Nonoperative Treatment of Rotator Cuff Tears

What happens to patients in the long term when we do not repair their cuff tears? Ten-year rotator cuff quality of life index (RC-QOL) outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears

Background

The purpose of this study was to examine long-term, greater-than-ten-year outcomes of patients with full-thickness rotator cuff tears treated nonoperatively.

Methods

Patients with a chronic, full-thickness rotator cuff tear (demonstrated on imaging) who were referred by their physician for shoulder surgery were enrolled in this prospective study between October 2008 and September 2010. Patients then participated in a comprehensive nonoperative treatment program. After the three-month program, patients were defined as "successful" or "failed." "Successful" patients were essentially asymptomatic and did not require surgery. "Failed" patients were symptomatic and consented to surgical repair. All patients were followed-up at 1 year, two years, and five years using a validated, disease-specific rotator cuff quality of life score (the RC-QOL) and whether or not they eventually underwent surgery during these time intervals. All of the patients who participated at the five-year follow-up were contacted for this study between 10 and 12 years (mean 11.4 years) after treatment.

Results

Original results from this study showed that 75% of patients were treated successfully with the nonoperative program, while 25% failed and needed surgery. These numbers were maintained at the two-year follow-up and five-year follow-up (previously reported). At greater than ten years, 88 patients were contacted for follow-up. Only two patients crossed-over from "success" at 5 years to "failed" at 10 years. The nonoperative "success" group had a mean RC-QOL score of 80 (SD = 18) at the previously reported two-year follow-up and 82 (SD = 16) at five-year follow-up. Forty-one patients provided follow-up RC-QOL data at a mean of 11.4 years. The mean RC-QOL scores of the successfully treated nonoperative group were actually higher than those who required surgery during the course of the study (success group mean 86, SD = 12; "failed"/surgery group mean 78, SD = 24), although this was not statistically different (P = .27). Two patients had crossed over from the successful group to undergo surgery between 5 and 11 years (one had an acute traumatic injury and the other reported aggravation with activity).

Conclusion

Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that nonoperative treatment delays inevitable surgical repair, this long-term study shows that patients can do very well over time.

Biologics in rotator cuff repair

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears.

Scapular morphology does not predict supraspinatus tendon tear propagation following an individualised exercise therapy programme

Purpose

To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size.

Methods

Fifty-nine individuals aged 40-70 years with isolated symptomatic high-grade partial or full-thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12-week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three-dimensional subject-specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation.

Results

The CSA was 30.0 ± 5.4°. Thirty-one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R 2 = 0.243) of variance in tear propagation (NS).

Conclusions

CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme.

Level of Evidence

II.

Injectable self-assembled GDF5-containing dipeptide hydrogels for enhanced tendon repair

Owing to the tissue characteristics of tendons with few blood vessels and cells, the regeneration and repair of injured tendons can present a considerable challenge, which considerably affects the motor function of limbs and leads to serious physical and mental pain, along with an economic burden on patients. Herein, we designed and fabricated a dipeptide hydrogel (DPH) using polypeptides P11-4 and P11-8. This hydrogel exhibited self-assembly characteristics and could be administered in vitro. To endow the hydrogel with differentiation and regeneration abilities, we added different concentrations of growth differentiation factor 5 (GDF5) to form GDF5@DPH. GDF5@DPH promoted the aggregation and differentiation of tendon stem/progenitor cells and promoted the regeneration and repair of tendon cells and collagen fibers in injured areas. In addition, GDF5@DPH inhibited inflammatory reactions in the injured area. Owing to its injectable properties, DPH can jointly inhibit adhesion and scar hyperplasia between tissues caused by endogenous inflammation and exogenous surgery and can provide a favorable internal environment for the regeneration and repair of the injured area. Overall, the GDF5@DPH system exhibits considerable promise as a novel approach to treating tendon injury.

Association of Preoperative Patient Resilience With Postoperative Patient-Reported Outcomes and Sleep Quality Following Arthroscopic Rotator Cuff Repair: A Systematic Review

Recent studies have shown that low preoperative resilience may lead to inferior outcomes following arthroscopic rotator cuff repair. Therefore, the purpose of this systematic review is to evaluate whether preoperative patient resilience is associated with outcome measures, including patient-reported outcome measurements (PROMs) and sleep quality, following arthroscopic rotator cuff repair. To perform the review, a literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the PubMed and Embase databases to gather studies related to the influence of preoperative resilience on postoperative outcomes of rotator cuff repair. Methodological quality and risk of bias were assessed using the Methodological Index for Non-randomized Studies (MINORS). Seven studies with 584 patients were included. Of 36 total reported postoperative outcomes, including PROMs and sleep quality, 14 had a significant positive correlation with higher preoperative resilience. One study reported that higher resilience was significantly correlated with worse sleep quality at a two-week follow-up but not at further follow-ups of up to 24 weeks. Significant differences in outcomes between patients with varying levels of resilience were assessed in five studies, all of which found that patients with higher resilience had significantly better outcomes or no significant differences in outcomes between patients with varying levels of preoperative resilience. In no study was it reported that patients with low resilience had better outcomes. Overall, approximately half of all reported postoperative outcome data was found to be significantly associated with preoperative resilience. Therefore, clinicians should preemptively identify those with low resilience and administer psychological interventions to limit inferior outcomes following arthroscopic rotator cuff repair.