Pre-operative factors correlated with arthroscopic reparability of large-to-massive rotator cuff tears

Assessment of the Rotator Cuff Muscles: State-of-the-Art MRI and Clinical Implications

Rotator cuff (RC) tears are a common cause of shoulder pain and, depending on the tear pattern, can substantially limit daily activities and affect quality of life. After a tendon tear, the RC muscle undergoes degenerative changes, including fatty degeneration and volume atrophy. The extent of fatty muscle degeneration has been associated with poorer functional and surgical outcomes after RC reconstruction, and the evaluation of the RC muscles is one of the most important factors for deciding whether to perform an RC repair. A variety of qualitative and quantitative methods are available to assess RC fatty muscle degeneration and volume atrophy based on MRI. This review provides a detailed overview of the RC muscle assessment, including qualitative measurements to assess the RC muscles, such as Goutallier grading, tangent sign, and fish backbone sign. Another focus is state-of-the-art quantitative MRI techniques, including chemical shift-based techniques such as single-voxel MR spectroscopy, multipoint water-fat separation, and MR relaxometry. Furthermore, the clinical relevance of qualitative and quantitative intramuscular fat assessment is addressed, and its potential importance for treatment planning and patient outcomes is discussed.

Primary Cuff Repair Augmented With a Balloon Spacer in a Large and Massive Rotator Cuff Tear Series: A Technique and Short-term Outcome and Imaging Study

Massive rotator cuff tears are a challenge for patients and surgeons. We explored the outcomes of patients with massive rotator cuff tears primarily treated with primary cuff repair augmented with a subacromial balloon spacer. The mean age of the patients was 64.3 years, with 24 (71%) having massive cuff tears and the remaining 29% having large cuff tears. Most patients (61%) exhibited significant fatty atrophy (at least grade 3 Goutallier). At 6 months, patients showed improved Constant score, UCLA score, and Oxford Shoulder Score. Pain scores also significantly decreased. A phase 1 study of postoperative imaging indicated balloon disintegration in 50% of cases at 6 weeks. Augmenting primary cuff repair with a subacromial balloon spacer demonstrates promising short-term outcomes. Our postoperative images suggest that balloon disintegration may occur as early as 6 weeks. We recommend caution in using a balloon spacer as a standalone therapy. [Orthopedics. 2025;48(1):e56-e61.].

Retear Rate Between 1 and 2 Years Postoperatively After Arthroscopic Rotator Cuff Repair Is Over 30% and Associated With Higher Tear Size and Fatty Degeneration

PURPOSE

The purpose of this study was to evaluate the integrity of the repaired rotator cuff between 1 and 2 years postoperatively after arthroscopic rotator cuff repair (ARCR) using magnetic resonance imaging (MRI), investigate the factors affecting its change, and assess the association between the change and postoperative clinical outcomes.

METHODS

Rotator cuff tear patients who underwent ARCR and were evaluated by MRI before surgery, and 1 and 2 years after ARCR with a minimum of 2-year follow-up were included in this study. Repair integrity was evaluated using Sugaya's classification, and according to the classification types IV and V were defined as retears. In addition, fatty degeneration of the rotator cuff muscles was evaluated using Goutallier's classification. Furthermore, the clinical scores were also assessed.

RESULTS

In total, 346 patients were evaluated. Retears were detected in 51 cases 1 year postoperatively, and the number of retear cases increased to 65 at 2 years' postoperation. The retear rate 1 to 2 years postoperatively was 33.3% of patients classified as Sugaya type III 1 year postoperatively, the highest among all types. The incidence of retears was significantly associated with preoperative tear size (P < .01) and fatty degeneration (P < .01) among these patients. The 2-year postoperative clinical scores of the retear group were significantly lower than those of the repaired group, although there was no significant difference 1 year postoperatively. Fatty degeneration after repair did not improve regardless of whether the repair was successful or not.

CONCLUSIONS

Retears between 1 and 2 years postoperatively are not uncommon. A follow-up of at least 2 years is necessary to determine short-term outcome after surgery, especially in patients with severe fatty degeneration preoperatively and those with diminished muscle thickness without discontinuity seen on MRI 1-year postoperatively.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of Clinical Outcomes Between Arthroscopic Rotator Cuff Repair and Reverse Total Shoulder Arthroplasty in Patients With Massive Rotator Cuff Tears and High-Grade Fatty Atrophy Without Glenohumeral Osteoarthritis

Background

Despite the effectiveness of reverse total shoulder arthroplasty (RSA) and arthroscopic rotator cuff repair (ARCR) for treating massive rotator cuff tears (MRCTs), controversies remain in patients without glenohumeral osteoarthritis (GHOA).

Purpose

To compare clinical outcomes of ARCR or RSA in patients with MRCT with high-grade fatty atrophy without GHOA.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective study on patients with MRCTs without GHOA and with grades 3 or 4 Goutallier muscle changes who underwent ARCR or RSA, with a minimum 2-year follow-up. Range of motion (ROM) and patient-reported outcomes (PROs) were collected-including visual analog scale for pain, American Shoulder and Elbow Surgeons score, Veterans Rand 12-Item Health survey, and Subjective Shoulder Value. Postoperative results were compared based on rotator cuff tendon healing in the ARCR group.

Results

A total of 81 patients met the study criteria-56 underwent ARCR and 25 underwent RSA. Patients in the RSA (age, 71.7 ± 7.7 years) group were older than those in the ARCR (age, 66.7 ± 7.4 years) group (P = .01) and more likely to have pseudoparalysis (52% vs 21.4%; P = .016). The mean follow-up for the ARCR and RSA groups was 56.5 ± 19 months and 36.1 ± 7.6 months, respectively (P < .001). The rate of patients with ≥2 tendons with grade 3 or 4 changes was higher in the RSA group compared with the ARCR group: 96% versus 47% (P < .001). PROs significantly improved after surgery in both groups (P < .05). Postoperative forward flexion (FF) and internal rotation were higher after ARCR compared with RSA-144°± 22° versus 113°± 25° and L3 ± L4 versus S1 ± S2, respectively (P <.001 and P = .002, respectively). Also, 31 of the rotator cuff repairs (55%) healed. PROs were similar between the healed and unhealed ARCR groups, with the only difference observed in postoperative FF-150°± 18° in the healed group versus 136°± 26° in the unhealed group (P = .044).

Conclusion

Both ARCR and RSA improved functional outcomes in patients with MRCT without GHOA. While healing was moderate after ARCR, the postoperative ROM was greater after ARCR compared with RSA in appropriately selected patients. Moreover, healed rotator cuffs demonstrated improved postoperative FF compared with unhealed repairs.

Trans-axillary sonography in the ABER (ABduction and External Rotation) position: a window to the subscapularis, teres major and latissimus dorsi

Shoulder ultrasound is a key tool used by musculoskeletal practitioners to diagnose and treat a variety of upper girdle diseases. While magnetic resonance imaging is the cornerstone of shoulder imaging, sonography is readily available, practical and superior in its ability for dynamic assessment of musculoskeletal pathologies. The subscapularis, teres major and latissimus dorsi muscles are commonly involved in a myriad of pathology including myofascial pain and spasticity. There is scarce literature on the assessment of these muscles for diagnostic and therapeutic purposes. Conventional approaches to shoulder ultrasound have not included a dedicated assessment of the subscapularis muscle due to its inherent anatomical location deep to the scapular blade which blocks sound wave penetration. We describe an approach to visualizing the subscapularis muscle as a short addition to the established shoulder sonography format, which also permits assessment of both the latissimus dorsi and teres major muscles, which are important muscles for shoulder spasticity. The patient is imaged in a semi-recumbent position with the arms elevated above and behind the head in the ABduction and External Rotation (ABER) position. The relative ease of positioning and sonographic access to the musculature coupled with the potential for assessment and intervention makes this approach extremely desirable to the musculoskeletal practitioner looking to diagnose or treat muscle belly pathologies of the subscapularis, teres major or latissimus dorsi.

Efficacy of Diagnostic In-Office Shoulder Ultrasound in the Surgical Treatment of Full-Thickness Rotator Cuff Tears

Background

Early surgical management of full-thickness traumatic rotator cuff tears (RCTs) may optimize functional outcomes, prioritizing timely diagnoses. Ultrasound and magnetic resonance imaging (MRI) are highly sensitive and specific modalities for RCT diagnosis, yet MRI remains the gold standard diagnostic tool despite increased costs and potential delays in care. Ultrasound can provide same-day diagnosis, thus possibly expediting care.

Hypothesis

The use of diagnostic shoulder ultrasound alone in the orthopaedic surgeon's office could increase the efficiency of diagnosis and care of traumatic full-thickness RCTs compared with MRI.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review of patients with full-thickness traumatic RCT diagnosed via ultrasound or MRI who subsequently underwent rotator cuff repair with 1 of 2 ultrasound-trained surgeons between January 1, 2014, and December 31, 2019, was performed. Inclusion criteria included patients ≥18 years old, documentation of a first-time traumatic event, and the patient's desire to have immediate surgical management. Revision surgeries, long-term shoulder instability, and nontraumatic injuries were excluded. Basic demographic data were collected, and the number of preoperative office visits and the timing from initial evaluation to diagnosis and surgery were calculated for the ultrasound and the MRI cohorts. A power analysis of 0.8 with an alpha of .05 required 38 patients per group.

Results

Overall, 133 patients were diagnosed via MRI compared with 76 via ultrasound. Besides body mass index, there were no significant differences in demographic variables or insurance status. Compared with the MRI cohort, patients in the ultrasound cohort received their diagnosis almost 2 weeks faster (P < .0001), were scheduled for surgery almost 3 weeks faster (P < .0001), and underwent surgery 2 weeks faster after initial evaluation (P < .0001) while requiring nearly half as many clinical visits (P < .0001). Regression analysis confirmed that ultrasound significantly reduced time to imaging, scheduling, and surgery after initial evaluation while requiring fewer clinical visits (P < .05).

Conclusion

The study findings indicated that ultrasound was a time-saving alternative diagnostic modality for traumatic RCT compared with MRI without compromising standard of care. These results were achieved independent of patient insurance status, disability index, or other demographic variables.

The Suprascapular Artery as a Reference for the Evaluation of Supraspinatus Fatty Infiltration on Magnetic Resonance Imaging

Background

Fatty infiltration (FI) of the supraspinatus is commonly seen in chronic large-to-massive rotator cuff tears. Evaluating FI in patients with severe muscle atrophy can be confusing.

Purpose/Hypothesis

The purpose of this study was to investigate the anatomic relationship between the suprascapular artery and supraspinatus muscle on magnetic resonance imaging (MRI) to provide a method for defining the border of the supraspinatus muscle on Y-view MRI. It was hypothesized that the branches of the suprascapular artery would encircle the supraspinatus muscle on Y-view and adjacent MRI slices and could be used for defining the supraspinatus outline on oblique sagittal images.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

A total of 172 shoulders that had undergone arthroscopic repair for large-to-massive rotator cuff tears were retrospectively included. Two methods, one based on the supraspinous fossa and trapezius (SF method) and the other based on the region bounded by the branches of the suprascapular artery (SA method), were used for defining the supraspinatus outline on Y-view MRI for the assessment of FI. Preoperative supraspinatus FI grade and tangent sign and postoperative tendon integrity were evaluated. Shoulder function was assessed using the American Shoulder and Elbow Surgeons (ASES) score and active range of motion.

Results

The branches of the suprascapular artery encircled the supraspinatus in all shoulders, with the diameter of the branches ranging from 0.5 to 3 mm. The agreement in supraspinatus FI grading between the SF and SA methods was 65.12%. When limited to the 61 shoulders with a positive tangent sign, the agreement dropped to 22.95% (κ = 0.032). The group (FI grade 2 by SA method and ≥3 by SF method) showed no significant difference in postoperative outcomes compared with the 2-vs-2 group but had significantly better postoperative ASES scores (P = .001) and active range of motion in forward elevation (P = .020) compared with the ≥3-vs-≥3 group. The tangent sign was positive in 92.16% of the 2-vs-≥3 group.

Conclusion

The suprascapular artery is a reliable reference for the evaluation of supraspinatus FI. When a positive tangent sign presents, supraspinatus FI is likely to be overestimated if the hyperintensity outside the region bounded by the branches of the suprascapular artery is mistaken as FI.

Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs).

METHODS

PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool.

RESULTS

Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0).

CONCLUSION

This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Clinical Outcomes and Re-Tear Rates for Partial Arthroscopic Rotator Cuff Repair With or Without Biceps Augmentation for Large-to-Massive Tears: A Systematic Review and Meta-analysis

BACKGROUND

The recent addition of biceps tendon augmentation to partial arthroscopic rotator cuff repair (ARCR) for the treatment of large-to-massive rotator cuff tears is proposed to improve clinical outcomes and reduce re-tears.

MATERIALS AND METHODS

The purpose of this systematic review and meta-analysis (5 studies) was to compare outcomes between partial ARCR with (142 patients) and without (149 patients) biceps augmentation.

RESULTS

Partial ARCR with and without biceps augmentation were comparable in pain, function, and range of motion. However, biceps augmentation vs no augmentation at all during ARCR may lower re-tear rates for irreparable large-to-massive rotator cuff tears (42.9% vs 72.5%, P=.007).

CONCLUSION

More research is needed to investigate this technique and guide surgical decision-making. [Orthopedics. 2024;47(5):e217-e224.].

Association of Preoperative Shoulder Osteoarthritis Severity Score With Change in American Shoulder and Elbow Surgeons Score at 2 Years After Rotator Cuff Repair

Background

The impact of early glenohumeral osteoarthritis (GHOA) on clinical outcomes after rotator cuff repair (RCR) remains unclear. The magnetic resonance imaging (MRI)-based Shoulder Osteoarthritis Severity (SOAS) score is a comprehensive approach to quantifying glenohumeral degeneration.

Purpose

To investigate the association between SOAS scores and changes in American Shoulder and Elbow Surgeons (ASES) scores in patients who underwent RCR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two reviewers independently analyzed the preoperative MRI scans of 116 shoulders and assigned SOAS scores. Spearman correlation was used to calculate the association of mean SOAS scores with patient demographic characteristics and change in ASES scores over the 2-year follow-up period (ΔASES). Multivariate regression analysis was performed between the independent variables of patient age, sex, body mass index, and significant SOAS score components as determined by univariate analysis, with the dependent variable being ΔASES. Significance was defined as P < .05 for univariate analysis and P < .0125 after application of the Bonferroni correction for multivariate analysis.

Results

The mean ASES scores were 55.8 ± 18.6 preoperatively and 92.1 ± 12.1 at 2 years postoperatively. The mean preoperative SOAS score was 15.2 ± 7.1. On univariate analysis, the total SOAS score was positively correlated with patient age (r S = 0.41; P < .001), whereas ΔASES was negatively correlated with patient age (r S = -0.27; P = .0032). Increasing SOAS subscores for supraspinatus/infraspinatus tear size (r S = -0.28; P = .024), tendon retraction (r S = -0.23; P = .015), muscle atrophy (r S = -0.20; P = .034), paralabral ganglia (r S = -0.23; P = .015), and cartilage degeneration (r S = -0.21; P = .024) were negatively correlated with ΔASES. A negative correlation was found between increasing total SOAS score and ΔASES (r S = -0.22; P = .016). On multivariate analysis, increasing supraspinatus/infraspinatus tear size was significantly and negatively correlated with ΔASES (β = -3.3; P = .010).

Conclusion

Increasing the total SOAS score was predictive of less improvement in ASES scores at 2 years postoperatively. On univariate analysis, SOAS subscores with the strongest negative correlations with ΔASES scores included tear size, muscle atrophy, tendon retraction, paralabral ganglia, and cartilage wear. On multivariate analysis, only tear size was significantly associated with a lower change in the ASES score.

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.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study

PURPOSE

Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years.

METHODS

In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma.

RESULTS

Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups.

CONCLUSION

In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic.

LEVEL OF EVIDENCE

III.

Accuracy of the rotator cuff reparability score

BACKGROUND

The reparability of large or massive rotator cuff tears is difficult to determine pre-operatively. We previously identified age ≥ 65 years, acromiohumeral interval ≤ 6 mm, and anteroposterior tear size ≥ 22 mm as risk factors for rotator cuff repair failure. We therefore developed a rotator cuff reparability score where each of the above risk factors is assigned a score of one point.

AIM

To determine the accuracy of a rotator cuff reparability score.

METHODS

This was a retrospective cohort study of recruited patients with large or massive rotator cuff tears treated at our institution between January 2013 and December 2019. Exclusion criteria were revision surgery and patients with contraindications for surgery. All patients underwent arthroscopic rotator cuff repair and were categorized into either complete or partial rotator cuff repair. Rotator cuff reparability scores were calculated for each patient. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were assessed. A receiver operating characteristic curve was plotted to determine the optimal cut-off rotator cuff reparability score.

RESULTS

Eighty patients (mean age, 61 years; range, 25–84 years; 41 females and 39 males) were recruited. Intra- and inter-observer reliabilities were good to excellent. The number of patients with 0, 1, 2, and 3 risk factors for rotator cuff repair failure were 24, 33, 17, and 6, respectively. Complete repair was performed in all patients without risk factors. Two of the 33 patients with one risk factor and seven of the 17 patients with two risk factors underwent partial repair. One of the six patients with three risk factors underwent complete repair. The area under the curve was 0.894. The optimal cut-off score was two points with a sensitivity of 85.71% and a specificity of 83.33%.

CONCLUSION

A rotator cuff reparability score of two was determined to be the optimal cut-off score for predicting the reparability of large or massive rotator cuff tears.

Arthritis Severity and Medical Comorbidities Are Prognostic of Worse Outcomes Following Arthroscopic Rotator Cuff Repair in Patients With Concomitant Glenohumeral Osteoarthritis

Purpose

To assess demographic factors, comorbidities, radiographic variables, and injury patterns as potential prognostic indicators of poor functional and patient-reported outcomes following arthroscopic rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

Methods

A retrospective review of consecutive patients with glenohumeral osteoarthritis who underwent arthroscopic supraspinatus repairs between 2013 and 2018 with a minimum of 1-year follow up was performed. Demographic variables included age, tobacco use, alcohol use, diabetes, sex, hypercholesterolemia, and body mass index while injury patterns included partial- versus full-thickness tear, bicep tendon involvement, and osteoarthritis severity. Multivariate linear regression was used to identify independent predictors of visual analog pain scale (VAS), subjective shoulder value (SSV), and American Shoulder and Elbow Surgeons (ASES) score as well as active range of motion (ROM) in forward flexion (FF) and external rotation (ER). Binary logistic regression was used to identify predictors of repair failure as well as postoperative strength in FF and ER.

Results

In total, 91 patients (mean age 61.48 ± 9.4 years) were identified with an average follow up of 26.3 ± 5.7 months. Repair failures occurred in 9.9% (9/91 patients) of the total cohort. Postoperative outcomes were significantly improved with regards to visual analog pain scale, subjective shoulder value, ASES score, ROM in FF, FF strength, and external rotation strength compared with preoperative baseline. Obesity (P = .023) and diabetes (P = .010) were significant independent predictors of greater pain scores postoperatively. Obesity (P = .029) and tobacco use (P = .007) were significant predictors of lower ASES scores postoperatively. Finally, moderate-to-severe osteoarthritis was a significant risk factor for poor ROM and strength in FF postoperatively compared to mild osteoarthritis (P = .029). No variables were predictive of repair failure.

Conclusions

Tobacco use, obesity, and diabetes are associated with worse pain and patient-reported outcomes following arthroscopic rotator cuff repair in the context of glenohumeral OA. In addition, moderate-to-severe OA is associated with worse strength and forward flexion compared to those with mild OA.

Level of Evidence

Level III, retrospective cohort study.

Clinical outcomes of reverse shoulder arthroplasty and rotator cuff repair in patients with massive rotator cuff tears without osteoarthritis: comparison using propensity score matching

BACKGROUND

The optimal management for massive rotator cuff tears (MRCTs) without osteoarthritis (OA) remains controversial. The purpose of this study was to evaluate and compare the clinical outcomes of reverse shoulder arthroplasty (RSA) vs. rotator cuff repair (RCR) in patients with MRCTs without OA.

METHODS

We conducted a retrospective data analysis of 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR between January 2014 and April 2019. Through propensity score matching, patients were matched for sex, age, tear size, and global fatty degeneration index. Thirty-nine patients in each group were included, and all patients had completed minimal 2-year follow-up. Postoperative radiologic evaluations of healing failure were performed. The visual analog scale score for pain, range of motion, and functional outcome measures including the American Shoulder and Elbow Surgeons score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Simple Shoulder Test score, and Constant score were assessed and compared between the 2 groups.

RESULTS

Healing failure was observed in 10 patients in the RCR group (32.3%). No statistically significant differences in preoperative range of motion and functional scores were found between the RCR and RSA groups. Both groups showed significant pain relief and functional improvement at final follow-up. Patients in the RCR group showed significantly greater forward elevation (156.4° ± 23.8° vs. 139.7° ± 22.4°, P < .001) and internal rotation (thoracic vertebra, T8.2 ± 1.2 vs. T9.7 ± 2.6, P = .001). The average American Shoulder and Elbow Surgeons score was 88.3 ± 12.2 in the RCR group and 81.8 ± 16.1 in the RSA group (P = .045). The QuickDASH score was significantly higher in the RCR group (P = .019). A significantly higher Simple Shoulder Test score (9.7 ± 2.8 vs. 8.1 ± 3.0, P = .01) and a significantly higher Constant score (67.2 ± 6.5 vs. 63.2 ± 7.1, P = .011) were seen in the RCR group.

CONCLUSION

Both RSA and RCR are effective and reliable treatment options for MRCTs without OA. However, the RCR group showed better shoulder function improvement than the RSA group. Considering the possible implications of RSA, RCR should be referred to as a first-line treatment option for patients with MRCTs without OA with proper indications.

Arthroscopic Long Head of the Biceps Transposition for Superior Capsular Augmentation Results in Comparable Clinical Outcomes to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tears

Purpose

To describe a modified arthroscopic technique of long head of biceps transposition (LHBT) for superior capsular augmentation; to investigate the outcomes and effectiveness of LHBT in patients with irreparable rotator cuff tears; and to compare the results with those of arthroscopic partial repair (APR) after a 2-year minimum follow-up.

Methods

We retrospectively reviewed patients who underwent arthroscopic repair of large to massive superior rotator cuff tears. The inclusion criteria were an irreparable rotator cuff with inability of the tendon to reach the original footprint and postoperative follow-up for a minimum of 2 years. We investigated 22 patients followed up for 30.7 months (mean); 10 patients underwent isolated partial repair and 12 patients underwent LHBT combined with partial repair. The acromiohumeral interval (AHI) was measured using anteroposterior radiographs. Cuff integrity was defined using Sugaya’s classification 2 years postoperatively. Clinical outcomes were assessed preoperatively and during postoperative follow-up (minimum 2 years) using the American Shoulder and Elbow Surgeons and University of California, Los Angeles shoulder rating scales.

Results

Postoperative functional scores significantly improved in both groups. In the LHBT group, both American Shoulder and Elbow Surgeons and University of California, Los Angeles scores significantly improved postoperatively from 52.0 ± 14.6 to 89.3 ± 10.4 points (P = .002) and 15.2 ± 2.2 to 32.5 ± 2.6 points (P = .002), respectively. In addition, the AHI at the final follow-up was significantly greater in the LHBT group (7.5 ± 2.0 mm) than in the APR group (5.8 ± 1.9 mm) (P = .032). The retear rate, forward flexion, and postoperative functional scores at the final follow-up were better in the LHBT group; however, the intergroup differences were not statistically significant.

Conclusions

Arthroscopic LHBT for irreparable rotator cuff tears showed comparable clinical outcomes and improvement in postoperative AHI compared with APR after a minimum 2-year follow-up.

Level of Evidence

Level III, retrospective comparative trial.

Advantages of 3-dimensional Measurements for Supraspinatus Intramuscular Fatty Evaluation in Patients With Medium to Massive Rotator Cuff Tears: Comparison With a Single Sagittal Slice

BACKGROUND

Fatty infiltration of the rotator cuff muscles is highly related to poor outcomes after rotator cuff tears. Fat fraction (FF) based on traditional 2-dimensional measurements (2D-FF) from a single sagittal Y-view slice cannot determine intramuscular FF in the rotator cuff muscles; the newly developed 3-dimensional method (3D-FF) is supposed to precede 2D measurements for intramuscular FF evaluation in accuracy and reliability.

PURPOSE

(1) To measure 3D-FF and (2) to compare 3D-FF and 2D-FF in terms of quantitative values and intra- and interobserver agreement.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Six-point Dixon magnetic resonance imaging was performed in patients with full-thickness supraspinatus tears. 2D-FF was calculated on a single sagittal Y-view. Semiautomatic segmentation software (ITK-SNAP) was used to reconstruct 3D volumes of the supraspinatus muscle and fat. 3D-FF was obtained by dividing the fat volume by the total volume of the supraspinatus muscle. A paired t test was used to compare the individual differences between 2D-FF and 3D-FF results. Linear regression and Bland-Altman analyses were performed to determine the agreement between 2D-FF and 3D-FF. Intraclass correlation coefficients (ICCs) were calculated to determine intra- and interobserver agreement.

RESULTS

The 3D muscular and fatty models presented an inhomogeneous distribution of intramuscular fat in the supraspinatus, indicating the superiority of 3D-FF over 2D-FF in capturing all muscle morphologic information. 2D-FF was significantly higher than 3D-FF in the supraspinatus with large (19.5% ± 5.9% vs 16.2% ± 3.7%; P = .002) and massive (34.8% ± 13.3% vs 26.2% ± 9.4%; P < .001) rotator cuff tears. 2D-FF overestimated the FF compared with 3D-FF by >50% in 14.7% of all patients and by >15% in 67.6% of patients with large or massive RCTs. The discrepancy between 2D-FF and 3D-FF increased with increasing mean FF. The intra- and interobserver agreement of 3D-FF (ICCs, 0.89-0.99 and 0.89-0.95) was superior to that of 2D-FF (ICCs, 0.71-0.95 and 0.64-0.79).

CONCLUSION

3D-FF indicated an inhomogeneous distribution of intramuscular fat by capturing all muscle and fat morphologic information. In patients with large and massive rotator cuff tears, 2D-FF of the supraspinatus was significantly higher than 3D-FF. 3D-FF was more reliable than 2D-FF for estimating fatty infiltration in the supraspinatus, with better intra- and interobserver agreement.

Posterior decentering of the humeral head in patients with arthroscopic rotator cuff repair

Background: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). Methods: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2 mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. Results: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 33.8, which was greater than that for tear size ≥3 cm and FD grade ≥3. Conclusions: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis

INTRODUCTION

One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR.

METHODS

Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate.

RESULTS

The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates.

CONCLUSION

In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR.

LEVEL OF EVIDENCE

Level III.

Does the Interval Slide Procedure Reduce Supraspinatus Tendon Repair Tension?: A Biomechanical Cadaveric Study

Background

The benefits of the interval slide (IS) procedure in retracted rotator cuff tears remain controversial.

Purpose

The purpose was to evaluate the effect of the IS procedure on repair tension (RT). It was hypothesized that the IS procedure (anterior IS [AIS], posterior IS [PIS], and intra-articular capsular release [CR]) would reduce the RT of a supraspinatus tendon.

Study Design

Controlled laboratory study.

Methods

A total of 31 Thiel-embalmed human cadaveric shoulders (mean age, 74 years; range, 68-84 years) were tested. Full-thickness supraspinatus tendon tears were created, and 1 cm of tendon was resected to simulate a retracted defect. Shoulders were randomized into intervention (n = 16) and control (n = 15) groups. In all shoulders, the load during tendon reduction to footprint was measured, an endpoint was defined as maximum tendon lateralization before 50 N was reached, and the RT (load during lateralization to endpoint) of the native tendon (t₁) was evaluated. In the intervention group, AIS (t₂), PIS (t₃), and CR (t₄) were performed in order, with RT measurement after each step. In the control group, RT was assessed at the same time points without the intervention.

Results

A complete reduction of the tendon was not achieved in any of the shoulders. Mean maximum lateralization was 6.7 ± 1.30 mm, with no significant differences between groups. In the intervention group, the overall IS procedure reduced RT about 47.0% (t₁ vs t₄: 38.7 ± 3.9 vs 20.5 ± 12.3 N; P < .001). AIS reduced RT significantly (t₁ vs t₂: 38.7 ± 3.9 vs 27.4 ± 10.5 N; P < .001), whereas subsequent PIS (t₂ vs t₃: 27.4 ± 10.5 vs 23.2 ± 12.4 N; P = .27) and CR (t₃ vs t₄: 23.2 ± 12.4 vs 20.5 ± 12.3 N; P = .655) did not additionally reduce tension. Comparison between groups at t₄ revealed a reduction of RT of about 47.8% (control vs intervention: 39.3 ± 4.0 vs 20.5 ± 12.3 N; P < .001).

Conclusion

The IS procedure reduces RT of the supraspinatus tendon in human cadaveric shoulders. However, performing PIS and CR subsequent to AIS does not reduce tension additionally.

Clinical Relevance

These findings provide surgeons with a biomechanical rationale regarding the efficacy of the IS procedure.

[Image and report quality of outpatient MRI examinations : Evaluation of organizational, technical and report-related parameters in patients with arthroscopically secured rotator cuff rupture]

BACKGROUND

MRI is commonly used to diagnose and assess prognosis for rotator cuff (RM) pathology in addition to history and clinical examination.

AIM

This study investigates the image and report quality of shoulder MRIs with regard to prognosis-relevant parameters in outpatients who subsequently underwent surgical treatment for RM rupture.

MATERIALS AND METHODS

Using a defined questionnaire, both the MR images and the original reports of 94 patients were evaluated by an experienced radiologist with regard to referral information, MRI technology and quality of the MRI reports.

RESULTS

Questions or comments on RC were noted in 39% (general practitioners) and 48% (orthopaedics/UCH) of referrals. In MRI reports with the diagnosis "complete rupture of the RC", no information on the size of the defect was available in 47% of cases. In 18 and 30% of the reports, respectively, a fatty infiltration of the RM musculature or atrophy of the musculature was mentioned. When a partial RC rupture (n = 25) was diagnosed; the depth diameter (< or > 50% of the tendon thickness) was determined in only one case. The protocol recommendations valid today for MRI diagnostics of the shoulder were implemented in 60% of the examinations. According to the evaluating radiologist, 93-97% of the available MRI examinations were able to answer prognostic-relevant questions of an RC rupture.

DISCUSSION

The questions by physicians referring to the MRI examination of a shoulder with a subsequently arthroscopically verified RC rupture were predominantly unspecific or insufficient. In the radiological reports of these MRI examinations, prognosis-relevant parameters could not be extracted in sufficient form and number, although the MRI technique would have allowed this.

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.

Predicting the surgical reparability of large-to-massive rotator cuff tears by B-mode ultrasonography: a cross-sectional study

PURPOSE

This study aimed to compare the ability of B-mode ultrasonography and magnetic resonance imaging (MRI) to predict the repairability of large-to-massive rotator cuff tears (RCTs).

METHODS

This cross-sectional study included participants with large-to-massive RCTs who underwent arthroscopic repair. B-mode ultrasonography and MRI were conducted prior to arthroscopic repair. B-mode ultrasonography was used to evaluate the echogenicity of the rotator cuff muscle using the Heckmatt scale. Intra-rater and inter-rater reliabilities were examined for two independent physicians. MRI was used to evaluate the degrees of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, two experienced orthopedic surgeons performed surgery and decided whether the torn stump could be completely repaired intraoperatively.

RESULTS

Fifty participants were included, and 32 complete repairs and 18 partial repairs were performed. B-mode ultrasonography showed good intra-rater reliability and inter-rater reliability for assessment of the muscle echogenicity of the supraspinatus and infraspinatus muscles. The correlation coefficients between B-mode ultrasound findings and MRI findings showed medium to large effect sizes (r=0.4-0.8). The Goutallier classification of the infraspinatus muscles was the MRI predictor with the best discriminative power for surgical reparability (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.81 to 0.98), while the Heckmatt scale for infraspinatus muscles was the most accurate ultrasound predictor (AUC, 0.85; 95% CI, 0.74 to 0.96). No significant differences in AUCs among the MRI and ultrasound predictors were found.

CONCLUSION

B-mode ultrasonography was a reliable examination tool and had a similar ability to predict surgical reparability to that of MRI among patients with large-to-massive RCTs.

Clinical and radiological outcomes with PEEK suture anchors used in rotator cuff repair: our experience confirm that a perianchor fluid signal on RM does not affect clinical outcome at one year of follow up

Introduction / objectives:

Osteolytic-type reactions of the perianchor bone which in magnetic resonance are manifested as hyperintensity of the signal in T2 images are reported in many studies. The doubt that this reaction of the bone could result in a loss of pull-out in the short and medium term and that it could therefore negatively affect tendon healing is the subject of an increasing number of studies. An osteolytic type signal around absorbable anchors can be explained by the metabilic processes in progress foreseen by the very nature of the material used, however this type of signal is also recognized around sutured implants or made of notoriously inert material. The objective of the present study is to evaluate and compare to the literature data the clinical and radiological results of a group of patients who underwent arthroscopic suture of a rotator cuff tear using polyetherketone (PEEK) suture anchors.

Materials and methods:

Twenty patients, aged between 44 and 73 years, who underwent arthroscopic repair of the rotator cuff for lesions smaller than 4 cm considered reparaible between August 2017 and January 2019, were enrolled in the present study. Patients were evaluated clinically with clinical examination, Constant scale and ASES scale pre and post surgery. MRI either pre and post operation at one year were evaluated to obtain data about tendon healing and evaluate bone reaction to PEEK anchors.

Results:

The mean lesion size was 16.8 mm +/- 7.8 mm and the mean tendon retraction was 15.6 mm +/- 14.9 mm. The mean increase in Constant and ASES scores at the one year-follow up was respectively 36.8 (p<0.01) and 47.2 (p<0.01). MRI analysis showed a tendon signal according to Sugaya classification of type 1 in the 25% of patients, type 2 in the 60% of cases and type 3 in the remaining 15% . Osteolysis was grade 0 in 65%, grade 1 in 30 % and grade 2 in 5% of cases. No anchors pull out or mobilization were reported.

Conclusions:

The presence of a T2 hyperintense signal osteolysis like on MRI control using PEEK anchors for the sutur of rotator cuff lesions does not find correlation whit the final clinical result of the procedure. Indeed, both patients with a major degree of osteolysis and those with degree 0 had an improvement both in terms of clinical and scores evaluation and in termsof tendon healing according to Sugaya’s score found in our cohort. (www.actabiomedica.it)

Partial Rotator Cuff Repair for Massive Tears Rarely Require Revision Surgery

Purpose

To determine the significance of initial and residual rotator cuff tear defect size on the need for revision surgery or additional nonsurgical therapy, in a consecutive group of patients undergoing partial repair of massive rotator cuff tears.

Methods

A retrospective chart review was carried out for all arthroscopic rotator cuff repairs performed by a single surgeon between January of 2013 and December of 2016. All patients with massive rotator cuff tears (>30 cm²) who underwent partial repair were included in the study. Outcomes for the surgical procedure were measured based on the necessity for revision surgery or adjunct therapy, including steroid injections or additional physical therapy after initial release from care.

Results

In total, 1954 patients who underwent arthroscopic rotator cuff repair were identified. Thirty-eight of these met the inclusion criteria. Those patients undergoing revision surgery represented 5.2% (2/38) of the series and had an average initial/residual tear defect area of 45.0/7.0 cm². Patients requiring adjunct therapy represented 7.9% (3/38) of the series and possessed an average initial/residual tear defect size of 40.0/16.0 cm². The remaining 33 (86.9%) patients did not require revision surgery or adjunct therapy at a minimum follow-up of 2 years. There was no significance between initial and/or residual rotator cuff tear defect size and the need for revision surgery. However, there was a significant difference in the mean residual defect size in the patients requiring additional nonoperative treatment after initial release from care (P = .012).

Conclusions

There was no relationship between residual defect size after partial repair and the need for revision surgery. Patients who returned for additional nonoperative treatment after being released from care were noted to have a statistically larger residual defect size at the time of index surgical intervention. Only 5% of patients underwent subsequent surgery at an average of more than 4 years’ follow-up, suggesting that partial repair of massive rotator cuff tears can provide a durable, joint-preserving intervention.

Level of Evidence

Level IV, Therapeutic Case Series

Factors Influencing the Reparability and Healing Rates of Rotator Cuff Tears

PURPOSE OF THE REVIEW

To discuss tear- and patient-related factors that influence the healing potential of rotator cuff tears and to clarify the terminology surrounding this topic.

RECENT FINDINGS

Over the last few years, further insight has been gained regarding rotator cuff tear features that are associated with poor healing rates after rotator cuff repair. Some of these features have been incorporated in prediction models developed to accurately predict rotator cuff healing rates utilizing preoperative risk factors weighted by importance. Rotator cuff tears may be considered functionally irreparable based on their size, chronicity, absence of adequate tendon length, atrophy, and fatty infiltration. Furthermore, advanced age, use of tobacco products, diabetes, and other patient-related factors may impair tendon healing. Careful analysis and discussion of all these factors with patients is essential to determine if surgical repair of a rotator cuff tear should be recommended, or if it is best to proceed with one of the several salvage procedures reviewed in this topical collection, including augmentation of the repair, superior capsular reconstruction, tendon transfers, and other.

Reliability of open architecture anchors in biocomposite material: medium term clinical and MRI evaluation. Our experience

OBJECTIVES

Comparing radiologic bone ingrowth and the clinical outcomes of an open-construct (PEEK) (polyether ether ketone) suture anchor with those of a bio-composite suture anchor (glycolic polylactic acid anchors, beta-tricalcium phosphate and calcium sulphate) in patients with arthroscopic rotator cuff repair.

METHODS

From August 2017 to January 2019, 33 patients of both sexes, aged between 44 and 78 years underwent arthroscopic rotator cuff repair for tears considered repairable with an extension not exceeding4 cm. The bioabsorbable anchors used comprised glycolic polylactic acid/beta-tricalcium phosphate/ calcium sulphate, and the non-absorbable anchors in polyetheretherketone (PEEK). All patients underwent MRI evaluation at 12 months postoperatively to determine complications and identify any re-tear.

RESULTS

Clinical scores showed an improvement from both clinical and functional point of view. There were no statistically significant changes compared to the physical examination. On radiographs, mobilizations, anchor pull-outs or other complications did not occur in each group.

CONCLUSIONS

Shoulder function improved after complete repair of the rotator cuff and similar clinical results were achieved regardless of the material and shape of the suture anchor. The bioabsorbable anchors in innovative open architecture material seem to have results comparable to peek anchors. Unfortunately, further studies are needed to define the advantages in using one material compared to the other. (www.actabiomedica.it).

Analysis of Greater Tuberosity from the Center of the Humeral Head: Progression to Femoralization

Background

Progression of the tear size and erosion of the greater tuberosity (femoralization) in the supraspinatus tear makes it difficult to repair or increases the risk of a re-tear. This study examined the proximal articular surface and greater tuberosity of the humeral head in plain radiography.

Methods

Two-hundred forty-seven cases, whose anteroposterior (AP) radiographs were taken correctly, were included from 288 cases, in whom the status of the supraspinatus had been confirmed by surgery. After downloading the plain AP radiograph as DICOM, the radius of the circle apposed at the superior half of the articular surface of the head, and the distance between the circle and the farthest point of the greater tuberosity (‘height’ of the greater tuberosity) were calculated using the software (TechHime, Korea). MRI checked the number of torn tendons and degree of muscular atrophy.

Results

The following were encountered: 93 intact supraspinatus, 50 partial-thickness tears, and 104 full-thickness tears. In the analysis using the 93 intact cases, the average radius of the rotation center was 25.3 mm in male and 22.3 mm in female. The average height of the greater tuberosity from the circle with the same rotation center was 4.3 mm in male and 4.2 mm in female with no statistical significance. The correlation between the reparability of supraspinatus and height of the greater tuberosity, fatty infiltration, and muscular atrophy was confirmed.

Conclusions

The height of the greater tuberosity from the circle with the same rotation center was 4.3 mm in male and 4.2 mm in female. This height was strongly correlated with muscular atrophy and fatty infiltration of the supraspinatus tendon.