Management of failed rotator cuff repair: a systematic review

Clinical Outcomes of Arthroscopic Treatment of High-grade Partial Thickness Rotator Cuff Tears with Augmentation using Bioinductive Collagen Implants Are Comparable to Tear Completion and Repair

PURPOSE

To evaluate and compare the functional outcomes and reoperation rates following bio-inductive collagen implant repair (BCIR) vs arthroscopic tear completion and rotator cuff repair (ARCR) for the management of partial rotator cuff tears at a minimum of 1 years follow-up.

METHODS

A retrospective review was carried out to identify patients ≥30 years old who underwent BCIR or ARCR for grade 3 partial thickness supraspinatus tears with ≥12 months follow up. Clinical outcomes assessed included range of motion, visual analogue score (VAS), American Shoulder Elbow Score (ASES) & Single Answer Numerical Evaluation (SANE) scores as well as clinical failure requiring revision surgery. A p-value of < 0.05 was considered to be statistically significant. The minimally important clinical difference (MCID) was calculated.

RESULTS

Participants included 48 patients who underwent BCIR and 37 who underwent ARCR, with a mean follow-up 27.3 ± 11.8 months, there were no significant baseline differences in demographics or tear characteristics between the cohorts. The mean surgical duration was shorter in the BCIR cohort (53 ± 10 vs 65 ± 17 minutes, p = 0.001). At final follow up there was no difference in ASES (p= .143), SANE (p = .167), VAS scores (p = .130), range of flexion (p = .159), abduction (p = .379) or external rotation (p = .281). Both groups obtained significant postoperative improvements (p < .02, for all). There was no difference in the achievement of the MCID for VAS (p = .999), SANE (p = .435) or ASES score (0.377). There was no significant difference in the rate of revision repair at final follow up 2.1% vs 5.4% (p = .577).

CONCLUSION

BCIR of high grade partial thickness rotator cuff tears results in reliable improvements in pain, shoulder function and range of motion equivalent to traditional suture anchor repair. There was no difference in the rate of MCID achievement or revision surgery.

STUDY DESIGN

Level III, retrospective comparative series.

Augmentation Techniques for Rotator Cuff Repairs

» Despite enhanced understanding of risk factors for failure and enhanced surgical repair techniques, the risk for failure of the rotator cuff to heal after surgery is still substantial.» A patient-specific approach to augmentation is essential, with decisions based on tear and patient characteristics.» Augmentation can improve repair strength and promote cellular infiltration, which collectively contribute to better healing outcomes.» Augmentation strategies may improve outcomes in rotator cuff repairs, particularly in high-risk cases; however, there is a lack of consensus among surgeons on the most effective strategies for each scenario.

Postoperative Outcomes Are Comparable Between Arthroscopic Subscapularis Repairs Performed With Either All-Suture Anchors or Hard-Body Anchors

Purpose

To compare clinical outcomes and tendon healing rates of patients undergoing arthroscopic rotator cuff repairs involving the subscapularis (SSC) tendon (isolated or combined) with all-suture anchors (ASAs) versus hard-body anchors (HBAs) and to compare SSC healing rates between these 2 anchors.

Methods

A retrospective comparative study was performed on patients who underwent arthroscopic rotator cuff repair of the SSC with either ASAs or HBAs and had a minimum 2-year follow-up. Range of motion and patient-reported outcomes were collected pre- and postoperatively, including a visual analog scale for pain, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value. Postoperative strength was measured, including Constant strength and belly press test. SSC healing was evaluated on ultrasounds at the final follow-up.

Results

Eighty-four patients met the study criteria. Twenty-eight underwent SSC repair with ASAs and 56 with HBAs. The mean follow-up for the ASA group and HBA group was 44 ± 22.7 months and 48.4 ± 28.3, respectively (P = .743). Baseline characteristics were comparable between groups (P > .05). Overall, patient-reported outcomes and range of motion showed significant improvements from baseline to the final follow-up in all groups (P < .001). Postoperatively, patients in the ASA group had greater improvement in forward flexion compared to the HBA group: 31° (95% confidence interval, 20°-42°) versus 14° (95% confidence interval, 5°-8°), respectively (P = .002). Postoperative Constant strength was higher in the ASA group compared to the HBA group: 17.5 ± 7.5 versus 13.5 ± 5.6, respectively (P = .04). No statistically significant difference in SSC retear rates was observed between groups: none in the ASA group and 3 (10.7%) in the HBA group (P = .27).

Conclusions

Arthroscopic SSC repair leads to significant functional improvement, with both ASAs and HBAs demonstrating similar low failure rates.

Level of Evidence

Level III, retrospective cohort study.

Revision rotator cuff repair versus primary repair: an assessment of longitudinal outcomes in revision rotator cuff repair

BACKGROUND

Information about outcomes after revision rotator cuff repair (RCR) is limited. A more thorough investigation of pain, range of motion (ROM), strength, and functional outcomes is needed. Comparing outcomes between primary and revision rotator cuff repair patients can help surgeons guide patient expectations of the revision procedure. The aim of this study was to compare the outcomes of a revision repair group to a control group of primary RCR patients. We expect revision RCR patients to have worse clinical outcomes than primary RCR patients.

METHODS

A retrospective review of patients who underwent primary or revision RCR between 2012 and 2020 was performed. The case group included 104 revision patients, and the control group included 414 primary RCR patients. Patient visual analog score for pain, ROM, strength, Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores were collected at baseline, 12 months, 24 months, and final follow-up.

RESULTS

The average final follow-up was 43.9 months for primary patients and 63.8 months for revision patients. Three hundred fifty-two primary patients and 55 revision patients had a final follow-up of 2 or more years. By the final follow-up, primary patients had less pain than revision patients (Δ of 2.11, P < .0001), but both groups improved overall. Primary patients had significant improvements in forward flexion, external rotation, internal rotation, and abduction at 2 years that were lost by final follow-up, but revision patients did not experience any long-term improvement in ROM. These differences in ROM between groups were not significant. Supraspinatus strength in the revision group did not improve nor decline by final follow-up. By final follow-up, both primary and revision patients had improved SST and ASES scores from baseline. Primary patient ASES scores were 17.9 points higher (P < .0001) than revision patients by final follow-up, and there was no difference between groups in SST scores at this time.

CONCLUSION

Revision RCR significantly improves patient pain, SST score, and ASES score at 4 years. Revision patients should not expect to see the improvements in ROM that may occur after primary repair.

Occurrence of cellular senescence in chronic human shoulder tendinopathies and its attenuation ex vivo by inhibition of Enhancer of Zeste 2

Aims

Our aim was to investigate occurrence of senescent cells directly in tendon tissue biopsies from patients with chronic shoulder tendinopathies, and to correlate senescence with Enhancer of zeste 2 (EZH2) expression, the functional subunit of the epigenetic master regulator polycomb repressive complex.

Methods

Human proximal long head of biceps tendons from patients with different chronic shoulder pathologies (n = 22), and controls from patients with humerus fracture (n = 6) and pathology (n = 4), were histologically scored for degeneration and analyzed for gene and protein expression of tendon specific factors, senescence markers, and EZH2. Tissues were further exposed to senotherapeutic compounds and the USA Food and Drugs Administration-approved selective EZH2 inhibitor EPZ-6438 and their senescence-associated secretory phenotype (SASP) assessed.

Results

Expression of senescence markers (CDKN2A/p16, CDKN2D/p19) and EZH2 was significantly higher in tendinopathies compared to fracture or healthy tissue controls and positively correlated with the degree of tissue degeneration. Immunofluorescent stainings demonstrated colocalization of p16 and p19 with EZH2 in tenocytes. Treatment of tendon biopsies with EPZ-6438 reduced secretion of a panel of SASP factors, including interleukin-6 (IL6), IL8, matrix metalloproteinase-3 (MMP3) or GRO1, similarly to the senotherapeutic compound AG490.

Conclusion

We demonstrate that senescence traits accumulate in pathological tendon tissues and positively correlate with tissue degeneration. Increased expression of CDKN2A/p16 and CDKN2D/p19 coincides with EZH2 expression, while its inhibition decreased the secretion of SASP factors, indicating a possible regulatory role of EZH2 in tenocyte senescence in tendinopathies. Reduction of cellular senescence, e.g. with EPZ-6438, opens ways to new potential therapeutic approaches for enhancing regeneration in chronic tendinopathies.

Does dynamically tensioning suture alter outcomes after rotator cuff repair?

BACKGROUND

Dynamically tensioning suture is now available as an alternative to traditional static tendon-repair sutures. The purpose of this study was to compare rotator cuff repair (RCR) patient-reported outcomes (PROs) between repairs performed using dynamic and static suture.

METHODS

A retrospective review was performed for patients who underwent rotator cuff repair by a single surgeon at an academic institution between 2016 and 2022. Patients who underwent RCR with either dynamically tensioning suture or traditional static suture were included. Intraoperative variables included tear width, tear retraction, number of anchors used in repair, repair construct, and Goutallier grades for supraspinatus, infraspinatus, teres minor, and subscapularis evaluated on preoperative magnetic resonance imaging. Patient-reported outcomes (PROs) collected preoperatively and at a minimum of 2 years postoperatively included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) pain score, and the Subjective Shoulder Value (SSV) score. We used both univariable and multivariable regression models, where the multivariable models estimated the dynamic suture effect controlling for a set of predictors selected a priori.

RESULTS

A total of 424 patients (441 shoulders) were included, with 2-year outcomes available for 78% (344 of 441). Patients were divided into dynamic (47.1%) and static (52.9%) tensioning suture groups. There were no significant preoperative differences in demographics, preoperative PROs, or intraoperative findings between the groups, except for acromial undersurface characteristics (P < .001). Postoperatively, there were no significant differences between the groups in ASES, VAS, or SSV scores. Multivariable regression analysis revealed that preoperative ASES score was independently associated with postoperative ASES score, and preoperative VAS score and tear size were independently associated with postoperative VAS score. There were no differences in postoperative outcomes between the dynamic and static groups.

CONCLUSION

Patient-reported outcomes did not differ significantly between the dynamic tensioning and static tensioning sutures in arthroscopic rotator cuff repair.

The Reverse Fragility Index: Interpreting the Evidence for Arthroscopic Rotator Cuff Repair Healing Associated With Early Versus Delayed Mobilization

Background: The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) note "strong" evidence that early and delayed mobilization protocols after small to medium arthroscopic rotator cuff repairs achieve similar rotator cuff healing rates. Purpose: We utilized the reverse fragility index (RFI) to assess the fragility of randomized controlled trials (RCTs) reporting no statistically significant difference in tendon re-tear rates after rotator cuff repair in those undergoing early versus delayed rehabilitation. Methods: Randomized controlled trials used in the most recent AAOS CPGs on the timing of postoperative mobilization after arthroscopic rotator cuff repairs were analyzed. Only RCTs with a reported P value ≥ .05 were included. The RFI at a threshold of P < .05 was calculated for each study. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. Results: In 6 clinical trials with a total of 542 patients, the number of tendon re-tear events was 48. The median RFI at the P < .05 threshold was 4 (range: 3.25-4.75), and the median RFQ was .05 (range: 0.03-0.08). The median loss to follow-up was 6 patients. Of the 6 studies investigated, 3 reported a loss to follow-up greater than their respective RFI. Conclusion: The equivalence in rotator cuff repair healing rates associated with early and delayed mobilization protocols rests on fragile studies, as their statistical non-significance can be reversed by changing the outcome status of only a handful of patients. Consideration should be given to the routine reporting of RFI in clinical practice guidelines including RCTs with statistically non-significant results.

Primary Rotator Cuff Bridging Reconstruction Shows Better Clinical and Radiographic Results Than Revision Bridging Reconstruction

Purpose

To evaluate the outcome of revision rotator cuff bridging reconstruction (BR) as compared to primary BR in a large cohort of patients.

Methods

A retrospective chart review was conducted for patients who underwent BR using dermal allograft for large/massive rotator cuff tears between 2010 and 2018. Patients who completed Western Ontario Rotator Cuff Index (WORC) and Disability of the Arm, Shoulder, and Hand (DASH) scores both pre- and postoperatively were included. Pre- and postoperative magnetic resonance imaging scans were compared to assess for differences in fatty infiltration, muscle atrophy, and graft status.

Results

Eighty patients met the inclusion criteria, including 43 patients who underwent BR as a primary surgery and 37 patients who underwent revision BR. The mean follow-up duration was 5.7 ± 1.9 years in the primary group and 5.8 ± 2.0 years in the revision group. Both WORC and DASH scores significantly improved from pre- to postoperatively for both the primary and revision groups (P < .05). The primary group had significantly better postoperative WORC and DASH scores at 6 months, 1 year, and final follow-up (P < .05). Failure rate of the graft was higher in the revision group compared to primary group (14.3% vs 6.1%, respectively; P = .337), and the amount of fatty infiltration of supraspinatus and infraspinatus muscles significantly improved in patients who received primary BR compared to revision BR (P < .05).

Conclusions

BR using dermal allograft for large/massive irreparable rotator cuff tears showed improvement of functional outcomes, with primary cases resulting in better improvement in patient-reported outcomes compared to revision cases. Primary BR was also associated with better postoperative fatty infiltration of supraspinatus and infraspinatus muscles.

Level of Evidence

Level III, retrospective cohort study.

Perioperative complications and outcomes in patients with paraplegia undergoing rotator cuff repair

Background

Patients with paraplegia often experience chronic shoulder pain due to overuse. We sought to determine if these patients have an increased prevalence of perioperative complications and higher rates of re-admissions and rotator cuff re-tears relative to able-bodied controls following rotator cuff repair (RCR).

Methods

We queried the NRD (2011-2018) to identify all patients undergoing primary RCR (n = 34,451) and identified cohorts of matched paraplegic and non-paraplegic patients (n = 194 each). We compared demographic factors, comorbidity profiles, perioperative complication rates, length of stay, revision rates, and re-admission rates between the two groups.

Results

Patients with paraplegia had lower rates of chronic obstructive pulmonary disease (p = 0.02), hypertension (p = 0.007), congestive heart failure (p = 0.027), obesity (p < 0.001), and prior myocardial infarction (p = 0.01). Additionally, patients with paraplegia experienced higher rates of urinary tract infections (11.9% vs. 2.1%, p < 0.001), lower rates of acute respiratory distress syndrome (0% vs. 3.1%, p = 0.041), and had a longer length of stay (4-days vs. 1-day, p < 0.001). Revision rates were similar for the two groups.

Conclusions

Compared to matched controls, patients with paraplegia were found to have similar demographic characteristics, less comorbidities, similar perioperative complication rates, and similar revision rates. These findings address a gap in the literature regarding surgical management of shoulder pain in patients with paraplegia by providing a matched comparison with a large sample size.

Intact revision rotator cuff repair stabilizes muscle atrophy and fatty infiltration after minimum follow up of two years

BACKGROUND

The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters.

METHODS

Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration.

RESULTS

19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 - 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively (p < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed.

CONCLUSION

Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration.

LEVEL OF EVIDENCE

Level IV; Therapeutic study.

A highly elastic absorbable monofilament suture fabricated from poly(3-hydroxybutyrate-co-4-hydroxybutyrate)

To address the growing demand for more elastic sutures free from unwanted knot loosening, we fabricated an absorbable monofilament suture from poly(3-hydroxybutyrate-co-4-hydroxybutyrate) and subjected it to physical property characterization and performance evaluation (in vitro and in vivo degradability tests and a porcine abdominal wall suture test). As this flexible, highly stretchable, and difficult-to-untie suture exhibited additional advantages of small knot size and medium to long-term bioabsorbability, it was concluded to be a safe alternative to existing monofilament sutures, with far-reaching potential applications.

Early revision rotator cuff repair: an analysis of outcomes and function

PURPOSE

Rotator cuff repair (RCR) is commonly performed and can have good functional outcomes. However, failure of RCR surgery can be challenging for both patient and surgeon alike. This study examines the outcomes of early revision RCR for the management of clinically failed RCRs.

METHODS

Thirty-six patients undergoing revision RCR within 1 year of primary surgery were evaluated. Range of motion (ROM) and patient-reported outcomes (PROMs) were assessed at baseline, post-primary RCR, and post-revision RCR.

RESULTS

Patients with a documented repair failure after primary RCR failed to improve in both ROM and PROMs compared to before primary RCR. Following early revision, RCR SANE (p = 0.024, p < 0.001), ASES (p = 0.004, p < 0.001), and SST (p < 0.001, p = 0.001) scores improved significantly compared to pre-primary and pre-revision scores, respectively. Documentation of a new traumatic injury did not affect clinical or functional outcomes compared to atraumatic re-tears. Number of tendons torn was positively correlated with higher SANE scores (r = 0.638, p = 0.008) and negatively correlated with SST score (r = -0.475, p = 0.03) and improvement in forward elevation (r = -0.368, p = 0.03) after primary RCR. There were significant correlations between number of tendons torn and improvement in SANE (r = 0.664, p = 0.007) and ASES scores (r = 0.468, p = 0.043) from post-primary RCR to post-revision RCR.

CONCLUSION

Early revision after failed RCR can lead to clinically significant improvement in functional outcomes. The presence of a traumatic re-injury does not appear to affect revision RCR outcomes as it does in the primary setting. Patients with early clinical failures of primary RCR may benefit from early revision RCR.

LEVEL OF EVIDENCE

III: Retrospective Case Series.

Re-Tear Rates Following Rotator Cuff Repair Surgery

Aim Re-tears following rotator cuff repair surgery are a common occurrence. Previous studies have identified several factors that have been shown to increase the risk of re-tears. The purpose of this study was to evaluate the rate of re-tear following primary rotator cuff repair and to identify the factors that may contribute to this rate. Method The authors performed a retrospective review, looking at rotator cuff repair surgeries performed between May 2017 and July 2019 performed in a hospital by three specialist surgeons. All methods of repair were included. All patients' medical data, including imaging and operation records, were reviewed. Results A total of 148 patients were identified. Ninety-three males and 55 females with a mean age of 58 years (range 33-79 years). Thirty-four patients (23%) had post-operative imaging with either magnetic resonance imaging or ultrasound, where it was found that 20 (14%) had a confirmed re-tear. Of these patients, nine went on to have further repair surgery. The average age of the re-tear patients was 59 (age range 39-73) and 55% were female. The majority of the re-tears were from chronic rotator cuff injuries. This paper did not identify any correlation between smoking status or diabetes mellitus and re-tear rates. Conclusions This study indicates that re-tear after rotator cuff repair surgery is a common complication. The majority of studies find increasing age to be the biggest risk factor; however, this was not the case in our study which found females in their 50s to have the highest rate of re-tear. Additional research is required to understand what factors can contribute towards rotator cuff re-rupture rates.

All-Arthroscopic Refixation of an Osteochondral Femoral Avulsion of the Anterior Cruciate Ligament with a Laxity-Minimizing Suture

Purpose

Torn anterior cruciate ligaments in children are rare injuries. The incidence of concomitant avulsion fracture in the skeletally immature patient is high. Reports of arthroscopic reconstruction in the literature are sparse.

Case Presentation

We present the case of a femoral avulsion fracture of the anterior cruciate ligament in a seven-year-old girl. The patient underwent arthroscopic refixation with Dynacord^TM Suture and Suture Button. At a follow-up of 8 weeks, the patient had free range of motion and a stable knee, with a negative Lachman- and Pivot-Shift-test in particular.

Conclusion

Refixation of femoral avulsion fracture can lead to good results. Open physes and size of the knee should be taken into account. Anatomic reconstruction is compulsory to receive bone on bone healing.

Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: final results of a prospective multicenter study

BACKGROUND

Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years.

METHODS

A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years.

RESULTS

Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by >90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery.

CONCLUSION

Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.

METHODS

Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).

RESULTS

The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.

CONCLUSION

Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases

BACKGROUND

Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far.

PURPOSE/HYPOTHESIS

To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up.

RESULTS

All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) (P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm² to 3.25 ± 1.92 cm² (P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 (P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years (P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years (P≤ .039).

CONCLUSION

Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Pulsed electromagnetic field therapy alters early healing in a rat model of rotator cuff injury and repair: Potential mechanisms

Rotator cuff repair failure remains common due to poor tendon healing, particularly at the enthesis. We previously showed that pulsed electromagnetic field (PEMF) therapy improved the mechanical properties of the rat supraspinatus tendon postoperatively. However, little is known about the mechanisms behind PEMF-dependent contributions to improved healing in this injury model. The objective of this study was to determine the influence of PEMF treatment on tendon gene expression and cell composition, as well as bone microarchitecture and dynamic bone metabolism during early stages of healing. We hypothesized that PEMF treatment would amplify tendon-healing related signaling pathways while mitigating inflammation and improve bone metabolism at the repair site. Rats underwent rotator cuff injury and repair followed by assignment to either control (non-PEMF) or PEMF treatment groups. Gene and protein expression as well as tendon and bone histological assessments were performed 3, 7, 14, 21, and 28 days after injury. Gene expression data demonstrated an upregulation in the bone morphogenetic protein 2 signaling pathway and increases in pro-osteogenic genes at the insertion, supporting important processes to re-establish the tendon-bone interface. PEMF also downregulated genes related to a fibrotic healing response. Anti-inflammatory effects were demonstrated by both gene expression and macrophage phenotype. PEMF significantly increased the rate of kinetic bone formation directly adjacent to the tendon enthesis as well as the number of cuboidal surface osteoblasts (active osteoblasts) in the humeral head. This study has provided insight into how PEMF affects cellular and molecular processes in the supraspinatus tendon and adjacent bone after injury and repair.

Management of the failed rotator cuff repair

Rotator cuff repair is increasingly being performed, and this is likely to continue to given the ageing population. An improvement in functional outcome can be achieved, with the best results noted in those tendons that go on to heal. Failure of repair following surgery can be associated with debilitating symptoms that are not always amenable to non-operative measures, so further surgery may be indicated for these patients. Several operative strategies have been described, but careful evaluation is required to determine the most suitable option. This review describes the decision-making strategies and treatment options available during management of a failed rotator cuff repair.

Achilles Tendon–Bone Block Allograft for Massive Rotator Cuff Tears With Bony Deficiency of the Greater Tuberosity: A Minimum 2-Year Follow-up Study

Background:

Massive rotator cuff tears associated with greater tuberosity bone loss are challenging to treat. Repairing the rotator cuff without addressing the greater tuberosity deficiency may result in poorer clinical outcomes.

Hypothesis:

Utilizing an Achilles tendon–bone block allograft to address both the massive rotator cuff tear and greater tuberosity bone loss concurrently can result in improved clinical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors performed a retrospective study of patients treated between January 2011 and December 2018 with Achilles tendon–bone block allograft for massive rotator cuff tears associated with greater tuberosity bone loss. The inclusion criteria were massive rotator cuff tear and bony deficiency of the greater tuberosity; patients with a history of bony metabolism disease, connective tissue disease, and previous surgery to the wrist or elbow of the affected limb were excluded. Range of motion, visual analog scale for pain, Constant score, and Single Numeric Assessment Evaluation score were assessed preoperatively and at a minimum of 2 years postoperatively. Radiographs and ultrasound images were evaluated to assess allograft union and rotator cuff integrity.

Results:

Five patients (3 male and 2 female; mean age, 54.0 ± 12.2 years) were included in the study. The mean follow-up was 80.6 ± 33.7 months. Preoperative to postoperative values improved significantly on the visual analog scale (from 45.8 ± 25.5 to 14.5 ± 14.1; P = .04), Constant score (from 36.8 ± 7.9 to 73.5 ± 3.1; P < .001), and Single Numeric Assessment Evaluation score (from 42.5 ± 26.3 to 82.5 ± 10.4; P = .04). Forward flexion improved significantly from 53° ± 47° to 149° ± 17° (P = .03). Four of the 5 patients achieved bony union. One patient required removal of symptomatic hardware at 6 months postoperatively, and 1 patient required revision surgery at 1 year postoperatively because of progressive osteonecrosis of the humeral head.

Conclusion:

In patients with massive rotator cuff tears and a greater tuberosity bony deficiency, utilizing an Achilles tendon–bone block allograft to restore the bony defect and reinforce the rotator cuff repair was safe and effective. At a minimum of 2 years postoperatively, most patients demonstrated improved clinical outcomes, tendon healing, and graft incorporation.

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair

BACKGROUND

This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR).

METHODS

We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair.

RESULTS

Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005).

CONCLUSION

Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.

Superior capsular reconstruction for irreparable rotator cuff tears: Autografts versus allografts

AIMS

Superior capsular reconstruction (SCR) is a treatment option for patients with massive irreparable rotator cuff tears. Different types of grafts from various donor sites have been described. There are no clinical studies comparing the different grafts available. The aim of this study is to compare the early clinical outcomes of patients who have undergone arthroscopic SCR with different types of grafts (allograft vs. autograft).

MATERIAL AND METHODS

This study is a retrospective analysis of data collected prospectively, from patients who underwent arthroscopic SCR with either a long head of biceps autograft (LHB) (n=40) or an acellular dermal allograft (n=40), between March 2015 and April 2018. The pre- and postoperative clinical data were compared between the 2 groups, as well as the incidence and type of complications.

RESULTS

All patients were monitored with a minimum follow-up of one year. Three patients (7.5%) in the autograft group, and 14 (35%) in the allograft group (p=0.005) had a complication, of which 2 (5%) and 5 (12.5%) respectively, required revision surgery (p=0.432). Linear regression ruled out any significant difference between the 2 groups, with respect to clinical scores. However, patients with a history of prior rotator cuff surgery had poorer results with regard to active elevation (β, -29.3; p=0.020), internal rotation (β, -3.4; p=0.003) and Subjective Shoulder Value (SSV) (β, -17.2; p=0.023). Older patients, as well as men, are associated with poorer postoperative internal rotation (β, -0.1; p=0.003 and β, -1.9; p=0.039 respectively), and type D lesions are associated with poorer external rotation and postoperative SSV (β, -11.3; p=0.012 and β, -12.4; p=0.048 respectively), compared to type C lesions. Postoperative graft integrity was improved in the autograft group compared to the allograft group. (Grade 1: 65.8% vs. 2.9%; Grade 5: 5.3% vs. 28.6%; p<0.001).

CONCLUSIONS

In both groups, clinical scores improved after SCR in patients with irreparable rotator cuff tears. Fewer complications and revisions were observed with the autograft compared to the allograft. If the LHB was still in place during surgery, its use appears valid, given the reasonable cost and low rate of complications associated with it. If absent, an allograft is also an option, considering the potential clinical improvement.

LEVEL OF EVIDENCE

III; Case-control study.

Safety and Efficacy of Autologous Dermal Fibroblast Injection to Enhance Healing After Full-Thickness Rotator Cuff Repair: First-in-Human Pilot Study

Background:

There is growing interest in various biological supplements to improve tendon healing in patients after arthroscopic rotator cuff repair. The ideal biological supplement to strengthen rotator cuff remains unknown.

Purpose:

To assess the safety and efficacy of autologous cultured dermal fibroblast (ADF) injection on tendon-to-bone healing in patients after arthroscopic rotator cuff repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 6 patients who underwent arthroscopic rotator cuff repair between June 2018 and March 2020; all patients had a full-thickness rotator cuff tear (>2 cm) involving the supraspinatus and infraspinatus tendons. The patients were injected with ADF between the repaired tendon and footprint during arthroscopic rotator cuff repair using the suture bridge technique. The safety of ADFs and the procedure was evaluated at 5 weeks postoperatively, and the anatomical healing of the repaired tendon was accessed at 6 months postoperatively using magnetic resonance imaging and at 12 months using ultrasonography. Outcomes including shoulder range of motion (ROM), visual analog scale (VAS) for pain, and functional scores were measured at 6 and 12 months postoperatively.

Results:

Adverse reactions to ADF injection were not observed at 6 months after surgery. VAS and functional scores at 6 and 12 months postoperatively were significantly improved compared with preoperative scores (all P < .05). However, there was no significant difference on any ROM variable between preoperative and postoperative measurements at 6 and 12 months (all P > .05). No healing failure was found at 6 and 12 months postoperatively.

Conclusion:

There was no adverse reaction to ADF injection, and all patients had successful healing after rotator cuff repair. A simple and easily accessible ADF injection may be a novel treatment option for increasing the healing capacity of torn rotator cuff tendons. Further clinical research is needed to verify the study results.

A Weaving Rip-Stop Technique Leads to a Significantly Increased Load to Failure and Reduction in Suture-Tendon Cut-Through in a Biomechanical Model of Rotator Cuff Repair

Purpose

To present an alternative arthroscopic rip-stop technique with a single suture tape weaved through the tendon from anterior to posterior and to biomechanically test its strength against a control technique consisting of a single-row repair with simple sutures.

Methods

This was a controlled biomechanical study. Dissection and harvesting of the supraspinatus muscle-tendon unit were performed along the cable in 9 matched-pair cadaveric shoulders. Samples were divided into 2 groups: simple suture repair only (SSR) and simple suture repair with rip-stop (SSPR). Biomechanical testing was performed with an initial preload, followed by cyclic loading and then ramp to failure. Peak-to-peak displacement, stiffness (in newtons per millimeter), load at failure (in newtons), and failure mechanism were recorded. Data were compared using the paired-sample t test.

Results

The average peak-to-peak displacement for SSR samples was not significantly different from that of SSPR samples (P = .96). Similarly, elongation in the SSR and SSPR groups was not significantly different (P = .82). Stiffness was significantly different between the SSR and SSPR groups (P = .0054): SSR samples were less stiff than SSPR samples. Moreover, SSR samples failed at significantly lower forces than did SSPR samples (P = .028). A larger percentage of failures occurred due to tendon cut-through among SSR samples versus suture breakage among SSPR samples.

Conclusions

An alternative rip-stop technique is presented in this biomechanical model that may assist surgeons to better deal with difficult rotator cuff repairs. Weaving a suture tape as a rip-stop can increase stiffness, achieve higher failure loads when compared with simple suture repair with no rip-stop, and reduce tendon cut-through.

Clinical Relevance

This study provides insight into a variation of rip-stop stitch techniques that may help solve the clinical problem of failure occurring at the suture-tendon interface, specifically tendon cut-through.

Design and Mechanical Evaluation of Sutureless Implants for the Surgery Treatment of Rotator Cuff Tears

Rotator cuff (RC) tears cause pain and functional disability of the shoulder. Despite advances in suture anchors, there are still reports about the incidence of surgical-related injuries to RC mainly associated with sutures. The purpose of this study was to design and evaluate the mechanical behavior of sutureless implants to repair RC tears. We hypothesized that the implants present mechanical characteristics suitable for the surgical treatment of RC tears as suture anchors. Three different implants (T1, T2, T3) were designed and fabricated with titanium: T1 has two rods and rectangular head; T2 has two rods with a small opening and enlarged rectangular head; and T3 has three rods and a circular head. The implants were fixed in rigid polyurethane foam blocks by a series of blows, and the applied mechanical loads along with the number of blows were quantified. Pullout tests using tapes fixed between the implant head and testing machine grip were conducted until implant failure. The maximum pullout strength and displacement of the implant relative to the rigid foam block were computed. Statistical significance was set at p < 0.05. Owing to its geometric configuration, implant T2 presented the best characteristics related to stability, strength, and ease of insertion. Implant T2 confirms our hypothesis that its mechanical behavior is compatible with that of suture anchors, which could lead to the reduction of RC repair failures and simplify the arthroscopic procedure.

Cell-based therapies for the treatment of sports injuries of the upper limb

Introduction: The use of cell-based therapies in the management of sports injuries of the upper limb is increasingly popular despite the limited scientific evidence available for their use. We aim to evaluate the evidence for the use of cell-based therapies in these injuries and recommend areas for further research.Areas covered: In accordance with a published protocol (PROSPERO; Registration No. CRD42020193258), a comprehensive search of the literature was performed using the MEDLINE and EMBASE databases from inception to June 2020. All human studies reporting on the clinical, histological, or radiological outcomes following the use of cell-based therapies in the management of epicondylitis or rotator cuff pathology were included in this study. This resulted in 22 studies being included in this review, all of which underwent risk of bias assessments.Expert opinion: The evidence for the use of cell-based therapies in upper limb sports injuries is limited and generally of low quality. Given the heterogeneity in the cell types used, their harvesting methods and cell amounts, future research should be targeted at developing standardization of the reporting of these studies and more direct comparative studies looking at the efficacy of the different cell types.

Re-tears after rotator cuff repair: Current concepts review

Re-tear following rotator cuff repair is common and has been reported to range from between 13 and 94% despite satisfactory clinical outcomes following rotator cuff surgery. Various risk factors have been associated with an increased tear rate, including patient factors, tear and shoulder morphology, repair technique, and rehabilitation regimes. Different modes of rotator cuff failure have been described. The management of re-tear in patients following rotator cuff repair is challenging and depends on the age, functional status and requirements of the patient, and re-tear size and residual tendon length. This article aims to review the factors associated with rotator cuff re-tear. It describes which of these are associated with poor clinical outcomes, and discusses the long-term outcomes of re-tear and treatment options.

Revision Rotator Cuff Repair Versus Primary Repair for Large to Massive Tears Involving the Posterosuperior Cuff: Comparison of Clinical and Radiological Outcomes

Background:

The retear rate after revision rotator cuff repair (rRCR) ranges from 50% to 90%. Patients who undergo primary RCR (pRCR) for large to massive rotator cuff tear (mRCT) also have unpredictable outcomes.

Purpose:

To compare the clinical outcomes after rRCR for a posterosuperior rotator cuff tear of any size with those after pRCR for mRCT and to identify the risk factors for poor outcomes and retear after rRCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among patients with posterosuperior cuff tear treated between 2010 and 2017, the clinical outcomes of 46 patients who underwent rRCR were compared with 106 patients who underwent pRCR for mRCT. Between-group differences in patient-reported outcomes (visual analog scale [VAS] for pain, VAS for satisfaction and American Shoulder and Elbow Surgeons [ASES] and Constant scores) at final follow-up were evaluated and compared with previously published minimal clinically important difference (MCID) values. Radiological outcomes were evaluated using magnetic resonance imaging or ultrasonography at a minimum 1-year follow-up. Multivariate linear regression analysis was performed to identify the risk factors for poor ASES score, and multivariate logistic regression analysis was used to assess the risk factors for retear after rRCR.

Results:

The mean follow-up was 26.4 months (range, 24-81 months). Although final VAS for pain, VAS for satisfaction, and ASES scores in the rRCR group were significantly worse than those in the pRCR group, the Constant score was similar between the groups. These differences in outcomes did not exceed the MCID threshold. The retear rate in the rRCR group was 50% compared with 39% for the pRCR group (P = .194). In the rRCR group, risk factors for worse ASES score were retear (P = .043; r = –11.3), lower body mass index (P = .032; r = 1.9), and lower preoperative VAS for pain (P = .038; r = 2.3), and risk factors for retear were preoperative high-grade fatty degeneration (Goutallier grades 3 and 4) of the supraspinatus muscle (P = .026; odds ratio, 5.2) and serum hyperlipidemia (P = .035; odds ratio, 11.8).

Conclusion:

Both study groups had similar clinical and radiological outcomes. Patients with symptomatic failed rotator cuff repairs having high-grade fatty degeneration of the supraspinatus muscle and/or serum hyperlipidemia had a greater likelihood of retear after rRCR.

Poor Prognostic Factors in Patients With Rotator Cuff Retear

Background:

The treatment for retears after arthroscopic rotator cuff repair (ARCR) has long been a challenge.

Purpose:

This study aimed to (1) summarize the characteristics of patients with a retear after primary ARCR and (2) determine the risk factors for poor clinical outcomes after a retear.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We collected the data of patients with a retear after primary ARCR between January 2011 and December 2016. There were 45 patients with retears included (19 men [42.2%] and 26 women [57.8%]; mean ± SD age, 63.11 ± 8.87 years). Initially, the demographic and outcome data of patients with a retear were analyzed. Patients were classified into good and poor outcome groups according to their overall satisfaction at final follow-up. Univariable and multivariable logistic regression analyses were performed to determine the factors for poor clinical outcomes after a retear.

Results:

A total of 31 patients were classified into the good outcome group, and 14 patients were classified into the poor outcome group. Both the good and the poor outcome groups showed that clinical scores significantly improved at the time of the retear diagnosis, but the final scores were maintained or worse compared with scores at the time of the retear diagnosis. Final range of motion (ROM), except external rotation in the good outcome group, was worse or had no significant change compared with ROM at the time of the retear diagnosis. On multivariable logistic regression analysis, current smoking (odds ratio [OR], 45.580 [95% CI, 3.014-689.274]; P = .006), female sex (OR, 32.774 [95% CI, 2.433-441.575]; P = .009), and retears of the same or larger size than the initial tear (OR, 10.261 [95% CI, 1.544-68.202]; P = .016) showed a higher OR for poor clinical outcomes after a retear.

Conclusion:

Smoking, female sex, and retears of the same or larger size than the initial tear were independent risk factors for poor clinical outcomes after a rotator cuff retear. Final clinical scores and ROM were similar or worse compared with the scores and ROM at the time of the retear diagnosis. Therefore, revision surgery should be actively considered in female patients or those who smoke with poor clinical outcomes and a larger retear size than the preoperative tear size at the time of the retear diagnosis.

Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears

BACKGROUND

Factors affecting a rotator cuff symptomatic retear after arthroscopic repair have yet to be clearly identified, since they usually influence the surgical decisions.

METHODS

Consecutive patients with full-thickness tear of the supraspinatus who underwent arthroscopic repair were retrospectively analyzed. Cases of symptomatic retear, defined as Sugaya type IV and V on magnetic resonance imaging, associated with intensive pain and/or functional impairment were identified at follow-up. The patients with no symptomatic retear were selected as the control group. Information from potential risk factors of symptomatic retear, including depression and subacromial corticosteroid injections, was extracted from the medical records. The statistical analysis included multivariant logistic regression.

RESULTS

The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration. They also had had more frequently subacromial corticosteroid injections and depression. However, following the multiple logistic regression analysis, only massive tears and moderate to severe fatty infiltration remained significantly associated. Similarly, in relation to the study hypothesis, both corticosteroid injections (odds ratio [OR] 6.66, 95% confidence interval [CI] 1.49, 29.81; P = .013) and depression (OR 8.26, IC 1.04, 65.62; P = .046) were significantly associated with symptomatic retear risk.

CONCLUSIONS

This study found support for the hypothesis that both depression and corticosteroid infiltration before surgery are independent risk factors for symptomatic retear after arthroscopic repair of rotator cuff.

Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: a prospective multicenter study

Background

Biologic technologies can potentially augment existing arthroscopic rotator cuff repair to improve retear rates and postoperative outcomes. The purpose of this study was to evaluate healing rates and clinical outcomes of full-thickness rotator cuff repairs augmented with a bioinductive bovine collagen implant.

Methods

In this prospective multicenter study, investigators enrolled 115 patients (mean age, 60.4 years) with full-thickness rotator cuff tears. There were 66 (57.4%) medium (1-3 cm) tears and 49 (42.6%) large (3-5 cm) tears. Eligible patients consisted of those ≥21 years of age with chronic shoulder pain lasting longer than 3 months and unresponsive to conservative therapy. Patients underwent single- or double-row repair augmented with a bioinductive bovine collagen implant. At the baseline, 3 months, and 1 year, magnetic resonance imaging was performed and patients were assessed for American Shoulder and Elbow Surgeons (ASES) Shoulder Score and Constant-Murley Score (CMS). The primary failure end point was retear, classified as any new full-thickness defect observed on magnetic resonance imaging.

Results

There were 13 retears (11.3%) at 3 months, with an additional 6 (19 total [16.5%]) found at 1 year. In large tears, double-row repair had a significantly lower rate of retear at 3 months (P = .0004) and 1 year (P = .0001) compared with single-row repair. ASES and CMS scores significantly improved between the baseline and 1 year for medium and large tears. At 1 year, the minimally clinically important difference for ASES and CMS was met by 91.7% (95% CI: 84.9-96.1) and 86.4% (95% CI: 78.2-92.4) of patients, respectively. Patients without retear and those <65 years of age had significantly better CMS scores at 1 year when compared with those with retear and those ≥65 years (P < .05). There was no statistically significant difference in outcomes based on treatment of the biceps tendon. Of 9 reported reoperations in the operative shoulder, only 2 were considered potentially related to the collagen implant.

Conclusion

Interim results from this prospective study indicate a favorable rate of retear relative to the literature and improvement in clinical function at 1 year after adjunctive treatment with the study implant augmenting standard arthroscopic repair techniques.

A case series of recurrent myotendinous rotator cuff tears repaired and augmented with dermal allograft: clinical outcomes at two years

When rotator cuff tears occur after a primary repair at the footprint, they often fail medially at the myotendinous junction, also called type II tears. These are difficult tears to treat, and little research has been published on how to address tears at the myotendinous junction and the clinical outcomes of the revised repairs. The purpose of this study is to evaluate the outcomes of type II rotator cuff tears repaired with a dermal allograft augmentation.

MATERIALS AND METHODS

We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound.

RESULTS

Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist.

DISCUSSION

Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

Biomechanical Comparison of Augmentation of Engineered Tendon-Fibrocartilage-Bone Composite With Acellular Dermal Graft Using Double Rip-Stop Technique for Canine Rotator Cuff Repair

Background

The retear rate after rotator cuff repair remains unacceptably high. Various biological engineered scaffolds have been proposed to reduce the retear rate. We have developed a double rip-stop repair with medial row knot (DRSK) technique to enhance suture-tendon strength and a novel engineered tendon-fibrocartilage-bone composite (TFBC) for rotator cuff repair.

Hypothesis

DRSK rotator cuff repair augmented with TFBC will have better biomechanical properties than that of DRSK repair with an acellular dermal graft (DG).

Study Design

Controlled laboratory study.

Methods

Fresh-frozen canine shoulders (n = 30) and knees (n = 10) were used. TFBCs were harvested from the patellar tendon-tibia complex and prepared for rotator cuff repair. The infraspinatus tendon was sharply detached from its bony attachment and randomly assigned to the (1) control group: DRSK repair alone, (2) TFBC group: DRSK repair with TFBC, and (3) DG group: DRSK repair with DG. All specimens were tested to failure, and videos were recorded. The footprint area, tendon thickness, load to create 3-mm gap formation, failure load, failure modes, and stiffness were recorded and compared. Data were recorded as mean ± SD.

Results

The mean load to create a 3-mm gap in both the control group (206.8 ± 55.7 N) and TFBC group (208.9 ± 39.1 N) was significantly higher than that in the DG group (157.7 ± 52.3 N) (P < .05 for all). The failure load of the control group (275.7 ± 75.0 N) and TFBC group (275.2 ± 52.5 N) was significantly higher compared with the DG group (201.5 ± 49.7 N) (P < .05 for both comparisons). The stiffness of the control group (26.4 ± 4.7 N/mm) was significantly higher than of the TFBC group (20.4 ± 4.4 N/mm) and the DG group (21.1 ± 4.8 N/mm) (P < .05 for both comparisons).

Conclusion

TFBC augmentation showed superior biomechanical performance to DG augmentation in rotator cuff tears repaired using the DRSK technique, while there was no difference between the TFBC and control groups.

Clinical Relevance

TFBC may help to reduce retear or gap formation after rotator cuff repair using the DRSK technique.

Revision rotator cuff repair: a systematic review

BACKGROUND

The incidence of revision rotator cuff repair (RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes.

METHODS

The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (r_s).

RESULTS

A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (r_s = 0.98). A strong positive correlation was also found between mean preoperative forward flexion and mean postoperative forward flexion (r_s = 0.83). The mean preoperative VAS pain score was strongly correlated with the mean postoperative VAS pain score (r_s = 0.88) and demonstrated a moderate negative association with the mean postoperative ASES score (r_s = -0.48). Finally, the mean preoperative ASES score was moderately correlated with the mean postoperative ASES score (r_s = 0.56).

CONCLUSIONS

The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Surgical Options for Failed Rotator Cuff Repair, except Arthroplasty: Review of Current Methods

Although the prevalence of rotator cuff tears is dependent on the size, 11% to 94% of patients experience retear or healing failure after rotator cuff repair. Treatment of patients with failed rotator cuff repair ranges widely, from conservative treatment to arthroplasty. This review article attempts to summarize the most recent and relevant surgical options for failed rotator cuff repair patients, and the outcomes of each treatment, except arthroplasty.

Arthroscopic rotator cuff repair: magnetic resonance arthrogram assessment of tendon healing

BACKGROUND

Many poor outcomes after arthroscopic rotator cuff (RC) repair relate to failure of tendon healing. The purposes of this study were to provide a better understanding of the magnetic resonance arthrography (MRA) characteristics of the RC tendon repair site after arthroscopic RC repair and to examine how these findings influence patient-reported outcome measures (PROMs) and the presence of persistent symptoms.

METHODS

We reviewed 48 shoulders (13 female and 35 male patients; average age, 53.8 years) at a minimum of 6 months (average, 11.4 months) after arthroscopic RC repair (average tear size, 2.2 cm). All patients completed PROMs and underwent MRA assessment. Detailed analysis of the RC repair site was undertaken, with findings correlated with clinical outcomes and PROMs.

RESULTS

The average preoperative American Shoulder and Elbow Surgeons (ASES) score of 39.5 improved to 92.8 (P < .001). All but 6 patients (87.5%) had increased signal intensity of the involved tendon, with interstitial splits and/or delamination in 65.6%. These changes had no effect on PROMs or patient satisfaction. Significant partial-thickness tears (>50%) were observed in 7 patients (14.6%), with no effect on outcomes (average ASES score of 95.2 and satisfaction score of 9). There were 2 recurrent full-thickness tears (4.2%), and 4 patients (8.3%) had a failure in continuity. The average ASES score in these 6 cases of failure was 76 (P < .001).

CONCLUSIONS

Structural abnormalities on MRA are common after RC repair but do not always result in clinical failure. However, our results suggest that an ASES score of less than 80 may be useful when considering postoperative imaging, especially in a patient with ongoing pain more than 6 months after surgery.

Rotator cuff tendon tissue cut-through comparison between 2 high-tensile strength sutures

BACKGROUND

High-tensile strength sutures are known to cut through tendon tissue when used for rotator cuff and other tendon repairs, resulting in mechanical failure. The purpose of this study was to test a new suture and compare it with an established suture in a controlled laboratory setting.

METHODS

Two sutures, Dynacord and FiberWire, both USP size No. 2, were passed through fresh infraspinatus tendons from 7 matched pairs of ovine shoulders (14 shoulders). Samples underwent cyclic testing for 1000 cycles, and the amount of cheese-wire tissue damage (tendon cut-through) was recorded. A clinical failure was defined as greater than 5 mm of tissue cut-through.

RESULTS

The mean amount of tendon cut-through was 3.72 ± 1.14 mm in the FiberWire specimens and 2.69 ± 1.02 mm in the Dynacord group. The difference was statistically significant (P = .012). In the matched-pair analysis, more tendon cut-through was noted with FiberWire in 13 specimens whereas a greater amount was found in only 1 Dynacord specimen. The FiberWire specimens showed 2 instances of tissue tendon cut-through exceeding 5 mm, defined as a clinical failure.

CONCLUSIONS

In this cadaveric ovine rotator cuff tendon model, we found less tendon cut-through from Dynacord suture compared with FiberWire. In addition, 2 of the FiberWire specimens showed complete tendon cut-through. Future studies focusing on patient-reported outcomes and healing rates with different types of suture materials are needed.

Tendon contains more stem cells than bone at the rotator cuff repair site

BACKGROUND

The rotator cuff (RC) repair failure rate is high. Tendon and bone represent sources of mesenchymal stem cells (MSCs), but the number of MSCs from each has not been compared. Bone channeling may increase bone-derived MSC numbers participating in enthesis re-formation at the "footprint" repair site. The effect of preoperative channeling on increasing bone MSC numbers has never been reported. We asked (1) whether bone contains more MSCs than tendon at the time of arthroscopic repair and (2) whether bone preoperative channeling at the RC repair site increases the number of bone-derived MSCs at the time of surgery.

METHODS

In 23 participants undergoing arthroscopic RC repair, bone was sampled from the footprint and tendon was sampled from the distal supraspinatus. We randomized participants to the channeling or no-channeling group 5 to 7 days before surgery. We enumerated MSCs from both tissues using the colony-forming unit-fibroblast (CFU-F) assay (10 per group). We identified MSC identity using flow cytometry and MSC tri-differentiation capacity (n = 3).

RESULTS

Tendon CFU-F per gram exceeded bone CFU-F per gram for both groups (479 ± 173 CFU-F/g vs. 162 ± 54 CFU-F/g for channeling [P = .036] and 1334 ± 393 CFU-F/g vs. 284 ± 88 CFU-F/g for no channeling [P = .009]). Ninety-nine percent of cultured cells satisfied the MSC definition criteria.

CONCLUSIONS

The distal supraspinatus tendon contained more MSCs per gram than the humeral footprint. Tendon may represent an important and overlooked MSC source for postoperative enthesis re-formation. Further studies are needed to evaluate the repair role of tendon MSCs and to recommend bone channeling in RC repair.

Is there a relation between rotator cuff injury and core stability?

BACKGROUND

Strong core stabilization not only minimizes the load on the vertebral column, but also improves strength and endurance of peripheral joints, and enables the energy transfer to distal segments. Despite the current interest surrounding core stability, none of the studies investigated the effect of core stability on the formation of rotator cuff tear or healing after repair.

OBJECTIVE

To determine the relationship between core stability and upper extremity functional performance in patients who underwent rotator cuff repair surgery and to compare those with healthy subjects of similar age.

METHODS

Patients who underwent rotator cuff repair (RC repair group, n= 58 patient) and healthy subjects of the similar age group (control group, n= 114) were included in the study. The mean age was 55.03 ± 9.84 years in the RC repair group and 52.71 ± 6.31 years in the control group. The RC repair group took standardized rehabilitation. The rehabilitation program did not include core strength and stability exercise. Core endurance was assessed with Flexor Endurance, Prone Bridge and Supine bridge test. Disabilities of the Arm, Shoulder and Hand (DASH), Short Form-36 (SF-36) and the Close Kinetic Chain Upper Extremity Stability (CKCUES) test were used to evaluate the upper extremity functional performance.

RESULTS

The core endurance (prone and supine bridge test) of the control group was statistically significantly better than the RC repair group (p⩽ 0.005). The DASH-T, SF-36 and CKCUES scores of the control group were also statistically significantly better.

CONCLUSION

The neuromuscular system should be considered as a whole, and addition of the core stabilization exercises to an effective rehabilitation program after RC repair surgery may be beneficial.

Failed rotator cuff repair

After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90̊ of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.

Rotator cuff failure after surgery: an all-arthroscopic transosseous approach

BACKGROUND

Tear recurrence is considered the main complication of a rotator cuff repair. The best arthroscopic technique has not yet been established. The aim of the present study was to evaluate, from a clinical and a radiological standpoint, the all-arthroscopic transosseous rotator cuff repair with cortical lateral augmentation, performed in the setting of a revision surgery.

MATERIALS AND METHODS

Eleven consecutive cases were prospectively followed up for a minimum of 12 month after a rotator cuff repair with a novel all-arthroscopic transosseous rotator cuff repair. VAS and UCLA score and patients' satisfaction with the outcomes were analyzed, along with MRI evolution of the repair. All patients underwent a standardized surgery and postoperative rehabilitation program.

RESULTS

All patients showed a significant improvement in pain reduction and functional score. Satisfaction was achieved in 10 out of 11 cases, and only 1 case showed a minor discontinuous tendon signal on the 12-month MRI assessment. No complications were noted.

CONCLUSIONS

Our results favor the use of the all-arthroscopic transosseous rotator cuff revision surgery with the 2MC configuration (double MC means the initials of the authors-MM and CC, who have originally described it). It appears to be safe and effective, providing good clinical, functional, and radiological results, with a very high patient satisfaction.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Recurrent tears of the rotator cuff: Effect of repair technique and management options

Retears of the rotator cuff, following operative repair, is not an uncommon event. Various factors have been shown to influence recurrence including the technique of repair. Multiple techniques have been performed with varying results and complications. The repair technique significantly affects the rate and pattern of retears. Although risk of retears with double row and suture bridge techniques is relatively low, medial cuff failure is a potential complication which poses significant challenges when revision repair is undertaken. Modifications in surgical techniques in, both, double row and suture bridge repairs can help decrease the risk of medial cuff failure. Thorough analysis of retear rates and patterns reported, and their relation with the repair technique, provides new insights about the pathogenesis of rotator cuff retears, their future prevention and appropriate management.

Advanced Rotator Cuff Tear Score (ARoCuS): a multi-scaled tool for the classification and description of rotator cuff tears

BACKGROUND

To introduce a (semi-)quantitative surgical score for the classification of rotator cuff tears.

MATERIAL AND METHODS

A total of 146 consecutive patients underwent rotator cuff repair and were assessed using the previously defined Advanced Rotator Cuff Tear Score (ARoCuS) criteria: muscle tendon, size, tissue quality, pattern as well as mobilization of the tear. The data set was split into a training (125 patients) and a testing set (21 patients). The training data set fitted a nonlinear predictive model of the tear score based on the ARoCuS criteria, while the testing data served as control. Based on the scoring results, rotator cuff tears were assigned to one of four categories (ΔV I-IV) and received a stage-adapted treatment. For statistical analysis, mean values ± standard deviation, interclass correlation coefficients (ICC) and kappa values were calculated.

RESULTS

Overall, 32 patients were classified as ΔV I, 68 as ΔV II and 37 as ΔV III. Nine patients showed ΔV IV tears. Patients of all ΔV groups improved significantly their Constant scores (p < 0.001) and profited from significant pain reduction after surgery (p < 0.001). To date, ten patients have undergone revision surgery with five of them primarily classified as ΔV IV. Kappa values for the interobserver reliability ranged between 0.69 and 0.95. ICC scores for the ΔV category were 0.95 for interobserver reliability.

CONCLUSIONS

The ARoCuS facilitates intra-operative decision-making and enables surgeons and researches to document rotator cuff tears in a standardized and reproducible manner.

Effects of pulsed electromagnetic field therapy at different frequencies and durations on rotator cuff tendon-to-bone healing in a rat model

BACKGROUND

Rotator cuff tears affect millions of individuals each year, often requiring surgical intervention. However, repair failure remains common. We have previously shown that pulsed electromagnetic field (PEMF) therapy improved tendon-to-bone healing in a rat rotator cuff model. The purpose of this study was to determine the influence of both PEMF frequency and exposure time on rotator cuff healing.

METHODS

Two hundred ten Sprague-Dawley rats underwent acute bilateral supraspinatus injury and repair followed by either Physio-Stim PEMF or high-frequency PEMF therapy for 1, 3, or 6 hours daily. Control animals did not receive PEMF therapy. Mechanical and histologic properties were assessed at 4, 8, and 16 weeks.

RESULTS

Improvements in different mechanical properties at various endpoints were identified for all treatment modalities when compared with untreated animals, regardless of PEMF frequency or duration. Of note, 1 hour of Physio-Stim treatment showed significant improvements in tendon mechanical properties across all time points, including increases in both modulus and stiffness as early as 4 weeks. Collagen organization improved for several of the treatment groups compared with controls. In addition, improvements in type I collagen and fibronectin expression were identified with PEMF treatment. An important finding was that no adverse effects were identified in any mechanical or histologic property.

CONCLUSIONS

Overall, our results suggest that PEMF therapy has a positive effect on rat rotator cuff healing for each electromagnetic fundamental pulse frequency and treatment duration tested in this study.

Clinical outcome and prognostic factors of revision arthroscopic rotator cuff tear repair

PURPOSE

The aim of this study was to evaluate the clinical outcome of arthroscopic rotator cuff revision surgery in a cohort of patients and to identify prognostic factors for this procedure.

METHODS

Fifty-one consecutive patients undergoing revision arthroscopic rotator cuff repair were prospectively followed over a minimum period of one year. Radiologic findings and clinical data regarding primary and revision surgery were collected. Clinical evaluation was performed pre- and post-operatively by means of Constant Score and Simple Shoulder Test.

RESULTS

Median age at the time of revision surgery was 60 years (range 36-77 years). Median follow-up was 25 months (range 12-58 months). There were 17 men (33.3%) and 34 women (66.7%). The majority of the tears affected the supraspinatus tendon alone (51%) or both the supra- and infraspinatus tendons (35.3%). Significant improvements were seen in terms of active forward elevation, active external rotation, pain, Simple Shoulder Test score, Constant Score, and post-operative satisfaction-age, gender, and time to revision surgery did not show significant predictive value. A smaller tear size and pre-operative elevation greater than 90° were demonstrated to be independent prognostic factors for better outcome. However, the mean increase in Constant Score was not related to the size of the tear, range of motion, or age.

CONCLUSION

The results of this study indicate that arthroscopic revision rotator cuff repair results in reliable improvement in shoulder function, pain, and satisfaction. Pre-operative active range of motion and tear size seem to determine final outcome. A similar increase in mean Constant Score can be achieved even in large tears in patients aged over 65 years.

LEVEL OF EVIDENCE

IV.