Factors affecting healing after arthroscopic rotator cuff repair

FAPs orchestrate homeostasis of muscle physiology and pathophysiology

As a common clinical manifestation, muscle weakness is prevalent in people with mobility disorders. Further studies of muscle weakness have found that patients with muscle weakness present with persistent muscle inflammation, loss of muscle fibers, fat infiltration, and interstitial fibrosis. Therefore, we propose the concept of muscle microenvironment homeostasis, which explains the abnormal pathological changes in muscles through the imbalance of muscle microenvironment homeostasis. And we identified an interstitial progenitor cell FAP during the transition from normal muscle microenvironment homeostasis to muscle microenvironment imbalance caused by muscle damage diseases. As a kind of pluripotent stem cell, FAPs do not participate in myogenic differentiation, but can differentiate into fibroblasts, adipocytes, osteoblasts, and chondrocytes. As a kind of mesenchymal progenitor cell, it is involved in the generation of extracellular matrix, regulate muscle regeneration, and maintain neuromuscular junction. However, the muscle microenvironment is disrupted by the causative factors, and the abnormal activities of FAPs eventually contribute to the complex pathological changes in muscles. Targeting the mechanisms of these muscle pathological changes, we have identified appropriate signaling targets for FAPs to improve and even treat muscle damage diseases. In this review, we propose the construction of muscle microenvironmental homeostasis and find the key cells that cause pathological changes in muscle after homeostasis is broken. By studying the mechanism of abnormal differentiation and apoptosis of FAPs, we found a strategy to inhibit the abnormal pathological changes in muscle damage diseases and improve muscle regeneration.

Rotator Cuff Tear Size: Could It Be Influenced by the Presence of One or More Diseases Capable of Altering the Peripheral Microcirculation?

Background: To date, it is not well known which systemic pathologies most frequently afflict patients with rotator cuff tear (RCT) and whether the coexistence of two or more pathologies can affect the lesion size. Therefore, we analyzed our database relative to a large group of patients who recently underwent rotator cuff repair. Methods: A total of 527 patients with full-thickness RCT were enrolled. For each patient, we checked the presence of at least one of diabetes, venous system diseases, cardiovascular diseases, hypercholesterolemia, blood hypertension, thyroid diseases, and a smoking habit. Patients were subdivided according to risk factors into five groups, representing those who had zero, one, two, three, and four or more risk factors, respectively. Statistical analysis was performed. Results: In total, 37% of our patients had no risk factors; 28% had one risk factor (arterial hypertension, smoking habit, and hypercholesterolemia were the most frequent); 23% had two risk factors (the hypertension/hypercholesterolemia association was the most frequent); and 8% suffered from three pathologies (the diabetes/arterial hypertension/hypercholesterolemia association was the most frequent). Comparing the cuff tear severity in patients without and with at least one risk factor, we observed that tear size increased in those with at least one risk factor. Conclusions: A total of 63% of patients with rotator cuff tears were either smokers and/or had at least one pathology capable of altering the peripheral microcirculation. Hypertension and hypercholesterolemia were the most frequent. Tear severity significantly increased with the presence of at least one risk factor.

Long head of biceps tendon augmentation in rotator cuff repair enhances tendon healing, shoulder function and patient-reported outcomes one-year post-surgery

Purpose

The aim is to determine the effect on healing and functionality of patients after 1 year of biceps augmentation of a rotator cuff repair (RCR) compared to RCR plus long head of the biceps (LHB) tenotomy. In addition, to analyse the main factors involved in the recovery after the surgery.

Methods

A prospective, comparative, non-randomized study (Level of Evidence III) was conducted. Patients with repairable rotator cuff tears were allocated to either the control group, with a double row transosseous equivalent RCR with LHB tenotomy, or the RCR+augmentation with LHB group. Patients were evaluated for radiological (MRI), clinical (cuff size, Patte and Goutallier scales) and functional variables (Constant and American Shoulder and Elbow Surgeons [ASES] scales) before the intervention. At 1-year follow-up cuff healing was confirmed through MRI and functional evaluation with Constant, ASES, simple shoulder test [SST] and Disabilities of the Arm, Shoulder and Hand scales.

Results

Seventy-seven patients underwent control or RCR+augmentation with LHB, there were no preoperative differences between the groups. After 1 year of the surgery, re-rupture occurred in 38.5% and 16% of the patients in control and RCR+augmentation with LHB groups, respectively (p = .026). Total functionality was higher (p < .05) in RCR+augmentation with LHB than in the control group: Constant, SST and ASES scales. Among the explored factors involved in healing, re-rupture occurred in 100% of the cases with high fatty degeneration. Besides, higher initial functionality (Constant scale) and RCR+augmentation with LHB increased the odds of healing (odds ratio [OR] = 1.12 [1.04-1.21]; OR = 5 [1, 61], respectively), while higher cuff length had a detrimental effect (OR = 0.92 [0.85-0.99]).

Conclusion

RCR+augmentation with LHB achieves a higher healing percentage and a better functional evolution than RCR+LHB tenotomy, 1 year after cuff repair. Fatty degeneration, cuff length and initial functionality are the main factors involved in cuff healing.

Level of Evidence

Level III randomized controlled trial.

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.

Compression of an Autograft Biceps Into an Augmentation Patch Does Not Cause Mechanical Damage to the Tenocyte

PURPOSE

To evaluate the effects of this graft preparation technique on histologic evidence of tenocyte mechanical damage.

METHODS

A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After suprapectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of the residual tendon was longitudinally split, resulting in 2 equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer's recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation.

RESULTS

Fifty-five shoulder procedures and 110 samples were sent for pathology analysis. Forty-two of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and noncompressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference in abnormal tenocyte morphology between the compressed and native groups was not statistically significant (P = .625).

CONCLUSIONS

Autograft biceps compression into a point-of-care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology.

CLINICAL RELEVANCE

Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty.

The effectiveness of intravenous zoledronic acid in elderly patients with osteoporosis after rotator cuff repair: a retrospective study

The aim of this study was to investigate the effect of zoledronic acid (ZA) on postoperative healing and functional rehabilitation in osteoporotic patients with rotator cuff (RC) injury. 96 Patients were divided into three groups according to bone mineral density and ZA use (Group A: normal BMD; Group B: osteoporosis and intravenous ZA use; Group C: osteoporosis, without ZA use). Radiologic, functional and Serological outcomes were evaluated 6 months after surgery. The functional scores in all groups exhibited significant improvement 6 months after surgery. Inter-group comparison showed that Constant Shoulder joint function Score (CSS) of group A not significantly differing from that of group B, the other indicators were significantly better than those of group B and C. There were no significant differences in shoulder forward flexion, abductive Range of Motion between group B and C. Other indicators of group B were significantly improved compared to group C. The retear rate in group C (30.3%, 10/33) was higher than group A (6.1%, 2/33) and group B (13.3%, 4/30). In conclusion, the application of ZA can significantly reduce the rate of RC retear in elderly patients with osteoporosis after surgery, which is significant for postoperative shoulder joint functional rehabilitation.

No Short-term Clinical Benefit to Bovine Collagen Implant Augmentation in Primary Rotator Cuff Repair: A Matched Retrospective Study

BACKGROUND

Bovine bioinductive collagen implants (herein, "bovine collagen implant") can be used to augment rotator cuff repair. Concern exists that these bovine collagen implants may not yield clinical benefits and may actually increase postoperative stiffness and the need for reoperation.

QUESTIONS/PURPOSES

Among patients who underwent primary rotator cuff repair with or without a bovine collagen implant, we asked: (1) Did the proportion of patients undergoing reoperation for postoperative stiffness and inflammation differ between the bovine collagen implant and control groups? (2) Did short-term patient-reported outcomes differ between the two groups? (3) Did the proportion of patients receiving postoperative methylprednisolone prescriptions and corticosteroid injections differ between the two groups?

METHODS

We performed a retrospective, matched, comparative study of patients 18 years and older with minimum 2-year follow-up who underwent primary arthroscopic repair of partial or full-thickness rotator cuff tears diagnosed by MRI. All procedures were performed by one surgeonbetween February 2016 and December 2021. During the period in question, this surgeon broadly offered the bovine collagen implant to all patients who underwent rotator cuff repair and who (1) consented to xenograft use and (2) had surgery at a facility where the bovine collagen implant was available. The bovine collagen implant was used in rotator cuff tears of all sizes per the manufacturer's instructions. A total of 312 patients were considered for this study (243 control, 69 implant). Minimum 2-year clinical follow-up data were available for 83% (201 of 243) of patients in the control group and 90% (62 of 69) of patients in the bovine collagen implant group. After we applied the exclusion criteria, 163 control and 47 implant group patients remained and were eligible for matching. Propensity score matching was conducted to balance cohorts by age, gender, race (Black, White, other), ethnicity (Hispanic, non-Hispanic), health insurance status, Area Deprivation Index, BMI, American Society of Anesthesiologists physical status classification, diabetes, smoking, rotator cuff tear size, concomitant surgical procedures, preoperative American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), VAS score for pain, and shoulder ROM. We included 141 patients (47 in the implant group and 94 in the control group) after matching. Patients were categorized according to whether they received the bovine collagen implant. Before matching, the control cohort was older (mean ± SD 57 ± 10 years versus 52 ± 11 years; p = 0.004), more likely to be White (58% versus 23%; p < 0.001), with a smaller proportion of concomitant distal clavicle excisions (43% versus 21%; p = 0.003), and a smaller proportion of "other" concomitant procedures (17% versus 6%; p = 0.011) compared with the implant cohort. After matching, the cohorts were well matched in all demographic variables. The primary study outcome was reoperation for inflammation and stiffness, defined as a failure of nonoperative treatment for a minimum of 9 months, including physical therapy, NSAIDs, at least one course of oral methylprednisolone, and at least one cortisone injection (reoperations for traumatic retears were excluded). Secondary outcomes were patient-reported outcomes (SSV, ASES score, and VAS score for pain), receipt of methylprednisolone prescriptions, and receipt of corticosteroid injections. Chi-square, Fisher exact tests, and independent-samples t-tests were used to assess relationships between treatment group and study outcomes.

RESULTS

A greater proportion of patients in the bovine collagen implant group (9% [4 of 47]) underwent reoperation for inflammation and stiffness than in the control group (0% [0 of 94; p = 0.01]). At minimum 2-year follow-up, the cohorts did not differ by ASES score (mean ± SD 81 ± 24 implant versus 85 ±19 control; p = 0.24), SSV (79 ± 24 implant versus 85 ± 18 control; p = 0.30), or VAS score for pain (2.0 ± 2.9 implant versus 1.5 ± 2.3 control; p = 0.11). The cohorts did not differ in the proportion who received postoperative corticosteroid injections (15% implant versus 11% control; p = 0.46) or methylprednisolone prescriptions (49% implant versus 37% control; p = 0.18).

CONCLUSION

At minimum 2-year follow-up, patients undergoing primary arthroscopic rotator cuff repair with bovine collagen implant augmentation had a greater proportion of reoperation due to inflammation and stiffness compared with patients who did not receive the implant. Furthermore, the implant offered no benefit in patient-reported outcomes or need for postoperative corticosteroid injections or methylprednisolone prescriptions. Because of the lack of clinical benefit and potential increase in postoperative complications, we recommend against the use of these bovine collagen implants unless high-quality randomized controlled trials are able to demonstrate their clinical effectiveness, cost-effectiveness, and overall safety.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Biologics in rotator cuff repair

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears.

Superior capsular reconstruction with the long head of the biceps tendon achieves excellent clinical results and low rotator cuff rerupture rates one year after cuff repair surgery

PURPOSE

To analyze the clinical one-year evolution of healed and rerupture lesions in patients who received a rotator cuff repair plus Superior Capsular Reconstruction (SCR) with the long head of the biceps (LHB). Moreover, to compare this evolution between men and women.

METHODS

A pilot study was conducted on patients who underwent a rotator cuff repair plus SCR with LHB between February 2021 and June 2022. All patients completed pre-operative and one-year post-operative evaluations for tendon type of tear and tendon integrity using Magnetic Resonance Imaging (MRI)after one year of the surgery. Besides, functionality was evaluated with the American Shoulder and Elbow Surgeons (ASES) score; the visual analog scale for pain (VAS); and the Constant score.

RESULTS

A total of 38 patients completed the one-year final evaluation, they presented an increased functionality score to 83 and 86 in Constant and ASES scales (p < .001), respectively. Besides, 84% of the patients presented a healed cuff, while rerupture occurred in 16% of the patients. There were differences between the healed and rerupture patients in the total Constant score, with a remarkable increase in the strength subscale, almost double for patients with healed cuff (p < .001); in the same way, daily life activity score, and balance subscale increased, while pain score decreased in the healed cuff group (p < .05). There was no difference in functionality between men and women (p > .05). Besides, almost all patients achieved the MCID in both ASES and Constant total scores, irrespectively of the healing group.

CONCLUSION

The cuff repair using SCR with the LHB achieved a low percentage of rerupture and a functional improvement after one year of follow-up. Patients who healed the lesion presented more strength and better performance in daily life activities than those with cuff repurture. Thus, SCR + LHB procedure can be considered an efficient technique for rotator cuff repair surgery for both men and women. Although a comparison with a control group is needed to confirm these findings.

The addition of mesenchymal stem cells in a bioabsorbable scaffold does not enhance tendon healing after a repair of rotator cuff tear

PURPOSE

The purpose of the study is to evaluate the healing potential of a full-thickness tendon defect in the rotator cuff of rabbits using a bioabsorbable scaffold impregnated with bone marrow-mesenchymal stem cells (BM-MSCs) or rotator cuff-derived mesenchymal stem cells (RC-MSCs).

METHODS

Sixteen adult rabbits were subjected to a full-thickness rotator cuff deficit. Rabbits were randomly assigned to four groups of four animals. In Group 0 (control), the deficit was left untreated. In Group 1, the deficit was treated with a single synthetic scaffold alone. In Group 2, the deficit was treated with the previous scaffold loaded with allogeneic BM-MSCs. In Group 3, the deficit was treated with the previous scaffold loaded with allogenic RC-MSCs. After animal sacrifice, tissue samples were subjected to histological and immunohistochemical analysis.

RESULTS

Group 1 showed the highest mean tendon maturing score (15.3 ± 0.9) postoperatively, being significantly higher, in comparison to groups 0, 2 and 3 (p = 0.01, 0.02 and 0.01, respectively). Group 1 showed the highest mean collagen I/collagen III ratio (1.4 ± 0.8) postoperatively but without any statistical significance.

CONCLUSIONS

The utilization of MSCs in rotator cuff repair in a rabbit model has not been associated with an enhancement in tendon healing in 16 weeks postoperatively, in comparison to controls and bioabsorbable scaffolds. The addition of MSCs does not result in better rotator cuff healing.

LEVEL OF EVIDENCE

Not applicable. This is an animal study.

Multiaxial filament winding of biopolymer microfibers with a collagen resin binder for orthobiologic medical device biomanufacturing

Multiaxial filament winding is an additive manufacturing technique used extensively in large industrial and military manufacturing yet unexplored for biomedical uses. This study adapts filament winding to biomanufacture scalable, strong, three-dimensional microfiber (3DMF) medical device implants for potential orthopedic applications. Polylactide microfiber filaments were wound through a collagen 'resin' bath to create organized, stable orthobiologic implants, which are sized for common ligament (e.g. anterior cruciate ligament) and tendon (e.g. rotator cuff) injuries and can be manufactured at industrial scale using a small footprint, economical, high-output benchtop system. Ethylene oxide or electron beam sterilized 3DMF samples were analyzed by scanning electron microscopy (SEM), underwent ASTM1635-based degradation testing, tensile testing, ISO 10993-based cytocompatibility, and biocompatibility testing, quantified for human platelet-rich plasma (PRP) absorption kinetics, and examined for adhesion of bioceramics and lyophilized collagen after coating. 3DMF implants had consistent fiber size and high alignment by SEM. Negligible mass and strength loss were noted over 4 months in culture. 3DMF implants initially exceeded 1000 N hydrated tensile strength and retained over 70% strength through 4 months in culture, significantly stronger than conventionally produced implants made by fused fiber deposition 3D printing. 3DMF implants absorbed over 3xtheir weight in PRP within 5 min, were cytocompatible and biocompatible in vivo in rabbits, and could readily bind tricalcium phosphate and calcium carbonate coatings discretely on implant ends for further orthobiologic material functionalization. The additive manufacturing process further enabled engineering implants with suture-shuttling passages for facile arthroscopic surgical delivery. This accessible, facile, economical, and rapid microfiber manufacturing platform presents a new method to engineer high-strength, flexible, low-cost, bio-based implants for orthopedic and extended medical device applications.

Home-Based or Supervised Physical Therapy Shows Similar Functional Outcomes and Healing After Massive Rotator Cuff Repair

PURPOSE

To compare postoperative clinical outcomes at the 3-month, 6-month, 12-month, and latest follow-up in patients undergoing supervised physical therapy (PT) or a home-based exercise program after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCTs).

METHODS

A retrospective review was conducted on a prospectively maintained database of patients who underwent either supervised PT or home-based therapy after ARCR of MRCTs between January 2015 and December 2018 at a single center with a minimum 24-month follow-up. At their 2-week postoperative routine follow-up, patients were allowed to choose between home-based and supervised PT. Patient-reported outcomes (PROs) and range of motion (ROM) were collected and compared between cohorts preoperatively and at the 3-month, 6-month, 12-month, and latest follow-up. The percentage of patients reaching or exceeding the minimal clinically important difference (MCID) and patient accepted symptomatic state (PASS) for visual analog scale for pain, American Shoulder and Elbow Surgeon (ASES) score, and Subjective Shoulder Value was recorded for both cohorts at each time point. Complications, healing, satisfaction, and return to work were reported. Healing was evaluated via ultrasound at the latest follow-up.

RESULTS

Ninety-nine patients met the study criteria: 61 in the supervised PT cohort and 38 in the home-based cohort. The supervised PT and home-based cohorts returned to the clinic for their most recent follow-up at 53 ± 20 and 55 ± 16 months (P = .496) after surgery, respectively. There was no difference when comparing tendon involvement (supraspinatus, P = .574; infraspinatus, P = .288; subscapularis, P = .592), tear retraction (P = .603), or high-grade fatty infiltration (supraspinatus, P = .684; infraspinatus, P = .397; subscapularis, P = .473) based on preoperative magnetic resonance imaging assessment and surgery-related factors, including anterior (P = .473) or posterior (P = .386) slides, fixation constructs (P = .829), or complete repair (P = .912). Both cohorts showed similar PROs and ROM at baseline. Postoperative PROs and ROM were similar among groups at the 3-month, 6-month, 12-month, and latest follow-up. However, ASES (71.4 vs 61.2; P = .013) and forward flexion (135° vs 118°; P = .023) were significantly higher at 3-month follow-up in the home-based cohort. Both groups comparably achieved MCID and PASS for PROs at the 3-month, 6-month, and 12-month follow-up. At the latest follow-up, the supervised PT and home-based cohort achieved MCID and PASS for visual analog scale (75% vs 81%, P = .573; 70% vs 72%, P = .911), ASES (76% vs 74%, P = .777; 72% vs 72%, P = .873), and Subjective Shoulder Value (82% vs 84%, P = .734; 72% vs 66%, P = .489), respectively. Satisfaction, healing, complication, and return-to-work rates were similar.

CONCLUSIONS

Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. Although patients with home-based therapy achieved higher forward flexion and ASES at the 3-month follow-up, these became comparable starting at the 6-month postoperative mark. MCID and PASS were achieved similarly for PROs at each time point.

LEVEL OF EVIDENCE

Level III, retrospective case series comparison.

Scapular morphology does not predict supraspinatus tendon tear propagation following an individualised exercise therapy programme

Purpose

To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size.

Methods

Fifty-nine individuals aged 40-70 years with isolated symptomatic high-grade partial or full-thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12-week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three-dimensional subject-specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation.

Results

The CSA was 30.0 ± 5.4°. Thirty-one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R 2 = 0.243) of variance in tear propagation (NS).

Conclusions

CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme.

Level of Evidence

II.

Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears

BACKGROUND

Nonsurgical management of chronic, degenerative rotator cuff tears (RCTs) can be an effective treatment strategy, but there is limited evidence to support conservative treatment of acute, traumatic RCTs. The objective of this study was to assess clinical outcomes and predictors of treatment success in patients with traumatic RCTs who elected for initial nonoperative treatment.

METHODS

Patients from a single institution were retrospectively identified using diagnostic codes for traumatic RCTs followed by confirmed initial treatment with ≥2 months of physical therapy. The exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on magnetic resonance imaging. At minimum 2-year follow-up, patients were contacted by telephone to collect interval surgical history and standardized patient-reported outcomes. Physical therapy was considered to have failed in all those who underwent surgical treatment and those with satisfaction ratings of "moderately dissatisfied" or "very dissatisfied."

RESULTS

Follow-up outcomes were obtained in 40 of 49 patients (82%), with an average follow-up time of 4.2 years. Of the RCTs, 9 (22%) were small (<1 cm), 22 (54%) were medium (>1 cm to <3 cm), and 9 (22%) were large (>3 cm to <5 cm). Grade I fatty infiltration was seen on 25% of magnetic resonance imaging scans (n = 10). Rotator cuff repair was performed in 18 patients (45%) following an average of 6 months of nonoperative treatment (range, 3-12 months). Nonoperative treatment was determined to have failed in 23 of 40 patients (58%) in total. Conservative management was more likely to fail in patients with multiple tendons torn (P = .014). Tear size and retraction were not significantly different between patients who underwent surgery and those who did not. Patients who underwent surgical management had an 83% satisfaction rate at final follow-up compared with a 55% satisfaction rate for patients who did not undergo surgery (P = .054). There was no statistically significant difference in the American Shoulder and Elbow Surgeons score or visual analog scale score between these groups. Although patients who underwent surgery had a higher mean Single Alpha Numeric Evaluation score (86.3 vs. 75.1, P = .041), this difference was below the previously established minimal clinically important difference.

CONCLUSION

Nonoperative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs.

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

PURPOSE

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis.

METHODS

A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures.

RESULTS

Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n = 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE.

CONCLUSIONS

Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic double row partial articular supraspinatus tendon avulsion bridge repair technique for shoulder: A transtendinous approach

Partial articular supraspinatus tendon avulsion (PASTA) lesions, a subset of partial rotator cuff tears, pose a surgical challenge, disrupting the integrity of the supraspinatus tendon. Transtendinous repair is the preferred choice in young individuals for limiting tear progression and preserving intact, high-quality cuff tissue, thus preventing tendon shortening, as compared to the tear completion and repair technique. Our approach leverages these advantages, specifically those indicated for Ellman's Grade 3 tears and cases where conservative treatments have failed. In our technique, we employ progressive dilation, anchor drill sleeve insertion to facilitate medial row anchor placement, followed by percutaneous spinal needles for suture shuttling, and finally locking sliding knots for compressive medial row repair, followed by lateral row fixation for additional stability. This method accelerates rehabilitation and restores optimal shoulder function.

The Reverse Fragility Index: Interpreting the Evidence for Arthroscopic Rotator Cuff Repair Healing Associated With Early Versus Delayed Mobilization

Background: The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) note "strong" evidence that early and delayed mobilization protocols after small to medium arthroscopic rotator cuff repairs achieve similar rotator cuff healing rates. Purpose: We utilized the reverse fragility index (RFI) to assess the fragility of randomized controlled trials (RCTs) reporting no statistically significant difference in tendon re-tear rates after rotator cuff repair in those undergoing early versus delayed rehabilitation. Methods: Randomized controlled trials used in the most recent AAOS CPGs on the timing of postoperative mobilization after arthroscopic rotator cuff repairs were analyzed. Only RCTs with a reported P value ≥ .05 were included. The RFI at a threshold of P < .05 was calculated for each study. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. Results: In 6 clinical trials with a total of 542 patients, the number of tendon re-tear events was 48. The median RFI at the P < .05 threshold was 4 (range: 3.25-4.75), and the median RFQ was .05 (range: 0.03-0.08). The median loss to follow-up was 6 patients. Of the 6 studies investigated, 3 reported a loss to follow-up greater than their respective RFI. Conclusion: The equivalence in rotator cuff repair healing rates associated with early and delayed mobilization protocols rests on fragile studies, as their statistical non-significance can be reversed by changing the outcome status of only a handful of patients. Consideration should be given to the routine reporting of RFI in clinical practice guidelines including RCTs with statistically non-significant results.

Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair-two hundred cases with minimum 2-year follow-up

Background

Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware.

Methods

This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded.

Results

Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR.

Discussion

The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate.

Conclusion

The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

Traumatic rotator cuff injury: does delayed surgery worsen functional outcomes?

PURPOSE

The optimal timing of surgery after traumatic rotator cuff tears (RCT) is unclear, with its impact on functional outcomes under debate. This study aimed to review functional outcomes after RCT repair in patients who underwent early vs delayed surgery at our unit.

METHODS

This was single-centre retrospective evaluation. Patients with an acute traumatic RCT that underwent repair between 2017 and 2019 and had local follow-up were included and placed into two groups: early surgery (within 6 months from injury) and delayed surgery (more than 6 months from injury). Patient demographics, RCT data and pre- and post-operative (after 12 months) Oxford Shoulder Score (OSS) were extracted from medical records. Data was analysed to compare OSS scores between groups, as well as the effect of cuff tear sizes on OSS scores.

RESULTS

Forty-nine patients were included in the analysis (15 early, 34 delayed). There were no significant differences in age, sex or cuff tear sizes between groups. No difference was identified in the mean post-operative OSS between early vs delayed groups (40.9 ± 6.34 vs 40.5 ± 7.65, p = 0.86). The mean improvement in OSS after surgery was also similar between groups (22.5 ± 7.81 vs 20.97 ± 7.19, p = 0.498). Having a large or massive RCT did not worsen OSS compared to small or medium RCT (p = 0.44), even when stratified by early or delayed surgery.

CONCLUSION

Delayed surgery for traumatic RCT greater than 6 months from injury did not negatively impact long-term functional outcomes at our unit. Patients should be reassured as applicable before surgery in the event of prolonged or unavoidable delays.

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.

A Systematic Review and Meta-analysis of Risk Factors for the Increased Incidence of Revision Surgery After Arthroscopic Rotator Cuff Repair

BACKGROUND

Approximately 90% of patients who undergo arthroscopic rotator cuff repair (RCR) are satisfied with their pain levels and function after surgery. However, a subset of patients experience continued symptoms that warrant revision surgery. Preoperative risk factors for RCR failure requiring revision surgery have not been clearly defined.

PURPOSE

To (1) determine the rate of RCR failure requiring revision surgery and (2) identify risk factors for revision surgery, which will help surgeons to determine patients who are at the greatest risk for RCR failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were performed. The initial search resulted in 3158 titles, and 533 full-text articles were assessed for eligibility. A total of 10 studies met the following inclusion criteria: (1) human clinical studies, (2) arthroscopic RCR, (3) original clinical research, and (4) evaluation of preoperative risk factors for revision.

RESULTS

After a full-text review, a total of 16 risk factors were recorded and analyzed across 10 studies. Corticosteroid injection was the most consistent risk factor for revision surgery, reaching statistical significance in 4 of 4 studies, followed by workers' compensation status (2/3 studies). Patients with corticosteroid injections had a pooled increased risk of revision surgery by 47% (odds ratio, 1.44 [95% CI, 1.36-1.52]). Patients with workers' compensation had a pooled increased risk of revision surgery by 133% (odds ratio, 2.33 [95% CI, 2.09-2.60]). Age, smoking status, diabetes, and obesity were found to be risk factors in half of the analyzed studies.

CONCLUSION

Corticosteroid injections, regardless of the frequency of injections, and workers' compensation status were found to be significant risk factors across the literature based on qualitative analysis and pooled analysis. Surgeons should determine ideal candidates for arthroscopic RCR by accounting for corticosteroid injection history, regardless of the frequency, and insurance status of the patient.

Cell Sheet Technology: An Emerging Approach for Tendon and Ligament Tissue Engineering

Tendon and ligament injuries account for a substantial proportion of disorders in the musculoskeletal system. While non-operative and operative treatment strategies have advanced, the restoration of native tendon and ligament structures after injury is still challenging due to its innate limited regenerative ability. Cell sheet technology is an innovative tool for tissue fabrication and cell transplantation in regenerative medicine. In this review, we first summarize different harvesting procedures and advantages of cell sheet technology, which preserves intact cell-to-cell connections and extracellular matrix. We then describe the recent progress of cell sheet technology from preclinical studies, focusing on the application of stem cell-derived sheets in treating tendon and ligament injuries, as well as highlighting its effects on mitigating inflammation and promoting tendon/graft-bone interface healing. Finally, we discuss several prerequisites for future clinical translation including the selection of appropriate cell source, optimization of preparation process, establishment of suitable animal model, and the fabrication of vascularized complex tissue. We believe this review could potentially provoke new ideas and drive the development of more functional biomimetic tissues using cell sheet technology to meet the needs of clinical patients.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

PURPOSE

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up.

METHODS

We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed.

RESULTS

In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105).

CONCLUSIONS

In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair

Background

Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI.

Methods

An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05).

Results

There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05).

Conclusion

Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.

Predictors of Postoperative Patient-Reported Outcome Measure Response Rates Among Patients With Rotator Cuff Repair

BACKGROUND

Patient-reported outcome measures (PROMs) contribute to evaluating and improving the quality of patient care. Patient outcomes after rotator cuff repair (RCR) have been researched; however, the relationship between PROM response rates and individual and health care correlates has not been thoroughly investigated.

PURPOSE

To examine differences in individual and health care factors among patients who had undergone RCR based on their PROM response rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Shoulder-specific and general PROMs were solicited via email and text message of all patients who underwent RCR between 2016 and 2020. Three subgroups were classified: (1) complete responders completed all 1-year postoperative PROMs, (2) partial responders answered enough questions to produce ≥1 usable score, and (3) nonresponders did not respond to a single measure. Correlates were assessed using analysis of variance and chi-square tests. Adjusted multinomial logistic regression models identified predictors of 1-year PROM response.

RESULTS

Of 2195 patients included at the 1-year follow-up, 34% were complete responders; 11%, partial responders; and 55%, nonresponders. Patients had a mean age of 61.8 years, 63% were men, and 90% were White. Pre- and postoperative PROM scores were similar across responder groups. In stepwise selection, 1-year responses (complete or partial) were associated with older age, later year of surgery, White race, and having workers' compensation insurance. The strongest predictor of PROM response was having workers' compensation insurance.

CONCLUSION

Patients with workers' compensation insurance compared with other insurance types responded to PROMs at disproportionately higher rates. This could distort postoperative PROM scores in the population studied because there are known differences among patients with this insurance status.