Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears

Editorial Commentary: Deteriorated Quality and Medial Retraction of Tendon Following Acute Traumatic Rotator Cuff Tear are Predictors of Retear After Arthroscopic Repair

Rotator cuff tears are a common cause of shoulder pain and dysfunction, affecting up to 33% of the population, and approximately 250,000 arthroscopic rotator cuff repairs are performed each year in the United States. Arthroscopic rotator cuff repair (RCR) is the gold standard for surgical management of full thickness rotator cuff tears and is associated with postoperative improvements in pain and function. However, reported retear rates based on postoperative magnetic resonance imaging (MRI) vary from 7%-90% following arthroscopic rotator cuff repair. Despite variations in repair techniques, implant technology, biologic and patch augmentation, and postoperative rehabilitation algorithms, retear rates following rotator cuff repair have remained high over the past several decades. As a result, there continues to be a significant interest in identifying predictive factors of retear after rotator cuff repair. That said, numerous well-designed studies have demonstrated a poor correlation between postoperative MRI findings and functional outcomes. Regardless, intraoperative evaluation of tendon quality, tear pattern, and tissue mobility is essential to predicting the likelihood of successful rotator cuff repair, although at the current time, this evaluation is largely subjective, and few validated assessment tools exist. As such, future, objective research is required to improve our assessment and documentation of these intraoperative factors, with artificial intelligence and machine learning models possibly serving as useful tools for identifying meaningful intraoperative patterns predictive of postoperative outcomes in the future.

Deteriorated Quality and Medial Retraction of Tendon After Acute Traumatic Rotator Cuff Tear Are Predictors of Retear After Arthroscopic Repair

PURPOSE

To investigate the structural outcomes of arthroscopic repair of traumatic rotator cuff (RC) tears and analyze the factors related to retears, focusing on tendon quality observed using arthroscopy.

METHODS

This retrospective study included patients who had undergone arthroscopic repair of traumatic full-thickness RC tears between 2014 and 2021. Traumatic RC tears were defined as the sudden onset or worsening of shoulder pain or function within 3 years after a slip or fall. Gross tendon quality was assessed using arthroscopic imaging and categorized as none (grade 0), mild (grade 1), or advanced (grade 2). RC retear was assessed using magnetic resonance imaging at 6 months and clinically evaluated at least 1 year after surgery.

RESULTS

A total of 121 patients were included in the study, and the RC retear rate was 27.3% (33 of 121). RC retears were significantly associated with supraspinatus (SSP) medial retraction (P = .015) and atrophy with fatty infiltration (P = .010) on magnetic resonance imaging, as well as tendon deterioration (P < .001) and anterior rotator cable rupture (P = .034) observed during arthroscopy. On multivariable analysis, advanced tendon deterioration (grade 1 vs grade 0: odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-1.3, P = .117; grade 2 vs grade 0: OR, 6.3; 95% CI, 1.9-21.2; P = .003) and the absence of initial pseudoparesis (OR, 0.1; 95% CI, 0.02-1.0; P = .045) were identified as significant predictors of retear. Additionally, SSP medial retraction (OR, 1.5; 95% CI, 1.0-2.2; P = .056) was identified as a potential predictor of retear. The final visual analog scale score for function was significantly lower in the RC retear group than in the intact group (7.1 ± 1.8 vs 8.0 ± 1.2, P = .013), whereas other shoulder function parameters were similar between the groups. Final shoulder function was not significantly affected by tendon quality.

CONCLUSIONS

Gross tendon quality, as assessed during arthroscopy, and SSP medial retraction, as well as the absence of initial pseudoparesis, were predictors of retear after the repair of traumatic RC tears. Intraoperative assessment of tendon quality is important for predicting surgical outcomes of traumatic RC tear repair.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic Repair of Rotator Cuff Tears in Older Adults: A Retrospective Case-Series Study

Introduction

Rotator cuff tears (RCTs) are a common source of pain in the shoulder girdle. There is still debate about the optimal treatment for older adults with RCTs. In clinical practice, patients who do not respond well to non-surgical management may still be eligible for operative treatment. In this study, we assessed the outcome of arthroscopic repair of RCTs in patients ≥60 years old.

Material and method

A retrospective case series was conducted to include patients who underwent arthroscopic repair of RCTs from 1 January 2018 to 1 January 2021. The study included individuals aged ≥60 years who had radiologically confirmed RCTs (verified by MRI) and clinical findings including sleep-disturbing pain and reduced range of motion. Preoperative treatment included physiotherapy for at least 6 months and one subacromial corticosteroid injection.

Results

Fifty-three RCTs were treated during the study period. After exclusion because of incomplete documentation, 45 patients remained. The mean age was 66 years and 80% had isolated supraspinatus tears and 25% had variable degrees of fatty infiltration (Goutallier grade 1-3) on MRI examination with positive tangent sign. There were no surgical site infections and three symptomatic re-ruptures (6%). At follow-up, (71%) reported no remaining sleep-disturbing shoulder pain. Abduction improved from 62° to 122°. Flexion improved from 68° to 135°. This study found that people aged 60 years and older who underwent repair of RCTs showed statistically significant clinical improvement in shoulder flexion and abduction with less sleep-disturbing shoulder pain. These encouraging results may contribute to the existing literature, favoring the choice of surgical treatment for symptomatic RCTs in this age group with failed nonoperative treatment.

Conclusion

The arthroscopic repair of RCTs in patients 60 years and older yielded a substantial increase in shoulder flexion and abduction, significantly reducing sleep-disturbing shoulder pain. Postoperative complications were minimal.

A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair

PURPOSE

The purpose of this study was to propose a modified Patte classification system for tendon retraction, including the cut-off points for predicting reparability and rotator cuff healing after arthroscopic rotator cuff repair (ARCR) and assess its prediction accuracy and measurement reliability.

METHODS

This retrospective study included 463 consecutive patients scheduled to undergo ARCR for full-thickness supraspinatus tears. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off points for predicting reparability and tendon healing. The modified Patte classification system, in which these cut-off points were combined with the original Patte classification, classified the tendon retraction as stages I-V. The prediction accuracy of reparability and tendon healing was assessed using the area under the curve (AUC). Measurement reliability was determined using Cohen's κ statistics.

RESULTS

Of the 402 included patients, 32 rotator cuff tears were irreparable and 71 of the remaining 370 were diagnosed with healing failure. ROC analysis determined the cut-off point of reparability at the medial one-fifth and that of tendon healing at the medial one-third of the humeral head. The AUC of the modified Patte classification for predicting reparability and tendon healing was 0.897 (excellent) and 0.768 (acceptable), respectively. Intra-rater reliability was almost perfect (mean κ value: 0.875), and inter-rater reliability was substantial (0.797).

CONCLUSION

Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day-by-day clinical work.

LEVEL OF EVIDENCE

Level III.

Postoperative Antiosteoporotic Treatment with Zoledronic Acid Improves Rotator Cuff Healing but Does Not Improve Outcomes in Female Patients with Postmenopausal Osteoporosis: A Prospective, Single-Blinded, Randomized Study

PURPOSE

To investigate the effect of the antiosteoporotic agent zoledronic acid (ZA) on rotator cuff healing and clinical outcomes in patients with postmenopausal osteoporosis.

METHODS

We prospectively enrolled 138 female patients with postmenopausal osteoporosis who were scheduled to undergo arthroscopic rotator cuff repair (ARCR) from March 2020 to March 2021. Patients were randomly allocated to the ZA group (ARCR followed by intravenous ZA infusions at postoperative Day 1 and 1 year later) and the control group (ARCR alone). All patients were followed up for 24 months. Tendon healing was evaluated by ultrasonography at 6 weeks and 24 months after surgery. The American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and Numeric Rating Scale (NRS) for pain were recorded at each follow-up, and the minimal clinically important difference (MCID) was calculated.

RESULTS

A total of 124 patients were included in the final analysis, 61 in the ZA group and 63 in the control group. There was no statistically significant difference in participant characteristics between the 2 groups. The ZA group had a significantly higher tendon healing rate than the control group at 2 years after surgery (odds ratio = 5.0; 95% confidence interval [CI], 1.4-18.7; P = .014). Regarding clinical outcomes, 100% of patients exceeded the MCID in both groups, and no significant differences were found at 2 years after surgery between the 2 groups (ASES: 2.5 [95% CI, -2.2 to 7.2; P = .291]; WORC index: 4.5 [95% CI, -0.117 to 9.117; P = .056]; NRS: -0.1 [95% CI, -0.3 to 0.1; P = .394]).

CONCLUSIONS

Antiosteoporotic treatment with ZA reduced the retear rate but did not significantly influence the clinical outcomes after ARCR in female patients with postmenopausal osteoporosis. Outcomes of ARCR showed good results in both groups and exceeded the MCID.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.