At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears

Favorable Clinical Outcomes After Humeral Head Depressor Muscle Coactivation Training With EMG for Patients With Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

BACKGROUND

The coactivation (Co-A) of shoulder muscles that contribute to humeral head depression can lead to mechanical unloading of the subacromial structures during abduction and thus can be beneficial for patients with arthroscopic rotator cuff repair (ARCR). The present study aims to examine the effectiveness of humeral head depressor muscle Co-A (DM-Co-A) training on clinical outcomes in a sample of patients with ARCR.

HYPOTHESIS

We hypothesized that DM-Co-A training with medioinferior vector during glenohumeral exercises can improve clinical results in the rehabilitation of ARCR.

STUDY DESIGN

Randomized controlled single-blind study.

LEVEL OF EVIDENCE

Level 1B.

METHODS

A total of 27 patients who underwent ARCR after a medium-sized rotator cuff tear and completed their Phase 1 training with ≥80% compliance were included. Together with 14 weeks of conservative treatment (6 weeks of Phase 2 training and 8 weeks of Phase 3 training), synchronized "DM-Co-A Training" was applied to the treatment group with an electromyography (EMG) biofeedback (EMG-BF) device. Patients in the treatment group were asked to voluntarily activate the humeral head depressor muscles guided by visual and auditory feedback of the EMG-BF device during the Phase 2 and Phase 3 conservative treatment exercises performed by the control group. Demographic characteristics of the participants were recorded. Visual analog scale and universal goniometer were used to assess pre- and posttreatment pain severity and joint range of motion, respectively. The Disabilities of Arm, Shoulder and Hand Questionnaire, Revised Oxford Shoulder Score, Modified Constant-Murley Shoulder Score, and the Western-Ontario Rotator Cuff Index were used to assess functionality.

RESULTS

There was a clinically meaningful improvement in pain severity, active ROM excluding internal rotation, and functionality in the treatment group compared with the control group (P < 0.05).

CONCLUSION

A 14-week duration DM-Co-A with EMG may be beneficial in the postoperative rehabilitation of patients after ARCR.

Protocol for a national intervention programme aimed to reduce unwarranted variation and overuse of shoulder arthroscopy in Norway

Several advice-based approaches have aimed to reduce the overuse of procedures characterised as low-value healthcare services but have so far shown marginal impact on utilisation rates. Differences in utilisation rates tend to be associated with type of healthcare provider. Commercial providers have a tendency to have higher utilisations rates compared with non-profit providers. Norway has a publicly funded universal health coverage system where healthcare services are mainly provided by publicly owned hospitals in addition to a small number of non-profit hospitals and commercial hospitals reimbursed by the regional health authorities. According to previous experiences, unwarranted variation in utilisation rates can be associated with the type of healthcare provider. The aim of the present study is to evaluate the impact of tailoring the interventions on reducing overuse of low-value care based on an analysis of the clinical pathways and the various types of healthcare providers. The National Decision Forum in Norway has decided that acromion resection in patients with impingement symptoms and repair of non-traumatic cuff rupture should not be offered as standard treatment. The present protocol describes the planned intervention to reduce the overuse of these procedures.

Does surgical intervention alter the natural history of degenerative rotator cuff tears? Comparative analysis from a prospective longitudinal study

BACKGROUND

The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short- to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively.

METHODS

This comparative study consists of 2 separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included visual analog scale pain, American Shoulder and Elbow Surgeons, active range of motion, strength, and ultrasonography.

RESULTS

There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9 ± 5.3 yr vs. 61.2 ± 7.8 yr, P = .04). The median follow-up for control subjects after pain development was 5.1 years (interquartile range [IQR] 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; P = .45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; P = .06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (P = .43 and P = .58, respectively). At final follow-up, the surgical group demonstrated significantly lower visual analog scale pain (0 [IQR 2] vs. 3.5 [IQR 4], P = .0002), higher composite American Shoulder and Elbow Surgeons (95 [IQR 13] vs. 65.8 [IQR 32], P = .0002), and activities of daily living scores (29 [IQR 4] vs. 22 [IQR 8], P = .0002), greater abduction strength (69.6 N [standard deviation {SD} 29] vs. 35.9 N [SD 29], P = .0002), greater active forward elevation (155° [SD 8] vs. 142° [SD 28], P = .002), greater active external rotation in abduction (mean 98.5°, SD 12 vs. mean 78.2°, SD 20; P = .0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, P = .05; 17% vs. 34%, P = .03; respectively).

CONCLUSION

This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment.

Diagnostic Accuracy and Interobserver Reliability of Rotator Cuff Tear Detection With Ultrasonography Are Improved With Attentional Deep Learning

PURPOSE

To improve the accuracy of 1-stage object detection by modifying the YOLOv7 with the convolutional block attention module (CBAM), known as YOLOv7-CBAM, which can automatically identify torn or intact rotator cuff tendon to assist physicians in diagnosing rotator cuff lesions through ultrasound.

METHODS

Between 2020 and 2021, patients who experienced shoulder pain for over 3 months and had both ultrasound and magnetic resonance imaging examinations were categorized into torn and intact groups. To ensure balanced training, we included the same number of patients in both groups. Transfer learning was conducted using a pretrained model of YOLOv7 and an improved model with CBAM. The mean average precision, sensitivity, and F1-score were calculated to evaluate the models. A gradient-weighted class activation mapping method was employed to visualize important regions using a heatmap. A simulation data set was recruited to evaluate the diagnostic performance of clinical physicians using our artificial intelligence-assisted model.

RESULTS

A total of 280 patients were included in this study, with 80% of 840 ultrasound images randomly allocated for model training. The accuracy for the test set was 0.96 for YOLOv7 and 0.98 for YOLOv7-CBAM, and the precision and sensitivity were 0.94 and 0.98 for YOLOv7 and 0.98 and 0.98 for YOLOv7-CBAM. F1-score and mean average precision were higher for YOLOv7-CBAM (0.980 and 0.993) than YOLOv7 (0.961 and 0.965). Furthermore, the gradient-weighted class activation mapping method elucidated that the deep learning model primarily emphasized a hypoechoic anechoic defect within the tendon. Following adopting an artificial intelligence-assisted model (YOLOv7-CBAM model), diagnostic accuracy improved from 80.86% to 88.86% (P = .01), and interobserver reliability improved from 0.49 to 0.71 among physicians.

CONCLUSIONS

The YOLOv7-CBAM model shows high accuracy in detecting torn or intact rotator cuff tendon from ultrasound images. Integrating this model into the diagnostic process can assist physicians in improving diagnostic accuracy and interobserver reliability across different physicians.

CLINICAL RELEVANCE

The attentional deep learning model aids physicians in improving the accuracy and consistency of ultrasound diagnosis of torn or intact rotator cuff tendons.

One-Year Follow-Up Is Sufficient Time for Patient-Reported Outcomes Following Rotator Cuff Repair: A Systematic Review and Meta-analysis

PURPOSE

To perform a systematic review to determine whether there were clinically significant differences in patient-reported outcome measures from 1- to 2-year follow-up following rotator cuff repair (RCR).

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) reporting on patient-reported outcomes at the 1- and 2-year follow-up following RCR were included. Meta-analysis was performed, and a P value <.05 was considered statistically significant.

RESULTS

Nineteen randomized controlled trials with 2,110 patients were included. There was a statistically significant difference in American Shoulder and Elbow Score score between the 1-year (mean, 87) and 2-year (mean, 89.4) follow-up (P < .00001), but this did not reach the minimal clinically important difference. There was no statistically significant difference in visual analog scale pain score between the 1-year (mean, 0.9) and 2-year (mean, 0.8) follow-up (P = .10). Additionally, the differences in Simple Shoulder Test; University of California, Los Angeles score; Constant score; and Western Ontario Rotator Cuff index between the 1- and 2-year follow-up did not reach the minimal clinically important difference despite statistically significant differences.

CONCLUSIONS

Statistically significant differences in patient-reported outcomes are reported between the 1- and 2-year follow-up points, although these differences fail to reach minimally clinically important differences. As a result, the 1-year follow-up may be sufficient to determine clinical outcomes from RCR.

STUDY DESIGN

Level II, systematic review of randomized control trials.

Supraspinatus Muscle Regeneration Following Rotator Cuff Tear: A Study of the Biomarkers Pax7, MyoD, and Myogenin

The success of rotator cuff tendon repair relies on both tendon healing and muscle recovery. The objective of this descriptive study was to investigate the regenerative potential of the supraspinatus muscle in rotator cuff tear conditions by quantifying the expression of Pax7, MyoD, and myogenin, basic factors that regulate myogenesis. Muscle biopsies were collected from thirty-three patients aged 34 to 73 years who underwent surgery for a rotator cuff tear affecting the supraspinatus muscle. Among these patients, twenty-seven percent were women, and the age of the lesions ranged from 2 to 72 months post-initial trauma. Biopsies were harvested from the supraspinatus muscle at the end closest to the tendon, and control biopsies were harvested from the ipsilateral deltoid muscle. The densities of immunohistochemically stained Pax7+, MyoD+, and myogenin+ nuclei/mm2 were used to estimate the myogenic potential of the muscle. Adjustments were made for patient age and lesion age. We found increased density of MyoD+ and myogenin+ cells in supraspinatus muscles compared to deltoid muscles (p < 0.001 and p = 0.003, respectively). Regression analyses that combined the density of positive nuclei with patient age showed a continuous increase in Pax7 with age but also a reduction of MyoD and myogenin in older patients. When combined with lesion age, there was a decline in the density of all myogenic markers after an initial rise. Pax7 density continued to be higher in supraspinatus compared to the deltoid muscle, but the density of MyoD and myogenin terminally dropped to a density lower than in the deltoid. Our findings suggest that the supraspinatus muscle in tear conditions showed signs of initial activation of muscle regeneration. When compared to the unaffected deltoid muscle, an apparent reduction in capacity to progress to full muscle fiber maturity was also demonstrated. This pattern of inhibited myogenesis seemed to increase with both patient age and lesion age. Our results on muscle regenerative capacity indicate that younger patients with rotator cuff tears have better chances of muscle recovery and may benefit from early surgical reconstruction.

Stem cell treatment for regeneration of the rotator cuff: study protocol for a prospective single-center randomized controlled trial (Lipo-cuff)

BACKGROUND

Rotator cuff tears (RCT) are a common musculoskeletal condition, especially in the aging population. The prevalence of rotator cuff tears varies based on factors like age, occupation, and activity level. In the general population, the prevalence of rotator cuff tears is estimated to be around 20 to 25%. Rotator cuff tears (RCT) have an impact in patients' pain level, shoulder function, sleep disturbance, and quality of life. Primary tendon surgery is in mostly cases necessary. This study aimed to examine if treatment of rotator cuff lesions with implantation of micro-fragmented adipose tissue can improve patients' reported pain and function compared to conventional surgery.

METHODS

The study is a prospective superiority parallel-group single-center randomized controlled trial including 30 patients between 40 and 69 years of age in Denmark. Patients will be allocated 1:1 ratio to reconstruction of the supraspinatus tendon with an injection of micro-fragmented adipose tissue into the related muscle (stem cell treatment) or the standard of care (SOC), which is conventional surgery. Patients, project assistants, physicians, and outcome adjudicators are not blinded to randomization due to practical constraints. The radiologist and the statistician performing the analysis will be blinded. The primary outcome will be the Oxford shoulder score at 12 months post-surgery.

DISCUSSION

This study will assess whether adding micro-fragmented adipose tissue therapy to conventional rotator cuff tear treatment can enhance recovery, accelerate return to daily activities, and improve functional outcomes. The research will also determine if this minimally invasive procedure could be standardized for routine patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06505135. Registered on July 10, 2024.

Fifteen-Year Results of a Comparative Analysis of Tendon Repair Versus Physiotherapy for Small-to-Medium-Sized Rotator Cuff Tears: A Concise Follow-up of Previous Reports

ABSTRACT

The optimal treatment for small-to-medium-sized rotator cuff tears remains a topic of debate. While both tendon repair and physiotherapy have shown comparable short-term results, there are concerns about the long-term effectiveness of physiotherapy. In 2 previous reports presenting the 5 and 10-year results of this trial, significant and increasing differences were observed in favor of tendon repair. Further investigation of the unexplored time interval after 10 years is essential to fully understand the implications of our treatment approaches. A total of 103 patients with a full-thickness rotator cuff tear not exceeding 3 cm were randomly allocated to tendon repair or physiotherapy with optional secondary repair. Measurements of shoulder function were performed by a blinded assessor at 6 months and 1, 2, 5, 10, and 15 years. The outcome of primary interest was the 15-year result for the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons (ASES) score; the Short Form-36 (SF-36) Health Survey; assessments of pain, motion, and strength; and patient satisfaction. Tear-size increase in unrepaired tears was assessed by sonography. Statistical analysis was by mixed-model analysis for repeated measurements and by intention to treat. Eighty-three (81%) of 103 patients attended the 15-year follow-up. Fifteen of 51 patients in the physiotherapy group had crossed over to secondary surgery. Results from primary tendon repair were superior by a mean difference of 11.8 points for the Constant score (p = 0.001), 13.9 points for the ASES score (p < 0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), and 16.2° and 22.4°, respectively, for pain-free abduction and flexion (p = 0.04 and 0.001). On the SF-36, differences did not reach significance for any of the scoring scales. In 26 tears treated by physiotherapy only, the mean tear size had increased from 16.2 to 31.6 mm in the anterior-posterior direction. Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up, supporting its use as the primary treatment for small-to-medium-sized rotator cuff tears.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Disparities in Rotator Cuff Tear Progression Definitions and Rates: A Systematic Review

Background

While rotator cuff tears are prevalent in the general population, the natural history of this disease is unclear. Understanding rotator cuff tear progression is crucial for refining surgical indications and evaluating the necessity of early interventions. This study presents an in-depth analysis of the existing literature on the definitions and progression rates of rotator cuff tears, aiming to enhance clinical decision making and patient outcomes.

Methods

A systematic literature search was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Medline (PubMed), Embase (Elsevier), and Web of Science databases on January 12, 2023. Articles were identified as relevant to the natural history and progression of asymptomatic and symptomatic partial-thickness (PT) and full-thickness (FT) rotator cuff tears. Those written in English reporting rotator cuff progression rates of tears in adults, based on magnetic resonance imaging (MRI) or ultrasound, were included. After reviewing the articles, the data on the rates of tear progression and associated risk factors were extracted, compiled, and analyzed. The risk of bias was determined using the Newcastle-Ottawa Scale.

Results

Twenty-one articles met the inclusion criteria, with 1,831 tears included. The progression rate for all partial thickness tears was 26.7% ± 12.8% at an average follow-up of 2.2 ± 0.9 years, with 5 definitions for tear progression. For FT tears, the progression rate was 54.9% ± 18.6% at a follow-up time of 3.0 ± 2.0 years, with 8 definitions for tear enlargement. A significant difference (p < 0.0001) was found between the progression rates of PT and FT tears. Patients who were initially asymptomatic and became symptomatic had higher progression rates (33%-63%) than those who remained asymptomatic (4%-38%).

Conclusion

Further research would benefit by identifying a clinically relevant and standardized definition of rotator cuff tear progression, to describe the natural history of rotator cuff disease, making results more comparable and optimizing treatment planning.

Level of Evidence

Level II. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Margin Convergence Repair Without Suture Anchors Improves Clinical Outcomes for Full- and Partial-Thickness Rotator Cuff Tears

Purpose

To evaluate the clinical outcome scores of an arthroscopic margin convergence technique without the use of suture anchors to repair different types of rotator cuff tears and to determine whether the type or extent of the tear has an effect on clinical outcome scores after this procedure.

Methods

Patients receiving arthroscopic margin convergence repair without suture anchors for rotator cuff tears from 2013 to 2018 were retrospectively analyzed. Arthroscopically determined partial- or full-thickness rotator cuff tears with a minimum follow-up period of 20 months were included. Outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) shoulder score; University of California, Los Angeles (UCLA) shoulder score; and visual analog scale (VAS) score. A 2-tailed distribution paired t test was used to determine statistical significance (P < .05) between preoperative scores and scores at final follow-up. Correlation tests and linear regression analysis were used to determine the correlation between various clinical variables and outcomes. A cohort-specific minimal clinically important difference analysis was performed for each outcome score, calculated as one-half of the standard deviation of the delta score.

Results

A total of 38 patients were included for analysis: 12 with partial-thickness tears and 26 with full-thickness tears. The mean postoperative follow-up period was 33.9 months (range, 22.2-94.5 months), with a minimum follow-up period of 22 months. The mean age of the patients was 62 ± 15.1 years. The minimal clinically important difference values for the ASES, UCLA, and VAS scores were 9.68, 2.92, and 1.13, respectively. There were significant improvements in the ASES (from 29.3 ± 18.3 preoperatively to 93.7 ± 8.3 postoperatively, P = .001), UCLA (from 14.3 ± 6.2 to 32.8 ± 2.6, P = .001), and VAS (from 7.37 ± 1.8 to 0.63 ± 1.02, P = .001) clinical outcome scores. However, patients with either Patte stage 3 retraction (P = .033 for ASES score and P = .020 for UCLA score) or U-shaped tears (P = .047 for ASES score and P = .050 for UCLA score) had significantly lower clinical outcome scores than patients with less severe retraction or differently shaped tears.

Conclusions

The arthroscopic margin convergence technique without the use of suture anchors may be a suitable option in patients with partial- or full-thickness rotator cuff tears.

Level of Evidence

Level IV, therapeutic case series.

Pre-operative transverse tendon thickness in small and mid-sized rotator cuff tears does not affect clinical outcomes after arthroscopic repair

INTRODUCTION

Previous studies on rotator cuff tears have examined both clinical and radiographic parameters which may influence post-operative clinical outcomes. While rotator cuff tears are frequently classified by size or depth, there is currently no literature available examining the thickness of the remnant tendon, and its impact on post-operative outcomes. We hypothesize that decreased pre-operative transverse tendon thickness will result in poorer post-operative clinical outcomes.

METHODS

We prospectively recruited patients who underwent arthroscopic repair of small to medium full-thickness rotator cuff tears. These patients were followed up for a minimum of 2 years post-operatively. Basic biodata, as well as Visual Analog Scale (VAS) for pain, Constant-Murley Score (CMS), UCLA Shoulder Score (USS), and Oxford Shoulder Score (OSS) at 3 different time points (pre-operatively, 1 year post-operatively, and 2 years post-operatively) were collected. Transverse tendon thickness was measured by independent blinded radiologists on pre-operative ultrasonographic images. Wilcoxon signed-rank test was used to compare outcome scores and multivariable robust linear model was fitted to assess the effect of transverse tendon thickness on post-operative scores.

RESULTS

A total of 63 patients were enrolled in this study, predominantly female (65%) and had a median age of 72 years. Pre-operatively, the median transverse cuff thickness was 5.0 ​mm and median tear size was 1.4 ​cm. The median VAS at preoperative was 7, which reduced to 0 ​at 2 year post-operative, indicating statistically significant improvement in pain levels (p ​< ​0.001). Statistically significant improvement in shoulder function measured by CMS, UCLA score and OSS were also seen over time (p ​< ​0.001). Robust regression analysis revealed that transverse cuff thickness had no statistically significant effect on VAS (p ​= ​0.99), CMS (p ​= ​0.84), UCLA score (p ​= ​0.22), and OSS scores (p ​= ​0.73) at 2 years postoperatively.

DISCUSSION

Pre-operative transverse tendon thickness of small- to mid-sized supraspinatus tears does not influence clinical outcomes after arthroscopic repair. Differences in transverse tendon thickness may have an association with tendon healing but do not translate to an association with post-operative outcomes in terms of pain, function, and patient-reported outcome measures.

LEVEL OF EVIDENCE

IV.

Comprehensive review of deep learning in orthopaedics: Applications, challenges, trustworthiness, and fusion

Deep learning (DL) in orthopaedics has gained significant attention in recent years. Previous studies have shown that DL can be applied to a wide variety of orthopaedic tasks, including fracture detection, bone tumour diagnosis, implant recognition, and evaluation of osteoarthritis severity. The utilisation of DL is expected to increase, owing to its ability to present accurate diagnoses more efficiently than traditional methods in many scenarios. This reduces the time and cost of diagnosis for patients and orthopaedic surgeons. To our knowledge, no exclusive study has comprehensively reviewed all aspects of DL currently used in orthopaedic practice. This review addresses this knowledge gap using articles from Science Direct, Scopus, IEEE Xplore, and Web of Science between 2017 and 2023. The authors begin with the motivation for using DL in orthopaedics, including its ability to enhance diagnosis and treatment planning. The review then covers various applications of DL in orthopaedics, including fracture detection, detection of supraspinatus tears using MRI, osteoarthritis, prediction of types of arthroplasty implants, bone age assessment, and detection of joint-specific soft tissue disease. We also examine the challenges for implementing DL in orthopaedics, including the scarcity of data to train DL and the lack of interpretability, as well as possible solutions to these common pitfalls. Our work highlights the requirements to achieve trustworthiness in the outcomes generated by DL, including the need for accuracy, explainability, and fairness in the DL models. We pay particular attention to fusion techniques as one of the ways to increase trustworthiness, which have also been used to address the common multimodality in orthopaedics. Finally, we have reviewed the approval requirements set forth by the US Food and Drug Administration to enable the use of DL applications. As such, we aim to have this review function as a guide for researchers to develop a reliable DL application for orthopaedic tasks from scratch for use in the market.

Rapamycin facilitates healing of the tendon-bone interface in an aging rat model of chronic rotator cuff injury

BACKGROUND

Tendon-bone interface (TBI) healing in chronic rotator cuff injury (CRCI) in older individuals is a common clinical challenge due to cellular senescence, as well as decreased tissue repair and regeneration. Many studies have demonstrated the antiaging, improved tissue repair, and bone regeneration properties of rapamycin (RPM) in multiple age-related diseases. This study aimed to explore the effects of RPM on TBI healing after CRCI in an aging rat model.

METHODS

A CRCI model was established in 60 Sprague-Dawley rats (24 months old). Rats were then randomly allocated into the control, 0.1 μg RPM, and 1 μg RPM groups. At 4 and 8 weeks postreconstructive surgery, the supraspinatus tendon-humerus complexes were harvested for biomechanical, microimaging, histological, and immunohistochemical evaluations.

RESULTS

Biomechanical testing results demonstrated that the failure load, ultimate strength, and stiffness of the 2 RPM groups were significantly higher than those of the control group at 4 and 8 weeks postoperatively. Microradiographically, both RPM groups had significantly higher values of bone mineral density and the ratio of trabecular bone volume to total volume than controls at each time point. Moreover, the RPM groups had higher histological scores and showed better regenerated TBI, characterized by better organizational tissue, more fibrocartilage cells, and more bone formation. Immunohistochemical evaluations showed that RUNX2-, SOX9-, and SCX-positive cells were significantly more in the 2 RPM groups than in the controls at each time point.

CONCLUSIONS

RPM may effectively enhance CRCI healing after reconstruction by facilitating osteogenesis, tenogenesis, and fibrocartilage reformation at the TBI, as well as improving biomechanical properties.

Effect of Tear Size and Location on Supraspinatus Tendon Strain During Activities of Daily Living and Physiotherapy

The supraspinatus tendon plays a crucial role in shoulder abduction, making it one of the common structures affected by injury. Clinically, crescent-shaped tears are the most commonly seen tear shape. By developing six specimen-specific, three-dimensional, supraspinatus-infraspinatus finite element model with heterogeneous material properties, this study aimed to examine the changes in tissue deformation (maximum principal strain) of the supraspinatus tendon due to specimen-specific material properties and rotator cuff tear size. FE models with small- and medium-sized full-thickness crescent-shaped tears were subjected to loads seen during activities of daily living and physiotherapy. Six fresh-frozen cadaveric shoulders were dissected to mechanically test the supraspinatus tendon and develop and validate FE models that can be used to assess changes in strain due to small (< 1 cm, equivalent to 20-30% of the tendon width) and medium-sized (1-3 cm, equivalent to 40-50% of the tendon width) tears that are located in the middle and posterior regions of the supraspinatus tendon. FE predictions of maximum principal strain at the tear tips were examined to determine whether failure strain was reached during activities of daily living (drinking and brushing teeth) and physiotherapy exercises (prone abduction and external rotation at 90° abduction). No significant differences were observed between the middle and posterior tear failure loads for small- and medium-sized tears. For prone abduction, there was a potential risk for tear progression (exceeded failure strain) for medium-sized tears in the supraspinatus tendon's middle and posterior regions. For external rotation at 90° abduction, one model with a middle tear and two with posterior tears experienced failure. For all daily activity loads, the strain never exceeded the failure strain. Our three-dimensional supraspinatus-infraspinatus FE model shows that small tears appear unlikely to progress based on the regional strain response; however, medium-sized tears are at higher risk during more strenuous physiotherapy exercises. Furthermore, differences in patient-specific tendon material properties are important in determining whether the tear will progress. Therefore, patient-specific management plans based on tear size may be beneficial to improve clinical outcomes.

Pain Neuroscience Education Following Arthroscopic Rotator Cuff Repair for Patients With Rotator Cuff Tears: A Double-Blind Randomized Controlled Clinical Trial

OBJECTIVE

This trial examines the efficacy of the pain neuroscience education on clinical outcomes in patients with arthroscopic rotator cuff repair.

DESIGN

A total of 36 participants undergoing arthroscopic rotator cuff repair were assigned to either the experimental group ( n = 18) or control group ( n = 18) in this randomized study. A 6-wk-long conventional physiotherapy program was administered for both groups. In addition, a pain neuroscience education protocol was administered for the experimental group for a whole period of 6 wks (1 session/week, 15-60 mins per session). The primary outcomes were to compare pretreatment and posttreatment scores of the experimental versus control groups on the pain and disability. Our secondary outcomes included the comparisons of scores on the catastrophizing, anxiety, depression, kinesiophobia, and quality of life. The participants were assessed both at baseline and posttreatment.

RESULTS

The improvement in pain catastrophizing, anxiety, depression, and kinesiophobia was greater in the experimental group ( P < 0.05). The improvement was similar in both groups in terms of the rest of outcome measures.

CONCLUSIONS

This study showed that the pain neuroscience education improved only psychological aspects of the chronic pain in arthroscopic rotator cuff repair. Therefore, adding pain neuroscience education to the conventional program might be useful to improve pain catastrophizing, anxiety, depression, and kinesiophobia in patients with arthroscopic rotator cuff repair.

Role of tear size and tendon degeneration for development of pain in rat models of rotator cuff tear

BACKGROUND

Rotator cuff tear (RCT) is a frequent etiology of shoulder pain and disability; however, the triggers for the onset and aggravation of pain remain obscure. In this study, we established novel rat RCT models to examine the impact of tear size and tendon degeneration on pain.

METHODS

Fifty-five adult male Sprague-Dawley rats were allocated into 4 study groups: large tear (L group, n = 10), small tear (S group, n = 15), small tear with scratching (S+ group n = 15), and sham surgery (Sham group, n = 15). Pain-related behaviors were evaluated by weight distribution of forelimbs during a 5-minute free gait using a dynamic weight-bearing apparatus at 2, 4, 6, and 8 weeks. Calcitonin gene-related peptide (CGRP) expressions in ipsilateral dorsal root ganglion (DRG) neurons of C4, C5, and C6 were evaluated at 4 and 8 weeks. The area of scar tissues around the torn tendon, infiltration of inflammatory cells, and severity of tendon degeneration (modified Bonar score) were histologically assessed at 4 and 8 weeks. Additionally, enzyme-linked immunosorbent assay (ELISA) was conducted to evaluate the levels of cyclooxygenase-2 (COX-2) and nerve growth factor (NGF) expression in torn tendons and surrounding tissues at 4 weeks.

RESULTS

The weight distribution ratio (ipsilateral and contralateral side) was significantly decreased in the L and S+ group compared with its baseline and Sham group (P < .05), but the S group showed no significant difference compared with the Sham. The ratio of CGRP-immunoreactive neurons in the DRGs was significantly higher in the L and S+ groups than in the S and Sham groups. The histologic assessment indicated that scar tissue formation was more extensive in the L group than in the S and S+ groups. Still, there was no significant difference between the S and S+ groups. The modified Bonar score was considerably higher in the S+ group than in the S group. Furthermore, ELISA analysis demonstrated no significant disparity in COX-2 levels between the groups; however, NGF levels were substantially higher in the S+ group than in the S and Sham groups.

CONCLUSION

The present study provides compelling evidence that large RCT is strongly associated with heightened pain severity in a rat model. Nevertheless, even a small tear can significantly aggravate pain when the torn tendon is degenerated. CGRP upregulation driven by peripheral NGF possibly played a pivotal role in the genesis and exacerbation of pain in small RCT.

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

INTRODUCTION

Insurance companies often mandate six weeks of physical therapy (PT) prior to approving MRIs for patients with atraumatic rotator cuff (RTC) tears. While this is designed to limit unnecessary imaging orders, it can increase healthcare costs and delay diagnosis and surgery. This study investigated the incidence of full- and partial-thickness tears when an MRI was ordered at the time of initial consultation for shoulder pain by an orthopedic provider.

METHODS

A retrospective review of patients who had an MRI ordered upon initial orthopedic consultation for chronic shoulder pain was conducted. The primary outcome measured was the presence of RTC tears as determined by the MRI report. The cost of six weeks of PT versus the cost of immediate MRI in these patients was collected from our institution's financial database. ANOVA, independent T-test, and chi-square test were used to analyze the differences between groups.

RESULTS

A total of 365 patients were included. There were no significant differences in demographics between patients with full, partial, or no tears, with the exception that patients with full-thickness tears were older. Specifically, 43.0% had a full-thickness tear, 24.7% had a partial-thickness tear, and 32.2% had no tear on MRI. A total of 56.1% of the full-thickness tears proceeded to surgery. The cost of an upper extremity MRI without contrast averages $2,268, while two sessions of PT per week for six weeks totals $2,328.

DISCUSSION

Over 67% of MRI orders yielded a positive finding of an RTC tear and remained at 67.2% in the absence of a history of conservative treatment, validating a specialist's clinical suspicion for an RTC tear and indication for MRI. Pre-MRI PT to satisfy insurance requirements may therefore delay intervention and increase healthcare costs when an orthopedic provider believes an MRI is warranted for clinical decision-making.

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

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

Double Row Rotator Cuff Repair for Massive Reparable Rotator Cuff Tear

Background

Massive rotator cuff tears, defined as those that involved 2 or more tendons or where the length of the greatest diameter is greater than 5 cm, present a unique surgical challenge as there can be significant scarring, retraction, and poor tissue quality. Furthermore, healing of these tears is less reliable. This video presents our technique for anatomic, double row repair of a massive reparable rotator cuff tear.

Indications

Indications for operative intervention include acute traumatic tears, as well as patients with pain and weakness who have failed to respond to conservative management, including physical therapy with confirmed large full thickness rotator cuff tear on advanced imaging. Of note, findings such as glenohumeral osteoarthritis, advanced muscle atrophy (Goutalier III/IV), superior migration of the humeral head >7 mm, and tears larger than 40 mm in length and width are concerning for irreparable tears, and may represent contraindications to surgical repair.

Technique Description

The patient is placed in the lateral decubitus position. After diagnostic arthroscopy is performed, a subacromial bursectomy is performed. A radiofrequency probe and arthroscopic shaver are used to perform releases in the subacromial space as well as superior to the glenoid. Preparation of the footprint of the humeral head is then performed to create a good healing surface. The rotator cuff is grasped to confirm tension free mobilization. The medial row anchors are then placed. Once placed, the sutures are incorporated into 2 lateral row anchors in sequential fashion. Subacromial decompression is then performed.

Results

Reduced pain and improved shoulder function are the goals of treatment, with sling immobilization lasting for roughly 6 weeks postoperatively prior to initiating strengthening and range of motion protocols.

Discussion/Conclusion

Arthroscopic double row repair produces an anatomic and stable reduction of reparable massive rotator cuff tears for patients that have failed conservative management.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Rotator Cuff Repair: The Compression SpeedBridge Technique

Background

While rotator cuff repair has generally produced good to excellent outcomes, re-tear rates remain variable, with rates ranging from 20% to 50%. The ideal rotator cuff repair includes 3 main components: restoration of the humeral footprint contact area, appropriate compression of the tendon to the humeral footprint, and minimal motion at the bone-tendon interface until bone-tendon healing is completed. This video takes a well-established knotless double-row technique for rotator cuff repair and augments it with a modification to promote additional compression of the medial row tendon to the humeral footprint.

Indications

This compression SpeedBridge technique is indicated for repair of T-type rotator cuff tears involving the supraspinatus and infraspinatus tendons in patients that have failed conservative management, including physical therapy, activity modification, and corticosteroid injections. This technique can also be applied to U-shaped or L-shaped tears by removing the initial step, which involves side-to-side repair of the "T" portion of the T-type tear. Of note, findings such as advanced muscle atrophy (Goutalier III/IV) and advanced glenohumeral arthritis are concerning for irreparable tears and may be contraindications for surgical repair.

Technique Description

With the patient in the lateral decubitus position, a diagnostic arthroscopy is performed, the rotator cuff tear is debrided, and the footprint prepared. Two side-to-side stitches are placed to repair the "T" portion of the tear. The medial row anchors are then sequentially placed, and the pre-loaded sutures are passed through the tendon in 4 sequential locations in specific fashion. After placement of looped sutures in the anterior and posterior rotator cables, the passed sutures are then incorporated into the lateral row anchors. The medial row compression is provided by shuttling previously placed compression stitches through the knotless mechanism in the medial row anchors and terminally tensioned.

Results

This technique provides additional medial row compression to an already-established knotless double-row rotator cuff repair technique to facilitate improved bone-tendon healing and construct strength.

Discussion/Conclusion

The compression SpeedBridge technique is a unique method to apply additional medial row compression to a double-row rotator cuff repair.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Public Perceptions of Rotator Cuff Tears

(1) Background: Full-thickness rotator cuff tears (RCTs) impact 25% of those over 60 and 50% over 80; however, minimal data exists on public understanding; (2) Methods: The primary outcome was to determine the public's baseline understanding of RCTs utilizing a 36-question survey regarding anatomy and function, risk factors, diagnosis and treatment options, and expectations. Secondarily, we evaluated the effect of an educational video and informational handout created by the authors to improve understanding. Participants ≥ 18 years were recruited from the senior author's clinic and online discussion platforms over a 5-month period; (3) Results: Baseline surveys were completed by 382 individuals: 56% men, 64% Caucasian, 27% with at least a master's degree, and 56% with very little or no RCT knowledge. Mean correct answer scores improved from 47% to 68% posteducational intervention (p < 0.001). Males, higher education level, healthcare experience, and a higher self-rated understanding of RCTs were significantly correlated with higher survey performance (p < 0.001); (4) Conclusions: The public's knowledge of RCTs at baseline was poor, with demographic factors correlating with survey performance. The educational intervention effectively enhanced participants' understanding. By focusing on common misconceptions, this data can help clinicians align patient expectations and enhance patient outcomes.

One- and 2-Year American Shoulder and Elbow Surgeons Scores Do Not Vary Significantly After Arthroscopic Rotator Cuff Repair: A Prospective Multicenter Analysis of 1,567 Patients

PURPOSE

To evaluate whether there are clinically significant changes in patient-reported outcomes between 1 and 2 years' postoperatively after arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective analysis of prospective, multicenter registry was queried for all patients who underwent RCR. Patients with preoperative, 6-month, 1-year, and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. We evaluated mean postoperative ASES scores, Δ (change from preoperative) ASES, and the %MOI (% maximum outcome improvement). We also evaluated achievement of clinically significant outcomes (CSOs) for the ASES score, including the minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state.

RESULTS

There were 1,567 patients with complete data through 2-year follow-up. There were small differences in achievement of CSOs from 1 to 2 years: 88% to 91% for MCID, 81% to 83% for substantial clinical benefit, and 65% to 71% for patient-acceptable symptom state. There were statistically significant differences from 1 to 2 years in mean ASES (87 to 88, P < .001), Δ ASES (37 to 39, P < .001), and %MOI (72% to 76%, P < .001); however, these changes were well below the MCID of 11.1. From 1 to 2 years, the mean ASES improved only 1.7 points (P < .001). At 1 year, patients achieved, on average, 97% of their 2-year ASES.

CONCLUSIONS

Both patient-reported outcomes and achievement of CSOs show small differences at 1 and 2 years after RCR. Given the large sample size, there were statistical differences, but these are unlikely to be clinically relevant.

LEVEL OF EVIDENCE

Level IV, case series.

Assessment of description and implementation fidelity of clinical trials involving exercise-based treatment in individuals with rotator cuff tears: a scoping review

BACKGROUND

For evidence-based practice, clinicians and researchers can rely on well-conducted randomized clinical trials that exhibit good methodological quality, provide adequate intervention descriptions, and implementation fidelity.

OBJECTIVE

To assess the description and implementation fidelity of exercise-based interventions in clinical trials for individuals with rotator cuff tears.

METHODS

A systematic search was conducted in PubMed, Embase, CINAHL, LILACS, Cochrane Library, Web of Science, SCOPUS and SciELO. Randomized clinical trials that assessed individuals with rotator cuff tears confirmed by imaging exam were included. All individuals must have received an exercise-based treatment. The methodological quality was scored with the Physiotherapy Evidence Database (PEDro) scale. The Template for Intervention Description and Replication (TIDieR) checklist and the National Institutes of Health Behaviour Change Consortium (NIHBCC) were used to assess intervention description and implementation fidelity, respectively.

RESULTS

A total of 13 studies were included. Despite their adequate methodological quality, the description of the intervention was poor with TIDieR scores ranging from 6 to 15 out of 24 total points. The TIDieR highest-scoring item was item 1 (brief name) that was reported in all studies. Considering fidelity, only one of the five domains of NIHBCC (i.e., treatment design) reached just over 50%.

CONCLUSION

Exercise-based interventions used in studies for individuals with rotator cuff tears are poorly reported. The description and fidelity of the intervention need to be better reported to assist clinical decision-making and support evidence-based practice.

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.

Three-month Delay in Rotator Cuff Repair: 2-year Follow-up

INTRODUCTION

This study examined 2-year outcomes of patients who underwent delayed rotator cuff repair (RCR) compared with those who underwent RCR without delay.

METHODS

In this prospective comparative study, two groups were formed: (1) patients planning RCR during a 6-week elective surgery ban and (2) patients undergoing RCR at least 6 weeks after the ban. The Simple Shoulder Test, American Shoulder and Elbow Surgeon score, and visual analog scale for pain were collected preoperatively and at 2 years postoperatively. Magnetic resonance imaging assessed healing 6 months postoperatively.

RESULTS

With a 93.3% 2-year follow-up (13/15 delay group, 15/15 control), there was an 87-day difference in presentation to surgery (P = 0.001), with no significant preoperative demographic or tear characteristic differences between groups. Intraoperatively, there were no differences between groups in repair characteristics. Preoperative versus postoperative differences in American Shoulder and Elbow Surgeon score (P < 0.001), visual analog scale (P < 0.001), and Simple Shoulder Test scores (P < 0.001) were significant but not between groups (P = 0.650, 0.586, 0.525). On MRI, 58% in the delay group and 85% in the control group had healed (P = 0.202).

DISCUSSION

Although a 3-month delay showed no statistically significant effect on outcomes, the delay group had an approximately 27% higher failure rate. Thus, although a 3-month period of nonsurgical treatment before RCR may be reasonable, larger studies are warranted for definitive conclusions.

Individuals with rotator cuff tears unsuccessfully treated with exercise therapy have less inferiorly oriented net muscle forces during scapular plane abduction

Exercise therapy for individuals with rotator cuff tears fails in approximately 25.0 % of cases. One reason for failure of exercise therapy may be the inability to strengthen and balance the muscle forces crossing the glenohumeral joint that act to center the humeral head on the glenoid. The objective of the current study was to compare the magnitude and orientation of the net muscle force pre- and post-exercise therapy between subjects successfully and unsuccessfully (e.g. eventually underwent surgery) treated with a 12-week individualized exercise therapy program. Twelve computational musculoskeletal models (n = 6 successful, n = 6 unsuccessful) were developed in OpenSim (v4.0) that incorporated subject specific tear characteristics, muscle peak isometric force, in-vivo kinematics and bony morphology. The models were driven with experimental kinematics and the magnitude and orientation of the net muscle force was determined during scapular plane abduction at pre- and post-exercise therapy timepoints. Subjects unsuccessfully treated had less inferiorly oriented net muscle forces pre- and post-exercise therapy compared to subjects successfully treated (p = 0.039 & 0.045, respectively). No differences were observed in the magnitude of the net muscle force (p > 0.05). The current study developed novel computational musculoskeletal models with subject specific inputs capable of distinguishing between subjects successfully and unsuccessfully treated with exercise therapy. A less inferiorly oriented net muscle force in subjects unsuccessfully treated may increase the risk of superior migration leading to impingement. Adjustments to exercise therapy programs may be warranted to avoid surgery in subjects at risk of unsuccessful treatment.

The Rehabilitation Journey of a Cricket Player With Partial Rotator Cuff Tear: A Case Report of Pre and Postoperative Physiotherapy

In adults, partial rotator cuff injuries can frequently be the root cause of pain in the shoulder. One recurrent pathology that may significantly impact a broad spectrum of individuals, including athletes, laborers, and sedentary people, is partial rotator cuff tears (RCTs). Physical therapy, anti-inflammatories, painkillers, rest or activity modifications, and corticosteroid injections are a few nonoperative treatment options for partial RCTs. We report a case of a 27-year-old male who sustained a rotator cuff injury of the right shoulder. The patient presented with pain and restriction of the right shoulder joint following the injury, which had occurred while throwing a ball forcefully with his right hand. The rehabilitation program emphasized pain management, restoring range of motion (ROM), increasing strength of muscles, and functional activities to optimize the patient's recovery. Concurrently, isometrics, ROM, and strengthening exercises were integrated into the rehabilitation program to enhance muscle strength, prevent tightness, and maintain ROM. The patient's progress was monitored by using the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Upper Extremity Functional Scale (UEFS) at specific intervals during rehabilitation. The treatment and healing of a patient with an RCT who underwent both pre and postoperative physiotherapy are explored in this case report.

Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies

BACKGROUND

There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling.

METHODS

A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates).

CONCLUSION

The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.

Does physiotherapy after rotator cuff repair require supervision by a physical therapist?: a meta-analysis

BACKGROUND

A supervised physiotherapy program (SPP) is a standard regimen after surgical rotator cuff repair (RCR); however, the effect of a home-based exercise program (HEP), as an alternative, on postoperative functional recovery remains unclear. Therefore, the purpose of this meta-analysis was to compare the functional effects of SPP and HEP after RCR.

METHODS

We searched electronic databases including Central, Medline, and Embase in April 2022. The primary outcomes included the Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and pain score. Secondary outcomes included range of motion, muscle strength, retear rate, and patient satisfaction rate. A meta-analysis using random-effects models was performed on the pooled results to determine the significance.

RESULTS

The initial database search yielded 848 records, five of which met our criteria. Variables at 3 months after surgery were successfully analyzed, including the Constant score (mean difference, -8.51 points; 95% confidence interval [CI], -32.72 to 15.69; P=0.49) and pain score (mean difference, 0.02 cm; 95% CI, -2.29 to 2.33; P=0.99). There were no significant differences between the SPP and HEP. Other variables were not analyzed owing to the lack of data.

CONCLUSIONS

Our data showed no significant differences between SSP and HEP with regard to the Constant and pain scores at 3 months after RCR. These results suggest that HEP may be an alternative regimen after RCR. Level of evidence: I.

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

PURPOSE/INTRODUCTION

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

METHODS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT04618484.

Minimum 10-Year Outcomes After Arthroscopic Repair of Partial-Thickness Supraspinatus Rotator Cuff Tears

BACKGROUND

The prevalence of partial-thickness rotator cuff tears (PTRCTs) has been reported to be 13% to 40% within the adult population, accounting for 70% of all rotator cuff tears. Approximately 29% of PTRCTs will progress to full-thickness tears if left untreated. The long-term clinical course after arthroscopic repair of PTRCTs is not well known.

PURPOSE

To investigate minimum 10-year patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (RCR) of the supraspinatus tendon and to report reoperation and complication rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were included who underwent arthroscopic RCR of a PTRCT performed by a single surgeon between October 2005 and October 2011. Arthroscopic RCR was performed with a transtendon repair of partial, articular-sided supraspinatus tendon avulsions, bursal-sided repair, or conversion into a full-thickness tear and repair. PRO data were collected preoperatively and at a minimum 10 years postoperatively. PRO measures included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the 12-Item Short Form Health Survey Physical Component Summary, and patient satisfaction. Subanalyses were performed to determine if tear location or age was associated with outcomes. Retears, revision surgery, and surgical complications were recorded.

RESULTS

In total, 33 patients (21 men, 12 women) at a mean age of 50 years (range, 23-68) met criteria for inclusion. Follow-up was obtained in 28 (87.5%) of the 32 eligible patients ≥10 years out from surgery (mean, 12 years; range, 10-15 years). Of the 33 PTCRTs, 21 were articular sided and 12 were bursal sided. Of the 33 patients, 26 underwent concomitant biceps tenodesis. At follow-up, the mean PROs were significantly improved when compared with preoperative levels: American Shoulder and Elbow Surgeons score from 67.3 to 93.7 (P < .001), Single Assessment Numeric Evaluation from 70.9 to 91.2 (P = .004), QuickDASH from 22.3 to 6.6 (P < .004), and 12-Item Short Form Health Survey Physical Component Summary from 44.8 to 54.2 (P < .001). Median postoperative satisfaction was 10 (range, 5-10). No patient underwent revision surgery.

CONCLUSION

Arthroscopic repair of PTRCTs results in excellent clinical outcomes and high patient satisfaction at minimum 10-year follow-up. Furthermore, the procedure is highly durable, with a clinical survivorship rate of 100% at 10 years.

Present situation and development prospects of the diagnosis and treatment of rotator cuff tears

Rotator cuff tears are an important cause of shoulder pain and are caused by degeneration or trauma of the shoulder tendon at the anatomical neck of the humeral head. The understanding and research of rotator cuff tears have a history of hundreds of years, and their etiology, diagnosis, and treatment have a complete system, but some detailed rules of diagnosis and treatment still have room for development. This research paper briefly introduces the diagnosis and treatment of rotator cuff tears. The current situation and its valuable research direction are described.

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.

Nonoperative Treatment of Rotator Cuff Tears

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial

BACKGROUND

Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery.

METHODS

Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events.

DISCUSSION

This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery.

TRIAL REGISTRATION

This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Which preoperative factors influence the patient's short-term subjective assessment after rotator cuff repair?

INTRODUCTION

To highlight the preoperative risk factors that influence postoperative patient satisfaction following Rotator Cuff Repair (RCR) and to determine whether this satisfaction was correlated with tendon healing.

HYPOTHESIS

Preoperative factors influence patient satisfaction, assessed by SSV (Subjective Shoulder Value) postoperatively, with a correlation with tendon healing.

METHODS

With a mean age of 60.6 years (40-72), 102 patients with arthroscopic RCR were included retrospectively. The preoperative SSV score was less than or equal to 50%. There was clinical and radiological follow-up with an ultrasound evaluation of tendon healing 6 months postoperatively. We divided the patients into 2 groups using a postoperative SSV of 85% as the cut-off; 55 patients in the first group (SSV>85%); and 47 patients in the second group (SSV<85%).

RESULTS

In multivariate analysis, Preoperative risk factors for poor postoperative SSV after RCR were: tobacco use [-8.41 (-13.64; -3.17) p=0.002], fatty infiltration [-3.65 (-6.24 -1.06) p=0.006] and workers compensation [-19.15 (-24.04; -14.27) p<0.001]. When patients were not in workers compensation, the lower their SSV score before surgery, the higher their postoperative SSV score. For patients in workers compensation, the higher the SSV preoperatively, the less elevated was SSV postoperatively. The Sugaya ultrasound classification did not influence the SSV score (p=0.15) CONCLUSIONS: Smoking, fatty infiltration and patients in workers compensation are factors of poorer subjective results evaluated by the SSV score. Tendon healing did not influence the SSV score and patient satisfaction.

LEVEL OF EVIDENCE

IV, cohort study.

Caveolin-1 is involved in fatty infiltration and bone-tendon healing of rotator cuff tear

BACKGROUND

Caveolin-1 has been predicted, based on RNA transcriptome sequencing, as a key gene in rotator cuff tear (RCT) and it is related to fatty infiltration. This study aims to elucidate the upstream and downstream mechanism of Caveolin-1 in fatty infiltration and bone-tendon healing after RCT in rat models.

METHODS

Differentially expressed genes related to RCT were screened, followed by functional enrichment analysis and protein-protein interaction analysis. GATA6 was overexpressed and Caveolin-1 was knocked down in tendon stem cells (TSCs) to evaluate their effects on the adipogenic differentiation of TSCs. In addition, a RCT rat model was constructed and injected with lentivirus carrying oe-GATA6, oe-Caveolin-1 alone or in combination to assess their roles in fatty infiltration and bone-tendon healing. RESULTS AND CONCLUSION: Caveolin-1 was identified as a key gene involved in the RCT process. In vitro results demonstrated that Caveolin-1 knockdown inhibited adipogenic differentiation of TSCs by activating the cAMP/PKA pathway. GATA6 inhibited the transcription of Caveolin-1 and inhibited its expression, thus suppressing the adipogenic differentiation of TSCs. In vivo data confirmed that GATA6 overexpression activated the cAMP/PKA pathway by downregulating Caveolin-1 and consequently repressed fatty infiltration, promoted bone-tendon healing, improved biomechanical properties and reduced the rupture risk of injured tendon in rats after RCT. Overall, this study provides novel insights into the mechanistic action of Caveolin-1 in the fatty infiltration and bone-tendon healing after RCT.

Risk factors of tear progression in symptomatic small to medium-sized full-thickness rotator cuff tear: relationship between occupation ratio of supraspinatus and work level

BACKGROUND

Previous studies reported that full-thickness rotator cuff tear (FTRCT) is a risk factor for tear progression. However, there is no clear consensus on the risk factors of tear progression in FTRCT.

PURPOSE

To identify the demographic and radiologic risk factors of tear progression in small to medium FTRCTs.

METHODS

We retrospectively reviewed 81 shoulders of patients diagnosed with small or medium FTRCTs using magnetic resonance imaging (MRI) who underwent conservative treatment from January 2017 to November 2021. Various demographic factors, including patient work level and radiological factors such as atrophy of rotator cuff muscles were analyzed to evaluate their association with tear progression. Work level was divided into high (heavy manual labor), medium (manual labor with less activity), and low (sedentary work activity). The atrophy of rotator cuff muscles was calculated by occupation ratio.

RESULTS

Tear progression was observed in 48% (39/81) of patients (criterion for tear progression was medial-lateral or anterior-posterior tear length > 5 mm). In patients with tear progression, the lengths of medial-lateral and anterior-posterior tears progressed by 6 mm and 3 mm, respectively. Among the rotator cuff muscles, fatty degeneration and occupation ratio of the supraspinatus were only worsened (P = .014, P = 0.013, respectively). The mean MRI follow-up duration was 14.8 ± 9.0 months. The significant risk factors of tear progression were high work level (odds ratio [OR], 7.728; 95% CI, 1.204-49.610; P = .031), and occupation ratio of the supraspinatus muscle (OR, 0.308; 95% CI, 0.158-0.604; P = .001). The optimal cutoff value for the occupation ratio of the supraspinatus was 0.55 (sensitivity 74%, specificity 62%).

CONCLUSIONS

Tear progression was observed in approximately 50% of patients with symptomatic small to medium FTRCTs. High physical work level and atrophy of the supraspinatus muscle were independent risk factors of tear progression. The risk of tear progression increases with occupation ratio of the supraspinatus muscle < 0.55 and heavy manual labor.

Pre-existing Mental Health Diagnoses Are Associated With Higher Rates of Postoperative Complications, Readmissions, and Reoperations Following Arthroscopic Rotator Cuff Repair

PURPOSE

To investigate the association between preoperative mental health disorders and postoperative complications, readmissions, and ipsilateral revision procedures among patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective cohort study from 2010 to 2020 was performed using the PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without mental health disorders who underwent arthroscopic RCR. Mental health disorders evaluated in this study include depressive disorder, major depressive disorder, major depressive affective disorder, bipolar disorder, dysthymic disorder, adjustment disorder, separation anxiety disorder, and posttraumatic stress disorder. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Rates of complications and subsequent surgeries were compared between patients with and without a preoperative diagnosis of a mental health disorder.

RESULTS

The 1-year preoperative prevalence of a mental health disorder from 2010 to 2020 was 14.6%. After 1:1 matching, patients with a mental health disorder who underwent arthroscopic RCR were nearly twice as likely to undergo a revision procedure (odds ratio 1.94, 95% confidence interval 1.76-2.14, P < .001) and more than twice as likely to experience conversion to shoulder arthroplasty (odds ratio 2.29, 95% confidence interval 1.88-2.80, P < .001) within 2 years of initial arthroscopy when compared with patients without a mental disorder. Patients with a mental disorder also experienced increased risk for 90-day readmission (1.9% vs 0%, P < .001) as well as multiple postoperative medical complications.

CONCLUSIONS

Patients with pre-existing mental health diagnoses experience increased rates of 90-day postoperative complications and readmissions following arthroscopic RCR. In addition, patients with mental health diagnoses are more likely to undergo revision repair and conversion to shoulder arthroplasty within 2 years of the index procedure.

LEVEL OF EVIDENCE

Level III.

Correlation of defect size with fatty infiltration on MRIs of rotator cuff tendinopathy

Introduction

Sizable rotator cuff defects with limited muscle atrophy and fat replacement may represent acute traumatic ruptures that are less likely to recur after surgery to close the defect, while closure of defects with poor quality muscle are associated with defect recurrence. These distinct lesions are both referred to as tears. We analyzed the relationship between rotator cuff defect size and muscle quality to determine the relative proportion of sizable defects associated with good muscle and factors associated with muscle deterioration.

Material and methods

A cohort of 230 consecutive shoulder MRIs in patients with full-thickness rotator cuff tendon defects, limited acromioclavicular arthrosis (to avoid hindrance of defect measurement), and a duration of symptoms in the radiology report from a large urban center in the United States was evaluated for the measured distance between the supraspinatus tendon edge and the greater tuberosity medial to lateral (coronal plane defect size), anterior to posterior (sagittal plane defect width), and fatty infiltration (Goutallier classification), and atrophy (Warner classification) of the supraspinatus. We sought factors independently associated with fatty infiltration and muscle atrophy in multivariable logistic regression analyses.

Results

Forty-nine of 109 shoulders (45%) with a coronal plane defect >20 mm had reasonable muscle quality as defined by Goutallier grade less than 2 and Warner grade less than 2. Both greater fatty infiltration of the supraspinatus muscle and greater supraspinatus muscle atrophy were associated with older age and greater coronal plane defect size.

Conclusion

The observation that supraspinatus muscle health deteriorates with age and defect size, but nearly half of the largest defects had good muscle, suggests an important distinction between relatively recent traumatic ruptures and old untreated rupture or gradual attrition that may be obfuscated by referring to all lesions as tears.

Level of evidence

Level III; Retrospective diagnostic cohort.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Milder impact of the COVID-19 pandemic on the practice of orthopaedic surgery in Greece and Cyprus than other European countries

PURPOSE

The aim of this study was to highlight the impact of the COVID-19 pandemic on the practice of orthopaedics in Greece and Cyprus.

METHODS

The survey used the online questionnaire from AGA (Gesellschaft für Arthroskopie und Gelenkchirurgie; Society for Arthroscopy and Joint Surgery) to facilitate the comparison between different European countries. The questionnaire was distributed online to members of the HAOST (Hellenic Association of Orthopaedic Surgery and Trauma), the ΟΤΑΜΑΤ (Orthopaedic and Trauma Association of Macedonia and Thrace) and the CAOST (Cypriot Association of Orthopaedic Surgery and Trauma). The questionnaire consisted of 29 questions, which included demographic data, questions on the impact of the pandemic on the practice of orthopaedic surgery and questions on the impact on the personal and family life of orthopaedic surgeons.

RESULTS

The questionnaire was sent to 1350 orthopaedic surgeons in Greece and Cyprus, 303 of whom responded (response rate 22.44%). 11.2% of the participants reported cancellation of overall orthopaedic procedures. According to 35.6-49.8% of the participants, arthroscopic procedures were continued. As regards elective primary arthroplasties, 35.3% of the participants reported that these continued to be performed at their hospitals. Post-operative follow-ups as well as physiotherapy were affected by the pandemic, and changes were also observed in the habits of orthopaedic surgeons in their personal and family lives.

CONCLUSION

The orthopaedic service in Greece and Cyprus decreased during the first wave of the COVID-19 pandemic. Arthroscopic procedures and total joint replacements decreased significantly, but not to the same extent as in other countries. Health systems were not fully prepared for the first wave of the pandemic and the various countries took social measures at different times and to different extents. Thus, studying the impact of the pandemic on the practice of orthopaedic surgery in different countries can help health systems to better prepare for future pandemics; public health can then be shielded and hospitals can continue to provide high-quality orthopaedic care.

LEVEL OF EVIDENCE

Level V.

Human Dermal Allograft Patch Augmentation of Degenerate Rotator Cuff Tendon Using a Single Lateral-Row Technique

The role of biological augmentation in arthroscopic rotator cuff repair surgery has increased over the years. It has shown favorable healing rates and functional outcomes. Patch augmentation is commonly applied in repairs of massively retracted cuff tears, full-thickness tears, revision repair, or open cuff surgery. There is a paucity of literature on the use of patch augmentation when dealing with a chronic degenerate tendon associated with small-sized cuff tears. In recent years, the resorbable bioinductive bovine collagen implant has gained popularity for its application in partial-thickness tears via an isolated bioinductive repair fashion, without traditional rotator cuff repair. These bioinductive implants, albeit promising in their biological properties for tendon repair, lack structural strength and do not confer similar biomechanical advantages as human dermal allograft. We share our surgical technique for an arthroscopic patch augmentation involving human dermal allograft, using a single-lateral row surgical fixation, to address a degenerate cuff tendon with small-sized rotator cuff tear. We believe that our use of a human dermal patch augmentation conferred increased biomechanical advantage and reduced costs while delivering favorable outcomes for patients in our value-driven care.

MPFL reconstruction results in lower redislocation rates and higher functional outcomes than rehabilitation: a systematic review and meta-analysis

PURPOSE

To determine the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes in skeletally mature patients with traumatic, first-time patellar dislocation.

METHODS

Three online databases MEDLINE, PubMed and EMBASE were searched from database inception (1946, 1966, and 1974, respectively) to August 20th, 2021 for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative Kujala score, as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. Quality assessment of included studies was performed for all included studies using the MINORS and Detsky scores.

RESULTS

A total of 19 studies and 1,165 patients were included in this review. The pooled mean redislocation rate in 14 studies comprising 734 patients in the rehabilitation group was 30% (95% CI 25-36%, I² = 67%). Moreover, the pooled mean redislocation rate in 5 studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2-17%, I² = 70%). The pooled mean postoperative Kujala anterior knee pain score in 7 studies comprising 332 patients in the rehabilitation group was 81 (95% CI 78-85, I² = 78%), compared to a score of 87 (95% CI 85-89, I² = 0%, Fig. 4) in 3 studies comprising 54 patients in the reconstruction group.

CONCLUSION

Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation of 7% in the reconstruction group vs 30% in the rehabilitation group and a higher Kujala score compared to the rehabilitation group. The information this review provides will help surgeons guide their decision to choose early MPFL reconstruction versus rehabilitation when treating patients with first-time patellar dislocations and may guide future studies on the topic.

LEVEL OF EVIDENCE

IV.

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.