic therapy of rotator cuff diseases published from 2001 to 2021 were obtained from the Web of Science Core Collection (WoSCC) database. The R software and VOSviewer software were used for the cross-sectional bibliometric and scientometric analysis.

Results

A total of 4,567 publications about arthroscopic therapy of rotator cuff diseases published between 2002 and 2021 retrieved from the WoSCC database were analyzed in our study. The results showed that the United States made the largest contribution to this field. The most relevant institutions were Seoul National University, Rush University, and Hospital for Special Surgery. Stephen S Burkhart was the most relevant researcher in this field with the largest number of publications, as well as the highest H-index and G-index. The journal ARTHROSCOPY contributed the largest number of publications in the past 2 decades. Considering the H-index and G-index, ARTHROSCOPY was also the journal with the largest impact in this field.

Conclusions

Arthroscopic Therapy of Rotator Cuff Diseases Related research presented a rising trend in the past 2 decades. The United States can be regarded as the leader because of its huge contributions to this field. The journal ARTHROSCOPY published the largest number of publications in this field. It can be predicted that research about advanced arthroscopic techniques and postoperative pain management of patients with rotator cuff diseases will be the next research hotspots in the following years.

Posterior Shoulder Pain and Muscle Wasting in an Older Adult

Musculoskeletal injuries are among the most common chief complaints in the geriatric population. Shoulder pain with associated deformity should be evaluated for possible joint dislocations, fractures, and musculotendinous tears. A comprehensive evaluation beginning with history and physical examination is important. Typical imaging utilized for the diagnosis of shoulder injuries includes plain radiography, ultrasound, and magnetic resonance imaging (MRI). We present a case of a 75-year-old male with massive rotator cuff tears and subsequent shoulder deformity. Management with non-surgical or surgical approaches should begin as soon as possible to delay the development of rotator cuff arthropathy.

Associations between range of motion, strength, tear size, patient-reported outcomes, and glenohumeral kinematics in individuals with symptomatic isolated supraspinatus tears

BACKGROUND

Clinical failure associated with nonoperative treatment of rotator cuff tears may be due to inadequate characterization of the individual's functional impairments. Clinically, restricted passive range of motion (ROM) (restrictions imply capsular tightness), limitations in muscle strength, and larger rotator cuff tears are hypothesized to be related to altered glenohumeral kinematics. Understanding these relationships, as well as the relationship between glenohumeral kinematics and patient-reported outcomes (PROs) prior to exercise therapy, may help characterize functional impairments in individuals with rotator cuff tears. The objectives of the study were to describe the baseline presentation of individuals with an isolated supraspinatus tear, including passive ROM, rotator cuff muscle strength, tear size, PROs, and glenohumeral kinematics, and to determine associations among these variables.

METHODS

One hundred one individuals with symptomatic isolated supraspinatus tears were recruited for the study and underwent assessments of passive glenohumeral ROM, isometric muscle strength, and ultrasonography to assess anterior-posterior tear size. Glenohumeral kinematics during scapular-plane abduction were measured using biplane radiography. Furthermore, PROs including the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) score were collected.

RESULTS

Individuals presented with decreased ROM, external rotation weakness compared with the uninvolved side, and pain and disability as measured by the ASES and WORC scores. These findings were not associated with glenohumeral kinematics, with the exception of a weak positive association between glenohumeral contact path lengths and WORC scores (ρ = 0.25, P = .03). Tear size was 11.7 ± 5.7 mm, and maximum anterior translation, superior translation, and contact path length were 3.0% ± 3.8% of glenoid width, 3.5% ± 3.8% of glenoid height, and 38.2% ± 20.7% of glenoid size, respectively.

CONCLUSION

Individuals with a symptomatic isolated supraspinatus tear presented with decreased ROM, external rotation weakness, and pain and disability as measured by the ASES and WORC scores. However, no abnormal kinematics associated with these limitations were observed. Thus, given that the tear is isolated to the supraspinatus tendon and no capsular restrictions are present, normal function of the glenohumeral joint may be possible during scapular-plane abduction.

[Research progress of arthroscopic long head of biceps tendon transposition in treatment of irreparable massive rotator cuff tears]

OBJECTIVE

To review the research progress of arthroscopic long head of biceps tendon (LHBT) transposition in treatment of irreparable massive rotator cuff tears.

METHODS

The domestic and foreign related literature in recent years on the treatment of irreparable massive rotator cuff tears with different LHBT transposition methods under arthroscopy was reviewed and analyzed.

RESULTS

Arthroscopic LHBT transposition is an effective method for irreparable massive rotator cuff tears, which mainly includes "proximal cut", "both two cuts", "distal cut", and "no cut". Different methods of LHBT transposition can achieve good effectiveness, but its long-term effectiveness needs further follow-up.

CONCLUSION

Arthroscopic LHBT transposition in treatment of irreparable massive rotator cuff tears is simple and effective. The patients can recover quickly after operation with less injury. But the technique has higher requirements for surgeons, and the indications must be strictly controlled.

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Chronic non-traumatic rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears.

Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality.

A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research.

PROSPERO registration: 244502 (24/03/2021)

Analysis of Functional Recovery and Subjective Well-Being after Arthroscopic Rotator Cuff Repair

Background: Rotator cuff tears are common causes of functional shoulder instability and often lead to arthroscopic rotator cuff repair. A well-programmed rehabilitation leads to successful tendon healing, positive functional recovery and subjective well-being (SWB). Objective: To evaluate the changes in shoulder functioning and SWB pre-, post-outpatient rehabilitation and after one-month follow-up. Materials and Methods: A total of 44 patients were assessed three times: at the beginning (six weeks’ post-surgery), at the end of outpatient rehabilitation (2–3 weeks) and one month after rehabilitation. The outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion (ROM), manual muscle testing (MMT), hand dynamometry (HD) and pain level by a Visual Analogue Scale (VAS). SWB was assessed by Rosenberg self-esteem scale (RSES), Positive and Negative Affect Schedule (PANAS) and the Lithuanian Psychological Well-Being Scale (LPWBS). Results are presented as a difference between periods. Results: Affected shoulder motor function (MMT, HD and ROM) significantly improved in three periods (p < 0.05); however, major recovery was observed in the follow-up period. VAS scores meaningfully decreased over all stages and negatively correlated with motor function recovery (p < 0.05). DASH rates exhibited significant retrieval in all phases, especially in follow-up. SWB results demonstrated the larger effects of self-evaluation in follow-up, improved daily functions and psychological wellness, then negative emotions significantly decreased (p < 0.05). Conclusions: The experienced pain and psychosocial factors significantly influence functional recovery of the shoulder during rehabilitation. The improvement in motor function, ability and pain relief during rehabilitation increases level of SWB, psychological wellness and positive emotional affect in long-term context.

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears. Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality. A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research. PROSPERO registration: 244502 (24/03/2021)