The Effect of Rotator Cuff Repair on Natural History: A Systematic Review of Intermediate to Long-Term Outcomes

What happens to patients in the long term when we do not repair their cuff tears? Ten-year rotator cuff quality of life index (RC-QOL) outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears

Background

The purpose of this study was to examine long-term, greater-than-ten-year outcomes of patients with full-thickness rotator cuff tears treated nonoperatively.

Methods

Patients with a chronic, full-thickness rotator cuff tear (demonstrated on imaging) who were referred by their physician for shoulder surgery were enrolled in this prospective study between October 2008 and September 2010. Patients then participated in a comprehensive nonoperative treatment program. After the three-month program, patients were defined as "successful" or "failed." "Successful" patients were essentially asymptomatic and did not require surgery. "Failed" patients were symptomatic and consented to surgical repair. All patients were followed-up at 1 year, two years, and five years using a validated, disease-specific rotator cuff quality of life score (the RC-QOL) and whether or not they eventually underwent surgery during these time intervals. All of the patients who participated at the five-year follow-up were contacted for this study between 10 and 12 years (mean 11.4 years) after treatment.

Results

Original results from this study showed that 75% of patients were treated successfully with the nonoperative program, while 25% failed and needed surgery. These numbers were maintained at the two-year follow-up and five-year follow-up (previously reported). At greater than ten years, 88 patients were contacted for follow-up. Only two patients crossed-over from "success" at 5 years to "failed" at 10 years. The nonoperative "success" group had a mean RC-QOL score of 80 (SD = 18) at the previously reported two-year follow-up and 82 (SD = 16) at five-year follow-up. Forty-one patients provided follow-up RC-QOL data at a mean of 11.4 years. The mean RC-QOL scores of the successfully treated nonoperative group were actually higher than those who required surgery during the course of the study (success group mean 86, SD = 12; "failed"/surgery group mean 78, SD = 24), although this was not statistically different (P = .27). Two patients had crossed over from the successful group to undergo surgery between 5 and 11 years (one had an acute traumatic injury and the other reported aggravation with activity).

Conclusion

Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that nonoperative treatment delays inevitable surgical repair, this long-term study shows that patients can do very well over time.

2024 Kappa Delta Ann Doner Vaughan Award: Nonsurgical Treatment of Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears-a Prospective Multicenter Cohort Study With 10-Year Follow-Up

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare.

Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines

Background

Utilization of magnetic resonance imaging (MRI) and computed tomography (CT) increases annually, raising concerns about overuse. Imaging appropriateness guidelines have the potential to standardize decisions regarding imaging based on best evidence, which might reduce unhelpful or potentially misleading imaging. We studied expert use of advanced imaging for musculoskeletal illness compared to published appropriateness recommendations.

Methods

First, 15 imaging guidelines with recommendations for advanced imaging of the upper extremity were collated. Next, members of the Science of Variation Group (SOVG) were invited to participate in a survey of 11 patient scenarios of common upper extremity illnesses and asked whether they would recommend MRI or CT. Guideline recommendations for imaging were compared with surgeon recommendations using Fisher's exact tests. We used Fleiss' kappa to measure the interobserver agreement among surgeons.

Results

For the 11 scenarios, most imaging appropriateness guidelines suggested that MRI or CT is useful, while most surgeons (n = 108) felt it was not. There was no correlation between surgeons and guidelines recommendations for imaging (ρ = 0.28; p = 0.40). There was slight agreement among surgeons regarding imaging recommendations (kappa: 0.17; 95% confidence interval: 0.023-0.32).

Conclusion

The available imaging appropriateness guidelines appear to be too permissive and therefore seem to have limited clinical utility for upper extremity surgeons. The notable surgeon-to-surgeon variation (unreliability) in recommendations for advanced imaging in this and other studies suggests a role for strategies to ensure that patient decisions about imaging are consistent with their values (what matters most to them) and not unduly influenced by patient misconceptions about imaging or by surgeon beliefs and habits.

Level Of Evidence

II, diagnostic.

Hydrotherapy after Rotator Cuff Repair Improves Short-Term Functional Results Compared with Land-Based Rehabilitation When the Immobilization Period Is Longer

Background: The evidence of hydrotherapy after rotator cuff repair (RCR) is limited as most studies either used it as an adjuvant to standard land-based therapy, or have different initiation timing. This study aimed to compare hydrotherapy and land-based therapy with varying immobilization time. Methods: Patients who underwent RCR with a 10-days or 1-month immobilization duration (early or late rehabilitation) were prospectively randomized. Results: Constant scores significantly differed at three months only, with the best score exhibited by the late hydrotherapy group (70.3 ± 8.2) followed by late land-based (61.0 ± 5.7), early hydrotherapy (55.4 ± 12.8) and early land-based (54.6 ± 13.3) groups (p < 0.001). There was a significant interaction between rehabilitation type and immobilization duration (p = 0.004). The effect of hydrotherapy compared to land-based therapy was large at three months when initiated lately only (Cohen's d, 1.3; 95%CI, 0.9-1.7). However, the relative risk (RR) of postoperative frozen shoulder or retear occurrence for late hydrotherapy was higher compared to early hydrotherapy (RR, 3.9; 95%CI, 0.5-30.0). Conclusions: Hydrotherapy was more efficient compared to land-based therapy at three months only and if initiated lately. Even though initiating hydrotherapy later brought greater constant scores at three months, it might increase the risk of frozen shoulders or retear compared to early hydrotherapy.

Effect of Bone Marrow Stimulation on Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background

Arthroscopic rotator cuff repair (RCR) is a common orthopaedic procedure, but it has a high rate of retears that can negatively affect the functional outcomes. Bone marrow stimulation (BMS) has been suggested as an additional treatment to improve the outcomes of RCR.

Purpose

To compare the effectiveness of the BMS procedure during RCR with conventional RCR.

Study Design

Systematic review; Level of evidence, 2.

Methods

A systematic literature search was conducted in MEDLINE/PubMed, Embase, Cochrane Library, and Scopus, on March 1, 2023, for studies comparing postoperative retear rates and functional outcomes between patients who underwent primary arthroscopic RCR with and without the BMS procedure. Only level 1 and 2 randomized controlled trials with a minimum 12-month follow-up were included. The primary outcomes were retear rates and functional outcomes as measured by the Constant; American Shoulder and Elbow Surgeons (ASES); and University of California, Los Angeles (UCLA) scores and by postoperative range of motion. Subgroup analyses were performed based on repair technique (single-row repair vs double-row or suture-bridge repair). The standardized mean difference (SMD) and odds ratio (OR) were utilized to synthesize continuous and dichotomous outcomes, respectively. Homogeneity was evaluated using the chi-square test and I2 statistic.

Results

The literature search yielded 661 articles, of which 6 studies (522 patients; 261 with BMS, 261 without BMS) met the eligibility criteria. The combined analysis showed no significant decrease in retear rates with the utilization of the BMS procedure during RCR (OR, 0.60; 95% CI, 0.35 to 1.03; P = .07; I2 = 24%). There was no significant intergroup difference in functional outcomes (Constant score: SMD, 0.13; 95% CI, -0.04 to 0.31; P = .13; I2 = 0%; ASES score: SMD, 0.04; 95% CI, -0.20 to 0.28; P = .73; I2 = 0%; UCLA score: SMD, -0.13; 95% CI, -0.50 to 0.23; P = .47; I2 = 0%). Subgroup analyses revealed no significant differences in postoperative retear risk or total Constant score according to the repair technique.

Conclusion

Based on the available evidence, this systematic review did not find a significant benefit of the BMS procedure at the footprint during arthroscopic RCR compared with conventional RCR in terms of retear rates and functional outcomes at short-term follow-up.

Chronic steroid use as a risk factor for postoperative complications following arthroscopic rotator cuff repair

Background

Steroids are a common treatment for many rheumatologic and inflammatory disorders. Chronic steroid use has been studied in joint arthroplasty and arthroscopy, but studies specifically on preoperative chronic steroid use in arthroscopic rotator cuff repair (aRCR) are limited. The purpose of this study is to determine the association between chronic steroid use and 30-day postoperative outcomes following aRCR.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify all patients who underwent aRCR between 2015 and 2020. Patients were divided into 2 cohorts: nonsteroid users and chronic steroid users. Univariate binomial regression analysis was used to compare demographics, comorbidities, and postoperative outcomes between cohorts. Multivariate regression analysis, adjusted for all significant demographics and comorbidities, was used to identify significant 30-day postoperative outcomes.

Results

A total of 39,876 patients remained after exclusion criteria, with 39,068 (97.97%) in the nonsteroid group and 808 (2.02%) in the chronic steroid group. Patient demographics and comorbidities significantly associated with chronic steroid use were age ≥65 (P < .001), female gender (P < .001), body mass index (BMI) ≥35, American Society of Anesthesiologists (ASA) ≥3 (P < .001), dependent functional status (P < .001), nonsmokers (P = .046), higher rates of dyspnea (P < .001), chronic obstructive pulmonary disease (COPD) (P < .001), congestive heart failure (P < .001), hypertension requiring medication (P < .001), open wound infection (P = .018), unintentional weight loss (P < .001), bleeding disorders (P < .001), and inpatient procedure (P = .013). Multivariate analysis found preoperative chronic steroid use to be an independent predictor of mortality within 30 days following aRCR (OR 8.15, confidence interval (CI) 1.45-45.86; P = .017).

Conclusion

Chronic steroid use was not found to be an independent risk factor for infection, readmission, or reoperation following aRCR. It was, however, found to be independently associated with higher rates of 30-day mortality following aRCR, although with a limited overall number of deaths reported.

Re-Tear Rates Following Rotator Cuff Repair Surgery

Aim Re-tears following rotator cuff repair surgery are a common occurrence. Previous studies have identified several factors that have been shown to increase the risk of re-tears. The purpose of this study was to evaluate the rate of re-tear following primary rotator cuff repair and to identify the factors that may contribute to this rate. Method The authors performed a retrospective review, looking at rotator cuff repair surgeries performed between May 2017 and July 2019 performed in a hospital by three specialist surgeons. All methods of repair were included. All patients' medical data, including imaging and operation records, were reviewed. Results A total of 148 patients were identified. Ninety-three males and 55 females with a mean age of 58 years (range 33-79 years). Thirty-four patients (23%) had post-operative imaging with either magnetic resonance imaging or ultrasound, where it was found that 20 (14%) had a confirmed re-tear. Of these patients, nine went on to have further repair surgery. The average age of the re-tear patients was 59 (age range 39-73) and 55% were female. The majority of the re-tears were from chronic rotator cuff injuries. This paper did not identify any correlation between smoking status or diabetes mellitus and re-tear rates. Conclusions This study indicates that re-tear after rotator cuff repair surgery is a common complication. The majority of studies find increasing age to be the biggest risk factor; however, this was not the case in our study which found females in their 50s to have the highest rate of re-tear. Additional research is required to understand what factors can contribute towards rotator cuff re-rupture rates.

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

Background

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

Methods

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

Results

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

Discussion and Conclusion

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

Do Age, Demographics, and Tear Characteristics Affect Outcomes After Rotator Cuff Repair? Results of Over 2000 Rotator Cuff Repairs at 5-Year Follow-up

Background:

The New Zealand Rotator Cuff Registry represents the largest prospective cohort of rotator cuff repairs. Despite this, there are limited medium- to long-term data of rotator cuff repair outcomes.

Purpose:

To (1) analyze the pain and functional outcomes of a large cohort of primary rotator cuff repairs and (2) evaluate the effect of patient factors and tear characteristics on medium-term outcomes.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

This was a multicenter, multisurgeon prospective cohort study of rotator cuff repairs from March 2009 until December 2010. Surgical data were collected by the operating surgeon. Primary outcome measures were the Flexilevel Scale of Shoulder Function (FLEX-SF) and a pain score, collected at baseline, 6, 12, and 24 months, and 5 years. Univariate and multivariate analyses were carried out.

Results:

Overall, 2533 primary rotator cuff repairs were analyzed with 81% follow-up at 5 years. The mean age of the cohort was 56 years. In the 2052 patients with final follow-up data, improvement on the FLEX-SF continued until 24 months postoperatively and remained high at 5 years. Mean improvement in FLEX-SF from baseline to 5 years was 15 points. Patients aged >70 years had lower FLEX-SF scores but no significant difference in improvement compared with patients ≤70 years. The mean anteroposterior tear size was 2.2 cm, and on multivariate analysis, tears >4 cm had worse 5-year FLEX-SF scores. If the affected tendon was easily reducible, there was no difference in FLEX-SF score for retracted or larger tears compared with smaller tears. The reoperation rate was 6.2%.

Conclusion:

Results indicated that rotator cuff repairs provide a sustained clinical improvement out past 5 years. Most functional improvement and pain relief occurred within the first 6 months, but improvement continued out to 24 months. Most population groups did well after rotator cuff repairs, including those >70 years. Tear size >4 cm and tendon reducibility correlated with outcome. Even patients with large tear sizes had clinically significant improvement in FLEX-SF scores after repair.

Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair

BACKGROUND AND HYPOTHESIS

Arthroscopic rotator cuff repair surgery is one of the most common shoulder procedures performed in the United States. Although several studies have shown considerable symptomatic relief in the short term following surgery, a relatively high rate of recurrent defects has led surgeons to question the long-term durability of this operation. We hypothesized that outcomes at a minimum of 15 years of follow-up in patients who underwent all-arthroscopic rotator cuff repair would be maintained and would remain significantly improved compared with the preoperative status.

METHODS

All-arthroscopic rotator cuff repairs were performed in 193 patients from 2003 to 2005. Patient-reported outcomes were collected preoperatively and at 1, 2, 5, and ≥15 years postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included Single Assessment Numeric Evaluation (SANE), Shoulder Activity Scale (SAS), visual analog scale, and Patient-Reported Outcomes Measurement Information System (PROMIS)-Upper Extremity (UE) scores. Patient demographic characteristics, revision surgical procedures, and complications were recorded. Generalized estimating equations were used to model scores over time, and multiple comparisons between time points were performed using Tukey adjustment.

RESULTS

This study included 60 patients with a mean follow-up period of 16.5 years (range, 15.8-17.7 years). The mean ASES score improved from 60.2 ± 18.8 preoperatively to 93.0 ± 9.4 at ≥15 years (P < .0001). The mean visual analog scale pain score decreased from 4.1 ± 0.7 preoperatively to 0.7 ± 0.3 at ≥15 years (P < .0001). The average SANE, SAS, and PROMIS-UE scores at ≥15 years were 87.8 ± 14.8, 8.8 ± 4.3, and 49.6 ± 10.2, respectively. Of 60 patients, 7 underwent revision surgery. Older age and female sex were associated with lower SAS scores at 15 years, whereas female sex was associated with lower PROMIS-UE scores. There were no factors predictive of ASES or SANE scores.

CONCLUSION

At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. This information is useful in counseling patients regarding the long-term results of this procedure.

Management of the failed rotator cuff repair

Rotator cuff repair is increasingly being performed, and this is likely to continue to given the ageing population. An improvement in functional outcome can be achieved, with the best results noted in those tendons that go on to heal. Failure of repair following surgery can be associated with debilitating symptoms that are not always amenable to non-operative measures, so further surgery may be indicated for these patients. Several operative strategies have been described, but careful evaluation is required to determine the most suitable option. This review describes the decision-making strategies and treatment options available during management of a failed rotator cuff repair.

Reverse Shoulder Arthroplasty After Prior Rotator Cuff Repair: A Matched Cohort Analysis

INTRODUCTION

Rotator cuff repair (RCR) is commonly performed before reverse shoulder arthroplasty (RSA) with conflicting evidence on the effect on arthroplasty outcomes. The purpose of this investigation was to evaluate the effect of a prior RCR on the outcomes and complications of primary RSA.

METHODS

Between 2007 and 2017, 438 RSAs performed in patients with a prior RCR and 876 case-matched controls were identified from a multicenter database. Patients were grouped based on a preoperative diagnosis of glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). Data collected included range of motion, strength, complications, and revisions. Additional clinical metrics included American Shoulder and Elbow Society score, Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test, and the University of California Los Angeles shoulder score.

RESULTS

Compared with controls, both GHOA and CTA study groups demonstrated lower postoperative forward elevation (FE) (133° versus 147°, P < 0.001; 133° versus 139°, P = 0.048) and FE trength (6.5 versus 8.2, P = 0.004; 6.1 versus 7.3, P = 0.014). In addition, inferior improvements were observed in the GHOA and CTA study groups with respect to abduction (38° versus 52°, P = 0.001; 36° versus 49°, P = 0.001), FE (41° versus 60°, P < 0.001; 38° versus 52°, P = 0.001), ER (16° versus 25°, P < 0.001; 10° versus 17°, P = 0.001), and Constant score (28.4 versus 37.1, P < 0.001; 26.2 versus 30.9, P = 0.016). Compared with controls, no differences were observed in the GHOA and CTA study groups with respect to notching (11.2% versus 5.6%, P = 0.115; 5.8% versus 7.9%, P = 0.967), complications (4.3% versus 1.6%, P = 0.073; 2.5% versus 2.7%, P = 0.878), and revision surgery (3.1% versus 0.9%, P = 0.089; 1.1% versus 1.3%, P = 0.822).

CONCLUSION

RSA after a prior RCR improves both pain and function, without increasing scapular notching, complications, or revision surgery. However, compared with patients without a prior RCR, postoperative shoulder function may be slightly decreased.

LEVEL OF EVIDENCE

III; Retrospective Cohort Study.

A randomized controlled trial of stem cell injection for tendon tear

Tendons have limited reparative ability and perform a relatively simple mechanical function via the extracellular matrix. Thus, the injured tendon might be treated successfully by stem cell transplantation. We performed a randomized, controlled study to investigate the effects of mesenchymal stem cell injection for treating partial tears in the supraspinatus tendon. We enrolled 24 patients with shoulder pain lasting more than 3 months and partial tears in the supraspinatus tendon. Participants were assigned to three groups: stem cells in fibrin glue, normal saline/fibrin glue mixture, and normal saline only, with which intra-lesional injection was performed. Pain at activity and rest, shoulder function and tear size were evaluated. For safety measures, laboratory tests were taken and adverse events were recorded at every visit. Participants were followed up at 6, 12 weeks, 6, 12 months and 2 years after injection. The primary outcome measure was the improvement in pain at activity at 3 months after injection. Twenty-three patients were included in the final analysis. Primary outcome did not differ among groups (p = 0.35). A mixed effect model revealed no statistically significant interactions. Only time significantly predicted the outcome measure. All participants reported transient pain at the injection site. There were no differences in post-injection pain duration or severity. Safety measures did not differ between groups, and there were no persistent adverse events. Stem cell injection into supraspinatus partial tears in patients with shoulder pain lasting more than 3 months was not more effective than control injections.ClinicalTrials.gov Identifier: NCT02298023.

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

Footprint preparation with nanofractures in a supraspinatus repair cuts in half the retear rate at 1-year follow-up. A randomized controlled trial

PURPOSE

To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up.

METHODS

Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes.

RESULTS

Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p = 0.014). Clinically both groups had significant improvements, but no differences were found between groups.

CONCLUSION

Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint.

LEVEL OF EVIDENCE

Level I.

Stem Cells for the Regeneration of Tendon and Ligament: A Perspective

Tendons are structures that connect muscles to the bones in our body and transmit the force generated by contraction of the muscles to the bones. Ligaments are structures that connect bones to bones, with histological properties similar to tendons. In tendon and ligament tissue, there are very small amounts of cells similar to mesenchymal stem cells (MSCs) called tendon stem/progenitor cells (TSPCs), or tenogenic stem cells. While the role of specific growth factors and transcription factors is well established in the osteogenic and chondrogenic differentiation of stem cells, a consensus has not been established for tenogenic differentiation. Injuries to tendons and ligaments are very common, but natural healing is very slow and inefficient due to limited vascularization. Currently, there is no adequate method for restoring extensive tendon or ligament defects. Procedures addressing the unmet need for regeneration of these tissues are needed. In this review, the current knowledge, as well as the authors’ ideas and perspective on stem cell and regenerative medicine for tendon and ligament defects are presented.

Patch Augmentation in Rotator Cuff Repair

PURPOSE OF THE REVIEW

Rotator cuff repair has excellent outcomes for many patients but continues to be suboptimal for large, retracted tears, and revision procedures. In these situations, patch augmentation may be considered in order to improve healing. The purpose of this article is to review the history, graft options, indications, surgical technique, outcomes, and complications associated with arthroscopic patch augmentation for rotator cuff repair.

RECENT FINDINGS

Patch augmentation has been shown in several studies to improve healing rates. After multiple investigations into different materials available for patch augmentation, acellular dermal allograft seems to be the graft with the best scientific support. While multiple techniques have been presented, few studies have compared their performance. While the arthroscopic technique for patch augmentation can be challenging, we present a systematic approach to this procedure with the potential to reliably and predictably perform patch augmentation. This technique is a valuable tool for surgeons that treat rotator cuff pathology.

A Randomized Controlled Trial of the Treatment of Rotator Cuff Tears with Bone Marrow Concentrate and Platelet Products Compared to Exercise Therapy: A Midterm Analysis

Injectable regenerative therapies such as bone marrow concentrate (BMC) and platelet-rich plasma (PRP) may represent a safe alternative in the treatment of rotator cuff tears. This is a midterm review of a randomized, crossover trial comparing autologous BMC and platelet product injections versus exercise therapy in the treatment of partial and full-thickness supraspinatus tears. Patients enrolled into the study were between 18 and 65 years of age presenting to an outpatient orthopedic clinic with partial to full thickness, nonretracted supraspinatus tendon tears. Enrolled patients were randomized to either ultrasound-guided autologous BMC with PRP and platelet lysate (PL) percutaneous injection treatment or exercise therapy. Patients could cross over to BMC treatment after at least 3 months of exercise therapy. Patients completed the Disability of the Arm, Shoulder and Hand (DASH) scores as the primary outcome measure. Secondary outcomes included the numeric pain scale (NPS), a modified Single Assessment Numeric Evaluation (SANE), and a blinded MRI review. At this midterm review, results from 25 enrolled patients who have reached at least 12-month follow-up are presented. No serious adverse events were reported. Significant differences were seen in patient reported outcomes for the BMC treatment compared to exercise therapy at 3 and 6 months for pain, and for function and reported improvement (SANE) at 3 months (p < .05). Patients reported a mean 89% improvement at 24 months, with sustained functional gains and pain reduction. MRI review showed a size decrease of most tears post-BMC treatment. These findings suggest that ultrasound-guided BMC and platelet product injections are a safe and useful alternative to conservative exercise therapy of torn, nonretracted supraspinatus tendons. This trial is registered with NCT01788683.

Clinical Function Improves After Subacromial Injection of Local Anesthetic in Full-Thickness Rotator Cuff Tears: A Randomized Control Trial

BACKGROUND

Rotator cuff pathology is the most common cause of shoulder pain in adults, accounting for nearly 70% of shoulder-related visits to clinicians. However, physical examination findings may be limited because of pain or patient inhibition.

PURPOSE

To establish whether a relationship exists between pain, range of motion, and strength in patients with a full-thickness rotator cuff tear.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A single-blind, randomized controlled study of 40 patients undergoing rotator cuff repair for full-thickness rotator cuff tears was performed. Patients were randomized to receive either a subacromial 10-mL 2% lidocaine injection or a sham injection, with no contents being injected into the subacromial space. Before the injection, patients were assessed using a visual analog scale for pain (VAS-Pain) as well as the Constant-Murley subjective questionnaire and objective physical examination. The examination was repeated 10 minutes after injection and 6 months postoperatively. VAS-Pain after injection was not assessed. The assessment at 6 months was performed to demonstrate improvement of rotator cuff function after operative management. Statistical analysis included Student t and chi-square tests as well as multivariate binomial logistic regression analyses to identify predictors for improvement after injection. Results were considered significant if P < .05.

RESULTS

Range of motion, strength, and Constant-Murley score significantly improved after a subacromial lidocaine injection (P < .05). Range of motion, strength, Constant-Murley score, and VAS-Pain significantly improved at final follow-up compared with the preinjection assessment for both groups (P < .05); however, there was no difference (P > .05) between groups at 6 months postoperatively.

CONCLUSION

After subacromial lidocaine injections, patients exhibited modest but significant improvements in range of motion, strength, and the Constant-Murley score. Pain may limit range of motion and strength in patients with full-thickness rotator cuff tears independent of the mechanical impact of the tear itself.

REGISTRATION

NCT02693444 (ClinicalTrials.gov identifier).

The Effect of Preexisting and Shoulder-Specific Depression and Anxiety on Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Few studies have considered the potential effect of depression or anxiety on outcomes after rotator cuff repair.

PURPOSE

To evaluate the effect of a preexisting diagnosis of depression or anxiety, as well as the feeling of depression and anxiety directly related to the shoulder, on the American Shoulder and Elbow Surgeons (ASES) score.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study is a retrospective review of prospectively collected data on patients who underwent arthroscopic rotator cuff repair and were evaluated by the ASES score preoperatively and at a minimum 12 months postoperatively as part of the senior author's shoulder registry. Preexisting diagnoses of depression and/or anxiety were recorded, and questions from the Western Ontario Rotator Cuff Index directed at feelings of depression or anxiety related to the shoulder were also evaluated. The Wilcoxon rank sum test was used to compare ASES scores between patients with and without anxiety and/or depression. Spearman correlation was used to correlate questions on depression and anxiety with ASES scores.

RESULTS

A total of 187 patients (63 females, 124 males; mean age, 58.6 years, SD, 8.7 years) undergoing arthroscopic rotator cuff repair were evaluated with a mean follow-up of 47.5 months (SD, 17.4 months; range, 12-77 months). Fifty-three patients (mean age, 60 years; SD, 8.6 years) had preexisting diagnoses of depression and/or anxiety and 134 patients (mean age, 58.1 years; SD, 8.7 years) did not. Patients with depression and/or anxiety had significantly lower preoperative and postoperative ASES scores (60.7 vs 67.8, P = .014; and 74.6 vs 87.1, P = .008, respectively). The change in ASES scores from preoperative to postoperative, however, was not significantly different (18.0 vs 14.9). A higher score of depression or anxiety related to the shoulder had a negative correlation with the preoperative (r = -0.76, P < .0001; and r = -0.732, P < .0001, respectively) and postoperative (r = -0.31, P = .0001; and r = -0.31, P = .0003, respectively) ASES scores, but a positive correlation (r = 0.50, P < .0001; and r = 0.43, P < .0001, respectively) with the change in ASES scores.

CONCLUSION

Patients with a history of depression and/or anxiety have lower outcome scores preoperatively and postoperatively; however, they should expect the same amount of relief from arthroscopic rotator cuff repair as those without a history of depression or anxiety. Stronger feelings of depression or anxiety directly related to the shoulder correlated with lower preoperative and postoperative outcome scores, but a greater amount of improvement from surgery. The results from this study suggest that a preexisting diagnosis of depression or anxiety, as well as feelings of depression or anxiety directly related to the shoulder, should be considered during the management of patients with rotator cuff tears.

Editorial Commentary: Does a Medialized Repair Allow Single-Row to Outperform Double-Row Rotator Cuff Repair?

The optimal surgical technique for arthroscopic rotator cuff repair remains controversial, with advantages and disadvantages to each of the most commonly used methods. The pattern as well as number of suture anchors relative to the footprint has been one of the most common sources of debate, with proponents and arguments for both single- and double-row arrangements. Although double-row techniques have been shown to be biomechanically superior and to improve footprint coverage, evidence has been mixed as to whether they are clinically superior, especially in small- and medium-sized tears. Whereas historically, single-row repairs have aimed to restore pre-tear tendon tension, there recently has been interest in a medialized single-row technique to reduce repair tension. Advantages of this technique include a reduced number of anchors and thus a reduced cost, an efficient technique, and a potential reduction in tension, which could improve healing rates. Disadvantages of this technique include a reduced tendon-to-bone area of contact, which may lead to higher rates of incomplete healing.

Long-term results after arthroscopic treatment of symptomatic Ellman grade 2 PASTA lesions

BACKGROUND

The purpose of this retrospective study was to evaluate the clinical and radiologic long-term results of medium-sized (Ellman grade 2) partial-thickness articular-sided supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically.

METHODS

Of 22 patients, 18 (82%) were available for follow-up evaluation after a mean of 15 ± 2 years (range, 12-17 years). The mean age at time of surgery was 55 ± 9 years (range, 35-66 years). The Constant score was used as the primary outcome instrument to evaluate shoulder function. Furthermore, the University of California-Los Angeles shoulder score, the American Shoulder and Elbow Surgeons score, and the Subjective Shoulder Value were collected. The patients' satisfaction with the outcome was investigated. Tendon integrity of the affected shoulder at final follow-up was assessed with magnetic resonance imaging or ultrasound in 89% of the cohort.

RESULTS

Overall, 94% of the patients were very satisfied or satisfied with the outcome. The average Constant score of the affected shoulder was 78 ± 21 points; the University of California-Los Angeles score, 31 ± 7 points; the American Shoulder and Elbow Surgeons score, 85 ± 24 points; and the Subjective Shoulder Value, 83% ± 21%. Radiologic evaluation showed progression to a full-thickness rotator cuff tear in 6% (1/16), and 60% of the patients (6/10) showed persistent signs of partial tearing evaluated by magnetic resonance imaging.

CONCLUSION

At long-term follow-up, arthroscopic treatment of medium-sized PASTA lesions resulted in good clinical results together with a high satisfaction level of the patients.