Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair

Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: a retrospective comparative study

BACKGROUND

Large to massive rotator cuff tears (RCTs) affect shoulder functions profoundly with unmanageable disability without intervention. The retear rates with arthroscopic rotator cuff repair (ARCR) in these patients are abysmal. Patch augmentation has been credited for preventing retears, improving functions by increasing the strength, and acting as a bioconductive scaffold. This study aimed to assess the retear rates and compare the clinical and radiological outcomes between the ARCR with and without acellular human dermal allograft (HDA) augmentation.

METHODS

This is a retrospective comparative study among patients diagnosed with large to massive, posterosuperior RCTs, operated between January 2020 and December 2021, including 36 patients (group I) with and 131 patients (group II) without HDA augmentation, with a mean follow-up of 20 (range, 12-35) months. The average age was 64 (range, 49-80) and 66 (range, 41-81) years in groups I and II, respectively. In group I, there were 16 male and 20 female patients, whereas in group II, there were 58 male and 73 female patients.

RESULTS

The visual analog scale score improved to 1.1 ± 1.7 in group I and 2.1 ± 1.7 in group II (P = .005). There was a greater improvement in the University of California, Los Angeles shoulder score to 30.1 ± 4.2 in group I compared with 23.2 ± 3.9 in group II (P = .046). Forward flexion (degrees) improved from a mean of 103.2 ± 18.6 to 138.9 ± 23.5 in group I and from 106.4 ± 21.3 to 127.0 ± 19.5 in group II (P = .004). The acromiohumeral interval (mm) measured in anteroposterior radiographs increased to 8.4 ± 1.8 in group I and 8.2 ± 2.0 in group II (P = .006). The satisfaction after the procedure was 4.4 ± 0.6 in group I and 3.1 ± 1.1 in group II (P = .044). The retear rate in the HDA-augmented group was 5.6% as compared with 29.1% in the nonaugmented group, which was statistically significant (P = .007). There were no complications or adverse tissue reactions against HDA seen in any patients.

CONCLUSION

In patients with large to massive, posterosuperior RCTs, patch augmentation with acellular HDA significantly averted the retears after ARCR without any graft-related complications. The augmentation also resulted in improved shoulder function and greater range of motion compared with the nonaugmented group.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Intravenous Tranexamic Acid Significantly Improved Visualization and Shortened the Operation Time in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis of Level I and II Studies

PURPOSE

To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time.

METHODS

We searched the PubMed, Cochrane Library, and Embase databases to find prospective randomized controlled clinical trials (RCTs) examining the use of TXA in ARCR. All included RCTs were evaluated for methodological quality using the Cochrane Collaboration's risk of bias tool. We used Review Manager 5.3 for meta-analysis and calculated the weighted mean difference (WMD) and 95% confidence interval (CI) of the related outcome indicators. The GRADE system was used to evaluate the strength of the clinical evidence provided by the included studies.

RESULTS

Six RCTs (3 Level I, 3 Level II) from four countries or regions were included in this study: 2 studies used intra-articular (IA) TXA, and 4 studies used intravenous TXA. A total of 451 patients underwent ARCR, including 227 patients in the TXA group and 224 patients in the non-TXA group. In 2 RCTs evaluating good visualization, intravenous TXA achieved a better surgical field of view in ARCR compared to the control group (P =.036; P = .045). Meta-analysis showed that compared with non-TXA, intravenous TXA shortened the operation time (WMD = -12.87 min, 95% CI: -18.81 to -6.93). These two RCTs did not reveal a statistically significant difference in the impact of intravenous TXA and non-TXA on mean arterial pressure (MAP) (P = .306; P = .549). Compared with epinephrine (EPN), IA TXA had no significant effects on improving the visual field clarity under arthroscopy, shortening the operation time or reducing the total amount of irrigation fluid (P > .05). Compared with saline irrigation, IA TXA improved the surgical field of vision and shortened the operation time (P < .001). No adverse events were reported for either intravenous TXA or IA TXA.

CONCLUSIONS

Intravenous TXA can shorten the operation time of ARCR, and the conclusions of existing RCTs suggest that intravenous TXA can improve visual field clarity during ARCR, thus supporting the application of intravenous TXA in ARCR. Compared with EPN, IA TXA was not better at improving the visual field clarity under arthroscopy and shortening the operation time, but it was better than saline irrigation.

LEVEL OF EVIDENCE

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

Fatty Degeneration of the Rotator Cuff Muscles Improves in Shoulders with Successful Arthroscopic Rotator Cuff Repair: A Prospective Study Using Quantitative T2 Mapping Techniques, with 2-Year Follow-up

Background

There remain arguments regarding whether fatty degeneration of the rotator cuff muscles improves following rotator cuff repair. The purpose of this study was to prospectively investigate changes in fatty degeneration of the rotator cuff muscles, quantitatively measured on magnetic resonance imaging (MRI) with use of transverse relaxation time (T2) mapping techniques, and to assess the relationship between these changes and clinical outcomes.

Methods

Patients were included if they were scheduled for arthroscopic rotator cuff repair using the suture-bridge technique between June 2014 and December 2015, underwent preoperative MRI including the T2 mapping sequence, and consented to participate in the study. Exclusion criteria consisted of trauma within 2 months before preoperative MRI, isolated subscapularis tears, patch augmentation, neuromuscular disease, and a follow-up duration of <2 years. MRI scans were acquired preoperatively and at 2 years postoperatively, and T2 values of the supraspinatus and infraspinatus muscles were measured, with smaller T2 values indicating less fat content. Shoulders were evaluated on the basis of active range of motion (ROM), Constant and University of California Los Angeles Shoulder Rating Scale scores, shoulder external rotation strength with the arm at the side, and rotator cuff integrity on postoperative MRI.

Results

A total of 103 patients (103 shoulders) with a mean age of 65 ± 9 years (range, 42 to 83 years) were included, of whom 52 were male and 51 were female. There were 13 partial, 18 small, 35 medium, 33 large, and 4 massive tears. Concomitant subscapularis tears were observed in 35 shoulders. Overall, ROM, clinical scores, and external rotation strength significantly improved postoperatively. Retears were found in 27 shoulders (26%). External rotation strength significantly improved postoperatively only in shoulders without a retear. Among shoulders without a retear, the postoperative T2 values of the supraspinatus and infraspinatus were significantly smaller than the preoperative values (p < 0.001 for both); however, no improvement was seen in shoulders with a retear.

Conclusions

Shoulders with successful repair demonstrated significantly smaller T2 values postoperatively as well as significantly improved external rotation strength. Fatty degeneration of the cuff muscles can be reversed, at least in part, and muscle strength improves in shoulders with successful repair.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Insurance Reimbursement Status on Pre- and Postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Scores After Arthroscopic Rotator Cuff Repair

BACKGROUND

Previous studies reported inferior patient-reported outcomes (PROs) after arthroscopic rotator cuff repair for patients receiving workers' compensation (WC) relative to patients with commercial insurance. The extent to which alternative insurance reimbursement, including Medicaid and Medicare, influences outcomes after arthroscopic rotator cuff repair remains understudied.

HYPOTHESIS

Compared with patients with commercial insurance reimbursement, patients with WC or government-issued reimbursement would report lower pre- and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores, report higher pre- and postoperative PROMIS Depression (D) and Pain Interference (PI) scores, and experience smaller levels of improvement in all PROMIS domains with surgical intervention.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Demographic and surgical data were extracted from the medical record, and PROMIS domains were prospectively collected. Patients were divided into cohorts based on insurance reimbursement status. Differences between insurance-based cohorts for baseline variables, pre- and postoperative PROMIS scores, and change from baseline to final follow-up (delta) for PROMIS scores were evaluated using Kruskal-Wallis or chi-square tests. Mixed-effects linear regression models were performed to assess the influence of insurance while controlling for other variables. Survival analysis was performed to determine time to achieve minimal clinically important difference (MCID) for each PROMIS domain per cohort.

RESULTS

1252 patients underwent arthroscopic rotator cuff repair, met inclusion criteria, and completed PROMIS questionnaires. Statistically significant differences were noted in demographic variables including age (P < .001), sex (P < .001), ethnicity (P < .001), and body mass index (P < .001) between insurance-based cohorts. Unadjusted analysis revealed significantly higher PF scores and lower PI and D scores for the group with commercial insurance relative to those with Medicare, Medicaid, and WC at 6- and 12-month follow-up (P < .01 all comparisons), except for the Medicare versus commercial subcohort analysis for PI at 6 months (P = .28). These differences persisted for the Medicare, Medicaid, and WC groups (P < .03 all comparisons) after adjustment for confounding variables in linear regression.

CONCLUSIONS

The baseline characteristics of patients undergoing arthroscopic rotator cuff repair differed based on insurance reimbursement. Patients with commercial insurance reported improved physical function, decreased pain interference, and improved mood (less depression) relative to patients with government-issued and WC insurance, with maximum improvement 6 to 12 months postoperatively. There were few significant differences between insurance groups in change of PROMIS scores from preoperative to postoperative intervals, indicating that differences in the baseline demographic and surgical characteristics of these groups accounted for differences in response to surgery.

Arthroscopic Repair of Massive Rotator Cuff Tears Leads to Functional Improvement in Most Patients at 4-Year Follow-up

Purpose

To assess functional outcomes and healing 4 years after arthroscopic repair of massive rotator cuff tears (MRCTs).

Methods

We conducted a retrospective study of patients who underwent arthroscopic rotator cuff repair of an MRCT-defined as a complete 2-tendon tear or a tear greater than 5 cm in any dimension-performed by 2 surgeons at different institutions between January 2015 and December 2018. At a minimum of 4 years postoperatively, patient-reported outcomes collected included the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12 (VR-12) score, and Subjective Shoulder Value (SSV) score. Repair technique and concomitant procedures were also gathered. Tendon healing was evaluated via ultrasound at final follow-up.

Results

Functional outcomes were available for 101 patients at a mean of 63.6 ± 8.8 months (range, 48-82 months) postoperatively. Mean ASES scores improved from 40.1 to 78 (P < .001); VR-12 scores, from 37.1 to 47.7 (P < .001); and SSV scores, from 36.7 to 84.6 (P < .001). Forward flexion improved from 126° to 144° (P = .001), external rotation remained unchanged (from 47° to 44°, P = .268), and internal rotation improved by 2 spinal levels (from L4 to L2, P = .0001). Eighty-eight percent of patients (89 of 101) were satisfied with the procedure, and only 5% underwent reverse shoulder arthroplasty within the study period. Among the 39 patients who underwent postoperative ultrasound to assess healing, 56% showed complete tendon healing. There was no difference in healing or outcomes according to tear pattern. Additionally, tendon healing did not affect outcomes.

Conclusions

Arthroscopic repair of MRCTs leads to functional improvements and patient satisfaction in most cases at 4-year follow-up. The rates of patients achieving the minimal clinically important difference were 77.5%, 87.6%, 59.7%, and 80.6% for the ASES score, SSV score, VR-12 score, and visual analog scale pain score, respectively. Complete tendon healing is difficult to achieve but does not appear to limit functional improvements.

Level of Evidence

Level IV, therapeutic case series.

Determination of the reference range for semi-quantified elasticity of healthy supraspinatus muscles using real-time tissue elastography and its clinical use in patients after rotator cuff repair

BACKGROUND

The quantitative assessment of healthy supraspinatus muscle elasticity may provide clinically useful preliminary information after rotator cuff repairs. We aimed to determine the reference range for supraspinatus muscle semi-quantified elasticity and describe how it can be used clinically after rotator cuff repair.

METHODS

The elasticity of healthy bilateral supraspinatus muscles in 43 participants aged between 24 and 75 years (categorized into two subgroups: <50 and ≥ 50 years) was measured as a strain ratio at 0° and 60° of shoulder abduction using real-time tissue elastography. The reference and modified reference ranges calculated by excluding outliers for elasticity were determined using normal distribution methods for logarithmically transformed data. The modified reference range was applied to eight cases of rotator cuff repair.

FINDINGS

Strain ratios under and over 50 years of age were 1.63 vs. 2.21 at 0° of shoulder abduction (P = 0.028) and 0.92 vs. 1.29 at 60° of shoulder abduction (P = 0.002), respectively. Modified reference ranges for under and over 50 years of age were 0.72-4.17 and 0.98-4.50 at 0° of shoulder abduction and 0.38-1.95 and 0.56-2.76 at 60° of shoulder abduction, respectively. Among eight cases, two showed strain ratios above the reference range at 1 month postoperatively, and rehabilitation protocols were adjusted.

INTERPRETATION

A strain ratio above the reference range, especially above the upper limit at 0° of shoulder abduction, may indicate increased passive stiffness of the musculotendinous unit. Clinically, the reference range has the potential to be used as a baseline after rotator cuff repairs.

A pilot randomised controlled trial assessing standard versus dermal patch-augmented rotator cuff repair found no adverse effects and suggest future trials need a minimum of 150 patients

PURPOSE

The aims of this pilot randomised controlled trial (RCT) were to assess the safety and efficacy of a human dermal allograft patch and assess the feasibility of a future RCT comparing retear rate and functional outcome 12 months following standard and augmented double-row rotator cuff repair.

METHODS

 A pilot RCT was conducted among patients undergoing arthroscopic repair of rotator cuff tear measuring between 1 and 5 cm. They were randomised to either augmented (double-row repair with human acellular dermal patch) or standard (double-row repair only). The primary outcome was rotator cuff retear determined on MRI scan at 12 months using the Sugaya's classification (grade 4 or 5). All adverse events were recorded. Functional assessment was performed at baseline and 3, 6, 9, and 12 months post-surgery using clinical outcome scores. Safety was assessed by complications and adverse effects, and feasibility by recruitment, follow-up rate and proof of concept statistical analyses of a future trial.

RESULTS

Between 2017 and 2019, 63 patients were considered for inclusion. Twenty-three patients were excluded, leaving 40 patients (20 per group) in the final study population. The mean tear sizes were 3.0 cm in the augmented and 2.4 cm in the standard group. There was one adhesive capsulitis in the augmented group, with no other adverse events. Retear was observed in 4/18 (22%) of patients in the augmented and 5/18 (28%) in the standard group. In both groups, functional outcome improved significantly which was clinically meaningful for all scores, with no difference between groups. Retear rate increased with tear size. Future trials are feasible but need a minimum total sample size of 150 patients.

CONCLUSION

 Clinically meaningful improved function without adverse effects was found with human acellular dermal patch-augmented cuff repairs.

LEVEL OF EVIDENCE

Level II.

An Injectable Calcium Phosphate Bone Graft Substitute Improves the Pullout Strength of Various Suture Anchor Designs in an Osteoporotic Bone Model

Purpose

To compare various suture anchor designs with and without calcium phosphate (CaP) augmentation in an osteoporotic foam block model and decorticated proximal humerus cadaveric model.

Methods

This was a controlled biomechanical study, consisting of 2 parts: (1) an osteoporotic foam block model (0.12 g/cc; n = 42) and (2) a matched pair cadaveric humeral model (n = 24). Suture anchors selected were an all-suture anchor, PEEK (polyether ether ketone)-threaded anchor, and a biocomposite-threaded anchor. For each study arm, one half the samples were first filled with injectable CaP and the other half were not augmented with CaP. For the cadaveric portion, the PEEK- and biocomposite-threaded anchors were assessed. Biomechanical testing consisted of a stepwise, increasing load protocol for a total of 40 cycles, followed by ramp to failure.

Results

For the foam block model, the average load to failure for anchors with CaP was significantly greater when compared with anchor fixation augmented without CaP; the all-suture anchor was 135.2 ± 20.2 N versus 83.3 ± 10.3 N (P = .0006); PEEK was 131 ± 34.3 N versus 58.5 ± 16.8 N (P = .001); and biocomposite was 182.2 ± 64.2 N versus 80.8 ± 17.4 N (P = .004). For the cadaveric model, the average load to failure for anchors augmented with CaP was again greater than anchor fixation without CaP; PEEK anchors went from 41.1 ± 21.1 N to 193.6 ± 63.9 N (P = .0034) and biocomposite anchors went from 70.9 ± 26.6 N to 143.2 ± 28.9 N (P = .004).

Conclusions

Augmenting various suture anchors with CaP has shown to significantly increase pull-out strength and stiffness in an osteoporotic foam block and time zero cadaveric bone model.

Clinical Relevance

Rotator cuff tears are common in the elderly patients, in whom poor bone quality jeopardizes treatment success. Exploring methods that increase the strength of fixation in osteoporotic bone to improve outcomes in this patient population is important.

Long-term functional and structural outcome of rotator cuff repair in patients 60 years old or less

Background

The long-term outcomes of rotator cuff repair (RCR) have not been well studied. The purpose of this study was to evaluate long-term functional and structural outcomes after RCR in younger patients.

Methods

A total of 49 patients (34 [69%] male) with a mean age of 51 ± 6 years were evaluated preoperatively, and at short- and long-term follow-ups (minimum 15 years). There were 13 (27%) small, 17 (35%) medium, 14 (29%) large, and 5 (10%) massive tears. 15 (31%) had an acute repair of a traumatic tear. Long-term evaluation included physical examination, plain radiographs, ultrasound, and patient reported outcome measures (PROMs) (visual analog scale pain, Disability of Arm, Shoulder and Hand, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and Short Form-36). Statistical analysis was performed to determine associations between preoperative and intraoperative factors and long-term functional and structural outcome.

Results

There were significant improvements in the mean short- and long-term PROMs compared to preoperatively that exceeded reported minimal clinically important differences and substantial clinical benefits. There was a slight decrease in the PROMs from the short-term to long-term follow-up. Male sex and traumatic rotator cuff tears were associated with better long-term outcomes. The number of medical co-morbidities was associated with worse long-term outcomes. Smaller initial tear size was associated with better long-term outcomes. There were 15 (31%) full thickness and 9 (18%) partial thickness recurrent rotator cuff tears, 17 (35%) had rotator cuff tear arthropathy (2 Hamada grade 1, 15 Hamada grade 2), 5 (10%) had revision surgery (2 revision RCR, 2 anatomic total shoulder, and 1 reverse total shoulder), and 13 (26%) had subsequent contralateral RCR. There were weak correlations between the presence of arthropathy and DASH (r = 0.34; P = .02) and visual analog scale pain (r = 0.29; P = .049). There were no significant correlations between the structural outcomes (recurrent rotator cuff tear, recurrent full thickness tear, acromiohumeral space, and critical shoulder angle,) and the PROMs.

Discussion and Conclusion

Long-term follow-up of RCR in this relatively young patient cohort demonstrated substantial and durable patient reported functional outcome and improvement despite considerable structural deterioration. This suggests that while RCR does not arrest the progression of rotator cuff disease it may delay this progression and that patients adapt to the structural changes as they age.