Surgical repair of chronic rotator cuff tears. A prospective long-term study

Editorial Commentary: Tuberoplasty Is a Reliable Option to Address Pain in Massive Irreparable Rotator Cuff Tears

The massive irreparable rotator cuff tear remains a challenging condition for which there are many reported treatment options, including biceps tenotomy or tenodesis, subacromial decompression, cuff debridement, partial or augmented rotator cuff repair, bursal acromial reconstruction, balloon spacer placement, superior capsular reconstruction, reverse total shoulder arthroplasty, and tendon transfer, among others. Optimally treating the condition relies on paying attention to several patient factors, including correctly identifying whether function loss is driven by pain or compromised shoulder kinematics. If pain is the primary limiting factor, then tuberoplasty, or "reversed subacromial decompression," seems to be a reliable option that can afford encouraging results in terms of pain and range of motion in correctly indicated individuals. It is important to note, however, that these results should not be expected in the patient with anterior-superior humeral escape or pseudoparalysis, in whom a kinematic-restoring option may be more appropriate. Considering a history of inconsistent terminology and definitions when it comes to defining massive tears, when they are irreparable, and when the patient has pseudoparesis versus pseudoparalysis, it is paramount to accurately describe patient factors, including preoperative function, in ongoing research.

Machine-learning models for diagnosis of rotator cuff tears in osteoporosis patients based on anteroposterior X-rays of the shoulder joint

OBJECTIVE

This study aims to diagnose Rotator Cuff Tears (RCT) and classify the severity of RCT in patients with Osteoporosis (OP) through the analysis of shoulder joint anteroposterior (AP) X-ray-based localized proximal humeral bone mineral density (BMD) measurements and clinical information based on machine learning (ML) models.

METHODS

A retrospective cohort of 89 patients was analyzed, including 63 with both OP and RCT (OPRCT) and 26 with OP only. The study analyzed a series of shoulder radiographs from April 2021 to April 2023. Grayscale values were measured after plotting ROIs based on AP X-rays of shoulder joint. Five kinds of ML models were developed and compared based on their performance in predicting the occurrence and severity of RCT from ROIs' greyscale values and clinical information (age, gender, advantage side, lumbar BMD, and acromion morphology (AM)). Further analysis using SHAP values illustrated the significant impact of selected features on model predictions.

RESULTS

R1-6 had a positive correlation with BMD respectively. The nine variables, including greyscale R1-6, age, BMD, and AM, were used in the prediction models. The RF model was determined to be superior in effectively diagnosing RCT in OP patients, with high AUC scores of 0.998, 0.889, and 0.95 in the training, validation, and testing sets, respectively. SHAP values revealed that the most influential factors on the diagnostic outcomes were the grayscale values of all cancellous bones in ROIs. A column-line graph prediction model based on nine variables was constructed, and DCA curves indicated that RCT prediction in OP patients was favored based on this model. Furthermore, the RF model was also the most superior in predicting the types of RCT within the OPRCT group, with an accuracy of 86.364% and 73.684% in the training and test sets, respectively. SHAP values indicated that the most significant factor affecting the predictive outcomes was the AM, followed by the grayscale values of the greater tubercle, among others.

CONCLUSIONS

ML models, particularly the RF algorithm, show significant promise in diagnosing RCT occurrence and severity in OP patients using conventional shoulder X-rays based on the nine variables. This method presents a cost-effective, accessible, and non-invasive diagnostic strategy that has the potential to substantially enhance the early detection and management of RCT in OP patient population.

Effect of Porcine-Derived Absorbable Patch-Type Atelocollagen for Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial

BACKGROUND

Even though arthroscopic rotator cuff repair is recognized as a standard treatment option, the risk of postoperative retear is a major concern.

PURPOSE

To evaluate the effect of porcine-derived absorbable patch-type atelocollagen during arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 64 patients with rotator cuff tears diagnosed on magnetic resonance imaging (MRI) were enrolled prospectively from November 2020 to December 2021. Both groups had repairs using the suture bridge technique. For the atelocollagen group, before securing the lateral anchors, we inserted porcine-derived absorbable patch-type atelocollagen between the footprint and the tendon. On postoperative day 2, the patients underwent MRI to confirm containment of the patch-type atelocollagen. At 6 months and 1 year postoperatively, the signal intensity of the repaired tendon was assessed using MRI. Patients were evaluated using the Constant score as the primary outcome, along with the visual analog scale for pain; range of motion; American Shoulder and Elbow Surgeons score; University of California, Los Angeles, score; and Korean Shoulder Score preoperatively and at 2, 3, 6, and 12 months postoperatively.

RESULTS

No significant changes in the Constant score as primary outcome, pain or other functional scores, and range of motion were observed between the groups at 1 year postoperatively. The patch-type atelocollagen was confirmed to be contained by the time-zero MRI scan taken 2 days postoperatively. Among the 55 patients included in final analysis, 12 retear cases were recorded (21.8% retear rate). A significantly lower retear rate was found in the atelocollagen group, as 3 cases were observed in this group (10.3%) and 9 cases were observed in the conventional repair group (34.6%) (P = .048).

CONCLUSION

The Constant score was not different between the groups. The retear rate after rotator cuff repair was significantly lower in the group that received porcine-derived absorbable patch-type atelocollagen compared with in the conventional group.

REGISTRATION

KCT0005184 (Clinical Research Information Service [CRIS]; https://cris.nih.go.kr).

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning

BACKGROUND

Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR.

METHODS

The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated.

RESULTS

The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size.

CONCLUSIONS

The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

Smokers Achieved Minimal Clinically Important Difference for Visual Analog Scale and American Shoulder and Elbow Surgeons Scores at a Lower Rate Than Nonsmokers Even When Repaired Supraspinatus Tendons Were Intact on Postoperative Magnetic Resonance Imaging

Purpose

To investigate the impact of smoking on clinical outcomes after repair of supraspinatus tendon in patients who had an intact repair found on postoperative magnetic resonance imaging.

Methods

Patients who received primary complete repair of supraspinatus tendon tear between 2014 and 2020 were retrospectively identified. Patients were excluded if a postoperative magnetic resonance imaging scan was not available or if the follow-up was less than 2 years. Visual analog score (VAS), American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion were assessed at the 2-year follow-up. The percentage of patients acquiring minimal clinically important difference (MCID) was reported.

Results

One hundred primary supraspinatus tendon repairs were included. The healing rate was 77% in smokers and 90% in nonsmokers. Smoking was the independent predictor of a poorer 2-year VAS (P < .001) and ASES (P < .001) scores. Significant improvement in clinical outcomes was observed between preoperation and the 2-year follow-up, regardless of the integrity of the repair or smoking status (P < .001). When the repaired tendon was intact, nonsmokers had a greater chance of achieving MCID in 2-year VAS and ASES scores than smokers. Ninety-nine percent of nonsmokers, compared with 82% of smokers, achieved MCID in VAS at the 2-year follow-up (P = .023). The corresponding figures for ASES were 98% and 71%, respectively (P = .004).

Conclusions

In this study, smoking was associated with poorer clinical outcomes, including a greater 2-year VAS pain score and a lower 2-year ASES score, when compared with nonsmokers, even in cases in which there was no full-thickness retear of the repaired supraspinatus tendon.

Level of Evidence

Level III, retrospective cohort study.

Ultrasonic shear wave elastography predicts the quality of the residual tendon before the rotator cuff repair

BACKGROUND AND PURPOSE

Effective evaluation of rotator cuff tear residual tendon quality is the key to surgical repair. However, until now, the evaluation of rotator cuff tissue by ultrasonic shear wave elasticity (SWE) has been controversial. This prospective study analyzed the association between preoperative SWE and arthroscopic residual tendon quality scores.

METHODS

The shear wave velocity (SWV) of the deltoid muscle, the supraspinatus tendon, and the supraspinatus muscle were measured in full-thickness rotator cuff tear patients. Tendon quality was scored according to tear size, tendon margin, tendon thickness, and footprint coverage during arthroscopy. The arthroscopic scores were used as the gold standard, and the SWV ratio of tendon and muscle (supraspinatus tendon/deltoid and supraspinatus muscle/deltoid) were calculated and correlated with the arthroscopic scores.

RESULT

Eighty-nine patients (129 shoulders) were enrolled, including 89 operation shoulders and 40 control shoulders. In the group of operation shoulders, both the SWV ratios of tendon (SWV-RT) and the SWV ratio of muscle (SWV-RM) were negatively correlated with arthroscopic scores (The correlation coefficient (R) ranged from -0.722 to -0.884 and -0.569 to -0.689). The SWV-RT and SWV-RM of the operation shoulders were significantly lower than that of the control shoulders (p < 0.05).

CONCLUSION

SWE could be used to predict the quality of the residual tendon before the rotator cuff repair. SWV of the supraspinatus tendon and muscle was a useful parameter to predict the quality of the residual tendon.

CRITICAL RELEVANCE STATEMENT

Measuring the shear wave velocity of the supraspinatus tendon and muscle with SWE is useful for predicting the quality of the residual tendon which is one of the key factors for a successful rotator cuff repair.

KEY POINTS

• Evaluating the quality of the residual tendon is important before surgery. • Elasticity measurements were negatively correlated with the arthroscopic score. • SWE is useful for predicting the quality of the residual tendon.

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Rotator cuff tears

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

Early Postoperative Stiffness After Arthroscopic Rotator Cuff Repair Correlates With Improved Tendon Healing

PURPOSE

To assess whether early postoperative stiffness predicts long-term stiffness and its relationship with repair integrity in patients who undergo arthroscopic rotator cuff repair (ARCR).

METHODS

This was a single-center retrospective study; 427 patients undergoing primary ARCR by a board-certified orthopaedic surgeon over 4 years were considered. Patients with at least 1 year of follow-up were categorized into stiff and non-stiff groups based on their range of motion (ROM) at 3 months' postoperatively. Stiffness was defined as passive forward flexion <120°, external rotation <30°, or internal rotation below L3. We evaluated clinical outcomes using demographics, ROM, Constant Shoulder (CS) score, University of California, Los Angeles (UCLA) score, and visual analog scale (VAS) for pain preoperatively and at 3, 6, and 12 months' postoperatively. Stiffness, retear rates, and tendon integrity were assessed via magnetic resonance imaging at 12 months.

RESULTS

Of 155 patients meeting the inclusion criteria, 68 (43.9%) were stiff, and 87 (56.1%) were non-stiff. The stiff group had significantly lower preoperative CS and UCLA scores (P = .013/.014) and greater VAS score (P = .034). At 3 months, this group showed lower ROM and functional scores (P < .001), persisting at 6 and 12 months (except internal rotation) (P < .001). Their 12-month VAS score was greater (P = .024). Postoperative stiffness occurred in 10.3% of the stiff group and 2.3% of the non-stiff group (P = .035). The 12-month retear rate was 5.9% in the stiff group and 17.2% in the non-stiff group (P = .032). Minimal clinically important difference analysis indicated ROM changes but limited functional score changes in the 2 groups.

CONCLUSIONS

This study showed that early postoperative shoulder stiffness correlates with lower preoperative functional scores and greater pain levels. Shoulder stiffness at 3 months' post-ARCR predicts 12-month shoulder stiffness but indicates better tendon integrity. While early stiffness is linked to lower functional scores and more pain, its long-term clinical impact seems limited.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Gene Expression in Synovium of Rotator Cuff Tear Patients Determined by RNA Sequencing

Rotator cuff tear (RCT) is a common shoulder disorder related to pain and dysfunction. However, the pathological mechanism of RCT remains unclear. Thus, this study aims to investigate the molecular events in RCT synovium and identify possible target genes and pathways as determined by RNA sequencing (RNA-Seq). The synovial tissue was biopsied from 3 patients with RCT (RCT group) and 3 patients with shoulder instability (Control group) during arthroscopic surgery. Then, differentially expressed (DE) mRNAs, long non-coding RNAs (lncRNAs) and micro RNAs (miRNAs) were comprehensively profiled by RNA-Seq. Gene ontology (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, and competing endogenous RNA (ceRNA) network analysis were performed to identify the potential functions of these DE genes. 447 mRNAs, 103 lncRNAs and 15 miRNAs were identified differentially expressed. The DE mRNAs were highlighted in inflammatory pathway including up-regulated T cell costimulation, positive regulation of T cell activation, and T cell receptor signaling. Down-regulated fatty acid degradation pathway and 5'-AMP-activated protein kinase (AMPK) signaling in RCT group are also enriched. Validation assay showed that the expression of pro-inflammatory molecules including IL21R, CCR5, TNFSF11, and MMP11 was significantly increased in RCT group compared with Control group. CeRNA analysis further revealed lncRNA-miRNA-mRNA regulatory networks involving IL21R and TNFSF11 in RCT. Activated synovial inflammation is the remarkable event of RCT. Importantly, increased T cell activation and disordered fatty acid metabolism signaling might play a significant role. ceRNA networks involving IL21R and TNFSF11 identified could potentially control the progression of RCT. In conclusion, our findings could provide new evidence for the molecular mechanisms of RCT and might identify new therapeutic targets.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up

Purpose

To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up.

Methods

A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound.

Results

We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores.

Conclusions

SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months.

Level of Evidence

Level IV, therapeutic case series.

The effect of medial shift of supraspinatus tendon on the glenohumeral joint motion-a cadaveric study

PURPOSE

Full-thickness retracted massive supraspinatus tears are a challenge for arthroscopic surgeons where multiple options for treatment exist, but medializing the attachment is a relatively easy procedure for which a decision can be taken intraoperatively. We investigate the viability of MATERIAL AND METHODS: Ten freshly thawed cadavers were taken and dissected. The supraspinatus tendon was resected, and then its attachment was progressively medialized. The range of motion (abduction, internal and external rotation) was recorded and compared. As a result, we noted a statistically significant decrease in abduction, internal and external rotation with progressive medialization of the supraspinatus insertion.

CONCLUSION

Medialized repair of the supraspinatus can be performed only to an extent beyond which it compromises glenohumeral motion. We noted a statistically significant decrease in ROM with even a 3 mm medialization of the tendon, but the acceptable medialization has to be determined on a case-to-case basis.

Patient Sex Is a Significant Factor in Arm Function Recovery After Arthroscopic Rotator Cuff Repair

Purpose

The purpose of this study was to investigate the impact of patient sex on arm functional recovery after arthroscopic rotator cuff repair (ARCR).

Methods

We retrospectively reviewed the clinical records of patients who underwent rehabilitation after ARCR at two affiliated hospitals between January 2014 and December 2019. Patient characteristics included age, sex, type of muscle tear, tear location, muscle strength, Japanese Orthopedic Association (JOA) score, and patient responses to the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We used mixed-effects regression models with random intercepts to evaluate the QuickDASH scores, JOA scores, and muscle strength relative to the nonoperated side.

Results

Of the 124 patients, 82 (66.1%) were 65-year-old men and 42 (33.9%) were 67-year-old women. The preoperative JOA scores (P = .03) and those at 6 months (P < .001) and 12 months (P = .04) after ARCR were significantly greater for men than for women. QuickDASH scores of men were significantly lower at 24 months (P = .02) and all other time points (P < .001) than those of women. The improvement in QuickDASH scores was significantly higher for women than for men (P < .01). The results of the multiple regression analysis showed that patient sex (95% confidence interval, 0.01-0.45; P < .05) had an impact on QuickDASH scores at 24 months after ARCR.

Conclusion

In this study, patient sex was a significant factor affecting the recovery and QuickDASH scores of patients who underwent ARCR. Level of Evidence: Level IV, prognostic case series.

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.

Effect of subscapularis repair on joint contact forces based on degree of posterior-superior rotator cuff tear severity in reverse shoulder arthroplasty

Massive irreparable rotator cuff tears (RCTs) affect the clinical outcomes of reverse shoulder arthroplasty (RSA). However, the effects of subscapularis repair on the outcomes of RSA, based on the degree of posterior-superior RCTs, are unclear. This study aimed to examine the effect of subscapularis repair on three-dimensional joint contact forces (JCFs) based on the degree of posterior-superior RCT severity in RSA. Ten human in vivo experimental data were used as input to the musculoskeletal model. A six-degrees-of-freedom (DOF) anatomical shoulder model was developed and validated against three-dimensional JCFs. The 6-DOF musculoskeletal shoulder model of RSA was then developed by importing the reverse shoulder implant into the validated anatomical shoulder model. Based on the various types of posterior-superior RCT severity, inverse dynamic simulations of subscapularis-torn and subscapularis-repaired models of RSA were performed: from isolated supraspinatus tears to partial or massive tears of the infraspinatus and teres minor. The intact rotator cuff model of RSA was also simulated for comparison with the different types of models. Our results showed that the more posterior-superior RCTs progressed in RSA, the more superior JCFs were observed at 90°, 105°, and 120° abduction in the subscapularis-torn model. However, subscapularis repair decreased the superior JCF at those angles sufficiently. In addition, the teres minor muscle-tendon force increased as infraspinatus bundle tears progressed in both the subscapularis-torn and -repaired models, in order to compensate for the reduced force during abduction. However, the teres minor muscle-tendon force was not as high as that of the infraspinatus muscle-tendon, which could result in muscle force imbalance between repaired subscapularis and teres minor. Therefore, our results suggest that repairing the subscapularis and the repairable infraspinatus during RSA can improve glenohumeral joint stability in the superior-inferior direction by restoring muscle force balance between the anterior cuff (i.e., subscapularis) and posterior cuff (i.e., infraspinatus and teres minor). The findings of this study can help clinician decide whether to repair the rotator cuff during RSA to enhance joint stability.

Improved Yet Varied Clinical Outcomes Observed With Comparison of Arthroscopic Superior Capsular Reconstruction Versus Arthroscopy-Assisted Lower Trapezius Transfer for Patients With Irreparable Rotator Cuff Tears

PURPOSE

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy-assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs).

METHODS

Over an almost 6-year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12-month follow-up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient-reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score.

RESULTS

We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P = .009), a higher global fatty infiltration index (1.5 vs 1.9, P = .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow-up of 2.9 ± 1.3 years (range, 1.0-6.3 years), no differences in patient-reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P = .017), higher forward elevation (FE) (156° vs 143°, P = .004), and higher FE strength (4.8 vs 4.5, P = .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P = .009), FE (56° vs 31°, P = .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P = .026). There was no statistically significant between-cohort difference in complication rate (9.4% vs 12.5%, P = .645) or reoperation rate (3.1% vs 10%, P = .231).

CONCLUSIONS

With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER.

LEVEL OF EVIDENCE

Level III, treatment study with retrospective cohort comparison.

Timing of retears after arthroscopic rotator cuff repair and associated factors: a retrospective analysis

BACKGROUND

Retear after arthroscopic rotator cuff repair (ARCR) remains a complication of important concern. Few reports have evaluated retear timing and its associated patient characteristics in large cohorts. This study aimed to investigate retear timing and patient characteristics and factors associated with this parameter.

METHODS

Of the 638 consecutive shoulders that underwent ARCR from August 2009 to November 2019, shoulders with retear complication within 1 year of surgery were included. Retears were defined as type IV or V of the Sugaya's classification, and magnetic resonance imaging was performed at 6 weeks, 3 months, 6 months, and 1 year after surgery. The distribution of patients with retears at the timing of retears was investigated. In addition, patients with retears were classified into the following two groups: early group with retears occurring at 6 weeks and 3 months postoperatively or late group with retears occurring between 6 months and 1 year postoperatively. Associated factors such as sex, age, tear size, pre and postoperative range of motion, surgical technique, and clinical outcome between the two groups were investigated.

RESULTS

The 41 shoulders with retears were divided into four groups: 1) within 6 weeks after surgery (n = 9, 22.0%), 2) 6 weeks-to 3 months after surgery (n = 19, 46.3%), 3) 3-6 months after surgery (n = 11, 26.8%), and 4) 6 months-1 year after surgery (n = 2, 4.9%). In addition, there were significantly larger retear sizes in the Sugaya's classification in the early group compared to the late group (P = .013), while there were significantly more males in the late group compared to the early group (P = .030).

CONCLUSION

The highest retear rate after ARCR was observed from 6 weeks to 3 months after surgery, with equivalent rates within 6 weeks and from 3 months to 6 months after surgery.

One-stage rotator cuff repair in stiff shoulders shows comparable range of motion, clinical outcome and retear rates to non-stiff shoulders: a systematic review

BACKGROUND

One-stage treatment involving rotator cuff repair and shoulder capsule release is mainly used to treat patients with rotator cuff tears (RCTs) and concomitant shoulder stiffness. Despite the increasing attention to the efficacy and safety of one-stage treatment, controversy still remains. Therefore, this systematic review aims to summarize the indications, operation procedure and rehabilitation protocol, and compare the range of motions (ROMs), functional outcomes and retear rates of one-stage treatment for RCTs in stiff shoulders and non-stiff shoulders.

METHODS

Multiple databases (PubMed, the Cochrane Library, Embase and MEDLINE) were searched for studies that investigated outcomes after one-stage treatment for RCTs concomitant with shoulder stiffness compared with rotator cuff repair for RCTs alone, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Descriptive statistics, including range of motion, patient-reported outcome and retear rate, are presented without meta-analysis due to the heterogeneity and low levels of evidence.

RESULTS

A total of 9 cohort studies were included, with 305 patients treated with one-stage treatment involving rotator cuff repair and simultaneous shoulder capsular release and 1059 patients treated with rotator cuff repair alone. Patients in both groups had significant symptom improvement and functional recovery after the one-stage treatment for the stiffness group and standard repair for the non-stiffness group, and most patients could return to normal life and work within 6 months after the operation. The retear rate in the one-stage treatment group was not higher than that in the rotator cuff repair group. No statistically significant differences between the two groups were observed in terms of range of motion and patient-reported outcomes in the vast majority of studies at the final follow-up, including the visual analog scale for pain, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California Los Angeles Shoulder Score, the Oxford shoulder score and the Simple Shoulder Test.

CONCLUSION

One-stage treatment for RCTs in stiff shoulders provides comparable ROM and patient-reported clinical outcomes as rotator cuff repair for non-stiff RCTs. In addition, the rate of postoperative retear in stiff shoulder treated with one-stage treatment was not higher than in non-stiff shoulders.

Rotator Cuff Repair with Knotless All-Suture Medial Row Anchors and Biceps Autograft Augmentation

Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.

A Comparison Study of the Western Ontario Rotator Cuff Index, and the Constant-Murley Score with Objective Assessment of External Rotator Muscle Strength and Pain in Patients after Arthroscopic Rotator Cuff Repair

Although rotator cuff injures are often associated with a limited range of motion and muscle weakness, being able to conduct pain-free and efficient performances of the activities as part of daily living seems to be more important for patients. The aim of this study was to investigate the correlation between two questionnaires-the disease-specific, subjective questionnaire termed the Western Ontario Rotator Cuff Index (WORC), and the shoulder-specific, subjective-objective questionnaire Constant-Murley score (CMS), with the objective assessment of external rotator muscle strength, and the subjective assessment of pain according to the visual analog scale (VAS) in patients after arthroscopic rotator cuff repair. The study was carried out among 47 patients twice-6 and 12 months after surgery, respectively. All patients completed the WORC, the CMS, and the VAS. Isokinetic evaluation of the external rotators was performed using the Biodex 4 ProSystem. The correlations of all assessed muscle strength parameters with both the CMS and the WORC were found to be statistically significant, being mostly average during the 1st examination and mostly strong during the 2nd examination. There was a significant improvement in all assessed tools as a result of the undertaken rehabilitation. There were weak correlations present between changes in the WORC and changes in the external rotator muscle strength, with correlations between WORC-Sport and EXT900-AVERAGE-POWER and PEAK-TORQUE also being found statistically significant. Correlations of changes in the CMS scale with changes in the external rotator muscle strength were weak and statistically insignificant. It seems that the WORC questionnaire can be recommended more for the population after rotator cuff repair, which allows for a reliable assessment of patients' ability to function and its changes in various areas of life, and at the same time does not require a direct assessment by a clinician or researcher.

Tranexamic acid has no effect on postoperative pain control after arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial

Background

The purpose of this study was to compare the efficacies of tranexamic acid (TXA) versus placebo after arthroscopic rotator cuff repair (ARCR).

Methods

This prospective, double-blind, and randomized study was conducted in 70 patients who underwent ARCR from 2021 to 2022 at our hospital. Thirty-four shoulders were randomly assigned to the TXA group, and 36 to the control group; TXA (10 mL) and normal saline (10 mL) were administered locally after surgery and in the control group, respectively. We evaluated visual analog scale pain scores at rest, during activity, and at night and the circumference and diameter of the shoulder joint in both groups preoperatively and at 1, 2, and 3 days, and 1 week after the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05.

Results

There was no significant difference in the visual analog scale scores at rest, during activity, and at night between the groups (p > 0.05). The circumference and diameter of the shoulder joint were not also significantly different between both groups (p > 0.05).

Conclusion

Local TXA administration in patients who undergo ARCR does not significantly impact postoperative pain levels and the circumference and diameter of the shoulder joint.

Adduction Manipulation of the Glenohumeral Joint versus Physiotherapy for Atraumatic Rotator Cuff Tears: A Randomized Controlled Trial

BACKGROUND

Atraumatic rotator cuff tears (ARCTs) are frequently concomitant with adduction restriction of the glenohumeral joint (GHJ). Adduction manipulation (AM) removes the restriction and relieves pain. The present study aimed to investigate the clinical efficacy of AM versus physiotherapy (PT) in ARCTs.

METHODS

Eighty-eight patients with adduction restriction were allocated to the AM and PT groups (n = 44 per group). The glenohumeral adduction angle (GAA) was calculated using X-rays at the first and last follow-up appointments. We recorded pain severity (visual analog scale, VAS), flexion, abduction, external rotation (ER), internal rotation (IR), and American Shoulder and Elbow Society (ASES) and Constant scores at baseline and at 1-, 3-, 6-, and 12- month follow-ups.

RESULTS

Forty-three patients (23 males, average age 71.3 years) in the AM group and 41 (16 males, average age 70.7 years) in the PT group were consequently analyzed. At the 1-month follow-up, VAS, shoulder motion except ER, ASES and Constant scores were much better in the AM group than in the PT group, whereas those in the PT group improved gradually up to 12 months. At the final follow-up, flexion, abduction, and Constant score were significantly better in the AM group than in the PT group. The GAA at the initial and final examinations was -21.6° and -3.2°, respectively, in the AM group, and -21.1° and -14.4°, respectively, in the PT group.

CONCLUSIONS

The AM procedure, which had better clinical efficacy than PT, is recommended as the first conservative treatment option for ARCTs.

Preemptive middle glenohumeral ligament release in arthroscopic rotator cuff repair does not reduce the postoperative stiffness: a retrospective comparative study

BACKGROUND

This study aimed to evaluate the efficacy of preemptive middle glenohumeral ligament (MGHL) release in arthroscopic rotator cuff repair (ARCR) to reduce postoperative stiffness.

METHODS

Patients who underwent ARCR were enrolled and allocated into two groups retrospectively: the preemptive MGHL release group (n = 44) and the preemptive MGHL non-release group (n = 42). Clinical outcomes were assessed and compared between the two groups, including the range of motion, Japanese Orthopedic Association Shoulder Score, Constant Shoulder Score, and the University of California, Los Angeles Score preoperatively and 3 months, 6 months, and 12 months postoperatively and complications. The integrity of the repaired tendon was assessed at the 12-month follow-up using magnetic resonance imaging.

RESULTS

There were no significant differences between the groups in all range of motion and all functional scores at any of the assessed time points. There was also no significant difference in the healing failure rate 2.3% in the preemptive MGHL group and 2.4% in the preemptive MGHL non-release group (p = .97), and postoperative stiffness was 2.3% in the preemptive MGHL group and 7.1% in the preemptive MGHL non-release group (p = .28). There was no postoperative instability in both group.

CONCLUSION

ARCR effectively facilitates the recovery of range of motion and function in patients with a rotator cuff tear. However, preemptive MGHL release could not be an effective method to reduce postoperative stiffness.

Development and clinical validation of deep learning for auto-diagnosis of supraspinatus tears

BACKGROUND

Accurately diagnosing supraspinatus tears based on magnetic resonance imaging (MRI) is challenging and time-combusting due to the experience level variability of the musculoskeletal radiologists and orthopedic surgeons. We developed a deep learning-based model for automatically diagnosing supraspinatus tears (STs) using shoulder MRI and validated its feasibility in clinical practice.

MATERIALS AND METHODS

A total of 701 shoulder MRI data (2804 images) were retrospectively collected for model training and internal test. An additional 69 shoulder MRIs (276 images) were collected from patients who underwent shoulder arthroplasty and constituted the surgery test set for clinical validation. Two advanced convolutional neural networks (CNN) based on Xception were trained and optimized to detect STs. The diagnostic performance of the CNN was evaluated according to its sensitivity, specificity, precision, accuracy, and F1 score. Subgroup analyses were performed to verify its robustness, and we also compared the CNN's performance with that of 4 radiologists and 4 orthopedic surgeons on the surgery and internal test sets.

RESULTS

Optimal diagnostic performance was achieved on the 2D model, from which F1-scores of 0.824 and 0.75, and areas under the ROC curves of 0.921 (95% confidence interval, 0.841-1.000) and 0.882 (0.817-0.947) were observed on the surgery and internal test sets. For the subgroup analysis, the 2D CNN model demonstrated a sensitivity of 0.33-1.000 and 0.625-1.000 for different degrees of tears on the surgery and internal test sets, and there was no significant performance difference between 1.5 and 3.0 T data. Compared with eight clinicians, the 2D CNN model exhibited better diagnostic performance than the junior clinicians and was equivalent to senior clinicians.

CONCLUSIONS

The proposed 2D CNN model realized the adequate and efficient automatic diagnoses of STs, which achieved a comparable performance of junior musculoskeletal radiologists and orthopedic surgeons. It might be conducive to assisting poor-experienced radiologists, especially in community scenarios lacking consulting experts.

Volumetric Analysis of Subacromial Space After Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears

Purpose

Subacromial volume measurement on magnetic resonance images is relatively new. It has been shown that decreased subacromial volume increases after surgical repair of full-thickness rotator cuff tears. There is no study examining subacromial volume changes after superior capsular reconstruction (SCR). The purpose of this study was to compare subacromial volume changes on magnetic resonance images (MRI) after superior capsular reconstruction performed for primary irreparable rotator cuff tears.

Methods

Patients who underwent an SCR procedure between 2017 and 2019 with a minimum 2-year postoperative follow-up were included in this retrospective study. Subacromial volume was measured on MRI using software. The preoperative and postoperative acromiohumeral distance, Constant Scores, graft thickness, and Hamada grades of the patients were evaluated.

Results

A total of 18 patients with a mean age of 59.7 years (range: 49-74 years) underwent an SCR for massive irreparable cuff tear. The mean preoperative subacromial volume was 3.54 ± 0.39 cm3 (range 2.88-4.36 cm3), which increased to 4.46 ± 0.39 cm3 (range 3.75-5.32 cm3) postoperatively (p =  < 0.001). The increase in subacromial volume and acromiohumeral distance did not correlate with Constant scores and graft thickness. We observed a significantly higher subacromial volume increase among Hamada grade 1 patients, compared to those with Hamada grade 2 (p = 0.011).

Conclusions

We observed that subacromial volume significantly increased after superior capsular reconstruction. However, the increase in subacromial volume did not correlate with clinical scores, acromiohumeral distance changes, or graft thickness.Level of evidence: Level III - Retrospective Cohort Study.

Tranexamic acid administration for arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial

BACKGROUND

The purpose of this study was to compare the efficacy of tranexamic acid versus placebo after arthroscopic rotator cuff repair.

METHODS

This prospective, double-blind, and randomized study involved 66 patients who consecutively underwent arthroscopic rotator cuff repair from 2020 to 2021 at our hospital. Thirty-three shoulders each were randomly assigned to the tranexamic acid and control groups. In the former group, 1000 mg of tranexamic acid (20 mL) was administered intravenously 10 min before surgery and the same volume of normal saline (20 mL) was administered intravenously in the control group. We evaluated visual clarity; visual analog scale pain scores at rest, during activity, and at night; the circumference and diameter of the shoulder joint in the groups before and after the surgery at 1, 2, and 3 days, and 1 week; estimated perioperative blood loss; and operative time. Visual clarity was rated using a numeric rating scale from grade 1 (poor) to grade 3 (clear) every 15 min throughout the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05.

RESULTS

Visual clarity was found to be significantly better in the tranexamic acid group, with a greater percentage of grade 3 visual clarity (75.6 ± 11.2% vs 68.1 ± 13.4%, p = 0.045). The visual analog scale scores at rest and at night in the control group were significantly lower than those in the tranexamic acid group for 1 week postoperatively (13.8 ± 14.8 vs 5 ± 9.3, p = 0.008, 36.1 ± 23.3 vs 19.3 ± 24, p = 0.012). The circumference and diameter of the shoulder joint, estimated perioperative blood loss, and operative time were not significantly different between the two groups.

CONCLUSION

Intravenous administration of tranexamic acid is an alternative way to improve visual clarity in arthroscopic rotator cuff repair; however, there are no other significant differences compared to the administration of placebo.

Long Head of the Biceps Autograft Performs Biomechanically Similar to Human Dermal Allograft for Superior Capsule Reconstruction After Rotator Cuff Tear

PURPOSE

To provide a biomechanical comparison between human dermal (HD) allograft and long head of biceps tendon (LHBT) autograft with and without posterior side-to-side suturing for superior capsule reconstruction.

METHODS

Eight fresh-frozen cadaveric shoulder specimens were tested in 5 conditions: (1) intact, (2) complete supraspinatus tear, (3) LHBT, (4) LHBT with side-to-side suturing, and (5) HD allograft with side-to-side suturing. Functional abduction force, superior translation of humeral head, translational range of motion, and rotational range of motion were tested at 0°, 30°, 60°, and 90° of abduction within each condition. Data were analyzed using analysis of variance with post-hoc Tukey testing for pairwise comparison, with a significance value set at .05.

RESULTS

Functional abduction force in the LHBT, LHBT + suture, and HD + suture conditions was significantly increased compared with the supraspinatus tear condition at abduction angles of 30° (P = .011, .001, and .017, respectively), 60° (P = .004, .001, and .002, respectively), and 90° (P = .013, .001, and .038, respectively). In addition, superior translation of the humeral head in the LHBT, LHBT + suture, and HD + suture conditions was significantly decreased compared with the tear condition at abduction angles of 30° (P = .03, .049, .03, respectively) and 60° (P = .02, .04, .03, respectively). All 3 reconstructive techniques were statistically identical to the intact rotator cuff condition in regard to translational and rotational range of motion.

CONCLUSIONS

Superior capsule reconstruction with LHBT autograft without side-to-side suturing, LHBT with posterior side-to-side suturing, and HD allograft with posterior side-to-side suturing all equivalently restore functional abduction force and decrease superior translation of the humeral head after a complete supraspinatus tear.

CLINICAL RELEVANCE

Superior capsule reconstruction with long head of the biceps tendon autograft and human dermal allograft both restore functional abduction force and decrease superior translation of the humeral head, while displaying no losses in the range of motion in a cadaveric model.

Does the Fatty Infiltration Influence the Re-tear Rate and Functional Outcome After Rotator Cuff Repair? A Systematic Review and Meta-analysis

Purpose

Fatty infiltration (FI) of the rotator cuff muscles occurs after rotator cuff tears (RCTs), which may affect the outcome of the repair procedure. This study aimed to determine the relationship between preoperative FI and the rate of re-tear and functional outcomes after rotator cuff repair.

Methods

Computerized databases, including PubMed, EMBASE, Web of Science, and Cochrane Library database were searched for studies published from the inception date to January 2022. Two reviewers independently screened the titles and abstracts using prespecified criteria. Articles were included if they clearly stated the effect of varying degrees of FI on the outcome after shoulder cuff repair. Comparison was performed by different degrees of FI analysis: no FI is grade 0-1, FI is grade 2 and above. Statistical analysis was performed using Review Manager 5.4.1 software.

Results

A total of 16 articles involving 1383 patients from 8 countries were included. The follow-up period ranged from 8 to 121 months. In terms of re-tear rate: patients with preoperative FI had significantly higher rates of re-tear compared with patients without FI (OR 4.60, 95% CI 2.22-9.54, p < 0.0001), supraspinatus FI VS no FI (OR 2.06, 95% CI 1.00-4.24, p = 0.05), infraspinatus FI VS no FI (OR 2.42, 95% CI 1.19-4.91, p = 0.01). In terms of functional scoring: patients without FI had higher postoperative Constant-Murley (Constant) scores than those with FI (MD - 5.06, 95% CI - 9.40 to - 0.72, p = 0.02), there was no clear evidence that preoperative FI was related to postoperative American Society of shoulder and elbow physicians scores and the University of California at Los Angeles scores and range of motion.

Conclusion

FI after RCTs significantly increases the risk of postoperative re-tear and leads to worse functional scores, especially FI of the infraspinatus muscle. However, FI does not seem to reduce postoperative range of motion.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00807-0.

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis

BACKGROUND

An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques.

MATERIAL AND METHODS

The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants.

RESULTS

A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0-56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5).

CONCLUSION

Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.

Repair of rotator cuff tears in patients aged 75 years and older: Does it make sense? A systematic review

Background

Rotator cuff injuries are common, and morbidity increases with age. The asymptomatic full-thickness tear rate is 40% in the over 75-year-old population.

Purpose

This study aimed to systematically review the literature on the outcomes of rotator cuff repair among >75 years old patients.

Study design

Systematic review.

Methods

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was performed in the electronic databases of PubMed, Medline, Embase, and The Cochrane Library. Studies in English evaluating repair of full-thickness rotator cuff tears in patients aged >75 years were included.

Results

Six studies were reviewed, including 311 patients (313 shoulders) treated with arthroscopic and/or open rotator cuff repair. Sixty-one patients were lost to follow-up, leaving 252 shoulders with outcome data. Patients in this age group demonstrated a significant improvement in the clinical and functional scores after rotator cuff repair, with a high satisfaction rate. The mean American Shoulder and Elbow Surgeons scores improved from 43.8 (range, 42.0-45.5) preoperatively to 85.3 (range, 84.0 to 86.5) postoperatively, and the mean Constant scores improved from 45.4 (range, 34.7-55.5) to 78.6 (range, 67.0-91.6). Pain, evaluated in all studies by the visual analog scale for pain, showed a significant improvement at the last follow-up compared with the mean preoperative score. Furthermore, range of motion and return to daily activities and sports gained marked improvements.

Conclusion

Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief. Although patients in this age group are at a high risk of retear, rotator cuff repair may offer a good option with significant functional and clinical improvement.

The use of long head biceps tendon autograft for massive rotator cuff tears: a PRISMA compliant systematic review

INTRODUCTION

Rotator cuff tears (RCT) are a common cause of shoulder pain and disability, with massive RCT accounting for 10-40% of all rotator cuff tears.

SOURCES OF DATA

A systematic search of PubMed and Scopus electronic databases was performed up to August 2022, and a total of 17 scientific articles were included in the present PRISMA compliant systematic review.

AREAS OF AGREEMENT

Understanding the geometric patterns in RCT is essential to achieve appropriate repositioning of the injured tendons in their anatomic location. The long head of the biceps tendon (LHBT) is usually exposed when defects of the anterolateral corner are present and can be easily used to augment rotator cuff repairs.

AREAS OF CONTROVERSY

There are no definite guideline regarding the management of massive rotator cuff tears.

GROWING POINTS

The use of LHBT graft is safe and effective, but technically demanding. All studies were level IV articles of medium to high quality.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective long term follow-up studies and randomized controlled trials are needed, adding imaging evaluation and appropriate clinical outcome measures at follow-up.

Sex Is Associated with the Success or Failure of Manipulation Alone for Joint Stiffness Associated with Rotator Cuff Repair

Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation.

Patch augmentation does not provide better clinical outcomes than arthroscopic rotator cuff repair for large to massive rotator cuff tears

PURPOSE

Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes.

METHODS

Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed.

RESULTS

This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups.

CONCLUSION

The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR.

LEVEL OF EVIDENCE

III.

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

Background

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

Methods

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

Results

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

Discussion and Conclusion

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

The relationship between clinical outcomes of arthroscopic rotator cuff repair and hemoglobin A1c

Background

The clinical outcomes of diabetic patients who underwent arthroscopic rotator cuff repair have been reported. However, few studies have focused on the relationship between these clinical outcomes and postoperative hemoglobin A1c. This study compared clinical outcomes of diabetic patients with a hemoglobin A1c < 7% to those with a hemoglobin A1c ≥ 7% at 12 months post-arthroscopic rotator cuff repair.

Methods

This retrospective study involved 51 consecutive patients who underwent arthroscopic rotator cuff repair from 2015 to 2020. Approximately 26 and 25 shoulders were assigned to a Low group (hemoglobin A1c < 7%) and High group (hemoglobin A1c ≥ 7%) at 12 months postoperatively, respectively. Patients with poorly controlled diabetes were preoperatively hospitalized for perioperative diabetic control. Clinical outcomes were shoulder range-of-motion, Constant Shoulder Score, and University of California, Los Angeles Score preoperatively and at 12 months postoperatively. Complications were also evaluated.

Results

Both groups showed significant improvement in their range-of-motion, Constant Shoulder Score, and University of California, Los Angeles score at 12 months post-arthroscopic rotator cuff repair (p < 0.05) except external rotation in High group. These improvements were significantly inferior in the High group compared to the Low group (Low/High group; 167.3 ± 7.7°/159.5 ± 16.3° for forward flexion; p = 0.013, 94.9 ± 7.6/90.1 ± 9.9 points for Constant Shoulder Score; p = 0.033, 32.6 ± 3.6/30.6 ± 4.1 points for University of California, Los Angeles score, p = 0.037). Hemoglobin A1c at 12 months postoperatively was also significantly inferior in the High group (Low/High group; 6.5 ± 0.3%/7.6 ± 0.8%; p < 0.05). The rate of rotator cuff retear was not significantly different between groups (Sugaya type4; p = 0.49, type5; p = 0.322) and there were no cases of infection or shoulder stiffness in either group.

Conclusion

Diabetic patients showed improvement of their range-of-motion and function after arthroscopic rotator cuff repair; however, patients with poorly controlled diabetes had significantly inferior improvement.

Three-Dimensional Software- and MR-Imaging-Based Muscle Volumetry Reveals Overestimation of Supraspinatus Muscle Atrophy Using Occupation Ratios in Full-Thickness Tendon Tears

Supraspinatus muscle atrophy is widely determined from oblique-sagittal MRI by calculating the occupation ratio. This ex vivo and clinical study aimed to validate the accuracy of 3D software- and MR-imaging-based muscle volumetry, as well as to assess the influence of the tear pattern on the occupation ratio. Ten porcine muscle specimens were volumetrized using the physical water displacement volumetry as a standard of reference. A total of 149 individuals with intact supraspinatus tendons, partial tears, and full-thickness tears had 3T MRI. Two radiologists independently determined occupation ratio values. An excellent correlation with a Pearson’s r of 0.95 for the variables physical volumetry using the water displacement method and MR-imaging-based muscle volumetry using the software was found and formed the standard of reference for the patient study. The inter-reader reliability was 0.92 for occupation ratios. The correlation between occupation ratios and software-based muscle volumes was good in patients with intact tendons (0.84) and partial tears (0.93) but considerably lower in patients with full-thickness tears (0.68). Three-dimensional-software- and MR-imaging-based muscle volumetry is reliable and accurate. Compared to 3D muscle volumetry, the occupation ratio method overestimates supraspinatus muscle atrophy in full-thickness tears, which is most likely due to the medial retraction of the myotendinous unit.

Insurance status is not a predictor of rotator cuff tear magnitude

Background

Rotator cuff tear (RCT) chronicity is an important factor in considering treatment options and outcomes for surgical repair. Many factors may contribute to delayed treatment, including timely access to care due to insurance status. The purpose of this study was to evaluate the relationship between the magnitude of RCT on presentation and insurance status. We hypothesize that publicly insured patients will have a greater incidence of chronic RCTs and shoulder pathology on initial presentation.

Methods

Retrospective chart review of patients undergoing RCT repair at an academic tertiary care institution from 2005 to 2019. Demographic data, including age, race, sex, and insurance carrier, were collected. Insurance carriers were categorized into public (Medicare and Medicaid) or private insurance coverage. Individual magnetic resonance imagings were then reviewed by a board-certified musculoskeletal radiologist for supraspinatus (SS), infraspinatus (IS), subscapularis, and biceps tendon tears, as well as acromioclavicular arthritis. In addition, rotator cuff atrophy was evaluated by the scapular ratio. Univariate analysis of variance and logistic regression analyses were used to compare demographics and rotator cuff pathology between those with Medicaid and Medicare, as well as between publicly and privately insured patients.

Results

Of the 492 patients in this study, 192 had private insurance, and 300 had public insurance (Medicaid: 50 and Medicare: 250). Insurance status was not found to be associated with differences in RCTs between Medicare and Medicaid patients. Those with Medicaid or Medicare (public), presented more frequently with SS or IS atrophy (SS atrophy, P = .002; IS atrophy, P = .039) than those with private insurance. However, after adjusting for age, no significant differences in rotator cuff tendon tear or atrophy frequencies were found between insurance groups.

Conclusions

Patients with private and public insurance tend to present with similar chronicity and magnitude of RCTs. Insurance status does not appear to influence timely access to surgical care for patients with RCTs at an academic medical center.

Evaluation of a deep learning method for the automated detection of supraspinatus tears on MRI

OBJECTIVE

To evaluate if deep learning is a feasible approach for automated detection of supraspinatus tears on MRI.

MATERIALS AND METHODS

A total of 200 shoulder MRI studies performed between 2015 and 2019 were retrospectively obtained from our institutional database using a balanced random sampling of studies containing a full-thickness tear, partial-thickness tear, or intact supraspinatus tendon. A 3-stage pipeline was developed comprised of a slice selection network based on a pre-trained residual neural network (ResNet); a segmentation network based on an encoder-decoder network (U-Net); and a custom multi-input convolutional neural network (CNN) classifier. Binary reference labels were created following review of radiologist reports and images by a radiology fellow and consensus validation by two musculoskeletal radiologists. Twenty percent of the data was reserved as a holdout test set with the remaining 80% used for training and optimization under a fivefold cross-validation strategy. Classification and segmentation accuracy were evaluated using area under the receiver operating characteristic curve (AUROC) and Dice similarity coefficient, respectively. Baseline characteristics in correctly versus incorrectly classified cases were compared using independent sample t-test and chi-squared.

RESULTS

Test sensitivity and specificity of the classifier at the optimal Youden's index were 85.0% (95% CI: 62.1-96.8%) and 85.0% (95% CI: 62.1-96.8%), respectively. AUROC was 0.943 (95% CI: 0.820-0.991). Dice segmentation accuracy was 0.814 (95% CI: 0.805-0.826). There was no significant difference in AUROC between 1.5 T and 3.0 T studies. Sub-analysis showed superior sensitivity on full-thickness (100%) versus partial-thickness (72.5%) subgroups.

DATA CONCLUSION

Deep learning is a feasible approach to detect supraspinatus tears on MRI.

Post-operative rehabilitation using a digital healthcare system in patients who had undergone rotator cuff repair: protocol for a single-center randomized controlled trial

Background

Operative repair of a rotator cuff tear requires up to 12 weeks of post-operative (post-op) home-based rehabilitation. Maintaining patients’ compliance in the post-op rehabilitation program is a pivotal component for generating successful outcomes. By developing a post-op rehabilitation-oriented digital healthcare system and applying it in patients who had undergone rotator cuff repair, we aim to increase the efficacy of the rehabilitation program and raise patients’ compliance levels. Here, we present a protocol developed for comparing the efficacy of rehabilitation using a newly developed augmented reality (AR)-based digital healthcare system with that of conventional rehabilitation for post-op rehabilitation of rotator cuff repair.

Methods

This study will recruit a total of 115 patients who had undergone rotator cuff repair within 3 days after surgery. Patients will be randomly allocated to rehabilitation using an AR-based digital healthcare system (digital group) or conventional rehabilitation (conventional group). Patients in both groups will perform brochure-based exercises from the immediate post-op period to post-op 6 weeks. From post-op 6 weeks to 12 weeks, patients in the digital group will use the AR-based system for post-op exercises, whereas patients in the conventional group will continue brochure-based rehabilitation exercises. The primary outcome will be scores on the Simple Shoulder Test at post-op 12 weeks. Secondary outcomes include numeric rating scale scores for pain, measures of range of motion and muscle strength of the affected shoulder, grip strength of the affected arm, scores on the Disabilities of the Arm, Shoulder and Hand test, the Shoulder Pain and Disability Index, and the EuroQoL-5D-5L quality-of-life measure. Analyses will be conducted using an intention-to-treat approach.

Discussion

This study will examine the effectiveness of an AR-based digital healthcare system for post-op rehabilitation in the patients after rotator cuff repair. The study will add evidence for the application of digital healthcare systems in post-op rehabilitation.

Trial registration

ClinicalTrials.gov NCT04511377. Registered on 10 August 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06648-4.

Histologic Differences in Human Rotator Cuff Muscle Based on Tear Characteristics

BACKGROUND

Fatty accumulation in the rotator cuff is associated with shoulder dysfunction and a risk of failure of rotator cuff repair. The aims of this study were to (1) describe cellular findings in rotator cuff muscles in patients presenting with varying degrees of rotator cuff tendon pathology by examining fat content and myofiber cross-sectional area of rotator cuff muscles and (2) correlate histologic features to magnetic resonance imaging (MRI) grades derived with the Goutallier classification.

METHODS

Rotator cuff muscle biopsies were performed in a consecutive series of patients undergoing arthroscopic shoulder surgery. Rotator cuffs were graded according to the Goutallier classification and labeled as either partial-thickness or full-thickness. Patients without a rotator cuff tear undergoing arthroscopic surgery served as controls. The biopsy specimens were examined using LipidTOX to visualize lipid accumulation. Laminin was used to quantify myofiber cross-sectional area.

RESULTS

Twenty-seven patients with a rotator cuff tear and 12 without a tear (controls) were included. There were 24 males (62%). The mean age was 55 years. Patients in the control cohort were younger (mean, 46 years) than those in the treatment group (mean, 60 years, p < 0.01). Within the treatment group, 12 and 15 patients were recorded as having partial and full-thickness rotator cuff tears, respectively. Lipid accumulation visualized at the cellular level was fairly-to-moderately correlated with the Goutallier classification on MRI (R s = 0.705, 95% confidence interval [CI] = 0.513, 0.829). Muscle biopsy specimens with a Goutallier grade of 2+ had significantly more lipid accumulation than those with grade-0 (p < 0.01) or grade-1 (p < 0.01) fatty accumulation. Muscle biopsies at the sites of full-thickness tears showed significantly greater lipid accumulation than those associated with either partial (p < 0.01) or no (p < 0.01) tears. Partial-thickness rotator cuff tears had no difference in lipid accumulation in comparison to the control group. Muscle biopsy specimens from full-thickness tears had significantly smaller myofiber cross-sectional area when compared with partial-thickness tears (p = 0.02) and controls (p < 0.01).

CONCLUSIONS

Cellular lipid accumulation correlates with the MRI Goutallier grade of fatty accumulation, thus verifying the Goutallier classification at the cellular level. Muscle biopsy specimens from partial-thickness tears are more similar to controls than to those from full-thickness tears, whereas full-thickness tears of all sizes showed significantly greater lipid content and smaller myofiber cross-sectional area compared with partial-thickness tears and controls.

CLINICAL RELEVANCE

Our research confirms the utility of using the Goutallier classification to predict rotator cuff muscle quality and shows that tendon attachment, even if partially torn, protects the muscle from fatty accumulation.

The subacromial spacer system for irreparable posterosuperior rotator cuff tears: A retrospective study of 47 patients with a two-year follow-up

BACKGROUND

Numerous surgical options are available for the management of massive irreparable rotator cuff tears, but there are no current definitive guidelines concerning the optimal treatment modality. The purpose of this study was to evaluate the efficacy and safety of a biodegradable subacromial spacer (InSpace) implantation in patients with irreparable rotator cuff tears.

METHODS

A retrospective study was conducted involving 47 patients treated with the InSpace balloon between 2016 and 2018. Shoulder function was assessed using Constant Score. Pain was scored using a visual analogue scale, with scores ranging from 0 to 10.

RESULTS

At an average follow-up of 24.6 months (range 12-38), the Constant Score had improved from 39.4 to 71.5 points (p < 0.0001). The range of motion, a main component of Constant Score, was improved after two years, from 27.6 to 42.2 points (p < .001). The visual analogue scale score decreased from 6.32 at baseline to a mean score of 2.7 points (p < 0.0001).

DISCUSSION

Arthroscopic deployment of the InSpace device was found to be a safe, reliable treatment option in patients with painful irreparable rotator cuff tears, with meaningful improvement in shoulder function without serious complications.

Posttreatment Imaging of the Shoulder

The shoulder joint is vulnerable for injuries following trauma and in the context of sporting activities. Degenerative rotator cuff disease is also a common entity. Conservative therapy is often not indicated or does not lead to the desired success, so surgical intervention is necessary. Routine follow-ups, but also persistent complaints, delayed healing, or recurrent trauma, usually need postoperative imaging of the shoulder. The choice of the adequate imaging modality and technique is important to reach the correct diagnosis. Additionally, knowledge of the most common surgical procedures, as well as typical normal findings and expected pathologies on different imaging modalities, is crucial for the radiologist to play a relevant role in the postoperative diagnostic process. This article addresses postoperative imaging after rotator cuff repair, shoulder arthroplasty, and surgery for shoulder stabilization with an emphasis on computed tomography and magnetic resonance imaging.

Tendon transfers for massive rotator cuff tears

Massive rotator cuff tears (MRCTs) present a particular challenge due to high rates of retear that can range from 18 to 94%, failure of healing after repair, and potential for irreparability.

Management of MRCTs must take into consideration the patient's characteristics, clinical examamination and expectation, number and quality of muscle tendons units involved.

Conservative treatment, arthroscopic long head of the biceps tenotomy, cuff debridement, partial repair, and superior capsule reconstruction are viable solutions to treat selected patients.

The goal of tendon transfers is to achieve stable kinematic by restoring rotational strength and force coupling of the shoulder joint.

The ideal candidate is a young, motivated patient with small degenerative changes of the glenohumeral joint, a massive irreparable cuff tear, significant atrophy, fatty infiltration, and functional deficit.

Patients with posterosuperior massive tears have impaired shoulder function with external rotation weakness and eventually lag sign If the teres minor is affected.

Latissimus dorsi transfer is the most used with results lasting for long follow-up and lower Trapezius transfer is becoming a surgical option. For anterosuperior tears, there is still controversial if pectoralis major is the best option when compared to latissimus dorsi although this last has a similar vector force with the supraspinatus tendon.

Complications associated with tendon transfers include neurovascular injury, infection, and rupture of the transferred tendon.

Use of a Nanofiber Resorbable Scaffold During Rotator Cuff Repair: Surgical Technique and Results After Repair of Small- to Medium-Sized Tears

Background:

The rate of retear after primary rotator cuff failure remains unacceptably high (up to 36% for small- to medium-sized tears). Augmentation of cuff repair with scaffold devices has been reported to improve healing after cuff repair.

Purpose/Hypothesis:

To describe the surgical technique of using an interpositional nanofiber scaffold during rotator cuff repair and report on a retrospective series of patients regarding functional outcomes and postoperative healing on magnetic resonance imaging (MRI). We hypothesized that augmentation of cuff repair with an interpositional scaffold would result in a high rate of tendon healing and excellent functional outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 33 patients underwent arthroscopic rotator cuff repair augmented with a nanofiber, bioresorbable polymer patch secured as an inlay between the tendon and underlying bone. Patients were evaluated preoperatively and postoperatively with the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) shoulder score, and active range of motion (ROM) measurements. Postoperative MRI was used to evaluate repair status.

Results:

At a minimum follow-up of 6 months, the patients showed significant improvement on SST and ASES scores (P < .0001 for both). ROM in forward flexion, abduction, internal rotation, and external rotation significantly improved at 6 months postoperatively (P < .05 for all). MRI at an average of 11 months postoperatively showed healing in 91% of patients; one patient had a recurrent tear with transtendon failure, and another patient had retear at the insertional site. The patch was not visible on postoperative imaging, suggesting complete resorption in all patients. No adverse events were associated with the patch.

Conclusion:

Our results demonstrate the preliminary safety and efficacy of a novel, bioresorbable synthetic scaffold for rotator cuff repair. The use of the scaffold resulted in a 91% tendon healing rate and significant improvements in functional and patient-reported outcome measures. The results are promising for improving the current unacceptably high rate of rotator cuff repair failure.

Are there differences in arthroscopic and histological features between traumatic and degenerative rotator cuff tears in elderly patients? A prospective dual-center analysis

Background

Discriminating traumatic rotator cuff tears (RCTs) from degenerative RCTs is sometimes difficult in elderly patients because the prevalence of asymptomatic RCTs increases with age. Little intraoperative information is available on the characteristics of traumatic and degenerative RCTs in elderly patients. The purpose of this study was to compare the arthroscopic findings and histological changes of the coracoacromial ligament (CAL) between traumatic and degenerative RCTs in elderly patients.

Methods

Forty-two shoulders of 42 patients aged ≥ 65 years underwent arthroscopic rotator cuff repair. Nineteen patients had traumatic full-thickness RCTs (Group T), and 23 had degenerative full-thickness RCTs (Group D). The quality of the rotator cuff tissue and the condition of the long head of the biceps were examined. The grade of CAL was evaluated both arthroscopically and histologically. The stiffness of the musculotendinous unit was calculated by measuring the force and displacement using a tensiometer. The arthroscopic and histological findings of the two groups were compared.

Results

Although the mean tendon displacement was comparable, the stiffness was different between Group T and Group D (0.56 ± 0.31 and 1.09 ± 0.67 N/mm, respectively; p < 0.001). Both arthroscopic and histological analysis of the CAL showed that the degenerative changes in the CAL were milder in Group T than in Group D (p < 0.001 and p < 0.001, respectively). There was a moderate positive correlation between the arthroscopic findings of CAL degeneration and the histopathological changes in this ligament (r = 0.47, p = 0.002).

Conclusions

Traumatic RCTs were characterized by preserved elasticity of the musculotendinous unit and milder CAL degeneration compared with degenerative RCTs even in elderly patients.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency

PURPOSE

We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes.

METHODS

Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected.

RESULTS

The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present.

CONCLUSION

Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes.

LEVEL OF EVIDENCE

IV, retrospective cohort.

Evaluation of patches for rotator cuff repair: A systematic review and meta-analysis based on animal studies

Based on the published animal studies, we systematically evaluated the outcomes of various materials for rotator cuff repair in animal models and the potentials of their clinical translation. 74 animal studies were finally included, of which naturally derived biomaterials were applied the most widely (50.0%), rats were the most commonly used animal model (47.0%), and autologous tissue demonstrated the best outcomes in all animal models. The biomechanical properties of naturally derived biomaterials (maximum failure load: WMD 18.68 [95%CI 7.71–29.66]; P = 0.001, and stiffness: WMD 1.30 [95%CI 0.01–2.60]; P = 0.048) was statistically significant in the rabbit model. The rabbit model showed better outcomes even though the injury was severer compared with the rat model.

•

The first systematic review & meta-analysis on rotator cuff patch materials.

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The quality of evidence for repair of rotator cuff injury with patch materials is very low.

•

Evidence-based research is an effective way to study patch materials.

Arthroscopic rotator cuff repair with biologically enhanced patch augmentation

OBJECTIVE

The purpose of this guide is to illustrate an arthroscopic rotator cuff repair (RCR) with two techniques for biologically enhanced patch augmentation.

INDICATIONS

Massive rotator cuff tears (> 5 cm) and revision RCR.

CONTRAINDICATIONS

Active joint or systemic infection; severe fatty muscle atrophy; severe glenohumeral arthropathy; American Society of Anesthesiologists Physical Status (ASA PS) IV.

SURGICAL TECHNIQUE

Dermal allograft patch augmented with concentrated bone marrow aspirate (cBMA), platelet-rich plasma (PRP) and platelet-poor plasma (PPP); or Regeneten patch augmented with bursa, PRP, PPP, and autologous thrombin.

POSTOPERATIVE MANAGEMENT

A 30° abduction sling for 6 weeks; unrestricted active-assisted external rotation and forward elevation after 12 weeks; focus on restoration of scapular stability and strength.

RESULTS

A total of 22 patients received revision massive RCR using a dermal allograft patch enhanced with cBMA and PRP with a mean follow-up of 2.5 years (1.0-5.8 years). There was a significant improvement in the preoperative Simple Shoulder Test (SST). There was also a trend towards improved pain and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. In this cohort, 45% reached the minimal clinically important difference (MCID), 41% achieved substantial clinical benefit (SCB), and 32% had a patient-acceptable symptomatic state (PASS) for the ASES score. Preliminary data using the Regeneten patch technique with bursa, PRP, PPP, and autologous thrombin was prospectively collected in five patients between 05/2020 and 03/2021 at the author's institution. Mean follow-up was 6.5 ± 1.3 (6-8 months). There was an improvement from preop to postop in pain, ASES, SANE, Constant-Murley (CM) score and active range of motion.

A new biomechanical classification system for split fractures of the humeral greater tuberosity: guidelines for surgical treatment

Background

Split fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method.

Methods

We created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCT) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed.

Results

The mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicate that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment.

Conclusions

Biomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.