Long-term Results of Arthroscopic Rotator Cuff Repair: Initial Tear Size Matters: A Prospective Study on Clinical and Radiological Results at a Minimum Follow-up of 10 Years

Effect of neuromuscular control on the shoulder function of patients with healed rotator cuff and those with retear after arthroscopic rotator cuff repair

PURPOSE

To compare functional outcomes such as muscle strength, neuromuscular control and patient-reported outcomes (PROs) between patients with healed rotator cuffs and those with retears after arthroscopic rotator cuff repair (RCR).

METHODS

One hundred and nine patients who underwent arthroscopic RCR were included (85 in the healed group, 24 in the retear group). Shoulder muscle strength and neuromuscular control index (acceleration time [AT]) were evaluated using an isokinetic device. PROs were assessed using the pain visual analogue scale (VAS), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores. Continuous variables were compared using independent t tests. Multiple linear regression analysis was used to identify the influence of the predictor variables on the dependent variable.

RESULTS

The muscle strength and ATs for external rotators (ERs), internal rotators (IRs) and forward flexors as well as PROs including VAS, SST and ASES scores, were not significantly different between the two groups pre- and postoperatively (n.s.). Multiple linear regression analysis revealed that postoperative ATs for the IRs (p = 0.006) and ERs (p = 0.028) in the operated shoulders were closely associated with the postoperative UCLA score.

CONCLUSIONS

Compared with the healed group after arthroscopic RCR, the retear group had no clinically relevant differences in muscle strength, ATs and PROs, including VAS, SST, ASES and UCLA scores. However, postoperative ATs for IRs and ERs in the operated shoulders were a significant predictor of postoperative UCLA scores. Therefore, clinicians and therapists need to be aware of the importance of neuromuscular control in patients who have undergone arthroscopic RCR and prioritize therapeutic exercises to restore neuromuscular control.

LEVEL OF EVIDENCE

Level III.

Effects of Biceps Rerouting on In Vivo Glenohumeral Kinematics in the Treatment of Large-to-Massive Rotator Cuff Tears

BACKGROUND

Arthroscopic repair with the biceps rerouting (BR) technique has been determined to lead to promising clinical and biomechanical outcomes for treating large-to-massive rotator cuff tears (LMRCTs). However, the in vivo effects of BR on glenohumeral kinematics during functional shoulder movements have not been fully elucidated.

PURPOSE

To investigate whether BR provides a better restoration of shoulder kinematics compared with conventional rotator cuff repair (RCR).

STUDY DESIGN

Controlled laboratory study.

METHODS

Patients who underwent either repair with the BR technique (BR group) or RCR alone (RCR group) for treating LMRCTs between January 2021 and May 2022 were enrolled. They underwent a 1-year postoperative kinematic evaluation of bilateral shoulders by performing scapular-plane abduction with a dual fluoroscopic imaging system. Glenohumeral translation in the superior-inferior (S-I) and anterior-posterior (A-P) directions was assessed in shoulder abduction at 10° increments. Moreover, the mean, maximum, minimum, and range of glenohumeral translation were calculated throughout the entire movement.

RESULTS

A total of 9 patients were enrolled in each group for final analysis, and baseline characteristics were comparable between the groups. In the RCR group, compared with contralateral shoulders, the operative shoulders showed increased superior humeral head translation during lower abduction angles of 30° to 50° (all P≤ .004), with a greater maximum (P = .014) and a larger range (P = .002) for S-I translation throughout the entire movement. In the BR group, no significant differences between operative and contralateral shoulders were detected in any kinematic variables for S-I translation (all P≥ .132); however, the operative shoulders exhibited a larger maximum (P = .031), a smaller minimum (P = .008), and a larger range (P < .001) for A-P translation throughout the entire movement compared with the contralateral shoulders.

CONCLUSION

BR successfully reduced residual superior humeral head translation compared with conventional RCR and restored normal S-I glenohumeral kinematics in the treatment of LMRCTs. However, A-P glenohumeral kinematics was not fully restored after BR, and its effect on long-term clinical outcomes requires further investigation.

CLINICAL RELEVANCE

BR can be a promising technique to treat LMRCTs. However, its potential adverse effects on A-P glenohumeral kinematics should not be ignored, requiring further clinical evidence to determine long-term outcomes.

Determinants of Patient-Rated Benefit 6 Months Post Arthroscopic Rotator Cuff Repair: An Analysis of 2010 Patients

INTRODUCTION

From the surgeon's perspective, a successful rotator cuff is one that remains intact. However, it is undetermined which factors contribute to an improved shoulder from the patient's perspective. The aim of this study was to determine the variables that predicted greater patient-rated benefit from presurgery to 6 months postarthroscopic rotator cuff repair.

METHODS

Multiple linear regression analysis was conducted on prospectively collected data of 2010 consecutive patients who underwent arthroscopic rotator cuff repair by a single surgeon to determine the predictors of greater patient-rated benefit. Patient-rated shoulder ranking was graded on a five-point Likert scale in response to "How is your shoulder overall?" preoperatively and at 6 months postoperatively. The patient-rated benefit was the difference in rankings between these time points.

RESULTS

Six months following rotator cuff repair, a self-reported benefit was observed in 84% of patients. Patients who rated their shoulder as poor preoperatively reported the greatest benefit (t = 22, P < 0.001). Other preoperative determinants of greater patient-rated benefit were lower patient-rated shoulder stiffness (t = 5, P < 0.001), an injury that was not related to work (t = 4, P < 0.001), stronger internal rotation strength (t = 4, P < 0.002), a more strenuous line of work preinjury (t = 3, P = 0.007), female sex (t = 2, P = 0.019), having a larger tear area (t = 2, P = 0.020), and weaker abduction strength (t = 2, P = 0.046).

CONCLUSIONS

Patients who were most likely to perceive a benefit from rotator cuff repair at 6 months postoperation were those who preoperatively rated their shoulder poorly, had a less stiff shoulder, an injury that was not related to work, stronger internal rotation, more strenuous line of work preinjury, were female, had larger tear area, and weaker abduction strength.

Editorial Commentary: Partial Rotator Cuff Repair and Deltoid Retraining Shows Positive Outcomes for Large to Massive Rotator Cuff Tear

In terms of rotator cuff repair, there is a goal for complete repair and healing, as rotator cuff integrity correlates with clinical and functional results. Retear has been shown to have a significant influence on progression toward osteoarthritis, and patients with an intact supraspinatus show superior abduction and flexion strength. However, in cases where complete repair may not be possible and/or cost limitations may prohibit augmentation, partial repair can provide a respectable outcome. Furthermore, regardless of healing status, partial repair may provide satisfactory relief for patients to still achieve the minimally clinically important difference threshold based on patient-reported outcomes. As introduced by Burkhart, repairing the tear margin and the transverse force couple (subscapularis and/or infraspinatus tears, if present) establishes a "suspension bridge" mechanism for force transmission, effectively creating a "functional cuff tear" by minimizing the defect size and allowing for a balanced shoulder joint with a stable fulcrum. A deltoid retraining program following a partial rotator cuff repair can restore range of motion and strength to the shoulder as alternative muscle activation (latissimus dorsi and teres major) in unison with the deltoid can compensate for the partial tear to limit superior migration of the humeral head and generate a stable glenohumeral fulcrum in cases of large to massive rotator cuff tears. Ultimately, as the rates of shoulder arthroplasty increase in patients under 50 years of age, in terms of societal burden, surgeons should consider joint-sparing techniques such as partial repair.

Arthroscopic Transosseous-Equivalent Double-Row Rotator Cuff Repair Augmentation With Interpositional Demineralized Bone Fiber Implant

Failure of rotator cuff repairs contributes to decreased patient satisfaction and quality of life. Biologic enhancement of repairs represents a novel augmentation strategy attempting to reproduce native healing while concomitantly potentially decreasing the existing high failure rates associated with rotator cuff repairs. Scaffolds placed on top of the rotator cuff have been widely studied, yet no recreation of the native enthesis is achieved via this augmentation strategy. Several strategies involving placement of demineralized bone matrix scaffolds on an inlay configuration (between bone and tendon) have been reported demonstrating enhanced recreation of the native bone-tendon unit. This Technical Note describes the surgical technique of inlay demineralized bone fiber scaffold augmentation of rotator cuff repairs to enhance biological healing in aims of recreating the native enthesis.

Rotator Cuff Tears and Mid-Term Shoulder Outcomes after Intramedullary Nail Fixation for Humeral Shaft Fracture: A Minimum Five-year Follow-up Study

Introduction

Antegrade intramedullary nail fixation for humeral shaft fractures yields satisfactory union rates. However, one of the related concerns is damage to the rotator cuff during nail insertion, which may affect long-term outcomes. The effect of a rotator cuff lesion on mid- and long-term shoulder outcomes remains unknown. This study aimed to investigate the incidence of rotator cuff tears 5 years or more after intramedullary nailing for humeral shaft fractures and to determine the impact of post-operative rotator cuff tears on mid-term outcomes.

Material and Methods

We retrospectively identified 27 patients who underwent antegrade intramedullary nail fixation for traumatic humeral shaft fractures and received follow-up for at least 5 years post-operatively. The patients were divided into two groups: those without tears and those with partial or complete tears, diagnosed using ultrasonography. We compared the functional and radiological shoulder outcomes between the two groups.

Results

Of the 27 patients, 10 had partial or complete supraspinatus tears with a mean follow-up of 7.5 years postoperatively. The incidence of acromial spurs was significantly higher in patients with partial or complete tears than in those without tears (P<0.001). There were no significant differences in the age and sex-adjusted Constant score, or the American Shoulder and Elbow Surgeon score between the two groups.

Conclusion

Our results revealed that 37% of patients developed partial or complete supraspinatus tendon tears in the mid-term. Post-operative rotator cuff tears were significantly associated with the formation of acromial spurs; however, they had no significant effect on mid-term shoulder functional outcomes.

Recent trends of stem cell therapies in the management of orthopedic surgical challenges

Emerged health-related problems especially with increasing population and with the wider occurrence of these issues have always put the utmost concern and led medicine to outgrow its usual mode of treatment, to achieve better outcomes. Orthopedic interventions are one of the most concerning hitches, requiring advancement in several issues, that show complications with conventional approaches. Advanced studies have been undertaken to address the issue, among which stem cell therapy emerged as a better area of growth. The capacity of the stem cells to renovate themselves and adapt into different cell types made it possible to implement its use as a regenerative slant. Harvesting the stem cells, particularly mesenchymal stem cells (MSCs) is easier and can be further grown in vitro . In this review, we have discussed orthopedic-related issues including bone defects and fractures, nonunions, ligament and tendon injuries, degenerative changes, and associated conditions, which require further approaches to execute better outcomes, and the advanced strategies that can be tagged along with various ways of application of MSCs. It aims to objectify the idea of stem cells, with a major focus on the application of MSCs from different sources in various orthopedic interventions. It also discusses the limitations, and future scopes for further approaches in the field of regenerative medicine. The involvement of MSCs may transition the procedures in orthopedic interventions from predominantly surgical substitution and reconstruction to bio-regeneration and prevention. Nevertheless, additional improvements and evaluations are required to explore the effectiveness and safety of mesenchymal stem cell treatment in orthopedic regenerative medicine.

Inlay Scaffold Augmentation of Rotator Cuff Repairs Enhances Histologic Resemblance to Native Enthesis in Animal Studies: A Systematic Review

PURPOSE

To investigate the outcomes of inlay positioned scaffolds for rotator cuff healing and regeneration of the native enthesis after augmentation of rotator cuff tendon repairs in preclinical studies.

METHODS

A literature search was performed using the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Preclinical studies reporting on outcomes after inlay tendon augmentation in rotator cuff repair were included. Preclinical study quality was assessed using an adapted version of the Gold Standard Publication Checklist for animal studies. The level of evidence was defined based on the inclusion of clinical analyses (grade A), biomechanical analyses (grade B), biochemical analyses (grade C), semiquantitative analyses (grade D), and qualitative histologic analyses (grade E).

RESULTS

Thirteen preclinical studies met the inclusion criteria. Quality assessment scores ranged from 4 to 8 points, and level-of-evidence grades ranged from B to E. Sheep/ewes were the main animal rotator cuff tear model used (n = 7). Demineralized bone matrix or demineralized cortical bone was the most commonly investigated scaffold (n = 6). Most of the preclinical evidence (n = 10) showed qualitative or quantitative differences regarding histologic, biomechanical, and biochemical outcomes in favor of interpositional scaffold augmentation of cuff repairs in comparison to controls.

CONCLUSIONS

Inlay scaffold positioning in preclinical studies has been shown to enhance the healing biology of the enthesis while providing histologic similarities to its native 4-zone configuration.

CLINICAL RELEVANCE

Although onlay positioned grafts and scaffolds have shown mixed results in preclinical and early clinical studies, inlay scaffolds may provide enhanced healing and structural support in comparison owing to the ability to integrate with the bone-tendon interface.

Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear After Arthroscopic Rotator Cuff Repair: A Systematic Review

PURPOSE

To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Of the initial 3,158 studies, a total of 31 met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting of clinical outcomes, (4) publication within the past 5 years, and (5) studies investigating preoperative risk factors for retear. After full-text review, 18 risk factors were analyzed.

RESULTS

The most consistently significant risk factors were acromiohumeral distance (80%), critical shoulder angle (67%), tear size (63%), anterior-posterior dimension (60%), fatty infiltration (FI) (58%), and retraction size (56%). FI was analyzed using different methods among studies, with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% of studies finding significant results and 63% of all studies performing quantitative analysis. Risk factors consistently found to be nonsignificant included age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index.

CONCLUSIONS

Tear size, FI, and retraction size were found to be significant risk factors in most of the included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. Risk factors that require further investigation include critical shoulder angle, acromiohumeral distance, and anterior-posterior tear dimension.

LEVEL OF EVIDENCE

Level III, systematic review of Level III-IV studies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

Differences in Clinical Outcomes Between Patients With Retear After Supraspinatus Tendon Repair and Those With Intact Repair at 5-Year Follow-up

BACKGROUND

It is well known that rotator cuff repair is associated with an overall retear rate of 21% to 26%. However, a cuff retear may not necessarily be associated with poor clinical outcomes.

HYPOTHESIS

There would be no difference in clinical outcomes between patients with a cuff retear and those with an intact repair at a midterm follow-up of 5 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was conducted involving patients who received arthroscopic complete repair of the supraspinatus tendon between January 2009 and December 2017. Patients who did not have a postoperative magnetic resonance imaging (MRI) scan or who had a follow-up of <5 years were excluded. Clinical outcomes, including the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion (FF) of the involved shoulder were assessed at the 2-year and 5-year follow-up points.

RESULTS

The study group included 105 patients with a mean follow-up of 85 months. MRI scans were performed at a mean of 20 months. Fourteen full-thickness cuff retears and 91 intact repairs were identified using postoperative MRI scans. Significant improvement in VAS score, ASES score, and FF were found between the preoperative assessment and the 2 designated follow-up points (2 years and 5 years) in both the cuff retear and the intact repair groups (P < .001). The VAS and ASES scores at the 2-year follow-up for the intact repair group were 1.8 ± 2.0 and 80.7 ± 18.1, respectively. The corresponding values for the retear group were 2.3 ± 2.2 and 71.9 ± 19.5, respectively. No significant difference was found between the 2 groups in the VAS and ASES scores at the 2-year follow-up. However, patients with an intact repair had a better VAS score (1.4 ± 1.8; P = .049) and ASES score (81.7 ± 17; P = .019) than those with a cuff retear at the 5-year assessment (3.0 ± 2.8 and 67.1 ± 22.9, respectively). In the intact repair group, 91% of patients achieved the minimal clinically important difference for the 5-year VAS score, compared with 54% in the cuff retear group (P < .001). The corresponding values for the 5-year ASES score were 80% and 54%, respectively (P = .044). FF measurements at the 5-year follow-up in patients with intact repair and those with a cuff retear were 161°± 23° and 144°± 37°, respectively (P = .059). Continuous improvement in VAS score and FF between the 2-year and 5-year follow-up was observed in the intact repair group (P = .005 and P = .04, respectively).

CONCLUSION

The patients with an intact repair had better VAS and ASES scores compared with those who had a cuff retear at a midterm follow-up of 5 years. Between the 2-year and the 5-year follow-up, some further improvement was observed in the VAS score and FF in the intact repair group.

Rotator cuff tears

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

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022

BACKGROUND

Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies.

RESULTS

A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11).

CONCLUSIONS

Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.

Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK)

PURPOSE/INTRODUCTION

Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair.

METHODS

In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively.

ETHICS AND DISSEMINATION

This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04618484.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy

Shoulder pain is a common musculoskeletal complaint, and rotator cuff (RC) pathologies are one of the main causes. The RC undergoes various tendinopathic and avascular changes during the aging process. Other degenerative changes affecting its healing potential make it an appealing target for biological agents. Platelet-rich plasma (PRP) has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators, and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle, ligaments, and tendinous cells. This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence. Due to the different characteristics and conflicting outcomes, clinicians should use PRP with moderate expectations until more consistent evidence is available. However, it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing. Its autologous origin makes it a safe treatment, and its characteristics make it a promising option for treating RC tendinopathy, but the efficacy has yet to be established.

Mechanics and differential healing outcomes of small and large defect injuries of the tendon-bone attachment in the rat rotator cuff

INTRODUCTION

Rotator cuff tear size affects clinical outcomes following rotator cuff repair and is correlated with the risk of recurrent tendon defects. This study aimed to understand if and how the initial defect size influences the structural and mechanical outcomes of the injured rotator cuff attachment in vivo.

METHODS

Full-thickness punch injuries of the infraspinatus tendon-bone attachment in Long Evans rats were created to compare differences in healing outcomes between small and large defects. Biomechanical properties, gross morphology, bone remodeling, and cell and tissue morphology were assessed at both 3- and 8-weeks of healing.

RESULTS

At the time of injury (no healing), large defects had decreased mechanical properties compared to small defects, and both defect sizes had decreased mechanical properties compared to intact attachments. However, the mechanical properties of the two defect groups were not significantly different from each other after 8-weeks of healing and significantly improved compared to no healing but failed to return to intact levels. Local bone volume at the defect site was higher in large compared to small defects on average and increased from 3- to 8-weeks. In contrast, bone quality decreased from 3- to 8-weeks of healing and these changes were not dependent on defect size. Qualitatively, large defects had increased collagen disorganization and neovascularization compared to small defects.

DISCUSSION

In this study, we showed that both large and small defects did not regenerate the mechanical and structural integrity of the intact rat rotator cuff attachment following healing in vivo after 8 weeks of healing.

Social determinants of health influence clinical outcomes of patients undergoing rotator cuff repair: a systematic review

BACKGROUND

Social determinants of health (SDOH) are the collection of environmental, institutional, and intrinsic conditions that may bias access to, and utilization of, health care across an individual's lifetime. The effects of SDOH are associated with disparities in patient-reported outcomes after hip and knee arthroplasty, but its impact on rotator cuff repair (RCR) is poorly understood. This study aimed to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following RCR.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and guidelines outlined by the Cochrane Collaboration. A search of PubMed, the Cochrane Library, and Embase from inception until March 2022 was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following RCR. The search term was created with reference to the PROGRESS-Plus framework. Methodological quality of included primary studies was appraised using the Newcastle-Ottawa Scale (NOS) for nonrandomized studies, and the Cochrane Risk of Bias Tool for randomized studies.

RESULTS

Thirty-two studies (level I-IV evidence) from 18 journals across 7 countries, published between 1999 and 2022, met inclusion criteria, including 102,372 patients, 669 physical therapy (PT) clinics, and 71 orthopedic surgery practices. Multivariate analysis revealed female gender, labor-intensive occupation and worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial or ethnic minority status, low-income place of residence and low-volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to health care and/or more severe disease state on presentation. Black race patients were found to have significantly worse postoperative clinical and patient-reported outcomes and experienced more pain following RCR. Furthermore, Black and Hispanic patients were more likely to present to low-volume surgeons and low-volume facilities. A lower education level was shown to be an independent predictor of poor surgical and patient-reported outcomes as well as increased pain and worse patient satisfaction. Patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes CONCLUSIONS: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.

Arthroscopic Rotator Cuff Repair Results in Improved Clinical Outcomes and Low Revision Rates at 10-Year Follow-Up: A Systematic Review

PURPOSE

To study the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following arthroscopic rotator cuff repair (ARCR) at a minimum of 10-years follow-up.

METHODS

Two independent reviewers performed a literature search of PubMed, Embase, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only studies reporting on outcomes of ARCR with a minimum 10-year follow-up were considered for inclusion. Patient demographics, satisfaction, and clinical, radiologic, and surgical outcomes were evaluated.

RESULTS

Our search found 9 studies including 455 shoulders in 448 patients (51.6% male patients), with age at time of surgery ranging from 45 to 90 years met our inclusion criteria. Overall follow-up ranged from 10 to 18 years. At final follow-up, the ranges of American Shoulder & Elbow Surgeons, age- and sex-adjusted Constant-Morley, and University of California Los Angeles scores were reported in 5, 6, and 3 studies, respectively, as 79.4 to 93.2, 73.2 to 94, and 26.5 to 33, respectively. Of the included studies, satisfaction rates varied in 6 studies from 85.7% to 100% in the long-term. Additionally, the overall radiologic retear rate ranged from 9.5% to 63.2%. The overall surgical revision rates ranged in 6 studies from 3.8% to 15.4%, with from 0% to 6.7% requiring revision ARCR and from 1.0% to 3.6% requiring revision subacromial decompression in 6 and 2 studies, respectively, at minimum 10-years' follow-up.

CONCLUSIONS

In this study, we found that ARCR results in high rates of patient satisfaction, satisfactory clinical outcomes with respect to patient-reported functional outcomes and range of motion, and low revision rates at minimum 10-years' follow-up. However, an overall 30% retear rate was observed in asymptomatic patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Black Race, Hispanic Ethnicity, and Medicaid Insurance Are Associated With Lower Rates of Rotator Cuff Repair in New York State

PURPOSE

To determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair.

METHODS

A retrospective review of the Statewide Planning and Research Cooperative System Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months of follow-up. Bivariate analysis using χ² tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair.

RESULTS

A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (adjusted odds ratio [aOR] 0.78; 95% confidence interval [CI] 0.69-0.87; P < .001), Hispanic/Latino ethnicity (aOR 0.91; 95% CI 0.85-0.97); P = .004), and Medicaid (aOR 0.75; 95% CI 0.70-0.80; P < .001), or other government insurance (aOR 0.82; 95% CI 0.78-0.86; P < .001) were independently associated with lower rates of rotator cuff repair. Male sex (aOR 1.18; 95% CI 1.14-1.22; P < .001), Asian race (aOR 1.27; 95% CI 1.00-1.62; P = .048), workers' compensation insurance (aOR 1.12; 95% CI 1.07-1.18; P < .001), and greater home ZIP code income quartile (aOR 1.19; 95% CI 1.09-1.30; P < .001) were independently associated with greater rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology.

CONCLUSIONS

In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017 to 2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home ZIP code income quartile.

CLINICAL RELEVANCE

This study reports disparities in the use of rotator cuff repair for individuals with rotator cuff pathology.

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

Background

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

Methods

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

Results

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

Discussion and Conclusion

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

Risk factors for the development of degenerative changes among patients undergoing rotator cuff repair: A systematic review

BACKGROUND

Osteoarthritis (OA) of the glenohumeral joint results in significant pain and functional limitations. It is unclear which risk factors increase the risk of developing glenohumeral OA amongst Rotator Cuff Repair (RCR) patients. The purpose of this systematic review was to examine the risk factors which may contribute to the development of osteoarthritic changes post-operatively.

METHODS

MEDLINE, Embase, and PubMed databases were searched to identify studies reporting on demographics of patients who develop OA following RCR.

RESULTS

Seventeen articles were identified investigating a total of 1292 patients. The overall quality of evidence was low. Pooled assessment of OA incidence following RCR at minimum 5 years follow-up found 26% of patients developed OA. Patients requiring revision surgery following retears developed OA at a rate of 29%. Surgical technique and patient demographics may also contribute to degenerative changes.

DISCUSSION

This review found correlations between the aforementioned risk factors and glenohumeral joint degeneration at long-term follow-up after RCR. These findings suggest that future long-term studies should aim to identify prognostic factors that may place a patient at increased risk of developing OA. Such data can be used to counsel patients with respect to long-term outcomes following surgical intervention.

Retear After Arthroscopic Rotator Cuff Repair Results in Functional Outcome Deterioration Over Time

PURPOSE

This study aimed to evaluate the effect of retear on long-term functional outcomes and glenohumeral joint osteoarthritis (OA) progression after arthroscopic rotator cuff repair (ASRCR).

METHODS

We retrospectively reviewed 201 patients who underwent ASRCR and were followed up for at least 5 years. Rotator cuff tendon structural integrity was evaluated using magnetic resonance imaging and/or ultrasonography. Pain, active range of motion, and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) were evaluated for functional outcomes. To evaluate deterioration over time, the minimal clinically important difference value of pain and ASES were used.

RESULTS

The mean follow-up period was 8.6 ± 2.2 years and overall retear rate was 21.4%. OA progression was strongly associated with retear (odds ratio 5.1, P < .001). Functional outcomes at the 2-year postoperative follow-up significantly improved compared to the preoperative status (all P < .017), regardless of retear. However, the retear group presented worse functional outcomes at the final follow-up (pain: 3.1 ± 2.6; ASES: 72.0 ± 17.4) than at the 2-year postoperative follow-up (pain: 1.2 ± 2.3, P = .014; ASES: 91.1 ± 9.9, P= .015) than the healed tendon group at final follow-up (pain: .6 ± 1.7; P < .001; ASES 95.5 ± 11.8; P < .001). The time for deterioration of pain (healed group vs. retear group: 5.5 ± 0.5 vs. 10.6 ± 0.4 years; P < .001) and ASES (healed group vs. retear group: 7.5 ± 0.5 vs. 12.8 ± 0.2 years; P < .001) decreased in the retear group.

CONCLUSIONS

The functional status improved after ASRCR in short- and long-term follow-up, regardless of retear. However, retear was strongly associated with OA progression, and long-term functional outcomes deteriorated over time in retear cases, which was not observed during short-term follow-up.

STUDY DESIGN

III, retrospective cohort study.

Long-term Results of Arthroscopic Repair of Full-Thickness Traumatic Rotator Cuff Tears in Active Duty Military Patients Under the Age of 40 Years

BACKGROUND

Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined.

PURPOSE

To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears.

RESULTS

At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military.

CONCLUSION

Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.

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

BACKGROUND AND HYPOTHESIS

Arthroscopic rotator cuff repair surgery is one of the most common shoulder procedures performed in the United States. Although several studies have shown considerable symptomatic relief in the short term following surgery, a relatively high rate of recurrent defects has led surgeons to question the long-term durability of this operation. We hypothesized that outcomes at a minimum of 15 years of follow-up in patients who underwent all-arthroscopic rotator cuff repair would be maintained and would remain significantly improved compared with the preoperative status.

METHODS

All-arthroscopic rotator cuff repairs were performed in 193 patients from 2003 to 2005. Patient-reported outcomes were collected preoperatively and at 1, 2, 5, and ≥15 years postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included Single Assessment Numeric Evaluation (SANE), Shoulder Activity Scale (SAS), visual analog scale, and Patient-Reported Outcomes Measurement Information System (PROMIS)-Upper Extremity (UE) scores. Patient demographic characteristics, revision surgical procedures, and complications were recorded. Generalized estimating equations were used to model scores over time, and multiple comparisons between time points were performed using Tukey adjustment.

RESULTS

This study included 60 patients with a mean follow-up period of 16.5 years (range, 15.8-17.7 years). The mean ASES score improved from 60.2 ± 18.8 preoperatively to 93.0 ± 9.4 at ≥15 years (P < .0001). The mean visual analog scale pain score decreased from 4.1 ± 0.7 preoperatively to 0.7 ± 0.3 at ≥15 years (P < .0001). The average SANE, SAS, and PROMIS-UE scores at ≥15 years were 87.8 ± 14.8, 8.8 ± 4.3, and 49.6 ± 10.2, respectively. Of 60 patients, 7 underwent revision surgery. Older age and female sex were associated with lower SAS scores at 15 years, whereas female sex was associated with lower PROMIS-UE scores. There were no factors predictive of ASES or SANE scores.

CONCLUSION

At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. This information is useful in counseling patients regarding the long-term results of this procedure.

Quantitative Magnetic Resonance Imaging measurement of muscle atrophy and fatty degeneration after arthroscopic rotator cuff repair

BACKGROUND

It is unclear whether muscle atrophy (MA) and fatty degeneration (FD) have improved after arthroscopic rotator cuff repair (ARCR). Therefore, the objective of this study was to perform quantitative magnetic resonance imaging (MRI) measurement to evaluate MA and FD before and after surgery. Correlations of clinical outcome with changes in MA and FD were also analyzed.

MATERIALS AND METHODS

From March 2013 to March 2017, 40 patients who had no re-tear up to 1 year after ARCR were enrolled. MA and FD of supraspinatus muscle before surgery, at 3 days after surgery, and at 1 year after surgery were measured quantitatively in conventional Y-view and supraspinatus origin-view (SOV). Measurement items were muscle area (mm²), occupation ratio (%), fatty infiltration (FI, %), and fatty degenerative area (mm²). Postoperative clinical outcomes were measured at 1 year after ARCR. Correlation between measure values and outcome scores were analyzed.

RESULTS

Inter-measurement reliability was high (ICC = 0.933, Cronbach-α = 0.963). There was no significant change in MA in conventional Y-view at 1 year after surgery (Occupation ratio, p = 0.2770; MA, p = 0.3049) or in SOV (MA, p = 0.5953). FI and fat area measured with the conventional method on Y-view and showed significant differences (p = 0.0001). However, FI and fat area measured with the modified method on Y-view and SOV showed no significant difference (all p > 0.05). Postoperative clinical outcomes showed significant improvement compared to preoperative ones (p = 0.0001). However, there was no significant correlation between FD and FA (p = 0.653).

CONCLUSION

Quantitative MRI measurement was shown to be a reliable and valid method. MA and FD do not improve after ARCR considering postoperative anatomical changes of supraspinatus at 1-year follow-up. FD of the supraspinatus in conventional Y-view, but not in SOV, showed a significant change at 1 year postoperatively. MA showed no significant improvement. There was no correlation between improvement in clinical scores and changes in FD and MA.

Rotator cuff repair with single row technique provides satisfying clinical results despite consistent MRI retear rate

BACKGROUND

The number of shoulder arthroscopies is steadily increasing to treat glenohumeral joint disorders, among which the rotator cuff tear is the most common. The prevalence of this condition ranges from 13% to 37% in the general population without considering the number of asymptomatic patients. The gold standard procedure for rotator cuff repair is still undefined. The purpose of this study is to evaluate a population who underwent a single row (SR) rotator cuff repair and correlate their clinical results with MRI findings.

MATERIALS AND METHODS

Sixty-seven consecutive rotator cuff procedures were retrospectively selected. All patients were diagnosed with a full-thickness rotator cuff tear and subsequently treated with an arthroscopic SR repair technique. Each patient was clinically assessed with the DASH questionnaire and the Constant-Murley Score to grade their satisfaction. Moreover, rotator cuff repair integrity was evaluated by MRI and graded using the Sugaya score.

RESULTS

Mean follow-up was 19.5 ± 5.7 months. The mean Constant score was 82.8 ± 13.0 points, with 55 patients reporting excellent results. No patient scored less than 30 points, which could be deemed as unsatisfying. Meanwhile, on the DASH questionnaire, 6.1% of our patients rated their clinical outcome as unsatisfying, whereas 75.8% rated their outcome as excellent. Postoperative MRI classified 45 patients (83.3%) as either Sugaya type I, II, or III, whereas 9 patients (16.7%) presented a Sugaya type IV consistent with a full-thickness cuff retear. Of these nine patients, five (55.6%) and three (33.3%) reported excellent results for the Constant score and DASH questionnaire, respectively. The Mann-Whitney test reported that the retear group had worse scores than the intact repaired cuff group for pain (8.3 ± 5.0 versus 13.1 ± 3.4), Constant Score (68.8 ± 18.5 versus 83.1 ± 11.6), and DASH (66.2 ± 22.1 versus 44.2 ± 14.9). Still, range of motion (ROM) differences were not significant, except for better forward flexion in the intact group (p < 0.039).

CONCLUSIONS

Both groups with intact repaired and retorn cuffs showed improvement in their condition, but unexpectedly, there is no significant  correlation between patient satisfaction and rotator cuff integrity.

LEVEL OF EVIDENCE

IV.

Increased Glenohumeral Joint Loads Due to a Supraspinatus Tear Can Be Reversed With Rotator Cuff Repair: A Biomechanical Investigation

PURPOSE

To evaluate the effect of an isolated full-thickness supraspinatus (SSP) tear on glenohumeral kinematics and contact mechanics, as well as to quantify improvement following rotator cuff repair (RCR).

METHODS

Ten fresh-frozen cadaveric shoulders (mean age: 63.1 ± 4.6 years) were tested using a dynamic shoulder simulator. A pressure-mapping sensor was placed between the humeral head and the glenoid. Each specimen underwent the following three conditions: 1) native, 2) isolated full-thickness SSP tear, and 3) RCR. Maximum abduction angle (MAA) and superior humeral head migration (SHM) were measured using 3D motion tracking software. Cumulative deltoid force (CDF) and glenohumeral contact mechanics, including contact area (GCA) and contact pressure (GCP), were assessed at the resting position, as well as at 15°, 30°, 45°, and 60° of glenohumeral abduction.

RESULTS

Compared to native, the SSP tear resulted in a significant decrease in MAA (Δ-8.3°; P < .001) along with a SHM of 6.4 ± 3.8 mm, while significantly increasing CDF (Δ20.5 N; P = .008), GCP (Δ63.1 kPa; P < .001), and peak GCP (Δ278.6 kPa; P < .001), as well as decreasing GCA (Δ-45.8 mm²; P < .001) at each degree of abduction. RCR reduced SHM to 1.2 ± 2.5 mm, while restoring native MAA, CDF (Δ1.8 N), GCA (Δ4.5 mm²), GCP (Δ-4.5 kPa) and peak GCP (Δ19.9 kPa) at each degree of abduction (P > .999, respectively).

CONCLUSION

In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. More specifically, RCR restored native glenohumeral contact area and contact pressure, while preventing superior humeral head migration and decreasing compensatory deltoid forces.

CLINICAL RELEVANCE

These time 0 observations indicate that undergoing rotator cuff repair may prevent the development of degenerative changes by significantly reducing glenohumeral joint loads and ensuring sufficiently stable joint kinematics.

A Systematic Review of Long-term Clinical and Radiological Outcomes of Arthroscopic and Open/Mini-open Rotator Cuff Repairs

BACKGROUND

Arthroscopic rotator cuff repair (aRCR) has shown similar midterm functional results and retear rates as open/mini-open rotator cuff repair (oRCR). A pooled analysis of long-term results of both techniques is yet missing.

PURPOSE

To evaluate the long-term results of aRCR and oRCR for full-thickness rotator cuff tears.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The CENTRAL (Cochrane), MEDLINE (PubMed), and Embase databases were searched for studies that reported on long-term clinical and radiographic outcomes of full-thickness aRCR and oRCR with a minimum follow-up of 9 years.

RESULTS

Eleven studies were included: 5 studies on aRCR and 6 studies on oRCR. Studies were based on 550 shoulders (539 patients) with a mean patient age of 56.3 years (range, 25-77). After a mean follow-up of 14.0 years (range, 9-20), the mean preoperative absolute Constant score (CS) and American Shoulder and Elbow Surgeons (ASES) shoulder score were significantly improved postoperatively (CS, 44 to 78 points; ASES, 52% to 91%; both comparisons, P < .001). The retear rate was 41% (141 of 342 shoulders) without a significant difference between groups (aRCR, 43%; oRCR, 39%) (P = .364). A retear was associated with significantly reduced CS as compared with a healed repair (P = .004). No significant differences were found in postoperative functional scores, complications, and retear rates after failed cuff repairs between the arthroscopic and open/mini-open repair groups.

CONCLUSION

Pooled analysis of arthroscopic and open rotator cuff repairs demonstrated sustained improvement in long-term shoulder scores and pain with a substantial retear rate in both groups, which was associated with inferior shoulder function. There were no significant differences in long-term functional outcomes, retear rates, and complications. Both surgical techniques may be used on the basis of factors such as patient or surgeon preference and cost. Further studies using a more robust randomized controlled trial or larger cohort design are recommended to ascertain whether one surgical repair technique is superior to the other.

REGISTRATION

CRD42020180448 (PROSPERO).

Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: Clinical and Radiological Results of a Prospective Randomized Controlled Trial Study at 10-Year Follow-Up

PURPOSE

The aim of the study is to compare, at 10-year follow-up, the clinical and radiological outcomes of arthroscopic rotator cuff repair with or without the addition of platelet-rich plasma (PRP) over the tendon-bone interface at the end of the surgical procedure.

METHODS

Of 53 patients recruited in the study, and randomly divided into 2 groups (PRP = 26; control = 27), 38 were re-evaluated at least 10 years after the index procedure. The clinical evaluation was carried out through: University of California at Los Angeles (UCLA) Shoulder Score, Visual Analogue Scale (VAS), Simple Shoulder Test, Constant-Murley Score (CMS), Single Assessment Numerical Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) and isometric strength in abduction, forward flexion and external rotation. Musculoskeletal ultrasonography had been used to evaluate the integrity of the repaired cuff.

RESULTS

A number of 38 (71%) patients (PRP = 17; control = 21) with a median age of 71 [64.75-76.50] years have been evaluated. Satisfaction at follow-up is high (90%), without statistically significant difference between the two groups. We report good and excellent clinical results in both groups (PRP vs control): CMS (81.62 [72.47-85.75] vs 77.97 [69.52-82.55] points), UCLA (34 [29.00-35.00] vs 33 [29.00-35.00] points), VAS (0.34 [0.00-1.85] vs 0.70 [0.00-2.45] cm). It was not possible to find a statistically significant difference for the variables analyzed, except for ASES and SANE. On average, 37% of the operated patients had a re-rupture at the ultrasound examination, regardless of the treatment group (P = 1.00). Compared with the previous radiological control at the 2-year follow-up, new retears occurred in 6% of the patients who received PRP treatment, whereas in the control group the percentage raises to 14% (P = .61).

CONCLUSION

The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the 2 groups. The minor differences that had been observed at 2-year follow-up disappeared at long term. Patients' satisfaction is still high 10 years after surgical treatment.

LEVEL OF EVIDENCE

Level II, randomized controlled trial, treatment study.

Treatment of partial rotator cuff lesions is associated with a higher frequency of post-operative shoulder stiffness. A prospective investigation on the role of surgery-related risk factors for this complication

PURPOSE

Post-operative shoulder stiffness (SS) is a common complication after arthroscopic rotator cuff (RC) repair. The aim of this prospective study is to evaluate the role of surgical risk factors in the development of this complication, with special focus on the characteristics of the RC tears.

METHODS

Two-hundred and twenty patients who underwent arthroscopic RC repair for degenerative posterosuperior RC tears were included. Surgery-related risk factors for development of post-operative SS belonging to the following five categories were documented and analyzed: previous surgery, RC tear characteristics, hardware and repair type, concomitant procedures, time and duration of surgery. The incidence of post-operative SS was evaluated according to the criteria described by Brislin and colleagues.

RESULTS

The incidence of post-operative SS was 8.64%. The treatment of partial lesions by tear completion and repair technique was significantly associated with development of post-operative SS (p = 0.0083, pc = 0.04). A multivariate analysis revealed that treatment of partial lesions in patients younger than 60 years was associated to a higher risk of developing post-operative SS (p = 0.007). Previously known pre-operative risk factors such as female sex and younger age were confirmed. No other significant associations were documented.

CONCLUSION

The treatment of partial lesions of the RC may lead to a higher risk of post-operative SS than the treatment of complete lesions, in particular in patients younger than 60 years. Possible explanations of this finding are the increased release of pro-inflammatory cytokines caused by the additional surgical trauma needed to complete the lesion and the different pain perception of the subgroup of patients who require surgical treatment already for partial tears.

EVIDENCE

A higher risk of post-operative SS should be expected after tear completion and repair of partial lesions, especially in young patients. Appropriate pre-operative counseling and post-operative rehabilitation should be considered when approaching this subgroup of RC tears.

LEVEL OF EVIDENCE

Prognostic study, level II.

Assessing the accuracy of arthroscopic and open measurements of the size of rotator cuff tears: A simulation-based study

BACKGROUND

Arthroscopic procedures are commonly performed for rotator cuff pathology. Repair of rotator cuff tears is a commonly performed procedure. The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair.

AIM

To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model.

METHODS

We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model (small and large U-shaped, oval-shaped). Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically, using a 5 mm probe, repeating the procedure three times, and then using a ruler (open technique). Arthroscopic, open and computerized measurements were compared.

RESULTS

A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope, compared to both the open and computerized measurements (mean differences up to -7.5 ± 5.8 mm, P < 0.001). No differences were observed between the open and computerized measurements (mean difference -0.4 ± 1.6 mm). The accuracy of arthroscopic and open measurements was 90.5% and 98.5%, respectively. When comparing between levels of experience, senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows.

CONCLUSION

This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears. Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

Long-term outcomes after arthroscopic transosseous-equivalent repair: clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years

PURPOSE

The objective of this study was to evaluate the long-term functional outcomes and structural integrity of medium to massive rotator cuff tears at 10-12 years of follow-up after arthroscopic transosseous-equivalent (TOE) repair.

METHODS

This was a retrospective study of a consecutive series of patients who underwent primary arthroscopic TOE repair of medium- to massive-sized degenerative rotator cuff tears performed by a single surgeon between January 2007 and August 2009. Patients were examined at a minimum follow-up of 10 years, and magnetic resonance imaging (MRI) was performed to assess tendon integrity. The Constant score (CS), American Shoulder and Elbow Surgeons score, and pain level documented using a visual analog scale were compared between intact repairs and recurrent defects. Univariate analysis was performed to identify factors related to recurrent defects.

RESULTS

A total of 102 patients met the inclusion criteria, and 79 shoulders in 76 patients (74.5% of eligible patients) with a mean age at surgery of 55 ± 8 years (range, 40-72 years) were available for clinical evaluation at a mean follow-up time of 10.9 years (range, 10-12 years). The mean anteroposterior tear size was 3.1 ± 1.1 cm, and there were 41 medium (52%), 26 large (33%), and 12 massive (15%) tears. MRI was performed in 72 shoulders in 69 patients (91% of available shoulders) and revealed that 13 shoulders had recurrent defects (Sugaya stages 4 and 5). During the follow-up period, 3 patients underwent revision surgery, and the overall recurrent defect rate was 21.3%. A clinically meaningful improvement was observed in all outcome measures at the final follow-up regardless of tendon integrity. Patients with intact repairs showed superior outcomes compared with those with recurrent defects; however, only the overall CS met the threshold for clinical relevance. A significant linear correlation was observed between the Sugaya classification and all outcome scores except the CS pain subscale; however, the strength of correlation was weak. The presence of diabetes (odds ratio [OR], 8.6; 95% confidence interval [CI], 2.25-33.2; P = .002), tear size (OR, 2.08; 95% CI, 1.16-3.46; P = .012), and tear retraction (OR, 4.07; 95% CI, 1.11-14.83; P = .033) were associated with recurrent defects in the univariate analysis.

CONCLUSION

Arthroscopic TOE repair of rotator cuff tears provided improved clinical outcomes with a recurrent defect rate of 21.3% at 10-12 years after surgery. Future research focusing on tendon healing is needed as repair integrity on MRI correlates with clinical outcomes.

Presurgical tear characteristics and estimated shear modulus as predictors of repair integrity and shoulder function one year after rotator cuff repair

Background

Rotator cuff repair provides pain relief for many patients; however, retears are relatively common and affect approximately 20%-70% of patients after repair. Although magnetic resonance imaging (MRI) offers the ability to assess tissue characteristics such as tear size, retraction, and fatty infiltration, it provides little insight into the quality of the musculotendinous tissues the surgeon will encounter during surgery. However, shear wave elastography (SWE) could provide an indirect assessment of quality (ie, stiffness) by measuring the speed of shear waves propagating through tissue. The objective of this study was to determine the extent to which estimated shear modulus predicts repair integrity and functional outcomes 1 year after rotator cuff repair.

Methods

Thirty-three individuals scheduled to undergo arthroscopic rotator cuff repair were enrolled in this study. Before surgery, shear modulus of the supraspinatus tendon and muscle was estimated using ultrasound SWE. MRIs were obtained before and 1 year after surgery to assess tear characteristics and repair integrity, respectively. Shoulder strength, range of motion, and patient-reported pain and function were assessed before and after surgery. Functional outcomes were compared between groups and across time using a two-factor mixed model analysis of variance. Stepwise regression with model comparison was used to investigate the extent to which MRI and shear modulus predicted repair integrity and function at 1 year after surgery.

Results

At 1 year after surgery, 56.5% of patients had an intact repair. No significant differences were found in any demographic variable, presurgical tear characteristic, or shear modulus between patients with an intact repair and those with a recurrent tear. Compared with presurgical measures, patients in both groups demonstrated significant improvements at 1 year after surgery in pain (P < .01), self-reported function (P < .01), range of motion (P < .01), and shoulder strength (P < .01). In addition, neither presurgical MRI variables (P > .16) nor shear modulus (P > .52) was significantly different between groups at 1 year after surgery. Finally, presurgical shear modulus generally did not improve the prediction of functional outcomes above and beyond that provided by MRI variables alone (P > .22).

Conclusion

Although SWE remains a promising modality for many clinical applications, this study found that SWE-estimated shear modulus did not predict repair integrity or functional outcomes at 1 year after surgery, nor did it add to the prediction of outcomes above and beyond that provided by traditional presurgical MRI measures of tear characteristics. Therefore, it appears that further research is needed to fully understand the clinical utility of SWE for musculoskeletal tissue and its potential use for predicting outcomes after surgical rotator cuff repair.

A Multicenter Randomized Controlled Trial Comparing Single-Row With Double-Row Fixation in Arthroscopic Rotator Cuff Repair: Long-Term Follow-up

BACKGROUND

The long-term outcomes of single- versus double-row fixation in arthroscopic rotator cuff repair are not currently known.

PURPOSE

To compare the treatment effects of the single- versus double-row suture technique in arthroscopic rotator cuff repair of full-thickness tears at 10-year follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients were evaluated at 10 years postoperatively. The primary outcome measure was the Western Ontario Rotator Cuff Index (WORC). Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Constant score, strength, and incidence of revision surgery. Ultrasound was used to evaluate the rotator cuff to determine repair integrity. Statistical analyses consistent with those of the main trial were conducted.

RESULTS

Of the original 90 participants, 77 (85%) returned at a mean follow-up of 10 years. At ten year follow-up, the WORC score was higher in the double row group (79.9 [95% CI, 16.2 to 99.1]) compared with the single row group (72.9, [95% CI, 4.3 to 100]), P = .020. From baseline to 2 years, the mean change in WORC scores for the single-row group was -48.5 compared with -40.6 for the double-row group, with a between-group difference of -7.8 (95% CI, -20.4 to 4.7). From 2 to 10 years, the change in WORC scores for the single-row group was 11.5 compared with -0.2 for the double-row group, with a between-group difference of 11.7 (95% CI, -0.7 to 24.3). From baseline to 10 years, the mean between-group difference was 3.9 (95% CI, -7.8 to 15.6). Similarly, a decrease in ASES scores was observed between 2 and 10 years for the single-row group (9.2 [95% CI, 0.9 to 17.5]; P = .029), with a nonsignificant decrease in ASES scores for the double-row group (6.2 [95% CI, -3.2 to 15.6]; P = .195) as well as a decrease in Constant scores for both the single- (9.5 [95% CI, 1.4 to 17.5]; P = .020) and double-row (14.4 [95% CI, 5.6 to 23.3]; P = .001) groups. Overall, 3 participants developed a full-thickness tear after 2 years: 2 from the double-row group and 1 from the single-row group. One participant from each study group underwent revision surgery after the 2-year time point.

CONCLUSION

A statistically significant (but likely not clinically important) difference in WORC scores was seen at 10-year follow-up in favor of double-row fixation. Between baseline and 10-year follow-up, a decrease in most outcome scores was observed in both the single- and the double-row groups.

REGISTRATION

NCT00508183 (ClinicalTrials.gov identifier).

Arthroscopic repair of the medium-size rotator cuff tear with the novel technique of the point union bridge: a minimum 2-year follow-up cohort study

BACKGROUND

Achieving secure fixation and preventing retear have been recognized as fundamental in arthroscopic repair of rotator cuff tears. Moreover, reducing internal implantation can lower medical expenses and minimize the operation time, which is essential for the surgical safety and postoperative rehabilitation of the patients. We have recently proposed the point union bridge (PUB) suture configuration as a novel method for not only providing equivalent fixation but also decreasing the operation time and medical expenses. However, no comparative clinical studies have been performed.

METHODS

From March 2014 to September 2016, a total of 88 patients with diagnoses of medium-size rotator cuff tears underwent arthroscopic repair with a randomly assigned technique-either the PUB technique (n = 42) or the double-row suture bridge (DRSB) technique (n = 46). All patients underwent a minimal 2-year follow-up. We used the Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, active and passive range of motion, and visual pain-simulation score (visual analog scale [VAS] score) to assess the functional outcomes. In addition, we recorded the arthroscopic operation time, medical costs, and postoperative complications. All patients received magnetic resonance imaging at the 6-month and 2-year postoperative evaluations to assess structural integrity and tendon healing.

RESULTS

At the 2-year follow-up, all scoring parameters evaluated (CMS, ASES score, and VAS score), as well as active and passive range of motion, improved significantly in both groups as compared with preoperative assessments. The PUB technique significantly decreased the operation time (55.9 ± 14.1 minutes vs. 72.2 ± 14.2 minutes for PUB vs. DRSB, P < .001) and medical expenses ($2608.0 ± $391.1 vs. $4056.9 ± $350.9 for PUB vs. DRSB, P < .001). However, no significant differences between the 2 techniques were found in any functional assessments of the shoulder (CMS, ASES score, and VAS score), repair integrity, or the retear rate at the 2-year follow-up.

CONCLUSION

Arthroscopic repair of the medium-size rotator cuff tear with either the PUB or DRSB technique could yield both satisfactory improvements in the shoulder function of patients and equivalent tendon integrity. With less consumption of internal implants, the PUB technique significantly reduced the operation time and decreased medical expenses.

Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.

Factors associated with the development of early- to mid-term cuff-tear arthropathy following arthroscopic rotator cuff repair

BACKGROUND

Few studies have specifically evaluated the development of cuff-tear arthropathy (CTA) after a rotator cuff repair in the postoperative early to mid-term. This study aimed to identify the factors associated with the development of CTA, to evaluate the effect of arthropathy on functional outcomes, and to evaluate the incidence of CTA 3-10 years after an arthroscopic rotator cuff repair.

METHODS

A total of 312 patients who underwent an arthroscopic repair of a large or massive full-thickness rotator cuff tear with a minimum follow-up of 3 years were retrospectively divided into 2 groups for analysis: those with postrepair CTA (arthritic glenohumeral changes due to rotator cuff insufficiency) and those without. CTA was assessed using the Seebauer and modified Hamada-Fukuda classification systems. Pre-, intra-, and postoperative patient characteristics; characteristics of the rotator cuff tear; clinical and radiological parameters; and pre- and postoperative functional scores were compared.

RESULTS

The rate of development of CTA was 11.5% (36 of 312 patients, 13 centric and 23 eccentric arthropathy). CTA was more frequently associated with the poor integrity of the supraspinatus tendon after repair (P < .001) and massive tears (P = .006). Postoperative pseudoparalysis (P < .001), symptomatic retear (P < .001), tear size (P = .026), critical shoulder angle (P = .001), preoperative acromiohumeral interval (P = .046), and the humeral head superior migration (P = .001) were found to be associated with the development of CTA. However, only postoperative pseudoparalysis was found to be an independent risk factor (P < .001, odds ratio: 2.965). Patients with postrepair CTA had significantly worse functional outcome scores.

CONCLUSION

The postoperative development of pseudoparalysis may be a marker of CTA in the future and that closer follow-up may be necessary.

Healing rates after rotator cuff repair for patients taking either celecoxib or placebo: a double-blind randomized controlled trial

Background

Use of anti-inflammatory medications (NSAIDs) is an important component of multimodal pain control after orthopedic procedures to avoid opioid overutilization and abuse. However, the deleterious effects of NSAIDs on tendon healing are of particular concern in rotator cuff repair (RCR). The purpose of this study was to evaluate the effect of celecoxib or placebo on healing rates after RCR when administered in the perioperative and immediate postoperative period using MRI evaluation at one year postoperatively. A secondary aim was to determine whether clinical differences existed between patients with intact or non-intact repairs.

Methods

Patients aged ≤65 years with partial- or full-thickness rotator cuff tear (<25x25 mm) were randomized to receive celecoxib 400 mg or placebo 1 hour before the procedure and 200mg bid for 3 weeks postoperatively. All patients were treated as clinically indicated at the time of surgery and followed standard postoperative protocol. Repair integrity was evaluated with MRI using the Sugaya classification for repair integrity. Data were analyzed using multivariable logistic regression by intent to treat.

Results

Seventy-nine patients were enrolled; 21 were lost to follow-up, 6 did not have cuff repair, 5 were revised, and 2 declined follow-up, leaving 45 patients with one-year follow-up. Five of these patients did not complete MRI, leaving 40 patients for review. Eighteen of 20 patients (90%) who received celecoxib completed all doses of study medication as did 15 of 20 patients (75%) who received placebo. The patient groups were similar for demographics, clinical results, and healing rate. After adjusting for tear size, no statistically significant difference in healing rate was found between groups, with 10 of 20 celecoxib patients (50%) having intact repair at 1 year compared with 14 of 20 placebo patients (70%) (OR = 0.53, 95% CI: 0.14, 2.08, P = 0.35).

Conclusion

Half of the patients who received celecoxib had an intact repair compared with 70% intact repair for patients receiving placebo. Although not statistically significant in this small study, larger studies are needed to clarify this important clinical concern. The authors do not recommend use of celecoxib for postoperative pain control after RCR.

The presence of gastroesophageal reflux disease increases the risk of developing postoperative shoulder stiffness after arthroscopic rotator cuff repair

BACKGROUND

Postoperative shoulder stiffness (SS) after arthroscopic rotator cuff (RC) repair has been reported with a variable incidence, and numerous preoperative risk factors have been described. This prospective study aimed to document the incidence of postoperative SS and to evaluate the role of preoperative risk factors in the development of this complication, with a special focus on the role of gastroesophageal reflux disease (GERD).

METHODS

Preoperative risk factors for SS were prospectively evaluated in 237 consecutive patients undergoing arthroscopic single-row RC repair. The presence of GERD was evaluated with the GerdQ diagnostic tool. Postoperative SS was diagnosed according to the criteria described by Brislin et al in 2007.

RESULTS

The incidence of postoperative SS was 8.02%. The presence of GERD was significantly associated with the development of postoperative SS (odds ratio [OR], 5.265; 95% confidence interval [CI], 1.657-1.731; P = .005). Older age (OR, 0.896; 95% CI, 0.847-0.949; P < .001), male sex (OR, 0.126; 95% CI, 0.0252-0.632; P = .012), and number of pregnancies (OR, 0.47; 95% CI, 0.228-0.967; P = .040) emerged as protective factors.

CONCLUSIONS

The presence of GERD significantly influences the development of postoperative SS after arthroscopic single-row RC repair. An underlying aspecific proinflammatory condition, characterized by increased expression of tumor necrosis factor α and transforming growth factor β, and disorders in retinoid metabolism are hypotheses that could explain this previously unknown association. The documented incidence of postoperative SS falls within previously reported ranges, with women being significantly more affected than men.

Success Criteria and Preclinical Testing of Multifunctional Hydrogels for Tendon Regeneration

Tendon injuries are difficult to heal, in part, because intrinsic tendon healing, which is dominated by scar tissue formation, does not effectively regenerate the native structure and function of healthy tendon. Further, many current treatment strategies also fall short of producing regenerated tendon with the native properties of healthy tendon. There is increasing interest in the use of cell-instructive strategies to limit the intrinsic fibrotic response following injury and improve the regenerative capacity of tendon in vivo. We have established multifunctional, cell-instructive hydrogels for treating injured tendon that afford tunable control over the biomechanical, biochemical, and structural properties of the cell microenvironment. Specifically, we incorporated integrin-binding domains (RGDS) and assembled multifunctional collagen mimetic peptides that enable cell adhesion and elongation of stem cells within synthetic hydrogels of designed biomechanical properties and evaluated these materials using targeted success criteria developed for testing in mechanically demanding environments such as tendon healing. The in vitro and in situ success criteria were determined based on systematic reviews of the most commonly reported outcome measures of hydrogels for tendon repair and established standards for testing of biomaterials. We then showed, using validation experiments, that multifunctional and synthetic hydrogels meet these criteria. Specifically, these hydrogels have mechanical properties comparable to developing tendon; are noncytotoxic both in two-dimensional bolus exposure (hydrogel components) and three-dimensional encapsulation (full hydrogel); are formed, retained, and visualized within tendon defects over time (2-weeks); and provide mechanical support to tendon defects at the time of in situ gel crosslinking. Ultimately, the in vitro and in situ success criteria evaluated in this study were designed for preclinical research to rigorously test the potential to achieve successful tendon repair before in vivo testing and indicate the promise of multifunctional and synthetic hydrogels for continued translation. Impact statement Tendon healing results in a weak scar that forms due to poor cell-mediated repair of the injured tissue. Treatments that tailor the instructions experienced by cells during healing afford opportunities to regenerate the healthy tendon. Engineered cell-instructive cues, including the biomechanical, biochemical, and structural properties of the cell microenvironment, within multifunctional synthetic hydrogels are promising therapeutic strategies for tissue regeneration. In this article, the preclinical efficacy of multifunctional synthetic hydrogels for tendon repair is tested against rigorous in vitro and in situ success criteria. This study indicates the promise for continued preclinical translation of synthetic hydrogels for tissue regeneration.

Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques

BACKGROUND

Arthroscopic rotator cuff repair (RCR) with suture anchor-based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results.

PURPOSE

To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture-grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis.

RESULTS

A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant.

CONCLUSION

Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.

A Randomized Controlled Trial of the Treatment of Rotator Cuff Tears with Bone Marrow Concentrate and Platelet Products Compared to Exercise Therapy: A Midterm Analysis

Injectable regenerative therapies such as bone marrow concentrate (BMC) and platelet-rich plasma (PRP) may represent a safe alternative in the treatment of rotator cuff tears. This is a midterm review of a randomized, crossover trial comparing autologous BMC and platelet product injections versus exercise therapy in the treatment of partial and full-thickness supraspinatus tears. Patients enrolled into the study were between 18 and 65 years of age presenting to an outpatient orthopedic clinic with partial to full thickness, nonretracted supraspinatus tendon tears. Enrolled patients were randomized to either ultrasound-guided autologous BMC with PRP and platelet lysate (PL) percutaneous injection treatment or exercise therapy. Patients could cross over to BMC treatment after at least 3 months of exercise therapy. Patients completed the Disability of the Arm, Shoulder and Hand (DASH) scores as the primary outcome measure. Secondary outcomes included the numeric pain scale (NPS), a modified Single Assessment Numeric Evaluation (SANE), and a blinded MRI review. At this midterm review, results from 25 enrolled patients who have reached at least 12-month follow-up are presented. No serious adverse events were reported. Significant differences were seen in patient reported outcomes for the BMC treatment compared to exercise therapy at 3 and 6 months for pain, and for function and reported improvement (SANE) at 3 months (p < .05). Patients reported a mean 89% improvement at 24 months, with sustained functional gains and pain reduction. MRI review showed a size decrease of most tears post-BMC treatment. These findings suggest that ultrasound-guided BMC and platelet product injections are a safe and useful alternative to conservative exercise therapy of torn, nonretracted supraspinatus tendons. This trial is registered with NCT01788683.