The Evolution of Arthroscopic Rotator Cuff Repair

Opportunistic Screening for Local Osteoporosis of the Proximal Humerus on the Basis of Hounsfield Units: A Study of Patients With Rotator Cuff Tears

OBJECTIVES

The accuracy of dual-energy x-ray absorptiometry (DXA) in predicting proximal humerus osteoporosis in patients with rotator cuff tears (RCTs) undergoing arthroscopic rotator cuff repair (ARCR) is uncertain. The aim of this study was to assess the correlation of computed tomography (CT) Hounsfield units (HU) and the deltoid tuberosity index (DTI) with bone mineral density (BMD), and to evaluate the predictive value of HU values for implant selection.

METHODS

This study analyzed the preoperative shoulder CT scans and x-rays of 184 patients who underwent ARCR. Preoperative CT scans were utilized to assess the multiple anatomical parts of the proximal humerus to ascertain the HU values, whereas preoperative x-rays were analyzed to derive the DTI. Among them, 104 patients with preoperative DXA data were grouped according to the WHO diagnostic criteria for osteoporosis to establish the threshold HU values. The correlation between HU values and DTI and the lowest T score on DXA was studied, and the relationship between the HU value and the type of implant selected was discussed. The Pearson correlation coefficient was employed to examine the relationship between HU values, DTI, and T scores. And the Spearman correlation coefficient was employed to examine the relationship between HU values and enhanced fixation.

RESULTS

There was a significant correlation between the HU values and DTI and the lowest T score (r HU&T score = 0.539-0.576, r DTI&T score = 0.288, p < 0.05). On the basis of the lowest T score grouping, the threshold HU values for diagnosing proximal humeral osteoporosis were obtained: proximal humerus = 47.44, humeral head = 97.62, greater tuberosity = 10.9, and lesser tuberosity = 5.38. There was no correlation between HU values and enhanced fixation (using 5.5-mm anchors or metal anchors instead of 4.5-mm anchors or all-suture anchors) (r = -0.143 to -0.027, p > 0.05).

CONCLUSION

Proximal humeral HU values were significantly correlated with DTI and the lowest T score on DXA. When the HU values in the proximal humerus in patients with RCTs fall below the thresholds, the surgery should be carefully planned. No correlation exists between HU values and enhanced fixation, thus further investigation through group studies is warranted.

LEVEL OF EVIDENCE

Level III, study of nonconsecutive patients, diagnostic study.

Surgical Interventions for Rotator Cuff Tears: A Comprehensive Literature Review

Rotator cuff tears in the shoulder joint are common musculoskeletal injuries that may present with or without symptoms. Rotator cuff tears are a common musculoskeletal condition that become increasingly prevalent with age. This mines various surgical interventions for rotator cuff tears, focusing on patient selection criteria and treatment outcomes across different subgroups. A comprehensive search was conducted to identify studies on rotator cuff tear classifications and surgical techniques. The review analyzes patient characteristics influencing treatment choices and outcomes. Rotator cuff tears are classified by size and extent. Surgical interventions range from arthroscopic repairs to reverse shoulder arthroplasty (RSA), each with specific indications. Patient factors such as age, tear size, activity level, and overall health influence the selection of surgical technique. Minimally invasive procedures generally offer reduced times and complications, while open surgeries may be necessary for complex tears. The choice of surgical treatment for rotator cuff tears is determined by multiple factors, including tear characteristics and patient demographics. Tailoring interventions to individual patient needs can optimize outcomes and restore shoulder function effectively.

Exosomes derived from tendon stem/progenitor cells enhance tendon-bone interface healing after rotator cuff repair in a rat model

The rate of retear after surgical repair remains high. Mesenchymal stem cells (MSCs) have been extensively employed in regenerative medicine for several decades. However, safety and ethical concerns constrain their clinical application. Tendon Stem/Progenitor Cells (TSPCs)-derived exosomes have emerged as promising cell-free therapeutic agents. Therefore, urgent studies are needed to investigate whether TSPC-Exos could enhance tendon-bone healing and elucidate the underlying mechanisms. In this study, TSPC-Exos were found to promote the proliferation, migration, and expression of fibrogenesis markers in BMSCs. Furthermore, TSPC-Exos demonstrated an ability to suppress the polarization of M1 macrophages while promoting M2 macrophage polarization. In a rat model of rotator cuff repair, TSPC-Exos modulated inflammation and improved the histological structure of the tendon-bone interface, the biomechanical properties of the repaired tendon, and the function of the joint. Mechanistically, TSPC-Exos exhibited high expression of miR-21a-5p, which regulated the expression of PDCD4. The PDCD4/AKT/mTOR axis was implicated in the therapeutic effects of TSPC-Exos on proliferation, migration, and fibrogenesis in BMSCs. This study introduces a novel approach utilizing TSPC-Exos therapy as a promising strategy for cell-free therapies, potentially benefiting patients with rotator cuff tear in the future.

Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair

Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.

Worse postoperative outcomes and higher reoperation in smokers compared to nonsmokers for arthroscopic rotator cuff repair

Background

This study aimed to determine if smokers at the time of arthroscopic rotator cuff repair met the minimally clinical important difference and substantial clinical benefit for Patient-Reported Outcomes Measurement Information System Upper Extremity, Depression, and Pain Interference scores in comparison to nonsmoking patients in a retrospective review.

Methods

Clinical outcomes and Patient-Reported Outcomes Measurement Information System scores were compared between a cohort of nonsmokers and current or former smokers (smokers). Further sub-analysis compared a cohort of nonsmokers propensity-matched 1:1 to a cohort of current/former smokers via age, body mass index, and tear size.

Results

A total of 182 patients, 80 smokers and 102 nonsmokers, were included. Smokers had statistically different-sized tears with more rated massive (P = 0.02) and more reoperations (P = 0.02). Smokers met substantial clinical benefit thresholds at a lower rate than nonsmokers for Patient-Reported Outcomes Measurement Information System Upper Extremity (P = 0.03). In the sub-analysis, 74 smokers were matched to 74 nonsmokers. Smokers had a lower change in Patient-Reported Outcomes Measurement Information System Upper Extremity (P = 0.007) and Patient-Reported Outcomes Measurement Information System Pain Interference (P = 0.03) postoperatively. Fewer smokers met minimally clinical important difference for Patient-Reported Outcomes Measurement Information System Upper Extremity postoperatively (P = 0.003) and more had reoperations (P = 0.02).

Discussion

Overall, smokers demonstrated smaller improvements in function, and pain, and were less likely to meet minimally clinical important differences and substantial clinical benefits for Patient-Reported Outcomes Measurement Information System Upper Extremity at 6 months follow-up when compared to nonsmokers after rotator cuff repair.

A Modified Mason-Allen Suture Enhancement Technique (Sunglasses Loop) for Single-Row Repair of Medium-to-Large Rotator Cuffs

We propose a single-row repair method for medium-to-large rotator cuff rotator cuff tears using a modified Mason-Allen suture enhancement technique (sunglasses loop), which uses high-tensile modified Mason-Allen sutures to close the medial rotator cuff tissues to form a sunglasses loop, resets the rotator cuff tissues via traction with the high-tensile suture, repairs the rotator cuff in a single row with triple-loaded suture anchor (anchor with 3 high-strength sutures), and finally employs an outer row of staples to secure the suture to the lateral aspect of the greater tuberosity, preventing the tendon from pulling out. This method uses a special sunglasses-shaped suture loop, which produces an increase in holding power and a reduction in tension relative to other single-row repair techniques and reduces the rate of rotator cuff retear.

Use of a Spinal Needle Through the Deep Rotator Cuff Tissue to Treat Rotator Cuff Tears Under Direct Articular Vision

Achieving sufficient attachment of deep rotator cuff tissue to the footprint area on the greater tubercle of the humerus is essential for functional recovery, yet the optimal approach remains uncertain. We introduce a surgical technique for rotator cuff tear repair using a spinal needle to penetrate deep rotator cuff tissue under direct arthroscopic visualization. After trimming the torn edge, an arthroscope is inserted into the joint cavity through a posterior portal, and a hole is drilled into the humeral head cartilage margin using an upper approach, facilitating the implantation of an internal shoulder row nail. A spinal needle is used to introduce a No. 2 polydioxanone (PDS; Johnson & Johnson) line through sufficient deep rotator cuff tissue. Graspers are then used to extract the stitch and PDS together through the anterolateral opening. Once the PDS is knotted, the stitch is introduced into the rotator cuff. This process is replicated to insert additional stitches into the rotator cuff. Our proposed technique, involving a spinal needle under direct visualization, ensures sufficient coverage of the deep rotator cuff tissue over the footprint area and promotes the healing of the repaired rotator cuff. This method is safe, effective, convenient, and reproducible.

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis

BACKGROUND

To reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE).

METHODS

This study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively.

RESULTS

The follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods.

CONCLUSIONS

TOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective matched control study.

Effects of propofol versus sevoflurane on surgical field visibility during arthroscopic rotator cuff repair: a randomized trial

BACKGROUND

During arthroscopic rotator cuff repair (ARCR), clear surgical field visibility (SFV) is the basis of successful surgery, but the choice of anesthesia maintenance drugs may have different effects on SFV. In this study, we aimed to compare the effects of propofol- and sevoflurane-based general anesthesia on SFV in patients undergoing ARCR.

METHODS

Patients (n = 130) undergoing elective ARCR in the lateral decubitus position were randomized into either the propofol group or sevoflurane group (65 per group). The duration of surgery and increased pressure irrigation (IPI), Boezaart score, rocuronium consumption and usage of remifentanil were recorded. The time of both spontaneous respiration recovery and extubation and the incidences of postoperative nausea and vomiting and agitation were also recorded.

RESULTS

The Boezaart score, duration of IPI and ratio of the duration of IPI to the duration of surgery (IPI/S ratio) were similar between the groups (P > 0.05). Rocuronium consumption, number of patients requiring remifentanil infusion and total remifentanil consumption were significantly lower in the sevoflurane group (P < 0.05). The spontaneous respiration recovery time was significantly longer in the propofol group (P < 0.05), but there were no differences in the extubation time between the groups(P > 0.05).

CONCLUSIONS

Compared with propofol, sevoflurane provides equally clear SFV while improving the convenience of anesthesia maintenance in ARCR patients with interscalene plexus (ISB) combined with general anesthesia.

TRIAL REGISTRATION

This single-center, prospective, RCT was retrospective registered at Chinese Clinical Trial Registry with the registration number ChiCTR2300072110 (02/06/2023).

Arthroscopic Double-Pulley Suture-Bridge Repair of Supraspinatus Tendon Tear

At present, the suture bridge is a widely used surgical pattern in the treatment of supraspinatus tendon tear, but the shortcomings of a suture bridge, including expensive lateral-row anchor and increased type 2 retear rate, is obvious. The double-pulley suture-bridge described in this Technical Note uses a double-loaded suture anchor (medial-row anchor) as lateral-row anchor instead of traditional lateral-row anchor, combined with double-pulley technology forming suture-bridge in treatment of supraspinatus tendon tears. The surgical technique is described in pearls, pitfalls, advantages, and disadvantages.

Efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tear with limited shoulder movement

BACKGROUND

To determine the clinical efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tendinopathy to improve the Constant-Murley and Visual Analogue Scale (VAS) scores, and shoulder flexion.

METHODS

Fifty-one patients with full-thickness rotator cuff tears and limited shoulder movement who were admitted to our hospital from October 2017 to October 2020 were selected; all patients were treated with arthroscopic rotator cuff suture and 360° capsular release. The Constant-Murley score, VAS score, and shoulder flexion angle were used to evaluate shoulder joint function before and during follow-up. Rotator cuff healing was assessed by MRI with the Sugaya classification.

RESULTS

After treatment, the Constant-Murley score (58.98 ± 9.84) was significantly improved compared with pre-treatment (29.33 ± 9.71), the VAS score (1.23 ± 0.87) was significantly lower than pre-treatment (7.54 ± 1.22), and the shoulder flexion angle (142.67 ± 8.59°) was significantly improved compared with pre-treatment (51.50 ± 2.10°); the difference was statistically significant (P < 0.05).

CONCLUSIONS

Arthroscopic rotator cuff suture and simultaneous 360° capsular release have a significant effect on the treatment of rotator cuff tear with limited shoulder movement.

The Correlation between Various Shoulder Anatomical Indices on X-Ray and Subacromial Impingement and Morphology of Rotator Cuff Tears

OBJECTIVES

Rotator cuff injury caused by subacromial impingement presents different morphologies. This study aims to investigate the correlation between various shoulder anatomical indexes on X-ray with subacromial impingement and morphology of rotator cuff tears to facilitate surgical management.

METHOD

This retrospective study was carried out between January 2020 and May 2022. Patients who were diagnosed as sub-acromial impingement associated with rotator cuff tears (without tendon retraction) and received arthroscopic surgery were enrolled in this study. The radiographic indexes of acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), acromial Index (AI), and sub-acromial distance (SAD) were measured on preoperative true AP view and outlet view. The location of rotator cuff tear (anterior, middle, posterior, medial, and lateral) and morphology of tear (horizontal, longitudinal, L-shaped, and irregular shaped) were evaluated by arthroscopy. Groups were set up due to different tear location and tear morphologies, by comparing the various radiographic indices between each group (one-way analysis of variance and t-test), the correlation between radiographic indices and tear characteristics was investigated.

RESULTS

We analyzed 92 shoulders from 92 patients with a mean age of 57.23 ± 8.45 years. The AS in anterior tear group (29.32 ± 6.91°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.000) and posterior tear group (24.01 ± 7.69°) (p = 0.041). The AS in posterior tear group (24.01 ± 7.69°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.029). The LAA in middle tear group (67.41 ± 6.54°) was significantly smaller than that in posterior group (72.74 ± 8.78°) (p = 0.046). The AS in longitudinal tear group (26.86 ± 8.41°) was significantly larger than that in horizontal tear group (22.05 ± 9.47°) (p = 0.035) and L-shaped group (21.56 ± 6.62°) (p = 0.032). The LAA in horizontal group (70.60 ± 6.50°) was significantly larger than that in L-shaped group (66.39 ± 7.31°) (p = 0.033). The AI in L-shaped tear group (0.832 ± 0.074) was significantly larger than that in horizontal tear group (0.780 ± 0.084) (p = 0.019) and irregular tear group (0.781 ± 0.068) (p = 0.047).

CONCLUSION

Acromion with a larger AS and a smaller LAA tend to cause anterior or posterior rotator cuff tears rather than middle tears in sub-acromial impingement. Meanwhile acromion with a larger AS tends to cause a longitudinal tear, a larger LAA tends to cause horizontal tears and a larger AI tends to cause L-shaped tears.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

BACKGROUND

Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated.

PURPOSE

To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes.

RESULTS

A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05).

CONCLUSION

This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

The Incidence of Postoperative Shoulder Stiffness After Arthroscopic Rotator Cuff Repair: A Systematic Review

Rotator cuff tear (RCT) is a common shoulder condition frequently treated with arthroscopic rotator cuff repair (ARCR) after conservative interventions have failed. Postoperative shoulder stiffness (POSS) is a common complication after ARCR. The purpose of this study is to determine the incidence of POSS after ARCR in total and based on tear extent prior to ARCR. A systematic review was performed using PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), and ScienceDirect databases. The search terms were "rotator cuff repair" AND "arthrofibrosis" OR "postoperative shoulder stiffness." Articles were selected based on ARCR and the presence of POSS documentation. Twenty-five articles out of 284 articles met the final selection criteria after reviewing for patients who received ARCR. Out of all patients (n=9,373), 597 had POSS (6.4%). Out of the 2,424 patients with a specified tear pattern, 96 out of 1,862 (5.2%) patients with full-thickness tears and 58 out of 562 (10.3%) patients with partial-thickness tears had POSS after ARCR. Partial-thickness tears are associated with higher rates of POSS after ARCR as compared to full-thickness tears (p<0.001). Overall, POSS is a common complication after ARCR with an incidence of 6.4%, regardless of tear type. POSS is more common in patients who receive ARCR for partial-thickness RCT (10.3%) as compared to patients who receive ARCR for full-thickness RCT (5.2%). More research is needed to determine other factors impacting the incidence of POSS after ARCR.

Soft Anchors for Rotator Cuff Repair: A Review

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All-suture anchors or so-called "soft" anchors, initially adapted for labral repairs, have increased in popularity for use in rotator cuff repair because of their smaller size, decreased occupation of the footprint, improved points of fixation, ease of use, and ease of revision.

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In limited series, soft anchors have demonstrated equivalent biomechanical and clinical performance compared with hard body anchors for rotator cuff repair.

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Perianchor cyst formation can occur with both hard body and soft anchors.

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Biomechanical and clinical data support aiming for vertical angles of insertion for soft anchors.

Combination of autologous osteochondral and periosteum transplantation effectively promotes fibrocartilage regeneration at the tendon-bone junction of the rotator cuff in rabbits

PURPOSE

Rotator cuff tendon-bone healing often leads to scarring and low biomechanical strength, resulting in a tendency to re-tear. This study examined whether combining autologous osteochondral transplantation and periosteum transplantation increases fibrocartilage transition zone regeneration and improves biomechanical fixation.

METHODS

A total of 48 New Zealand white rabbits were divided into the periosteum, autologous osteochondral, combination of autologous osteochondral and periosteum, and control groups. The supraspinatus tendon was cut from the greater tuberosity and repaired by different transplants. A total of 12 rabbits were used for histological examination (haematoxylin and eosin staining, Masson's staining and Safranin-O staining) at 4, 8 and 12 weeks after the repair, and 36 rabbits were used for biomechanical tests (maximal failure load and stiffness).

RESULTS

At 4 weeks following the operation, each group had a large tendon-bone gap with a small number of disordered collagen fibres. At 8 weeks, the tendon-bone gap was smaller than that before the operation, and the tendon-bone gap in each experimental group was smaller with neater and denser collagen fibres and chondrocytes than in the control group, with the osteochondral combined periosteum group having the best results. At 12 weeks, the typical tendon-bone transitional structure was observed in the osteochondral combined periosteum group, and more collagen fibres and chondrocytes were generated in each group. The osteochondral combined periosteum group had the largest staining area and the largest amount of cartilage. The maximum tensile strength and stiffness of each group increased over time. There was no significant difference in each group's maximum tensile strength and stiffness at 4 weeks after the operation. However, the maximum tensile strength and stiffness of the osteochondral combined periosteum group at 8 and 12 weeks after operation were significantly higher than those of other groups (P < 0.05).

CONCLUSION

Histological and biomechanical results show that autologous osteochondral transplantation combined with periosteum transplantation can effectively promote the regeneration of fibrous cartilage in the tendon-bone junction of the rotator cuff. It is concluded that this technique is a new treatment method to promote tendon-bone healing in the rotator cuff.

Absorbable suture knots on the supraspinatus tendon prevent adverse effects of nonabsorbable suture knots in a rat model

PURPOSE

To compare the absorbable and nonabsorbable suture knots on the tendon on bone-to-tendon healing during the early phase in a rat rotator cuff tear (RCT) model.

METHODS

Fifty-two male Sprague-Dawley rats (10 weeks old; mean weight, 380 g) were used in this study, and 51 of them were randomly assigned into three groups: absorbable suture group (ASG, n = 22), nonabsorbable suture group (NSG, n = 22), and sham surgery group (SSG, n = 7), and the remaining rat was used to take surgical pictures. Bilateral supraspinatus tendon tears were created and repaired immediately in ASG and NSG. Three rats from ASG and NSG were killed for Western blot and histological evaluation at 3 days, 1 week, and 4 weeks after surgery. At 4 weeks, four rats from each group were killed for biomechanical test, and three rats from SSG were used for histological evaluation.

RESULTS

Absorbable suture knots on the tendon completely degraded at 4 weeks. However, nonabsorbable suture knots remained intact between the tendon and articular side. ASG showed a stronger inflammatory reaction at 3 days and 1 week, but a weaker reaction at 4 weeks as confirmed by gross observation and Western blot. Besides, ASG showed superior biomechanical properties in terms of maximum load to failure and stiffness at 4 weeks. Modified Bonar score revealed superior maturity for tissue healing in ASG to that in NSG at 4 weeks. Furthermore, inferior bone-to-tendon interface and weakest link formation were observed in NSG on histologic images.

CONCLUSION

Absorbable suture knots on the tendon contributed to better mechanical properties compared with the nonabsorbable one after rotator cuff repair.

Comparative effectiveness of different platelet-rich plasma for arthroscopic rotator cuff repair: A protocol for systematic review and network meta-analysis

BACKGROUND

Rotator cuff tears are one of the most common injuries of the shoulder joint in adults. Arthroscopic rotator cuff repair (ARCR) has become the gold standard for the treatment of rotator cuff injuries, but it still has a high rate of retear. Platelet-rich plasma (PRP) has been widely used as an adjunct to ARCR. However, the comparative efficacy of different PRP for ARCR remain unclear. In order to evaluate the relative efficacy of PRP for individuals with ARCR, we will conduct a systematic review and network meta-analysis of randomized controlled trials.

METHODS

A systematic literature search will be conducted in Embase, PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Database, and Chinese Biomedical Literature Database will be searched up to October 2022. The primary outcome will focus on the retear rate at the last follow-up. The secondary outcomes include the Visual Analogue Scale for postoperative pain and functional capacity scores. The risk of bias for individual studies will be assessed according to the revised Cochrane risk-of-bias tool for randomized trials (RoB 2.0). Data analysis will be performed using R 4.1.2. Publication bias will be examined using comparison-adjusted funnel plots and Egger's test using STATA 15.0. The quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

The results of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSIONS

The review will compare the efficacy of different PRP for patients with ARCR. The result of the study will provide evidence-based medical evidence for ARCR with PRP augmentation.

si-Tgfbr1-loading liposomes inhibit shoulder capsule fibrosis via mimicking the protective function of exosomes from patients with adhesive capsulitis

BACKGROUND

Adhesive capsulitis is a common shoulder disorder inducing joint capsule fibrosis and pain. When combined with rotator cuff tear (RCT), treatments can be more complex. Currently, targeted therapy is lacking. Since adhesive capsulitis is reported to be related to circulating materials, we analyzed the contents and biology of circulating exosomes from RCT patients with and without adhesive capsulitis, in an attempt to developing a targeting treatment.

METHODS

Samples from a consecutive cohort of patients with RCT for surgery were collected. Circulating exosomal miRNAs sequencing were used to detect differentially expressed miRNAs in patients with and without adhesive capsulitis. For experiments in vitro, Brdu staining, CCK-8 assay, wound healing test, collagen contraction test, real-time quantitative polymerase chain reaction, and western blot were conducted. Histological and immunofluorescent staining, and biomechanical analysis were applied in a mouse model of shoulder stiffness. The characteristics of liposomes loaded with siRNA were measured via dynamic light scattering or electron microscopy.

RESULTS

Circulating exosomal miRNAs sequencing showed that, compared to exosomes from patients without adhesive capsulitis, miR-142 was significantly up-regulated in exosomes from adhesive capsulitis (Exo-S). Both Exo-S and miR-142 could inhibit fibrogenesis, and the anti-fibrotic effect of Exo-S relied on miR-142. The target of miR-142 was proven to be transforming growth factor β receptor 1 (Tgfbr1). Then, liposomes were developed and loaded with si-Tgfbr1. The si-Tgfbr1-loading liposomes exhibited promising therapeutic effect against shoulder stiffness in mouse model with no evidence toxicity.

CONCLUSION

This study showed that, in RCT patients with adhesive capsulitis, circulating exosomes are protective and have anti-fibrotic potential. This effect is related to the contained miR-142, which targets Tgfbr1. By mimicking this biological function, liposomes loaded with si-Tgfbr1 can mitigate shoulder stiffness pre-clinically.

Three Medial All Suture Anchors Improves Contact Force Compared to Two Hard Body Anchors in a Biomechanical Two-Tendon Rotator Cuff Tear Model

Purpose

To biomechanically compare a knotless double-row construct with 3 medial all-suture (3AS) anchors with a standard 2 medial hard body (2HB) anchor construct.

Methods

Twelve matched cadaveric shoulder specimens with a mean age of 57 years (range: 54-61 years) were randomized to receive a knotless double-row repair with either a 3AS or 2HB construct. In the 3AS construct, three 2.6-mm all-suture anchors were placed adjacent to the articular margin and secured laterally with two 4.75-mm knotless hard body anchors. In the 2HB construct, two 4.75-mm medial hard body anchors were placed medially, lateral fixation was identical to the 3AS construct. Creep, displacement, stiffness, and ultimate load were recorded for each sample. In addition, a SynDaver model was used to compare contact pressure between the 2 repair constructs.

Results

There were no differences in cyclic displacement at 1, 30, and 100 cycles (P = .616, .497, .190, respectively), cyclic stiffness (.928), ultimate load (.445), or load to failure (P = .445) between the 2 constructs. The 3AS repair construct had improved contact pressure between tendon and bone when compared with the 2HB construct at loads of 20 N, 30 N, and 40 N (P = .01, .02, and .04, respectively).

Conclusions

Displacement and load to failure properties are similar between knotless constructs using either 2HB or 3AS for the medial row. However, contact force may improve with the use of 3 medial all-suture anchors.

Clinical Relevance

As all-suture anchors are smaller in size when compared with hard body anchors. For this reason, there is potential to place an additional all-suture medial anchor to improve contact force and potentially improve rotator cuff healing when compared with the use of hard body anchors.