The societal and economic value of rotator cuff repair

Editorial Commentary: Deteriorated Quality and Medial Retraction of Tendon Following Acute Traumatic Rotator Cuff Tear are Predictors of Retear After Arthroscopic Repair

Rotator cuff tears are a common cause of shoulder pain and dysfunction, affecting up to 33% of the population, and approximately 250,000 arthroscopic rotator cuff repairs are performed each year in the United States. Arthroscopic rotator cuff repair (RCR) is the gold standard for surgical management of full thickness rotator cuff tears and is associated with postoperative improvements in pain and function. However, reported retear rates based on postoperative magnetic resonance imaging (MRI) vary from 7%-90% following arthroscopic rotator cuff repair. Despite variations in repair techniques, implant technology, biologic and patch augmentation, and postoperative rehabilitation algorithms, retear rates following rotator cuff repair have remained high over the past several decades. As a result, there continues to be a significant interest in identifying predictive factors of retear after rotator cuff repair. That said, numerous well-designed studies have demonstrated a poor correlation between postoperative MRI findings and functional outcomes. Regardless, intraoperative evaluation of tendon quality, tear pattern, and tissue mobility is essential to predicting the likelihood of successful rotator cuff repair, although at the current time, this evaluation is largely subjective, and few validated assessment tools exist. As such, future, objective research is required to improve our assessment and documentation of these intraoperative factors, with artificial intelligence and machine learning models possibly serving as useful tools for identifying meaningful intraoperative patterns predictive of postoperative outcomes in the future.

ARC (Australian Rotator Cuff) trial: study protocol for a randomised placebo-controlled trial comparing rotator cuff repair to no repair during arthroscopic shoulder surgery for people with shoulder pain and non-acute rotator cuff tears

BACKGROUND

Degenerative rotator cuff tears are common and are often treated with surgical repair. Randomised trials have not shown a clear advantage to surgery over non-surgical treatment, but there have been no published placebo-controlled trials investigating rotator cuff repair. This study aims to compare arthroscopic shoulder surgery with rotator cuff repair to surgery without rotator cuff repair (placebo) for improving shoulder pain and function in people with shoulder pain and full-thickness degenerative rotator cuff tears.

METHODS

The study is a multicentre two-parallel arm, blinded, individually randomised controlled trial (RCT). Participants will be people aged 40-75 years (inclusive) with more than 6 months of shoulder pain, a degenerative (non-traumatic) full thickness rotator cuff tear 1 to 4 cm in length for whom surgery is recommended and repair of the tear is the main reason for surgery. The intervention is arthroscopic surgery (including-as indicated-bursectomy, debridement, acromioclavicular joint resection, acromioplasty and biceps tenodesis or tenotomy) with rotator cuff repair. The control is the same arthroscopic shoulder surgery without rotator cuff repair. Participants will be randomised to cuff repair or no cuff repair in a 1:1 ratio intra-operatively, after all other surgical procedures have been performed. Participants, follow-up surgeons, physiotherapists, study staff and statisticians will be blinded. Post-surgical rehabilitation will be usual care for rotator cuff repair in both groups. The primary outcome will be shoulder pain and function measured using the Western Ontario Rotator Cuff Index at 6 months post-surgery.

DISCUSSION

The ARC trial will provide low bias evidence on a common surgical procedure: rotator cuff repair for degenerative tears.

TRIAL REGISTRATION

The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000789965) on 5 August 2020 and the WHO International Clinical Trials Registry Platform (universal trial number U1111-1251-6599).

Infection following mini-open rotator cuff repair: a single surgeon experience

BACKGROUND

Surgical technique has been shown to influence risk of surgical site infection following rotator cuff repair (RCR). Few studies have reported the rate of infection associated with mini-open RCR. The goal of this study was to report the postoperative infection rate and risk factors for infection among patients undergoing RCR performed by a single surgeon using a modified mini-open technique. Our hypothesis was that the rate of infection after mini-open RCR would be lower than previously reported for this surgical approach.

METHODS

We retrospectively reviewed an institutional shoulder surgery database to identify patients who underwent mini-open RCR performed by 1 surgeon at an academic tertiary care institution between 2003 and 2020. Patient records were reviewed to determine which individuals returned within 3 months postoperatively with a superficial or deep surgical site infection requiring operative management. Patient demographics, preoperative clinical characteristics, intraoperative variables, microbiological findings, infection management, and clinical course after infection were recorded. Backward elimination multivariate regression was used to assess for significant risk factors for infection.

RESULTS

Of the 925 patients identified, 823 (89%) had at least 3 months of follow-up and were included for further analysis. A majority of the patients undergoing RCR were men (57%). The mean age was 58.4 ± 9.9 years, and the mean body mass index was 29.3 ± 5.9 kg/m2. Fourteen cases (1.7%) of postoperative surgical site infection were identified in 13 patients. Ten infections (1.2%) were superficial and 4 (0.49%) were deep. The most commonly identified organisms were Staphylococcus aureus and Cutibacterium acnes. Male sex (odds ratio [OR] 4.3, 95% CI 1.2-15.3) and diabetes mellitus (OR 3.9, 95% CI 1.2-12.6) were found to be associated with greater odds of infection. The RCR construct was found to be intact in all 10 patients with superficial infections and 2 of the 4 patients with deep infections. All infections were successfully treated with 1 round of surgical débridement and wound irrigation, and with 6 or fewer weeks of intravenous antibiotic therapy. All patients with postoperative infections recovered with no sequelae at a median final follow-up of 63.5 months (range, 3-215 months).

CONCLUSIONS

This single-surgeon series of a large patient cohort undergoing mini-open RCR over an 18-year period demonstrated a low overall infection rate of 1.7%. Only 4 infections were deep, which suggests that deep infection after mini-open RCR is uncommon and approximates infection rates seen with arthroscopic techniques.

Effects of early exercise and immobilization after arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Early exercise is a physical adjuvant therapy that begins on day 1 postoperatively. It prevents postoperative stiffness, fatty infiltration, muscle atrophy and loss of range of motion. Usually, use of a brace fixation that immobilizes the shoulder in 30° of abduction during the postoperative rehabilitation period reduces tension on the repaired tendon, which improves tendon-bone healing. To investigate the effect of early exercise and brace fixation on postoperative recovery after arthroscopic rotator cuff repair by systematic review, thereby providing evidence-based evidence for clinical practice.

METHODS

Chinese and English databases (PubMed, Web of Science, Cochrane Library, CNKI, Wanfang database, and VIP database) were searched by keywords until November 15, 2024. Randomized controlled studies comparing early exercise versus brace fixation after arthroscopic rotator cuff repair surgery were included, along with an evaluation of such studies using the Cochrane Collaboration risk assessment tool. Afterward, the effect of the intervention on the visual analogue scale (VAS) for pain, function, shoulder range of motion (forward flexion, abduction, internal rotation, external rotation), and postoperative complications (stiffness, re-tear) was evaluated based on a fixed or random effects model.

RESULTS

Eleven high-quality randomized controlled studies were included. Compared with brace fixation, early exercise improved the range of motion of the subjects' shoulders. Compared with brace fixation, shoulder flexion (WMD of 6 weeks = 10.57, 95% CI: 1.30, 19.84, WMD of 3 months = 12.39, 95% CI: 7.51, 17.27, WMD of 6 months = 2.88, 95% CI: 1.02, 4.73, WMD of 1 year = 2.59, 95% CI: 0.40, 4.77) and shoulder abduction (WMD of 6 weeks = 13.17, 95% CI: 9.80, 16.55, respectively). The improvement degree of WMD = 2.28 in 6 months and internal rotation (WMD = 5.08, 95% CI: 3.16, 7.01, in 6 weeks and WMD = 8.23, 95% CI: 4.23, 12.23, in 3 months) was statistically different. Early exercise also reduced the risk of postoperative stiffness (RR = 0.34; 95%CI:0.19, 0.60). However, compared with brace fixation, there was no statistical difference in pain score (WMD = 0.05, 95% CI:0.09, 0.18) and shoulder joint recovery score (SMD = 0.05, 95% CI: 0.12, 0.03).

CONCLUSION

Early exercise can improve the range of motion of early shoulder joint and reduce the risk of postoperative stiffness, but the effect of pain and function improvement is not obvious, which can play a positive role in postoperative rehabilitation of patients, but it needs more comprehensive research and improvement to guide clinical practice.

Arthroscopic rotator cuff repair with bioinductive patch achieves equivalent patient-reported outcomes and retear rate at 1 year

Purpose

The purpose of this study was to evaluate the safety and efficacy of a bioinductive patch augmentation following arthroscopic rotator cuff repair (RCR) in terms of patient-reported outcomes, motion, and complications stratified by tear size.

Methods

A retrospective review of patients undergoing primary RCR with and without bioinductive bovine collagen patch augmentation for supraspinatus/infraspinatus tears from 2014 to 2022 at two centers was performed. Exclusion criteria included: age <18 years, revisions, or lack of 6-month postoperative follow-up. Patients were propensity-score matched 2:1 to patch-augmented patients based on age, sex, BMI, and tear size. Outcomes were compared between the patch and control groups after being stratified by tear size.

Results

A total of 125 patients patch augmented RCRs were matched to 250 controls. No significant differences in demographics or comorbidities between groups. Following stratification by tear size, VAS for partial and small/medium tears in the patch cohorts were lower (p = 0.02) at 3 months. Functional scores were not statistically different. Patch-augmented partial and small/medium tears showed increased forward elevation (p < 0.05) at 1-year follow-up. Retear rates were statistically similar.

Conclusions

Bioinductive patch augmentation demonstrates equivalent outcomes for pain and function, retear rate, but is associated with improved forward elevation up to 1-year for partial and small/medium tears.

Level of evidence

Level III, retrospective cohort study.

Baseline characteristics and 2-year functional outcome data of patients undergoing an arthroscopic rotator cuff repair in Switzerland, results of the ARCR_Pred study

The ARCR_Pred study was initiated to document and predict the safety and effectiveness of arthroscopic rotator cuff repair (ARCR) in a representative Swiss patient cohort. In the present manuscript, we aimed to describe the overall and baseline characteristics of the study, report on functional outcome data and explore case-mix adjustment and differences between public and private hospitals. Between June 2020 and November 2021, primary ARCR patients were prospectively enrolled in a multicenter cohort across 18 Swiss and one German orthopedic center. Baseline characteristics, including sociodemographic and diagnostic variables, were reported. Clinical scores and patient-reported outcome measures were assessed up to 24-month follow-up. After screening 2350 individuals, 973 patients with ARCR were included. Follow-up rates reached 99%, 95%, 89% and 88% at 6 weeks, 6, 12, and 24 months, respectively. While the proportion of massive tears was higher in the study population (44% vs. 20%, Std. Diff. = 0.56), there were no other major differences in key characteristics between enrolled and non-enrolled patients or in patients lost to follow-up. Functional scores improved over time, with positive changes rates ranging from 83% to 92% at 6-month, reaching 91% to 97% at 12- and 24-month follow-up. In linear mixed models, used to estimate the associations between baseline factors, hospital type and standardized 0-100 scores, marginal effects for time ranged from 20 to 30, 28 to 39 and 34 to 41 points at the 6-, 12- and 24-month follow-up, respectively. Except at the 12-month follow-up, where marginal effects for the interaction terms ranged from -5 to -4 points in the standardized scores, there were no consistent outcome differences between public and private hospitals. Increasing number of years of education was consistently associated with better scores, greater feelings of depression and anxiety, smoking and ASA group III-IV were consistently associated with worse scores. Tear severity showed a consistent negative association solely for the Constant-Score. The ARCR_Pred study shows high potential for generalizability to the population of patients undergoing an ARCR in Switzerland. Further analyses are needed to establish relevant clinimetrics for the Swiss population and to compare outcomes for surgical techniques, surgeon experiences profiles and post-operative management.

Primary Human Macrophage and Tenocyte Tendon Healing Phenotypes Changed by Exosomes Per Cell Origin

The high failure rate of surgical repair for tendinopathies has spurred interest in adjunct therapies, including exosomes (EVs). Mesenchymal stromal cell (MSC)-derived EVs (MSCdEVs) have been of particular interest as they improve several metrics of tendon healing in animal models. However, research has shown that EVs derived from tissue-native cells, such as tenocytes, are functionally distinct and may better direct tendon healing. To this end, we investigated the differential regulation of human primary macrophage transcriptomic responses and cytokine secretion by tenocyte-derived EVs (TdEVs) compared with MSCdEVs. Compared with MSCdEVs, TdEVs upregulated TNFa-NFkB and TGFB signaling and pathways associated with osteoclast differentiation in macrophages while decreasing secretion of several pro-inflammatory cytokines. Conditioned media of these TdEV educated macrophages drove increased tenocyte migration and decreased MMP3 and MMP13 expression. In contrast, MSCdEV education of macrophages drove increased gene expression pathways related to INFa, INFg and protection against oxidative stress while increasing cytokine expression of MCP1 and IL6. These data demonstrate that EV cell source differentially impacts the function of key effector cells in tendon healing and that TdEVs, compared with MSCdEVs, promote a more favorable tendon healing phenotype within these cells.

Advancements in biomaterials and scaffold design for tendon repair and regeneration

Tendon injuries present a significant clinical challenge due to their limited natural healing capacity and the mechanical demands placed on these tissues. This review provides a comprehensive evaluation of the current strategies and advancements in tendon repair and regeneration, focusing on biomaterial innovations and scaffold design. Through a systematic literature search of databases such as PubMed, Scopus, and Web of Science, key studies were analyzed to assess the efficacy of biocompatible materials like hydrogels, synthetic polymers, and fiber-reinforced scaffolds in promoting tendon healing. Emphasis is placed on the role of collagen fiber architecture, including fiber diameter, alignment, and crimping, in restoring the mechanical strength and functional properties of tendons. Additionally, the review highlights emerging techniques such as electrospinning, melt electrowriting, and hybrid textile methods that allow for precise scaffold designs mimicking native tendon structures. Cutting-edge approaches in regenerative medicine, including stem cell therapies, bioelectronic devices, and bioactive molecules, are also explored for their potential to enhance tendon repair. The findings underscore the transformative impact of these technologies on improving tendon biomechanics and functional recovery. Future research directions are outlined, aiming to overcome the current limitations in scaffold mechanical properties and integration at tendon-bone and tendon-muscle junctions. This review contributes to the development of more effective strategies for tendon regeneration, advancing both clinical outcomes and the field of orthopedic tissue engineering.

Biologic Adjuvants to Rotator Cuff Repairs Induce Anti-inflammatory Macrophage 2 Polarization and Reduce Inflammatory Macrophage 1 Polarization In Vitro

PURPOSE

To examine the effect of various biologic adjuvants on the polarization of macrophages in an in vitro model for rotator cuff tears.

METHODS

Tissue was harvested from 6 patients undergoing arthroscopic rotator cuff repair. An in vitro model of the supraspinatus and subacromial bursa was created and treated with control, platelet-rich plasma (PRP), autologous activated serum (AAS), or a combination of PRP+AAS. The effect of treatment on macrophage polarization between M1 proinflammatory macrophages or M2 anti-inflammatory macrophages was measured using gene expression, protein expression, flow cytometry, and nitric oxide production.

RESULTS

Tendon and bursa treated with PRP, AAS, and PRP+AAS significantly decreased the gene expression of M1 markers interleukin (IL)-12 and tumor necrosis factor-alpha while significantly increasing the expression of M2 markers arginase, IL-10, and transforming growth factor-β (P < .05) compared with treatment with control. Enzyme-linked immunosorbent assay analysis of protein production demonstrated that, compared with control, coculture treated with PRP, AAS, and PRP+AAS significantly decreased markers of M1-macrophages (IL-6, IL-12, and tumor necrosis factor-alpha) while significantly increasing the expression of markers of M2-macrophages (arginase, IL-10, and transforming growth factor-beta) (P < .05). Flow cytometry analysis of surface markers demonstrated that compared with control, tendon and bursa treated with PRP, AAS, and PRP+AAS significantly decreased markers of M1-macrophages (CD80, CD86, CD64, CD16) while significantly increasing the expression of markers of M2-macrophages (CD163 and CD206) (P < .05). Treatment of the coculture with PRP, AAS, and PRP+AAS consistently demonstrated a decrease in nitric oxide production (P < .05) compared with control. AAS and PRP+AAS demonstrated an increased macrophage shift to M2 compared with PRP alone, whereas there was not as uniform of a shift when comparing PRP+AAS with AAS alone.

CONCLUSIONS

In an in vitro model of rotator cuff tears, the treatment of supraspinatus tendon and subacromial bursa with PRP, AAS, and PRP+AAS demonstrated an increase in markers of anti-inflammatory M2-macrophages and a concomitant decrease in markers of proinflammatory M1-macrophages. AAS and PRP+AAS contributed to a large shift to macrophage polarization to the anti-inflammatory M2 compared with PRP.

CLINICAL RELEVANCE

The mechanism of biologic adjuvant effects on the rotator cuff remains poorly understood. This study suggests that they may contribute to polarization of macrophages for their proinflammatory (M1) state to the anti-inflammatory (M2) state.

Comparing Conventional Double-Row With Transosseous Equivalent Suture Bridge Fixation in Arthroscopic Rotator Cuff Repairs: A Multicenter Retrospective Cohort Study

Background

Biomechanical studies have shown that the transosseous equivalent suture bridge (TOE-SB) rotator cuff repair technique improves contact areas and pressure between the tendon and footprint, which may facilitate healing. However, few studies have directly compared its outcomes with traditional double-row (DR) repair.

Purpose/Hypothesis

The primary objectives of this study were to (1) compare the functional outcomes of DR with TOE-SB fixation in patients undergoing arthroscopic rotator cuff repairs and (2) compare healing rates between the 2 groups and investigate whether any factors were associated with healing. It was hypothesized that arthroscopic rotator cuff repair using DR repair would demonstrate no difference in disease-specific quality of life, patient-reported outcomes, or healing rates compared with TOE-SB repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a cohort study conducted as a subanalysis of 2 larger randomized controlled trials. Patients ≥18 years old with degenerative rotator cuff tears confirmed by magnetic resonance imaging who had persistent symptoms of pain and functional impairment after 6 months of nonoperative management were enrolled in prospective randomized controlled trials and underwent either a traditional DR repair or a TOE-SB rotator cuff repair. Functional outcomes were assessed using the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, and the Constant score at baseline and 3, 6, 12, and 24 months postoperatively. Healing rates were determined using ultrasound at 24 months postoperatively.

Results

A total of 184 patients were included in this study; 34 patients underwent conventional DR repair and 150 underwent TOE-SB repair. Postoperative changes in the outcome measures from baseline were statistically significant for all outcomes in both groups (P < .0001). No statistically significant differences were found between outcomes at any of the follow-up times, except a significant difference in the Constant score at 24 months in favor of the DR group (mean ± SE, 80.5 ± 1.1 [95% CI, 78.4-82.7]) and TOE-SB and DR, respectively (mean ± SE, 85.7 ± 2.2 [95% CI, 81.2-90.1]) (P = .041). Healing rates were 77.8% for DR and 83% for TOE-SB (odds ratio, 1.34 [95% CI, 0.53-3.38]; P = .53). Multivariable regression analysis showed a positive correlation between nonhealing rates and the rotator cuff tear size in the sagittal plane (odds ratio, 1.97 (95% CI, 1.02-3.78); P = .042).

Conclusion

No difference was found between DR and TOE-SB rotator cuff repair in the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, Constant strength subscore, or the healing rate. The Constant score at the 24-month follow-up favored DR repair but did not reach the minimal clinically important difference. An association was found between higher healing rates and smaller sagittal plane tear sizes.

Factors contributing to persistent shoulder pain after arthroscopic rotator cuff repair: Protocol for a scoping review

Introduction

Rotator cuff (RC) tears are the most common and disabling musculoskeletal ailments among patients with shoulder pain. Although most individuals show improvement in function and pain following arthroscopic rotator cuff repair (ARCR), a subgroup of patients continue to suffer from persistent shoulder pain following the surgical procedure. Identifying these factors is important in planning preoperative management to improve patient outcomes.

Objective

This scoping review aims to identify biological factors, psychological factors, and social determinants of health contributing to the development of persistent pain in individuals after the ARCR procedure.

Inclusion criteria

All prospective and retrospective longitudinal studies reporting the risk factors contributing to persistent pain three months or longer after the ARCR surgery will be considered for this scoping review.

Methods

Our review will adhere to the Joanna Briggs Institute (JBI) scoping review methodology. Four electronic databases PubMed, CINAHL, Embase, and Scopus will be searched for studies in the English language. Additional studies can be found by conducting a citation analysis of the included studies. Title and abstract screening will be performed by two independent reviewers following the inclusion criteria, a third reviewer will be consulted about any differences. Next, full-text screening will be conducted, and the remaining search results will be reviewed to extract data, as well as to synthesize findings from all research. An overview of findings will be depicted in tabular format accompanied by a narrative summary of various factors contributing to persistent pain.

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

Background

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

Hypothesis

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

Study Design

Cohort study; Level of evidence, 3.

Methods

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

Results

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

Conclusion

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

Distal Mononeuropathy and Nerve Release After Open and Arthroscopic Shoulder Surgery: A Matched Cohort Analysis

PURPOSE

The purpose of this study was to determine if patients who have undergone prior open or arthroscopic shoulder surgery and develop distal mononeuropathy (DMN) achieve the same clinical benefit after nerve release compared with those who did not have a prior shoulder procedure.

METHODS

Patients were identified by Current Procedural Terminology code for shoulder arthroplasty, shoulder stabilization, and rotator cuff repair and if they had an ensuing nerve release (cubital or carpal tunnel) within 2 years of shoulder surgery. Another cohort that underwent nerve release surgery for DMN with no prior history of shoulder surgery was identified and subsequently matched to the first cohort by a 3:1 (control:case) ratio. Patients were included if they were over the age of 18 years. Chart reviews and surveys stored using REDCap were used to collect demographics, surgical history, EMG/nerve conduction velocity results, postoperative symptoms, and patient-reported outcomes with a minimum 2-year follow-up.

RESULTS

In total, 120 patients were included in this analysis (28 cases, 92 controls). The most common nerve release for DMN across both cohorts was open carpal tunnel release. Following nerve release, the case group had more postoperative persistent numbness/tingling than the control group. Both groups were similar with regard to postoperative pain, weakness, or patient-reported outcome measures. Residual postoperative numbness following nerve release was more likely to occur in the forearm for the case group than the control group.

CONCLUSIONS

Patients with a history of arthroscopic rotator cuff repair and reverse total shoulder replacement shoulder surgery before the presentation of DMN are more likely to experience persistent numbness or tingling after nerve release surgery as well as experience symptoms in the forearm than those without prior shoulder surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom prevalence retrospective study III.

Bioinductive patch as an augmentation for rotator cuff repair, a systematic review and meta-analysis

BACKGROUND

Rotator cuff tears are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be pursued. A significant and common complication after rotator cuff repair (RCR) is retearing or nonhealing. Numerous augmentations to traditional suture RCR have been studied. Of these, the Smith + Nephew Regeneten bioinductive collagen patch has had promising initial results; however, analytic data for its use are lacking, and there is no meta-analysis comparing the available data to historical RCR outcomes.

METHODS

A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMED, Cochrane, and ClinicalTrials.gov. Thirteen studies met inclusion and exclusion criteria. Only clinical trials on full and partial-thickness tears were included. American Shoulder and Elbow Surgeon score, Constant-Murley Score, the visual analog scale for pain, the minimal clinically important difference (MCID), tendon thickness, and complication rates were primary outcomes of interest. A meta-analysis was performed to determine the overall complication and retear rate from the included studies.

RESULTS

American Shoulder and Elbow Surgeon score, Constant-Murley Score, and visual analog scale for pain improved significantly in all studies that reported them, and most patients achieved MCID. Patient-reported outcome measure improvements were similar to historical improvements in standard RCR, and a similar proportion of patients achieved MCID after standard repair. Tendon thickness improved significantly and to a similar degree as standard RCR. Overall retear rate after full thickness RCR augmented with the bioinductive patch was 8.3%. For partial thickness RCR, total retear rate was of 1.1% across all patients. The overall complication rate with the bioinductive patch was 15.5% across all full-thickness RCR studies and 16.2% in partial thickness RCR. We found overall retear rate to be lower after augmentation with the bioinductive patch compared to traditional repair; however, the overall complication rate was similar for full-thickness tears and higher for partial-thickness tears. Lastly, adverse reactions to the bioinductive patch were noted at 0.2%.

CONCLUSIONS

The bioinductive collagen patch appears to be a safe augmentation for rotator cuff repair. Patients are likely to experience significant subjective improvement in patient-reported outcome measures and significant increases in tendon thickness. Retear rate has been a concern after RCR for decades, and the bioinductive patch may help mitigate this risk. There is lack of case-control studies comparing the bioinductive patch to traditional suture RCR. Such data are needed to better determine the role of the bioinductive patch in the treatment of full and partial-thickness rotator cuff repairs.

Combination of different local anesthetic adjunct for supraclavicular brachial plexus block after arthroscopic shoulder surgery: a prospective randomized controlled trial

BACKGROUND

Acute pain is a major concern after arthroscopic shoulder surgery, supraclavicular brachial plexus blockade has shown favorable postoperative analgesic effects. However, its duration of analgesia does not meet clinical needs. We aimed to explore whether the combination of different local anesthetic adjunct can prolong the analgesic duration of supraclavicular brachial plexus block for arthroscopic shoulder surgery.

METHODS

In this prospective randomized controlled trial, we allocated 80 patients into four groups: Group DMD (dexamethasone 10 mg + ropivacaine 100 mg + dexmedetomidine 50 µg + magnesium sulfate 250 mg), Group DM (ropivacaine 100 mg + dexmedetomidine 50 µg + magnesium sulfate 250 mg), Group M (ropivacaine 100 mg + magnesium sulfate 250 mg) and Group D (ropivacaine 100 mg + dexmedetomidine 50 µg). The primary outcome was the time to first request for analgesia. Secondary outcome measures included cumulative opioid consumption at 6, 12, 18, 24, and 48 h postoperatively, VAS scores at 6, 12, 18, 24, and 48 h postoperatively and so on.

RESULTS

The time to first request for analgesia in Group DMD was significantly longer than Group DM (P = 0.011) and Group M (P = 0.003). The cumulative opioid consumption at 18 h postoperatively in Group DMD was significantly lower than in Group DM (P = 0.002) and Group M (P = 0.007). The cumulative opioid consumption at 24 h postoperatively in Group DMD was significantly lower than in Group DM (P = 0.016). The VAS score at 6 h postoperatively in Group DMD was significantly lower than in Group DM and Group M. The VAS score at 12 h postoperatively in Group DMD was significantly lower than in Group M. For American Shoulder and Elbow Surgeons Score, Group DMD had a better score than Group DM and Group D.

CONCLUSIONS

The analgesic efficacy of supraclavicular brachial plexus blockade combined with dexamethasone, magnesium sulfate, and dexmedetomidine is significantly superior to the combination of magnesium sulfate and dexmedetomidine, and significantly superior to the use of magnesium sulfate alone.

TRIAL REGISTRATION

This trial was registered in Chinese Clinical Trial Registry. (ChiCTR2200061181, Date of registration: June 15, 2022, http://www.chictr.org.cn ).

Rotator cuff-related shoulder pain (RCRSP): semistructured patient interviews to explore the barriers and enablers to rehabilitation exercises

This study aimed to explore the barriers and enablers to physiotherapist-prescribed rehabilitation exercises for people with rotator cuff-related shoulder pain (RCRSP) and to guide the development of a theoretically informed intervention for people with this condition. Eleven people receiving physiotherapy for RCRSP (M=69 ± 12 years) participated in semistructured interviews. Data were analysed using content analysis, the Theoretical Domains Framework (TDF). The following barriers and enablers were identified in line with the six themes and assigned relevant TDF domains. (1) The impact of previous knowledge and experience on beliefs, (2) therapeutic relationships, (3) expectations around diagnosis, (4) a long and slow pathway to treatment, (5) patients' experience of doing the home exercise rehabilitation programme and (6) seeing positive outcomes. Patients' beliefs that an investigation was necessary to make a diagnosis are incongruent with clinical guidelines. Several enablers identified that influence adherence to shoulder rehabilitation exercises will inform the development of interventions designed to improve adherence. Our findings highlight the importance of educating patients to alleviate identified barriers to self-management for RCRSP. Furthermore, it underscores the need to train healthcare professionals with the necessary skills to effectively educate patients, specifically about misconceptions and uncertainties about the condition and exercise.

The influence of sex is a neglected focus in rotator cuff repair: A systematic review and meta-analysis

PURPOSE

Rotator cuff (RC) disorders are the most common cause of shoulder disability. The aim of this study was to quantify the evidence on the sex-related differences in RC repair.

METHODS

A systematic review of the literature was performed in January 2023 in PubMed, Wiley Cochrane Library and Web of Science on research articles on humans with RC tears treated surgically. A meta-analysis was performed to compare results in men and women. The Downs and Black score and the modified Coleman methodology score (MCMS) were used to assess the retrieved studies.

RESULTS

A total of 39,909 patients were enroled in the 401 studies analysed (45% women, 55% men). A trend toward more sex-balanced recruitment was observed over time. Only 4% of the studies on 1.5% of the documented patients presented disaggregated outcome data and were quantitatively analysed. A tendency for lower range of motion values after surgery was found for external shoulder rotation in women, with 39.9° ± 6.9° versus 45.3° ± 4.1° in men (p = 0.066). According to Downs and Black scores, four studies were good and 12 fair, with a main MCMS score of 69/100.

CONCLUSION

There is a lack of awareness on the importance to document women- and men-specific data. Only 4% of the articles disaggregated data, and it was possible to analyse only 1.5% of the literature population, a sample which cannot be considered representative of all patients. The lack of disaggregated data is alarming and calls for action to better study men and women differences to optimise the management of RC tears. This will be necessary to provide sex-specific information that could be of clinical relevance when managing RC repair.

LEVEL OF EVIDENCE

Level IV.

Patient-Reported Outcomes After Arthroscopic Superior Capsule Reconstruction With an Acellular Porcine Dermal Xenograft for Irreparable Rotator Cuff Tears

Background

Currently, there is no consensus on the adequate management of irreparable rotator cuff tears. Arthroscopic superior capsule reconstruction (SCR) seems to be an alternative treatment option.

Purpose/Hypothesis

The purpose of this study was to evaluate patient-reported outcomes up to 2 years after the treatment of irreparable rotator cuff tears with SCR using an acellular porcine dermal xenograft. It was hypothesized that SCR treatment with an acellular porcine dermal xenograft would not result in a significant clinical improvement or pain relief in patients with irreparable rotator cuff tears if the xenograft fails.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 26 consecutive patients with irreparable rotator cuff tears were enrolled in the study between 2015 and 2019. All patients underwent SCR with acellular porcine dermal xenograft. Patient-reported outcome measures including visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Veterans RAND 12- Item Health Survey (VR-12), and the Single Assessment Numeric Evaluation (SANE) were followed up for 2 years. For statistical analysis, the 1-way analysis of variance was used to compare means for VAS, ASES, VR-12, and SANE results between pre- and posttreatment. Magnetic resonance imaging (MRI) records were obtained at 1 year postoperatively to evaluate graft integrity.

Results

In total, 22 patients were included in the patient-reported outcomes with 4 being lost at final follow-up. The mean VAS score decreased from 4.2 ± 2.5 to 1.0 ± 1.4 (P < .001) from pretreatment to 2 years postoperatively. The mean ASES - index score improved significantly from 47.7 ± 15.3 to 86.4 ± 12.9 (P < .001) and the SANE score improved from 34.0 ± 20.4 to 77.3 ± 20.2 (P < .001). In addition, a clinically important difference in the patients' quality of life was achieved, as shown by the mean changes in the VR-12 physical (+4.3) and mental scores (+9.3). Based on postoperative MRI, the dermal graft on the humeral side was intact in 15 (68.2%) patients after surgery.

Conclusion

Our arthroscopic SCR with an acellular porcine dermal matrix showed significant and continuous improvement in pain and clinical scores up to a 2-year follow-up in patients with irreparable rotator cuff tears, even with structural graft failure. However, further studies and evaluation of larger patient groups are needed to evaluate the long-term effect of this procedure.

Concomitant Biceps Tenodesis Does Not Compromise Arthroscopic Rotator Cuff Repair Outcomes

PURPOSE

To compare outcomes of patients who underwent rotator cuff repair (RCR) with concomitant biceps tenodesis with those who underwent an isolated RCR.

METHODS

Exclusion criteria included previous ipsilateral shoulder surgery, irreparable rotator cuff tears, rotator cuff arthropathy, calcific tendinitis, adhesive capsulitis requiring a capsular release, or advanced osteoarthritis of the glenohumeral joint. Patients were indicated for biceps tenodesis if they had any degree of tendon tearing, moderate-to-severe tenosynovitis, instability, or a significant degenerative SLAP tear. Primary outcome measures included American Shoulder and Elbow Surgeons score, Simple Shoulder Test, EuroQoL 5-Dimension 5-Level visual analog scale, EuroQoL 5-Dimension 5-Level, and a site-specific questionnaire, which focused on surgical expectations, satisfaction, and complications. Multivariate analysis of variance to analyze descriptive statistics and determine significant differences between the patient groups for subjective and objective outcome measures were performed.

RESULTS

There were no significant differences for pain/visual analog scale (0.34 ± 0.09 vs 0.47 ± 0.09, P = .31), American Shoulder and Elbow Surgeons score (96.69 ± 0.87 vs 94.44 ± 0.91, P = .07), and Simple Shoulder Test (11.42 ± 0.17 vs 10.95 ± 0.18, P = .06) between the RCR with concomitant biceps tenodesis and isolated RCR at a minimum of 2 years' postoperatively. This is despite the RCR with concomitant biceps tenodesis group having significantly larger rotator cuff tears (4.25 ± 0.30 cm2 vs 2.80 ± 0.32 cm2, P = .001) than the isolated RCR group.

CONCLUSIONS

This study revealed that concomitant biceps tenodesis does not compromise outcomes when compared with an isolated RCR at 2-year follow-up, despite this group having larger rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective case study.

Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair

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

Adoption of a Societal Perspective in Economic Evaluations of Musculoskeletal Disorders: A Conceptual Paper

Economic evaluations are used to compare the costs and consequences of healthcare interventions, including those for musculoskeletal (MSK) disorders, which are very common and a major source of morbidity and absence from work. Reimbursement decisions for interventions for MSK disorders by decision-makers rely on the findings of economic evaluations, the design and results of which depend largely on the perspective adopted. Despite methodological advancements in economic evaluations, there are no clear guidelines on the perspective to adopt. This paper explores the adoption of a societal perspective in economic evaluations of MSK disorders. Within health economics evaluations, the most commonly used perspectives include the payer perspective, the healthcare perspective, and the societal perspective. To facilitate optimal resource allocation decisions in order to reduce the significant economic burden of MSK disorders and improve the health outcomes of individuals with these disorders, all costs and benefits associated with interventions for them should be included. Thus, the societal perspective is arguably a preferable option to the others for economic evaluations of interventions for MSK disorders.

Association between timing of initiating supervised physical rehabilitation after rotator cuff repair and incidence of repeat repair and capsulitis: a population-based analysis

BACKGROUND

There is limited consensus on the optimal time to initiate supervised physical rehabilitation after a rotator cuff repair (RCR). We examined whether timing of initiating supervised physical rehabilitation was associated with repeat RCR or development of adhesive capsulitis within 12 months postoperatively in an observational cohort of commercially insured adults.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters Database. We included adults aged 18-64 who underwent a unilateral outpatient RCR between 2017 and 2020 and initiated supervised physical rehabilitation 1-90 days postoperatively. Multivariable logistic regression models examined the adjusted association between time of initiating supervised physical rehabilitation (1-13, 14-27, 28-41, and 42-90 days postoperatively) and each of the primary outcomes: repeat RCR and capsulitis. In a sensitivity analysis, time to rehabilitation was alternatively categorized using a data-driven approach of quartiles (1-7, 8-16, 17-30, and 31-90 days postoperatively). We report adjusted odds ratios (OR).

RESULTS

Among 33,841 patients (86.7% arthroscopic index RCR), the median time between index RCR and rehabilitation initiation was 16 days (interquartile range 7-30), with 39.9% initiating rehabilitation at 1-13 days. Additionally, 2.2% underwent repeat RCR within 12 months, and 12-month capsulitis was identified in 1.9% of patients. There were no significant associations between timing of initiating rehabilitation and 12-month repeat RCR (OR 0.85-0.93, P = .18-.49) or 12-month capsulitis (OR 0.83-0.94, P = .22-.63). Lack of associations between timing and outcomes was supported in sensitivity analyses.

CONCLUSIONS

Timing of initiating rehabilitation was not significantly associated with adverse outcomes after RCR. The finding of no increased odds of repeat RCR or capsulitis with the earliest timing may support earlier initiation of rehabilitation to accelerate return to daily activities. Findings should be replicated in another dataset of similarly-aged patients.

3D-printed Mg-incorporated PCL-based scaffolds improves rotator cuff tendon-bone healing through regulating macrophage polarization

Introduction: Rotator cuff tear (RCT) is a common shoulder injury impacting mobility and quality of life, while traditional surgeries often result in poor healing. Tissue engineering offers a promising solution, with poly (ε-caprolactone) (PCL) being favored due to its slow degradation, biocompatibility, and non-toxicity. However, PCL lacks sufficient compression resistance. Incorporating Mg, which promotes bone growth and has antibacterial effects, could enhance RCT repair. Methods: The Mg-incorporated PCL-based scaffolds were fabricated using a 3D printing technique. The scaffolds were incorporated with different percentages of Mg (0%, 5%, 10%, 15%, and 20%). The osteogenic activities and anti-inflammatory properties of the scaffolds were evaluated in vitro using human osteoblasts and macrophages. The tissue ingrowth and biocompatibility of the scaffolds were assessed in vivo using a rat model of RCT repair. The ability of the scaffolds to enhance macrophage polarization towards the M2 subtype and inhibit inflammation signaling activation was also investigated. Results: It was found that when incorporated with 10% Mg, PCL-based scaffolds exhibited the optimal bone repairing ability in vitro and in vivo. The in vitro experiments indicated that the successfully constructed 10 Mg/PCL scaffolds enhance osteogenic activities and anti-inflammatory properties. Besides, the in vivo studies demonstrated that 10 Mg/PCL scaffolds promoted tissue ingrowth and enhanced biocompatibility compared to the control PCL scaffolds. Furthermore, the 10 Mg/PCL scaffolds enhanced the macrophages' ability to polarize towards the M2 subtype and inhibited inflammation signaling activation. Discussion: These findings suggest that 3D-printed Mg-incorporated PCL scaffolds have the potential to improve RCT by enhancing osteogenesis, reducing inflammation, and promoting macrophage polarization. The incorporation of 10% Mg into PCL-based scaffolds provided the optimal combination of properties for RCT repair augmentation. This study highlights the potential of tissue engineering approaches in improving the outcomes of RCT repair and provides a foundation for future clinical applications.

Facile and rapid fabrication of a novel 3D-printable, visible light-crosslinkable and bioactive polythiourethane for large-to-massive rotator cuff tendon repair

Facile and rapid 3D fabrication of strong, bioactive materials can address challenges that impede repair of large-to-massive rotator cuff tears including personalized grafts, limited mechanical support, and inadequate tissue regeneration. Herein, we developed a facile and rapid methodology that generates visible light-crosslinkable polythiourethane (PHT) pre-polymer resin (∼30 min at room temperature), yielding 3D-printable scaffolds with tendon-like mechanical attributes capable of delivering tenogenic bioactive factors. Ex vivo characterization confirmed successful fabrication, robust human supraspinatus tendon (SST)-like tensile properties (strength: 23 MPa, modulus: 459 MPa, at least 10,000 physiological loading cycles without failure), excellent suture retention (8.62-fold lower than acellular dermal matrix (ADM)-based clinical graft), slow degradation, and controlled release of fibroblast growth factor-2 (FGF-2) and transforming growth factor-β3 (TGF-β3). In vitro studies showed cytocompatibility and growth factor-mediated tenogenic-like differentiation of mesenchymal stem cells. In vivo studies demonstrated biocompatibility (3-week mouse subcutaneous implantation) and ability of growth factor-containing scaffolds to notably regenerate at least 1-cm of tendon with native-like biomechanical attributes as uninjured shoulder (8-week, large-to-massive 1-cm gap rabbit rotator cuff injury). This study demonstrates use of a 3D-printable, strong, and bioactive material to provide mechanical support and pro-regenerative cues for challenging injuries such as large-to-massive rotator cuff tears.

Arthroscopic Modified Double-Pulley Suture-Bridge Repair of Medium-Sized Supraspinatus Tendon Tears

At present, the repair patterns for medium-sized supraspinatus tendon tears are double- and single-row repairs. However, the limitations of double-row repair include excessive anchor implantation and incremental surgical cost and time, whereas a deficient tendon-bone contact area exists with single-row repair. The modified double-pulley suture-bridge repair presented in this study is an arthroscopic technique using 3 double-loaded suture anchors combined with a double-pulley technique to form a hybrid repair pattern with a double row as the mainstay and a single row as the supplement. In the treatment of medium-sized tendon tears, the modified double-pulley suture-bridge repair can not only maximize the tendon-bone contact area but also lower the surgical cost and shorten the operative time. The surgical technique is described, including pearls and pitfalls, as well as advantages and disadvantages.

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.

Factors affecting return to work following arthroscopic rotator cuff repair

Background

Prolonged work absence following arthroscopic rotator cuff repair (ARCR) is a major concern, yet factors influencing return to work are poorly understood. The primary aim of this study is to retrospectively assess the proportion of patients who successfully resume equivalent occupational demands after ARCR, along with the time taken for their return to work.

Methods

Eighty-three patients underwent ARCR. Work intensity and worker's compensation status were recorded. Patients were interviewed at ≥12 months to determine return to work rate and timing.

Results

In total, 83 patients were included, with a median age of 58.7 (±8.36) and a follow-up of at least 12 months. 98.8% returned to work at a median of eight weeks. Heavy manual labor significantly delayed return to work compared to light work (HR 0.15 95% CI). Receiving worker's compensation was associated with delayed return to work (HR 0.26 95% CI).

Conclusion

This study found that nearly all patients returned to work following ARCR, but high-intensity manual labor and worker compensation status significantly delayed their return to work. Patients with physically demanding jobs and those receiving workers' compensation had a 60-85% lower likelihood of returning to work at any given time point compared to light work and noncompensated patients.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears With and Without Augmentation With a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement

PURPOSE

To compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant.

METHODS

The study group comprised 24 patients (17 male subjects) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 male subjects) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion and patient-reported outcomes were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging was obtained in 20 of 24 collagen implant patients and 17 of 24 control patients at minimum 6 months' follow-up to assess tendon healing.

RESULTS

American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in range of motion and patient-reported outcomes were similar in both groups. Magnetic resonance imaging revealed intact repairs in 11 of 20 (55%) patients in the patch group and 9 of 17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty.

CONCLUSIONS

Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Factors associated with genetic markers for rotator cuff disease in patients with atraumatic rotator cuff tears

For atraumatic rotator cuff tears, genetics contributes to symptomatic tear risk and may influence rotator cuff healing after surgical repair. But little is known about how genetic factors influence rotator cuff tear patient characteristics at presentation. We collected saliva samples for genotyping from atraumatic rotator cuff tear patients. We examined nine single nucleotide polymorphisms (SNPs) associated with cuff tears in prior literature. We estimated associations of SNP dosage with (1) age at tear diagnosis, (2) bilateral atraumatic tear prevalence, and (3) tear size. Linear regression was used to estimate associations with diagnosis age adjusted for sex and principal components. Logistic regression and ordinal logistic regression were used to estimate associations with bilateral tear prevalence and tear size category, respectively, adjusting for age, sex, and principal components. Of 344 eligible patients, 336 provided sufficient samples for genotyping. Median age at tear diagnosis was 61, 22% (N = 74) had bilateral atraumatic tears, and 9% (N = 29) had massive tears. SNP rs13107325 in the SLC39A8 gene and rs11850957 in the STXBP6 gene were associated with younger diagnosis age even after accounting for multiple comparisons (rs13107325: -4 years, 95% CI = -6.5, -1.4; rs11850957: -2.7 years, 95% CI = -4.3, -1.1). No other significant associations were observed with diagnosis age, tear size, or bilateral tear prevalence. SLC39A8 encodes a Mn transporter. STXBP6 may play a role in inflammatory responses by altering phagocytosis and antigen presentation of monocytes and macrophages. Further research is needed to determine if genetic markers can be used alongside patient characteristics to aid in identifying optimal surgical repair candidates.

The subacromial bursa modulates tendon healing after rotator cuff injury in rats

Rotator cuff injuries result in more than 500,000 surgeries annually in the United States, many of which fail. These surgeries typically involve repair of the injured tendon and removal of the subacromial bursa, a synovial-like tissue that sits between the rotator cuff and the acromion. The subacromial bursa has been implicated in rotator cuff pathogenesis and healing. Using proteomic profiling of bursa samples from nine patients with rotator cuff injury, we show that the bursa responds to injury in the underlying tendon. In a rat model of supraspinatus tenotomy, we evaluated the bursa's effect on the injured supraspinatus tendon, the uninjured infraspinatus tendon, and the underlying humeral head. The bursa protected the intact infraspinatus tendon adjacent to the injured supraspinatus tendon by maintaining its mechanical properties and protected the underlying humeral head by maintaining bone morphometry. The bursa promoted an inflammatory response in injured rat tendon, initiating expression of genes associated with wound healing, including Cox2 and Il6. These results were confirmed in rat bursa organ cultures. To evaluate the potential of the bursa as a therapeutic target, polymer microspheres loaded with dexamethasone were delivered to the intact bursae of rats after tenotomy. Dexamethasone released from the bursa reduced Il1b expression in injured rat supraspinatus tendon, suggesting that the bursa could be used for drug delivery to reduce inflammation in the healing tendon. Our findings indicate that the subacromial bursa contributes to healing in underlying tissues of the shoulder joint, suggesting that its removal during rotator cuff surgery should be reconsidered.

Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study

OBJECTIVE

The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed.

RESULTS

Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%).

CONCLUSION

Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes.

IMPACT

Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

[Early effectiveness of arthroscopic tri-anchor double-pulley suture-bridge repair of medium-size supraspinatus tendon tears]

Objective

To explore the early effectiveness of arthroscopic tri-anchor double-pulley suture-bridge in treatment of medium-size supraspinatus tendon tears.

Methods

Between December 2020 and January 2023, 40 patients with medium-size supraspinatus tendon tears were treated with arthroscopic tri-anchor double-pulley suture-bridge. There were 18 males and 22 females, with an average age of 62.6 years (mean, 45-73 years). Among them, 17 patients had trauma history. The main clinical symptom was shoulder pain with hug resistance test (+). The interval from symptom onset to operation was 10.7 months on average (range, 3-36 months). Visual analogue scale (VAS) score, University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, and shoulder range of motion (ROM) of forward flexion, abduction, and external rotation were used to evaluate shoulder function. MRI was performed to assess the structural integrity and tension of reattached tendon. Patient satisfactions were calculated at last follow-up.

Results

All incisions healed by first intention, no complications such as incision infection or nerve injury occurred. All patients were followed up 12-37 months (mean, 18.2 months). At 12 months after operation, VAS score, UCLA score, and ASES score significantly improved when compared with the preoperative scores ( P<0.05). At 3 and 12 months after operation, the ROM of external rotation significantly improved when compared with preoperative one ( P<0.05), and further improved at 12 months after operation ( P<0.05). However, the ROMs of abduction and forward flexion did not improve at 3 months after operation when compared with those before operation ( P>0.05), but significantly improved at 12 months after operation ( P<0.05). Twenty-six patients underwent MRI at 3-6 months, of which 23 patients possessed intact structural integrity, good tendon tension, and tendon healing; 3 patients underwent tendon re-tear. The self-rated satisfaction rate was 92.5% at last follow-up.

Conclusion

Arthroscopic tri-anchor double-pulley suture-bridge in treatment of medium-size supraspinatus tendon tears can maximize the tendon-bone contact area, obtain satisfied early effectiveness with high satisfaction rate and low incidence of tendon re-tear. However, the function of abduction is limited at 3 months after operation, and patients need to adhere to rehabilitation training to further improve the joint activity.

Optimized design of an enthesis-mimicking suture anchor-tendon hybrid graft for mechanically robust bone-tendon repair

Repair of functionally graded biological interfaces requires joining dissimilar materials such as hard bone to soft tendon/ligament, with re-injuries/re-tears expected to be minimized by incorporating biomimicking, stress-reducing features within grafts. At bone-tendon interfaces (entheses), stress can be reduced via angled insertion, geometric flaring, mechanical gradation, and interdigitation of tissues. Here, we incorporated enthesis attributes into 3D in silico and physical models of a unique suture anchor-tendon hybrid graft (SATHG) and investigated their effects on stress reduction via finite element analyses (FEA) studies. Over 20 different simulations altering SATHG angulation, flaring, mechanical gradation, and interdigitation identified an optimal design, which included 90° angulation, 25° flaring, and a compliant (ascending then descending) mechanical gradient in SATHG's bone-to-tendon-like transitional region. This design reduced peak stress concentration factor (SCF) by 43.6 % relative to an ascending-only mechanical gradient typically used in hard-to-soft tissue engineering. To verify FEA results, SATHG models were fabricated using a photocrosslinkable bone-tendon-like polyurethane (QHM polymer) for ex vivo tensile assessment. Tensile testing showed that ultimate load (132.9 N), displacement-at-failure (1.78 mm), stiffness (135.4 N/mm), and total work-to-failure (422.1 × 10-3 J) were highest in the optimized design. Furthermore, to assess envisioned usage, SATHG pull-out testing and 6-week in vivo implantation into large, 0.5-cm segmental supraspinatus tendon defects was performed. SATHG pull-out testing showed secure bone attachment while histological assessment such as hematoxylin and eosin (H&E) together with Safranin-O staining showed biocompatibility including enthesis regeneration. This work demonstrates that engineering biomaterials with FEA-optimized, enthesis-like attributes shows potential for enhancing hard-to-soft tissue repair. STATEMENT OF SIGNIFICANCE: Successful repair of hard-to-soft tissue injuries is challenging due to high stress concentrations within bone-tendon/ligament grafts that mechanically compromise repair strength. While stress-reducing gradient biomaterials have been reported, little-to-no attention has focused on other bone-tendon/ligament interface (enthesis) features. To this end, a unique bone-tendon graft (SATHG) was developed by combining two common orthopaedic devices along with biomimetic incorporation of four enthesis-like features to reduce stress and encourage widespread clinician adoption. Notably, utilizing designs based on natural stress dissipation principles such as anchor insertion angle, geometric flaring, and mechanical gradation reduced stress by 43.6 % in silico, which was confirmed ex vivo, while in vivo studies showed SATHG's ability to support native enthesis regeneration. Thus, SATHG shows promise for hard-to-soft tissue repairs.

A novel and efficient murine model for investigating tendon-to-bone healing

BACKGROUND

Tendon-to-bone healing is a critical challenge in sports medicine, with its cellular and molecular mechanisms yet to be explored. An efficient murine model could significantly advance our understanding of this process. However, most existing murine animal models face limitations, including a propensity for bleeding, restricted operational space, and a steep learning curve. Thus, the need for a novel and efficient murine animal model to investigate the cellular and molecular mechanisms of tendon-to-bone healing is becoming increasingly evident.

METHODS

In our study, forty-four 9-week-old male C57/BL6 mice underwent transection and reattachment of the Achilles tendon insertion to investigate tendon-to-bone healing. At 2 and 4 weeks postoperatively, mice were killed for histological, Micro-CT, biomechanical, and real-time polymerase chain reaction tests.

RESULTS

Histological staining revealed that the original tissue structure was disrupted and replaced by a fibrovascular scar. Although glycosaminoglycan deposition was present in the cartilage area, the native structure had been destroyed. Biomechanical tests showed that the failure force constituted approximately 44.2% and 77.5% of that in intact tissues, and the ultimate tensile strength increased from 2 to 4 weeks postoperatively. Micro-CT imaging demonstrated a gradual healing process in the bone tunnel from 2 to 4 weeks postoperatively. The expression levels of ACAN, SOX9, Collagen I, and MMPs were detected, with all genes being overexpressed compared to the control group and maintaining high levels at 2 and 4 weeks postoperatively.

CONCLUSIONS

Our results demonstrate that the healing process in our model is aligned with the natural healing process, suggesting the potential for creating a new, efficient, and reproducible mouse animal model to investigate the cellular and molecular mechanisms of tendon-to-bone healing.

Distinct human stem cell subpopulations drive adipogenesis and fibrosis in musculoskeletal injury

Fibroadipogenic progenitors (FAPs) maintain healthy skeletal muscle in homeostasis but drive muscle degeneration in chronic injuries by promoting adipogenesis and fibrosis. To uncover how these stem cells switch from a pro-regenerative to pro-degenerative role we perform single-cell mRNA sequencing of human FAPs from healthy and injured human muscles across a spectrum of injury, focusing on rotator cuff tears. We identify multiple subpopulations with progenitor, adipogenic, or fibrogenic gene signatures. We utilize full spectrum flow cytometry to identify distinct FAP subpopulations based on highly multiplexed protein expression. Injury severity increases adipogenic commitment of FAP subpopulations and is driven by the downregulation of DLK1. Treatment of FAPs both in vitro and in vivo with DLK1 reduces adipogenesis and fatty infiltration, suggesting that during injury, reduced DLK1 within a subpopulation of FAPs may drive degeneration. This work highlights how stem cells perform varied functions depending on tissue context, by dynamically regulating subpopulation fate commitment, which can be targeted improve patient outcomes after injury.

Orthopedic surgeon-scientist representation is low among National Institutes of Health grants for rotator cuff research

Background

The purpose of this study is to characterize National Institutes of Health (NIH) funding for rotator cuff research and evaluate the impact of orthopedic surgeons on this portfolio.

Methods

The NIH's Research Portfolio Online Reporting Tools Expenditures and Results database was queried for "rotator cuff repair" or "rotator cuff tear" from the 2011 to 2021 fiscal years. Compound annual growth rates were calculated and grants were categorized by basic, clinical, or translational research. Funding totals were compared by Principal Investigator (PI) and grant characteristics.

Results

A total of 52 grants were awarded to 38 PIs between 2011 and 2021, totaling $40,156,859. Annual NIH funding for rotator cuff tear and rotator cuff repair increased by a Compound annual growth rate of 11.0% from 2011 to 2021, compared to 3.4% for the total NIH budget. Orthopedic surgeon-scientists received $9,208,212 (22.9%), most commonly through R01 (80.5%) and K08 (7.1%) mechanisms. No significant difference in funding was found by PI sex (P = .332), degree (P = .460), academic rank (P = .118), or researcher type (P = .227). Professors had a higher h-index than associate and assistant professors (P = .001). Orthopedic surgeon-scientists had a higher h-index (mean 36.3 ± 9.4) compared to clinician-scientists (mean 8.0 ± 1.4) and research-scientists (35.5 ± 40.7) (P = .044). Clinical topics receiving the highest funding were rehabilitation (23.9%), diagnosis, (22.3%) and surgical technique (14.8%). Orthopedic surgeon-scientists acquired funding for diagnosis (57.1%), rehabilitation (17.0%), and surgical technique (14.5%).

Discussion

While NIH funding for rotator cuff research is growing, orthopedic surgeon representation is low. Future studies should evaluate barriers to obtaining funding for orthopedic surgeon-scientists.

Bone Marrow Mobilization and Local Stromal Cell-Derived Factor-1α Delivery Enhances Nascent Supraspinatus Muscle Fiber Growth

Rotator cuff tear is a significant problem that leads to poor clinical outcomes due to muscle degeneration after injury. The objective of this study was to synergistically increase the number of proregenerative cells recruited to injure rotator cuff muscle through a novel dual treatment system, consisting of a bone marrow mobilizing agent (VPC01091), hypothesized to "push" prohealing cells into the blood, and localized delivery of stromal cell-derived factor-1α (SDF-1α), to "pull" the cells to the injury site. Immediately after rotator cuff tendon injury in rat, the mobilizing agent was delivered systemically, and SDF-1α-loaded heparin-based microparticles were injected into the supraspinatus muscle. Regenerative and degenerative changes to supraspinatus muscle and the presence of inflammatory/immune cells, mesenchymal stem cells (MSCs), and satellite cells were assessed via flow cytometry and histology for up to 21 days. After dual treatment, significantly more MSCs (31.9 ± 8.0% single cells) and T lymphocytes (6.7 ± 4.3 per 20 × field of view) were observed in supraspinatus muscle 7 days after injury and treatment compared to injury alone (14.4 ± 6.5% single cells, 1.2 ± 0.7 per 20 × field of view), in addition to an elevated M2:M1 macrophage ratio (3.0 ± 0.5), an indicator of a proregenerative environment. These proregenerative cellular changes were accompanied by increased nascent fiber formation (indicated by embryonic myosin heavy chain staining) at day 7 compared to SDF-1α treatment alone, suggesting that this method may be a promising strategy to influence the early cellular response in muscle and promote a proregenerative microenvironment to increase muscle healing after severe rotator cuff tear.

Evaluating medical students' knowledge of patient-reported outcomes and the impact of curriculum intervention in consecutive cohorts

BACKGROUND

Patient-reported outcomes (PROs) collection and utilization improves patient-provider communication, symptom reporting, and patient satisfaction. Despite their significance, the science and utility of PROs are not part of required curriculum in medical education. The authors describe the results of a survey distributed to medical students evaluating their experience, knowledge, and perceptions of PROs, report on outcomes of the impact of formal PRO education on medical student knowledge, and describe strategies to foster the spread of PRO education into other programs.

METHODS

The authors developed and distributed a 20-question web-based survey distributed to medical students at two U.S. medical schools to evaluate students' experience, knowledge, and perceptions of PROs. To compare medical students' knowledge in their pre-clinical years (M1-M2) to those in their clinical years (M3-M4), the authors calculated odds ratios and determined significance determined using chi-squared tests. To determine the utility of formal education on medical students' knowledge of PROs, the authors invited 4th year medical students at a single institution to participate in a survey before and two weeks after receiving formal PRO education as part of the medical school curriculum, spanning three years.

RESULTS

137 (15%) medical students responded to the initial survey. Respondents' knowledge of PROs was low and did not differ when comparing pre-clinical to clinical years in school. Less than 10% had received education on PROs and only 16% felt prepared to use PROs in patient care. Respondents demonstrated positive attitudes towards PROs, with 84% expressing interest in learning about PROs. In the second phase education cohort of 231 (77% response rate) 4th -year medical students over three years, formal education improved correct response rates to PRO questions. After education, 90% (121/134) agreed PROs are an important component of high-quality care.

CONCLUSIONS

This study identifies a gap in knowledge about PROs among medical students irrespective of year in training. It also shows that structured education may help fill the PRO knowledge gap, potentially providing future clinicians with the skills to implement PROs into clinical practice, aligning with the broader shift towards patient-centric evidence-based healthcare practices.

Mitochondrial Biogenesis as a Therapeutic Target for Rotator Cuff Tendon Tears

Rotator Cuff Injuries (RCI) are highly prevalent and characterized by shoulder pain, restricted shoulder movement, and difficulty with overhead activity, radiating pain in the deltoid muscle, and atrophy of the rotator cuff muscles. Increasing age, hand dominance, smoking, hypertension, hyperlipidemia, and obesity are common risk factors. Chronic inflammation plays a critical role in the underlying pathogenesis. RCI accounts for massive healthcare expenditure costing about $15,000 per repair, and over 4.5 million physician visits per year, however, there is still no therapeutic target to improve clinical outcomes. Mitochondrial biogenesis in response to inflammatory stimuli supports increased cellular energy requirements, cell proliferation, and differentiation. This suggests that mitochondrial biogenesis may play a role in healing RCI by serving as a protective factor against free oxygen species and promoting homeostasis within the rotator cuff. There is evidence highlighting the potential therapeutic benefits of mitochondrial biogenesis in various inflammatory diseases, but no study explored the role of mitochondrial biogenesis in rotator cuff tears. Since hypercholesterolemia is a risk factor for RCI, we investigated the effects of hypercholesterolemia on the expression of PGC-1α, a marker of mitochondrial biogenesis, in rotator cuff muscle. The findings revealed an increased gene and protein expression of inflammatory mediators and PGC-1α, suggesting enhanced inflammation and increased mitochondrial biogenesis due to hypercholesterolemia. Additional studies are warranted to further investigate the chronic effect of hyperlipidemia induced RCI to elucidate the cause of insufficient mitochondrial biogenesis unable to protect the rotator cuff and the therapeutic effect of promoting mitochondrial biogenesis.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy

INTRODUCTION

Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy.

METHODS

A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy.

RESULTS

Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results.

CONCLUSION

In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

Total Intravenous Anesthesia Compared to Inhalational Anesthesia in Patients Undergoing Arthroscopic Rotator Cuff Repair

Background Inhalation anesthesia (IA) and total intravenous anesthesia (TIVA) are common general anesthesia techniques. During rotator cuff repair (RCR), an interscalene block is beneficial for intraoperative and early postoperative pain control. This study aimed to evaluate postoperative outcomes and opioid usage in patients undergoing arthroscopic RCR with an interscalene block and either IA or TIVA. Methodology A retrospective observational study was performed of 478 patients undergoing RCR at a single institution. Demographics, surgical details, intra and postoperative medications, and 90-day outcomes were collected. Univariate and multivariate analyses were performed to evaluate differences between groups. Results In total, 309 (64.6%) patients received IA and 169 (35.3%) received TIVA. Patients receiving IA were more likely to have comorbidities, such as diabetes (p = 0.002), sleep apnea (p = 0.006), gastroesophageal reflux disease (p < 0.001), and hypertension (p < 0.001). After adjusting for differences between groups in the multivariate analysis, patients who received TIVA had significantly shorter surgical time (β = -14.85, p < 0.001) and perioperative time (β = -21.01, p < 0.001) and significantly lower first post-anesthesia care unit Pasero opioid-induced sedation scores (β = -0.022, p = 0.040). Patients who received TIVA were less likely to receive intraoperative narcotics (odds ratio = 0.38; p = 0.031). Conclusions TIVA appears to be a safe and effective anesthetic for patients undergoing arthroscopic RCR. TIVA is a potentially beneficial alternative to IA for this patient population.

Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis

BACKGROUND

Delivering high-value orthopedic care requires optimizing value, defined as health outcomes achieved per dollar spent. Published literature is stippled with inaccurate proxies for cost, including negotiated reimbursement rates, fees paid, or listed prices. Time-driven activity-based costing (TDABC) offers a more robust and accurate approach to calculating cost, including shoulder care. In the present study, we sought to determine the drivers of total cost in arthroscopic rotator cuff repair (aRCR) using TDABC.

METHODS

Consecutive patients undergoing aRCR at multiple sites associated with a large urban health care system between January 2019 and September 2021 were identified. Total cost was determined using TDABC methodology. The episode of care was defined by 3 phases: preoperative, intraoperative, and postoperative care. Patient, procedure, rotator cuff tear morphology, and surgeon characteristics were collected. Bivariate analysis was performed across all characteristics between high-cost (top decile) and all other aRCRs. Multivariable linear regression was used to identify the key cost drivers.

RESULTS

In total, 625 aRCRs performed by 24 orthopedic surgeons and 572 aRCRs performed by 13 orthopedic surgeons were included in the bivariate and multivariable linear regression analyses, respectively. By TDABC analysis, total aRCR cost varied 6-fold (5.9×) from least to most costly. Intraoperative costs accounted for 91% of average total cost, followed by preoperative costs and postoperative costs (6% and 3%, respectively). Biologic adjuncts (regression coefficient [RC] 0.54, 95% confidence interval [CI] 0.49-0.58, P < .001) and surgeon idiosyncrasy (RC of highest-cost surgeon 0.50, 95% CI 0.26-0.73, P < .001) were the major cost drivers in aRCR. Patient age, comorbidities, number of rotator cuff tendons torn, and revision surgery were not significantly associated with total cost. The amount of tendon retraction (RC 0.0012, 95% CI 0.000020-0.0024, P = .046), average Goutallier grade (RC 0.029, 95% CI 0.0086-0.049, P = .005), and the number of anchors used (RC 0.039, 95% CI 0.032-0.046, P < .001) were also significantly associated with cost, but with far smaller effect sizes.

DISCUSSION AND CONCLUSION

Episode of care costs vary nearly 6-fold in aRCR and are almost exclusively dictated by the intraoperative phase. Tear morphology and repair technique contribute to cost, although the largest cost drivers of aRCR are the use of biologic adjuncts and surgeon idiosyncrasy, defined as something a surgeon does or does not do that impacts total cost and is not controlled for in the current analysis. Future work should seek to better delineate what these surgeon idiosyncrasies may represent.

What is the Optimal Construct to Reduce Failure in Arthroscopic Four Anchor Rotator Cuff Repair?

Background

Re-tear following rotator cuff repair (RCR) is a concerning complication that can lead to poor patient outcomes and necessitate the need for revision surgery. The purpose of our study was to look at the combined construct of knotted vs. knotless medial row and suture vs. suture tape, focusing primarily on re-tear rates following surgery.

Methods

A retrospective observational study of 343 consecutive patients undergoing arthroscopic double row, 4-anchor rotator cuff repair from February 2014 to March 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities and tear characteristics between patients who experienced a symptomatic re-tear and those who did not.

Results

The overall symptomatic re-tear rate was 7.6%. Patients who had a knotted medial row repair had a significantly lower rate of re-tear (4.7 vs. 11.3%, p = 0.022). Patients that had a knotted medial row and suture tape repair were significantly less likely to experience a re-tear (OR: 0.180, p = 0.001).

Discussion

The use of suture tape and a knotted medial row repair decreases the incidence of symptomatic re-tear following rotator cuff repair. The combined construct of suture tape and a knotted medial row in rotator cuff repair decreases the risk for symptomatic re-tear following surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures (POPE) for Isolated Arthroscopic Rotator Cuff Repair, but POPE Are Increasing at a Faster Rate than Total Healthcare Utilization Reimbursement from Payers

PURPOSE

The purpose of this study is to categorize and trend annual out-of-pocket expenditures for arthroscopic RCR patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting.

METHODS

Patients who underwent outpatient arthroscopic RCR in the U.S. from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE.

RESULTS

52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353) and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, p=0.001) and 280.5% more than patients with managed care plans ($502, p=0.001). All components of POPE increased over the study period with the largest observed increase being POPE for the immediate procedure (p=0.001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high deductible insurance most significantly increased POPE.

CONCLUSION

POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE three times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Lastly, ASCs significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts.

The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair

Some nutritional factors have been suggested to improve postoperative outcomes in rotator cuff (RC) repair, but dietary effects on the recovery speed after the surgery remain undefined. To investigate the potential roles of dietary habits in this context, we analyzed the 12-month follow-up data of 55 patients with RC repair and found that these patients could be categorized into a rapid recovery group (n = 35) and slow recovery group (n = 20) according to their postoperative recovery patterns. Group-based logistic analysis revealed that habitual intakes of meat (OR = 1.84, 95%CI, 1.22-2.76, p = 0.003), fruits (OR = 2.33, 95%CI, 1.26-5.67, p = 0.01), and wheat-flour foods (OR = 1.62, 95%CI, 1.2-2.25, p = 0.002) were significantly associated with rapid recovery. Moreover, among all intakes of wheat-flour foods, intakes of steamed and boiled flour products were also associated with rapid recovery. Further mediation analysis showed that eosinophilic granulocytes (EOs) significantly mediated the association between rapid RC recovery and the habitual intakes of meat (mediation proportion = 17.5%, P-mediation < 0.0001), fruits (17.9%, p < 0.0001), and wheat-flour foods (11.4%, p < 0.0001). Thus, our study suggests that certain dietary habits play beneficial roles in the context of postoperative recovery for RC repair.

Biologically-coupled bisphosphonate chaperones effectively deliver molecules to the site of soft tissue-bone healing

Tendon injuries are common and often treated surgically, however, current tendon repair healing results in poorly organized fibrotic tissue. While certain growth factors have been reported to improve both the strength and organization of the repaired enthesis, their clinical applicability is severely limited due to a lack of appropriate delivery strategies. In this study, we evaluated a recently developed fluorescent probe, Osteoadsorptive Fluorogenic Sentinel-3 that is composed of a bone-targeting bisphosphonate (BP) moiety linked to fluorochrome and quencher molecules joined via a cathepsin K-sensitive peptide sequence. Using a murine Achilles tendon-to-bone repair model, BP-based and/or Ctsk-coupled imaging probes were applied either locally or systemically. Fluorescence imaging was used to quantify the resultant signal in vivo. After tendon-bone repair, animals that received either local or systemic administration of imaging probes demonstrated significantly higher fluorescence signal at the repair site compared to the sham surgery group at all time points (p < 0.001), with signal peaking at 7-10 days after surgery. Our findings demonstrate the feasibility of using a novel BP-based targeting and Ctsk-activated delivery of molecules to the site of tendon-to-bone repair and creates a foundation for further development of this platform as an effective strategy to deliver bioactive molecules to sites of musculoskeletal injury.

Disparities in arthroplasty utilization for rotator cuff tear arthropathy

BACKGROUND

Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA.

METHODS

A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races.

RESULTS

Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01).

CONCLUSION

Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.

Microfragmented adipose tissue in the treatment of a full-thickness supraspinatus tear: a case report

A 70-year-old female presented with an 8-month history of right anterior shoulder pain and weakness, unresolved with conservative management. Among other shoulder pathology, the patient was diagnosed with a full-thickness supraspinatus tear and elected to proceed with the microfragmented adipose tissue procedure to treat the injured tendon and nearby relevant structures. Improvements in pain and function were documented along with progressive healing of the supraspinatus on ultrasound and MRI following the procedure. This case demonstrates the efficacy of microfragmented adipose tissue as a relatively novel approach to treating non-retracted, full-thickness rotator cuff tears.

Tailored modulation of S100A1 and RASSF8 expression by butanediamide augments healing of rotator cuff tears

Objectives

This investigation sought to elucidate promising treatment modalities for rotator cuff tears (RCTs) by delving into the molecular machinations instigating the affliction. The focus was on differentially expressed genes (DEGs) linked to RCTs, and the exploration of their roles and operative pathways.

Methods

DEGs were discerned from GEO datasets, followed by the establishment of a protein-protein interaction (PPI) network. Subsequently, the network's core genes were determined employing a Venn diagram. Enrichment analysis facilitated the unveiling of the biological roles and signal transduction pathways of these pivotal genes, thus shedding light on molecular strategies for RCT-targeted treatment. The Discovery Studio 2019 software was employed to sift through FDA-sanctioned drugs targeting these essential proteins. Moreover, the efficaciousness of these FDA-endorsed drugs vis-à-vis RCTs was corroborated by the construction of an in vivo animal model of the injury and the in vitro cultivation of tendon-derived stem cells.

Results

Bioinformatics outcomes revealed a significant overexpression of S100A1 and RASSF8 in RCT patients. The FDA drug repository indicated that Butanediamide has a selective affinity for S100A1 and RASSF8. Subsequent in vivo and in vitro experimentation demonstrated that Butanediamide could suppress S100A1 expression and bolster TDSC proliferation, thereby facilitating RCT healing.

Conclusions

S100A1 and RASSF8 are pivotal genes implicated in RCTs, and their roles have been elucidated. The FDA-approved compound, Butanediamide, may represent a prospective therapeutic agent for RCTs by targeting S100A1 and RASSF8, respectively.