Ultrasonic evaluation of the repair integrity can predict functional outcomes after arthroscopic double-row rotator cuff repair

Determining the Patient Acceptable Symptom State (PASS) for Shoulder Strength After Subscapularis Arthroscopic Repair and Evaluating the Preoperative Predictors for PASS Achievement

Background

Restoring shoulder strength after arthroscopic rotator cuff repair (ARCR) is critical, but there is limited understanding as to what patients consider satisfactory postoperative strength.

Purpose

To determine the Patient Acceptable Symptom State (PASS) values for the Constant score strength parameter and internal rotation (IR) strength in patients who underwent ARCR for rotator cuff tears involving the subscapularis (SSC) muscle and evaluate for associations between preoperative and intraoperative patient characteristics with PASS achievement.

Study Design

Case-control study; Level of evidence, 3.

Methods

A retrospective analysis was conducted on prospectively collected data for 278 patients with an SSC tear (isolated or combined) who underwent ARCR and had minimum 2-year follow-up data. Functional outcomes (patient-reported outcomes, range of motion, Constant strength, and IR strength) were assessed preoperatively and at the latest follow-up. The overall, male, and female PASS values for postoperative strength measures were evaluated using receiver operating characteristic analysis. Correlation and logistic regression analyses were used to evaluate the relationship between preoperative variables and PASS achievement for Constant and IR strengths.

Results

The mean follow-up time was 72.8 months. The overall, male, and female PASS values were 9.9 lb (4.5 kg), 14.5 lb (6.6 kg), and 8.5 lb (3.9 kg), respectively, for Constant strength and 15.2 lb (6.9 kg), 20.7 lb (9.4 kg), and 12.1 lb (5.5 kg), respectively, for IR strength. Older age, high fatty infiltration of the SSC tendon (Goutallier grades 3 and 4), and failure of SSC healing correlated negatively with PASS attainment for the strength measures. High fatty infiltration of the supraspinatus and infraspinatus muscles correlated negatively with Constant strength. Decreased coracohumeral distance (CHD) and larger SSC tears correlated negatively with achieving PASS for IR strength. Workers' compensation, high supraspinatus and SSC fatty infiltration, and the use of knotted suture anchors were predictors of not achieving the overall Constant strength PASS, while lower SSC fatty infiltration and high CHD were predictors of achieving the overall IR strength PASS.

Conclusion

This study established the PASS values for Constant and IR strengths for patients after ARCR involving the SSC tendon. Workers' compensation, high supraspinatus and SSC fatty infiltration, and the use of knotted suture anchors were predictors of not achieving the overall Constant strength PASS, while lower SSC fatty infiltration and high CHD were predictors of achieving the overall IR strength PASS.

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.

Hawkins award 2023: clinical outcome and tendon healing after arthroscopic repair of isolated supraspinatus tears: a retrospective comparative study in patients older than 70 years vs. patients younger than 50 years

Background

The purpose of this study was to evaluate and compare the clinical and structural outcomes after arthroscopic repair of isolated supraspinatus tears in patients older than 70 years vs. patients younger than 50 years to determine whether age influences the treatment of these tears.

Methods

We conducted a retrospective, comparative study of 87 shoulders of 86 patients older than 70 years who underwent rotator cuff repair after isolated full-thickness supraspinatus tear between January 2010 and December 2020. A control group of 87 patients younger than 50 years was matched for sex, body mass index, smoking habits, tendon retraction according to Patte and fatty infiltration according to Goutallier. Clinical assessment used Constant-Murley Score (CMS), age- and sex-matched Constant Scores and Subjective Shoulder Value at 6 months. Cuff integrity was evaluated using ultrasonography based on the Sugaya criteria, types I-II-III being considered as healed.

Results

The CMS significantly improved by +17.91 points in elderly patients compared with +7.47 points in controls (P < .1) and activity (P = .2), mobility (P < .1), and strength (P < .1). The adjusted CMS significantly improved by +24.94 in elderly patients compared with +8.49 points in controls (P < .1). The Subjective Shoulder Value improved by +29.48 points in elderly patients compared with +23.47 points in controls. The improvement was similar in both groups. (P < .10). Satisfaction was similar in both groups (P = .31). Regarding structural outcomes, patients younger than 50 years presented better results in terms of healing than patients older than 70 years, as the healing rate was 73.7% in the elderly group and 88.5% in the control group (P = .1). The clinical outcomes were not significantly associated with the tendon healing (P = .1).

Conclusion

Functional gain for patients older than 70 years is better than their younger peers despite their low-grade healing. Arthroscopic repair after isolated supraspinatus tears should be considered as a valuable treatment regardless the age.

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair

BACKGROUND

Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking.

PURPOSE

To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs).

RESULTS

Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC.

CONCLUSION

The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Arthroscopic repair for isolated subscapularis tear: successful functional outcomes and high tendon healing rate can be expected nine years after surgery

BACKGROUND

Literature describing outcomes and integrity after isolated subscapularis (SSC) tendon repair is emerging but remains limited to a few small case series with short-term follow-up. The aim of this study was to evaluate the long-term clinical outcomes and repair integrity in patients who underwent arthroscopic repair of isolated SSC tears.

METHODS

A retrospective study was conducted with the following inclusion criteria: (1) primary and elective shoulder arthroscopy for isolated SSC repair, (2) type III (a full-thickness tear in the upper two-thirds of the tendon) or IV (a complete tear without tendon retraction) SSC tear according to the Lafosse classification, and (3) a minimum 24-month follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley score (CMS) and at follow-up, the ROM, the University of California-Los Angeles (UCLA) Shoulder Rating Scale, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the CMS were evaluated; an ultrasonographic assessment of tendon healing was performed according to the Sugaya classification.

RESULTS

The final sample consisted of 45 patients with an average age of 55 ± 9 years. After a mean follow-up time of 107 ± 54 months, the mean UCLA and DASH scores were 8.7 ± 1.3 and 42.2 ± 6.4, respectively. ROM and CMS showed statistically significant improvements (all P < .001). Before surgery, the mean CMS was 49% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 94.2% that of sex- and age-matched healthy individuals, and no patients showed CMS of 30 or less. The mean increase in the CMS was 41.4 ± 9.8 points (range, 23-60 points). The ultrasonographic assessment showed SSC tendon healing in 39 (86.7%) cases; tendon retear was recorded in 5 (13.3%) cases. All scores directly correlated with the healing of the tendon. A higher postoperative DASH score was associated with male sex (P = .039, β = 5.538) and a longer follow-up period (P = .044, β = 0.001). The postoperative CMS (P < .001) and UCLA scores (P = .001) were significantly higher in patients younger than 60 years of age at surgery than in older individuals.

CONCLUSION

Arthroscopic repair of isolated SSC tears achieves excellent clinical and functional results at a mean of 9 years postoperatively, with a satisfactory healing rate. Better functional outcomes correlate with SSC tendon integrity and were observed in male patients and in those younger than 60 years at surgery.

Arthroscopic rotator cuff repair in patients over 65 years of age: successful functional outcomes and a high tendon integrity rate can be obtained after surgery

Background

Although interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears.

Methods

A retrospective study was conducted with the following inclusion criteria: (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness posterosuperior tears; (2) age over 65 years at surgery; and (3) participation in 24 months of follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the 12-Item Short Form Survey, the American Shoulder and Elbow Surgeons, and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification.

Results

The final sample consisted of 110 patients with an average age of 69.2 ± 3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all P < .001) after a mean follow-up time of 54.5 ± 22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (P < .001, β = -6.085) and lower age (P = .004, β = -0.533). Higher postoperative American Shoulder and Elbow Surgeons were associated with lower age (P = .020, β = -0.414). Higher postoperative 12-Item Short Form Survey physical component score and mental component score were associated with lower age (P = .013, β = -0.550 and P < .001, β = -0.520, respectively) and shorter preoperative physical therapy period (P = .013, β = -2.075 and P = .006, β = -1.093, respectively).

Conclusion

A significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical, and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

Postoperative Antiosteoporotic Treatment with Zoledronic Acid Improves Rotator Cuff Healing but Does Not Improve Outcomes in Female Patients with Postmenopausal Osteoporosis: A Prospective, Single-Blinded, Randomized Study

PURPOSE

To investigate the effect of the antiosteoporotic agent zoledronic acid (ZA) on rotator cuff healing and clinical outcomes in patients with postmenopausal osteoporosis.

METHODS

We prospectively enrolled 138 female patients with postmenopausal osteoporosis who were scheduled to undergo arthroscopic rotator cuff repair (ARCR) from March 2020 to March 2021. Patients were randomly allocated to the ZA group (ARCR followed by intravenous ZA infusions at postoperative Day 1 and 1 year later) and the control group (ARCR alone). All patients were followed up for 24 months. Tendon healing was evaluated by ultrasonography at 6 weeks and 24 months after surgery. The American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and Numeric Rating Scale (NRS) for pain were recorded at each follow-up, and the minimal clinically important difference (MCID) was calculated.

RESULTS

A total of 124 patients were included in the final analysis, 61 in the ZA group and 63 in the control group. There was no statistically significant difference in participant characteristics between the 2 groups. The ZA group had a significantly higher tendon healing rate than the control group at 2 years after surgery (odds ratio = 5.0; 95% confidence interval [CI], 1.4-18.7; P = .014). Regarding clinical outcomes, 100% of patients exceeded the MCID in both groups, and no significant differences were found at 2 years after surgery between the 2 groups (ASES: 2.5 [95% CI, -2.2 to 7.2; P = .291]; WORC index: 4.5 [95% CI, -0.117 to 9.117; P = .056]; NRS: -0.1 [95% CI, -0.3 to 0.1; P = .394]).

CONCLUSIONS

Antiosteoporotic treatment with ZA reduced the retear rate but did not significantly influence the clinical outcomes after ARCR in female patients with postmenopausal osteoporosis. Outcomes of ARCR showed good results in both groups and exceeded the MCID.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up

Background

Few studies have reported clinical outcomes and tendon healing rates after arthroscopic isolated subscapularis (SSC) repair (AISR).

Purpose/Hypothesis

The primary purpose of this study was to evaluate clinical outcomes and tendon healing after AISR. It was hypothesized that AISR would result in satisfactory clinical outcomes along with a high rate of tendon healing at the midterm follow-up. The secondary purpose was to assess the influence of tear size and muscle atrophy on SSC tendon healing and patient-reported outcomes. It was hypothesized that both would be negatively correlated with healing but would have no effect on clinical outcomes .

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective analysis was conducted on prospectively collected data for 77 patients who underwent primary AISR between 2011 and 2021 at a single institution, with a minimum 2-year postoperative follow-up for all patients. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Shoulder Value (SSV), and the visual analog scale for pain. Repair techniques and concomitant procedures were also collected. SSC tendon healing was evaluated via ultrasound at the final follow-up. Linear regression analysis was performed to determine factors affecting SSC healing.

Results

The mean follow-up was 58.1 ± 3.3 months. ASES scores significantly improved from 41.5 to 81.6, and the SSV improved from 38.2 to 80.5 (P < .01 for both). Among the 40 patients (51.9%) who underwent postoperative ultrasound, 87.5% showed complete tendon healing. There were no significant differences in outcome scores between healed and unhealed tendons. Increased muscle atrophy and larger tears were correlated with failure of SSC healing (β = -0.285 [P = .015] and β = -0.157 [P = .045], respectively).

Conclusion

Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. Smaller tear sizes with less muscle atrophy were correlated with improved tendon healing. However, even when the tendon incompletely healed, the procedure improved functional outcomes.

Clinical and radiological outcome after arthroscopic rotator cuff repair using PEEK-CF anchors

PURPOSE

The goal of this study was to evaluate the clinical and radiological outcome after arthroscopic rotator cuff repair using new carbonfiber reinforced polyetheretherketone (CF-PEEK) suture anchors.

METHODS

One hundred (n=100) patients with rotator cuff tears were enrolled at seven French hospitals between July 2019 and June 2020. Pain levels, Constant score and Subjective Shoulder Value (SSV) were taken preoperatively and 6months postoperatively. Ultrasonography (US) was performed at 6months postoperatively to evaluate tendon healing using the Sugaya classification. Statistical analysis was done with the Student t-test with 95% confidence intervals.

RESULTS

One hundred patients of the 100 patients were followed at 6months. The mean SSV and Constant score improved from 40.1% preoperatively to 78% at 6months (p<0.0001) and from 43 points preoperatively to 65 points at 6months (p<0.0001), respectively. The mean level of pain, as measured with the visual analogue scale, decreased from 5.9 to 1.6 (p<0.001). There were no postoperative complications that resulted in revision surgery.

CONCLUSION

The study showed good results at 6months follow-up using carbonfiber reinforced PEEK anchors with improved Constant and SSV scores as well as a high ultrasonographic tendon healing rate, making PEEK-CF anchors safe to use, comparable to commonly used anchors.

LEVEL OF EVIDENCE

IV.

Early versus late physiotherapy following arthroscopic repair of small and medium size rotator cuff tear: a randomized clinical trial

PURPOSE

We compared early and late physiotherapy for patients with small and medium size rotator cuff tears following arthroscopic repair.

METHODS

A single-centre, single-blinded, prospective parallel RCT was performed with two arms: early physiotherapy (start within the first week) versus late physiotherapy (start 4 weeks after surgery). Patients with small- to medium-sized isolated full-thickness superior rotator cuff tears were included and followed for 12 months. The primary outcome measures were shoulder function and range of motion (ROM) measured by the Constant-Murley score (CMS) at three months, six months, and 12 months. The other outcomes were the visual analog scale (VAS) pain and the rotator cuff ultrasound (US) evaluation by the Sugaya classification.

RESULTS

In three and six month follow-ups, CMS was significantly superior in the intervention group compared to controls (P < 0.05). However, only at the three month follow-up between-group difference met the minimal clinically important difference (MCID) (MCID = 10.4) (59.8 vs. 48.9). The intervention group experienced less pain than controls in the first six months (P < 0.001), and only the three month follow-up was clinically meaningful based on MCID (MCID = 1.4). Moreover, in the first six months, the shoulder ROM favoured the intervention group (P < 0.05). US grading of the supraspinatus and infraspinatus was similar between groups (P = 0.07). One retear occurred in the intervention group and another in the controls, detected by examination and US evaluation.

CONCLUSION

Following the arthroscopic repair of a small- to medium-sized rotator cuff tear, early physiotherapy showed promising results for pain, function, and range of motion.

LEVEL OF EVIDENCE

Level I therapeutic.

The effect of augmenting suture material with magnesium and platelet-rich plasma on the in vitro adhesion and proliferation potential of subacromial bursa-derived progenitor cells

Background

Connective tissue subacromial bursa-derived progenitor cells (SBDCs) have been suggested as a potent biologic augment to promote healing of the repaired rotator cuff tendon. Maximizing the amount of retained progenitor cells at the tendon repair site is essential for ensuring an optimal healing environment, warranting a search for proadhesive and proliferative adjuvants. The purpose was to evaluate the effect of magnesium (Mg), platelet-rich plasma (PRP), and a combination of both adjuvants on the in vitro cellular adhesion and proliferation potential of SBDCs on suture material commonly used in rotator cuff surgery.

Methods

SBDCs were isolated from subacromial bursa samples harvested during rotator cuff repair and cultured in growth media. Commercially available collagen-coated nonabsorbable flat-braided suture was cut into 1-inch pieces, placed into 48-well culture dishes, and sterilized under ultraviolet light. Either a one-time dose of 5 mM sterile Mg, 0.2 mL of PRP, or a combination of both adjuvants was added, while a group without treatment served as a negative control. Cellular proliferation and adhesion assays on suture material were performed for each treatment condition.

Results

Augmenting the suture with Mg resulted in a significantly increased cellular adhesion (total number of attached cells) of SBDCs compared to PRP alone (31,527 ± 19,884 vs. 13,619 ± 8808; P < .001), no treatment (31,527 ± 19,884 vs. 21,643 ± 8194; P = .016), and combination of both adjuvants (31,527 ± 19,884 vs. 17,121 ± 11,935; P < .001). Further, augmentation with Mg achieved a significant increase in cellular proliferation (absorbance) of SBDCs on suture material when compared to the PRP (0.516 ± 0.207 vs. 0.424 ± 0.131; P = .001) and no treatment (0.516 ± 0.207 vs. 0.383 ± 0.094; P < .001) group. The combination of Mg and PRP showed a significantly higher proliferation potential compared to PRP alone (0.512 ± 0.194 vs. 0.424 ± 0.131; P = .001) and no treatment (0.512 ± 0.194 vs. 0.383 ± 0.094; P < .001). There were no significant differences in the remaining intergroup comparisons (P > .05, respectively).

Conclusion

Augmenting suture material with Mg resulted in a significantly increased cellular adhesion of SBDCs compared to untreated suture material, as well as augmentation with PRP alone or a combination of both adjuvants. Further, Mg with or without PRP augmentation achieved a significant increase in the cellular proliferation of SBDCs on suture material compared to untreated sutures and augmentation with PRP alone. Application of Mg may be a clinically feasible approach to optimizing the use of SBDCs as a biological augment in rotator cuff repair, while combined augmentation with PRP may harness the full potential for optimized tissue recovery due to the high concentration of PRP-derived growth factors.

Arthroscopic Repair of Massive Rotator Cuff Tears Leads to Functional Improvement in Most Patients at 4-Year Follow-up

Purpose

To assess functional outcomes and healing 4 years after arthroscopic repair of massive rotator cuff tears (MRCTs).

Methods

We conducted a retrospective study of patients who underwent arthroscopic rotator cuff repair of an MRCT-defined as a complete 2-tendon tear or a tear greater than 5 cm in any dimension-performed by 2 surgeons at different institutions between January 2015 and December 2018. At a minimum of 4 years postoperatively, patient-reported outcomes collected included the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12 (VR-12) score, and Subjective Shoulder Value (SSV) score. Repair technique and concomitant procedures were also gathered. Tendon healing was evaluated via ultrasound at final follow-up.

Results

Functional outcomes were available for 101 patients at a mean of 63.6 ± 8.8 months (range, 48-82 months) postoperatively. Mean ASES scores improved from 40.1 to 78 (P < .001); VR-12 scores, from 37.1 to 47.7 (P < .001); and SSV scores, from 36.7 to 84.6 (P < .001). Forward flexion improved from 126° to 144° (P = .001), external rotation remained unchanged (from 47° to 44°, P = .268), and internal rotation improved by 2 spinal levels (from L4 to L2, P = .0001). Eighty-eight percent of patients (89 of 101) were satisfied with the procedure, and only 5% underwent reverse shoulder arthroplasty within the study period. Among the 39 patients who underwent postoperative ultrasound to assess healing, 56% showed complete tendon healing. There was no difference in healing or outcomes according to tear pattern. Additionally, tendon healing did not affect outcomes.

Conclusions

Arthroscopic repair of MRCTs leads to functional improvements and patient satisfaction in most cases at 4-year follow-up. The rates of patients achieving the minimal clinically important difference were 77.5%, 87.6%, 59.7%, and 80.6% for the ASES score, SSV score, VR-12 score, and visual analog scale pain score, respectively. Complete tendon healing is difficult to achieve but does not appear to limit functional improvements.

Level of Evidence

Level IV, therapeutic case series.

Comparison of all-suture anchors with metallic anchors in arthroscopic cuff repair: Structural and functional properties and clinical suitability

Purpose

This study examined and compared all-suture anchors with metallic anchors in the arthroscopic repair of small to medium supraspinatus tears; a multi-dimensional evaluation protocol assessed (i) clinical, (ii) ultrasonographical, and (iii) functional criteria at mid-term.

Materials and methods

A sample of 40 patients, prescreened from a larger group who had undergone arthroscopic rotator cuff repair, were resolved into two groups of 20, based on the type of anchor used in their surgery (all-suture or metallic) and were evaluated postoperatively (mean = 44.3 months, SEM = 22.4 months, minimum period = 10.3 months). Clinical assessments included (i) objective and subjective scores (Constant, DASH, SPADI, SST), (ii) ultrasonographical examination, as well as (iii) isometric and isokinetic strength testing. Raw data from the operated side was compared with those from the contralateral side within each group. Raw data for the PROMs and for the US evaluation were compared between groups. Strength data, as well as the Constant score values, were further analyzed based on (i) the difference between operated and intact sides, as well as (ii) the strength ratio between operated and intact sides; the transformed data were then compared between the two groups.

Results

We found no statistically significant differences in any of the parameters considered between shoulders operated using ASAs or MAs, nor between operated and non-operated sides in each group.

Conclusion

Our findings indicate that the reliability and performance characteristics of all-suture anchors and metallic anchors are practically indistinguishable for arthroscopic treatment of small to medium lesions of the supraspinatus tendon.

Fibrillar matrix, Echogenicity, Contour, Thickness, and Suture (FECTS) vs. Global: A comparison of 2 scales developed to assess ultrasound images post rotator cuff repair

BACKGROUND

Ultrasound is commonly used to assess rotator cuff repair (RCR), but no standardized criterion exists to characterize the tendon.

PURPOSE

The aims of this study were to (1) develop content validity for ultrasound specific criteria to grade the postoperative appearance of a tendon after RCR, (2) assess the reliability of the criteria, and (3) assess the feasibility to use these assessments.

METHODOLOGY

Following expert consultation and literature review for content validity, 2 scales were created: 1) the Fibrillar matrix, Echogenicity, Contour, Thickness, and Suture (FECTS) scale and 2) the Rotator Cuff Repair-Investigator Global Assessment (RCR-IGA). A prospective cohort study was undertaken on patients who had received a RCR and serial B-mode ultrasound images. Four raters assessed the 64-ultrasound images using the scales created in a blinded fashion using intraclass correlation coefficients.

RESULTS

The FECTS scale was a composite score with 5 key parameters and the RCR-IGA scale was a 5-point global score. The intrarater reliability for the FECTS scale was excellent for the most experienced rater (0.92) and fair for the rater with no experience (0.72). The intrarater reliability for the RCR-IGA scale was excellent for 3 of the 4 raters (0.80-0.87) and fair when used by the least experienced rater (0.56). Inter-rater testing for all the FECTS scale parameters had excellent reliability (0.82-0.92) except for Fibrillar matrix (0.73). The average time to complete the FECTS scale per image was 23 seconds and 11 seconds for the RCR-IGA scale.

CONCLUSION

The FECTS scale and the RCR-IGA scale are reliable tools to assess the ultrasonic appearance of the repaired rotator cuff tendon. The FECTS scale was more reliable for less experienced assessors. The RCR-IGA scale was easier, more time efficient and reliable for those with experience.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Comparison of Locking-Loop Suture Bridge Repair and Single-Row Suture Anchor Repair in Small to Medium Rotator Cuff Tears: A Prospective Cohort Study With Clinical and Ultrasound Evaluations

Background

Single-row (SR) and double-row repair techniques have been described to treat rotator cuff tears. We present a novel surgical strategy of arthroscopic-assisted mini-open repair in which a locking-loop suture bridge (LLSB) is used.

Purpose

To compare the functional outcomes and repair integrity of LLSB technique to the SR technique for arthroscopic-assisted mini-open repair of small to medium rotator cuff tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 39 patients who underwent LLSB repair (LLSB group) and 44 patients who underwent SR suture anchor repair (SR group) from 2015 to 2018. We evaluated all patients preoperatively and at 3, 6, 12, and 24 months postoperatively using the visual analog scale (VAS) for pain, Oxford Shoulder Score (OSS), and American Shoulder and Elbow Surgeons (ASES) score. Also, shoulder sonography was performed at 12 months postoperatively to evaluate repair integrity using the Sugaya classification system. The independent-sample t test was used to analyze functional outcomes (VAS, OSS, and ASES scores), and the Fisher exact test was used to analyze postoperative sonography results.

Results

Patients in both the LLSB and SR groups saw a significant improvement on all 3 outcome measures from preoperatively to 24 months postoperatively (P < .001 for all). However, when comparing scores between groups, only the scores at 3 months postoperatively differed significantly (VAS: P = .002; OSS: P < .001; ASES: P = .005). Shoulder sonography at 12 months postoperatively revealed no significant difference in repair integrity between the LLSB and SR groups (retear rate: 10.26% and 6.82%, respectively; P = .892).

Conclusion

Better outcome scores were seen at 3-month follow-up in the LLSB group, with no difference in retear rates compared with the SR group at 12 months postoperatively. The LLSB technique was found to be a reliable technique for rotator cuff repair of small- to medium-sized tears.

Management of normal long head of the biceps tendon in isolated grade-1 supraspinatus tear: Research protocol for a multicenter prospective single-blind randomized study

BACKGROUND

The long head of the biceps (LHB) tendon is a common locus of pain in rotator cuff tear and of residual pain after tendon repair. Therefore, systematic LHB tenotomy, with or without tenodesis, is usually recommended. However, the recent literature suggests that long-term functional results of supraspinatus tendon repair are comparable between conservation of a normal biceps and tenotomy. The study objective is to compare functional results between sectioning and sparing a normal LHB in treating isolated grade-1 supraspinatus tendon tear. The study hypothesis is that sparing the normal LHB is clinically preferable to sectioning in the particular case of distal supraspinatus tear.

METHODS AND ANALYSIS

A French nationwide prospective single-blind randomized clinical study will include 194 patients undergoing arthroscopic repair of grade-1 supraspinatus tear with normal LHB. They will be randomized to 2 parallel groups: LHB sparing and sectioning. The main endpoint is Constant-Murley score, and secondary endpoints comprise ASES and SSV scores, clinical assessment of the biceps, pain on VAS, ultrasound assessment of cuff repair healing and conserved LHBs, impact on return to work and sport, pathologic assessment of sectioned LHBs, and analysis of risk factors for cuff repair failure.

ETHICAL APPROVAL AND PUBLICATION

The protocol has been approved by the data protection committee (art.L.1122-1) and meets the criteria of the Declaration of Helsinki and of the SPIRIT statement defining standard protocol items for clinical trials. Results will be published in a peer-reviewed journal.

LEVEL OF EVIDENCE

not applicable.

Comparison of two arthroscopic repair techniques for small-medium supraspinatus tendon tear: 1 triple-loaded vs 2 double-loaded metallic sutures anchors

INTRODUCTION

Surgical repair of the rotator cuff is based on the use of anchors whose ideal numbers and configurations continue to be controversial. We compared the clinical-functional results arising from the arthroscopic repair of shoulders, with small-medium lesions of the supraspinatus tendon, among patients using one anchor with three sutures, or two anchors with two sutures.

METHODS

In this retrospective study patient were resolved into 2 groups. Clinical and functional results were assessed based on Constant Score and instrumental isometric examination.

RESULTS

Patients in Group 1 experienced shoulder repair using a single anchor with three sutures (n = 21, mean age = 56 years, range = 51-65). In Group 2, patients received two anchors with two sutures each (n = 24, mean age = 59 years, range = 24-75). The mean follow-up time was 15 months. The mean values of the operated shoulders' Constant Score were 88.05 and 88.25 respectively. Examination of isometric test results in operated shoulders, healthy shoulders and the two different rotator cuff repair techniques did not reveal any statistically significant differences.

CONCLUSION

In the arthroscopic repair of small-medium supraspinatus tendon tears, the short to mid-term clinical and functional outcomes arising from use of 1 triple-loaded or 2 double-loaded metallic sutures anchors are comparable.

Functional and radiologic results of the crimson duvet procedure in rotator cuff treatment: a randomized controlled clinical trial

BACKGROUND

Rotator cuff tears are one of the more frequent pathologies of the shoulder. Arthroscopic techniques and biologic augmentation have been developed to improve the rate and quality of healing. The crimson duvet procedure (CDP) theoretically provides mesenchymal stem cells through microfracture treatment of the footprint. The aim of this research was to evaluate the effect of CDP in patients who had undergone arthroscopic surgery for complete rotator cuff repair.

METHODS

A prospective randomized clinical trial was performed in a total of 123 patients, consisting of 59 women and 64 men, with a mean age of 58 years. We included patients with a clinical and radiologic diagnosis of a complete rotator cuff tear. All patients were treated with arthroscopic rotator cuff repair. In group 1, the surface of the footprint was débrided; in group 2, the footprint underwent microfracture. The primary outcome was the nonhealing rate, which was detected by magnetic resonance imaging (MRI) or ultrasonography, and the secondary outcome was the functional result. A Sugaya classification of I to III was considered to indicate healing. For clinical evaluation, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Constant scores were evaluated, along with the range of motion. The functional evaluation was performed preoperatively and at 6 months and 1 year postoperatively. The radiologic (MRI or ultrasonography) evaluation was performed at 6 months. Neither the patients nor the radiologists and physical therapists who performed the postoperative evaluations were informed of the random selection.

RESULTS

We observed a healing rate of 85.11% in the control group and 93.7% in the CDP group, which was not significant (P = .19). However, a significant improvement in function was observed in all patients. The ASES score improved from 68.9 (SD 13.8) preoperatively to 92.2 at 6 months and to 96.4 (SD 6.2) at 12 months (P < .05), but no difference was observed between the groups. A similar level of improvement was observed in the Constant score.

CONCLUSION

The arthroscopic repair of complete rotator cuff tears presents good and excellent clinical results in most patients. Nevertheless, nonhealing occurs at a rate that depends mainly on the age of the patient and the size of the tear. The addition of CDP did not improve the functional results or the healing rate.

Efficacy of Arthroscopic Shavers for the Retrieval and Processing of Connective Tissue Progenitor Cells from Subacromial Bursal Tissue

The purpose of this study is to determine if arthroscopic shavers can effectively collect and process connective tissue progenitor (CTP) cells from subacromial bursal tissue for utilization in rotator cuff repair augmentation. Subacromial bursal tissue was collected and processed using two arthroscopic shavers, Shaver A and Shaver B, in 10 patients undergoing arthroscopic rotator cuff repair. Each shaver was used in a random order for the same patient. Tissue samples underwent testing for cellular proliferation, cellular concentration, number of colony-forming units (CFU), live/dead assay, fluorescence-activated cells sorting (FACS) analysis, cytokine analysis, and growth factor analysis. Shaver A produced more CFUs compared to Shaver B (210.3 vs. 125.9; p < 0.001). At 3 weeks, cells collected via Shaver A had greater cellular proliferation (0.35 vs. 0.51; p < 0.001) as well as more viable cells (214,773 vs. 132,356 cells/gram; p < 0.001). Tissue collected with Shaver B had greater amounts of the cytokines MMP-1 (3741 vs. 5500 pg/mL; p < 0.001), MMP-3 (1131 vs. 1871 pg/mL; p < 0.001), and MMP-13 (179 vs. 401 pg/mL; p < 0.001), while those collected with Shaver A had greater vascular endothelial growth factor (VEGF) (47.8 vs. 9.0 pg/mL; p < 0.05). Arthroscopic shavers are capable of harvesting and processing CTP cells from subacromial bursal tissue. Different shavers may produce different yields of viable CTP cells.

Arthroscopic Side-to-Side Repair of Massive Rotator Cuff Tears Maintains Adequate Functional Improvement at 12 to 14 Years' Follow-up

BACKGROUND

Rotator cuff tears are common shoulder injuries that often cause pain and loss of function. Nonanatomic side-to-side techniques facilitate repair by minimizing tensions within tendons to improve healing and optimize the thickness of sutured tissues.

PURPOSE/HYPOTHESIS

The purpose was to evaluate long-term clinical and radiographic outcomes of arthroscopic side-to-side repair of massive rotator cuff tears (mRCTs). The hypothesis was that, at a minimum follow-up of 12 years, arthroscopic side-to-side repair maintains clinically important improvements.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors reviewed records of all patients who underwent arthroscopic repair of mRCTs over 2 consecutive years. A total of 30 adult patients met the eligibility criteria and underwent side-to-side repair. Patients were evaluated clinically using the Constant score (CS) and ultrasound to assess retears at 3 timepoints after surgery: 2 to 4 years, 5 to 7 years, and 12 to 14 years.

RESULTS

At first follow-up (3.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 13 retears (43%). At second follow-up (6.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 2 new retears (total 50%). At final follow-up (13.0 ± 0.7 years), only 21 patients had clinical assessment (1 died and 8 could not be reached), and only 19 patients had ultrasound assessment, which revealed 6 new retears (total 79%). Both absolute CS and age-/sex-adjusted CS improved significantly from baseline values at first follow-up (73.5 and 96.6, respectively), and remained stable at second follow-up (69.0 and 91.9, respectively), and final follow-up (64.4 and 87.0, respectively). Compared to shoulders with intact repairs, those with retears tended to have lower absolute CS at all follow-up visits, although differences were not statistically significant.

CONCLUSION

Patients with mRCTs maintain satisfactory clinical scores at 12 to 14 years after arthroscopic side-to-side repair despite a high incidence of retears. Repair is a safe and effective treatment for mRCTs, providing a less invasive and less complex alternative to reverse shoulder arthroplasty and tendon transfer procedures.

Partial and complete repairs of massive rotator cuff tears maintain similar long-term improvements in clinical scores

PURPOSE

The authors have previously published early outcomes of arthroscopic repairs of 86 massive rotator cuff tears (mRCTs) and aimed to determine whether their clinical scores are maintained or deteriorate after 5 more years.

METHODS

Of the initial series of 86 shoulders, 2 had deceased, 16 lost to follow-up and 4 reoperated, leaving 64 for assessment. The repairs were complete in 44 and partial in 20, and 17 shoulders had pseudoparalysis. Preoperative assessment included absolute Constant score, shoulder strength, tear pattern, tendon retraction, and fatty infiltration. Patients were evaluated at 8.1 ± 0.6 years (range 7.1-9.3) using absolute and age-/sex-adjusted Constant score, subjective shoulder value (SSV), and simple shoulder test (SST).

RESULTS

Absolute Constant score was 80.0 ± 11.7 at first follow-up (at 2-5 years) but diminished to 76.7 ± 10.2 at second follow-up (at 7-10 years) (p < 0.001). Adjusted Constant score was 99.7 ± 15.9 at first follow-up and remained 98.8 ± 15.9 at second follow-up (ns). Comparing other outcomes revealed a decrease in strength over time (p < 0.001) but no change in pain, SSV or SST. Partially-repaired shoulders had lower strength at both follow-ups (p < 0.05). Pseudoparalytic shoulders had lower absolute and adjusted Constant score at second follow-up (p < 0.05), but their net improvements in absolute Constant score were higher (p = 0.014).

CONCLUSIONS

Both partial and complete arthroscopic repairs grant satisfactory long-term outcomes for patients with mRCTs, regardless of their tear pattern, fatty infiltration and presence of pseudoparalysis. Absolute Constant score decreased over time for both repair types, but adjusted Constant score remained stable, suggesting that decline is due to aging rather than tissue degeneration. The clinical relevance of this study is that arthroscopic repair should be considered for mRCTs, even if not completely repairable, rather than more invasive and/or risky treatments, such as reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

IV.

Lateral acromioplasty cannot sufficiently reduce the critical shoulder angle if preoperatively measured over 40°

PURPOSE

To investigate whether arthroscopic lateral acromion resection can sufficiently reduce the critical shoulder angle (CSA) without damaging deltoid muscle insertion.

METHODS

Ninety patients who underwent arthroscopic rotator cuff (RC) repair were retrospectively analysed. According to the preoperative CSA, patients were categorized as Group I (CSA < 35°) and Group II (CSA ≥ 35°). Additional arthroscopic lateral acromion resection was performed in Group II. The CSA was measured 1 week postoperatively, while RC integrity and the deltoid attachment were assessed at 3, 6 and 12 months via ultrasound. Deltoid function was evaluated using the Akimbo test, in which patients place their hands on the iliac crest with abduction in the coronal plane and internal rotation of the shoulder joint while simultaneously flexing the elbow joint and pronating the forearm.

RESULTS

Large and massive RC tears were more prevalent in Group II (p = 0.017). In both groups, the CSA reduction was statistically significant (Group I = 1°: range 0°-3°, Group II = 3.7°: range 1°-8°; p < 0.001). When the preoperative CSA was > 40°, the respective postoperative CSA remained > 35° in 83.3% of cases (p < 0.001). Final shoulder strength was correlated with the amount of CSA reduction (rho = 0.41, p = 0.002). The postoperative CSA was higher, but not significantly different (n.s.), in patients with re-torn (36°, range 32°-40°) than with healed RC (33°, range 26°-38°). No clinical detachment or hypotrophy of the deltoid was observed with the Akimbo test and ultrasound evaluation.

CONCLUSIONS

Arthroscopic lateral acromion resection is a safe procedure without affecting deltoid muscle origin or function, and it is effective in significantly reducing the CSA. However, the CSA cannot always be reduced to < 35°, especially in patients with preoperative CSA values > 40°.

LEVEL OF EVIDENCE

III.

Prospective study of tendon healing and functional gain after arthroscopic repair of isolated supraspinatus tear

INTRODUCTION

In case of failure of non-operative treatment of isolated supraspinatus tear, tendon surgery can improve shoulder function and alleviate pain. The present study hypothesis was that isolated supraspinatus repair shows good healing, with improved clinical results.

MATERIALS AND METHODS

A prospective multicentre study followed up 199 patients (mean age, 57 years) for one year. Inclusion criteria comprised: isolated full-thickness supraspinatus tear, retraction grade<3, with the same double-row arthroscopic technique. Clinical assessment used Constant score at 6 weeks and 3, 6 and 12 months. Ultrasound control checked tendon repair quality on the Sugaya criteria, types I-II-III being considered as healed.

RESULTS

At one year, mean Constant score had increased by 26 points (p<0.001). Healing rate was 94% (n=187): Sugaya type I, 46% (n=92); type II, 41% (n=81); type III, 7% (n=14). Mean Constant score was significantly higher in case of healing: 81 vs. 70 points (p=0.002). Constant score progression was identical in both healing groups throughout follow-up. Univariate analysis showed no correlation between epidemiological or tear-related factors and tendon healing.

CONCLUSION

Arthroscopic repair of isolated small supraspinatus tear provided 94% healing. Clinical results were better when healing was achieved.

LEVEL OF EVIDENCE

I, prospective cohort study.

Subacromial Bursa-Derived Cells Demonstrate High Proliferation Potential Regardless of Patient Demographics and Rotator Cuff Tear Characteristics

PURPOSE

To investigate the influence of patient demographics and rotator cuff tear characteristics on the cellular proliferation potential of subacromial bursa-derived cells (SBDCs).

METHODS

Patients undergoing arthroscopic rotator cuff repair between December 2017 and February 2019 were considered for enrollment in the study. Basic demographic information as well as medical and surgical history were obtained for each patient. Subacromial bursa was harvested from over the rotator cuff tendon. Cellular proliferation was evaluated after 3 weeks of incubation by counting nucleated SBDCs. Fluorescence-activated cell sorting (FACS) analysis was performed to confirm the presence of mesenchymal stem cell (MSC) specific surface markers. Using preoperative radiographs and magnetic resonance imaging (MRI), acromiohumeral distance (AHD), severity of cuff tear arthropathy, and rotator cuff tear characteristics were evaluated.

RESULTS

Seventy-three patients (mean age: 57.2 ± 8.5 years) were included in the study. There was no significant difference in cellular proliferation of SBDCs when evaluating the influence of age, sex, body mass index (BMI), smoking status, and presence of systemic comorbidities (p > .05, respectively). Similarly, there was no significant difference in cellular proliferation of SBDCs when looking at rotator cuff tear characteristics (size, tendon retraction, fatty infiltration, muscle atrophy), AHD, or severity of cuff tear arthropathy (p > .05). FACS analysis confirmed nucleated SBDCs to have a high positive rate of MSC specific surface markers.

CONCLUSION

Subacromial bursa consistently demonstrated a high cellular proliferation potential regardless of patient demographics, rotator cuff tear characteristics, and severity of glenohumeral joint degeneration.

CLINICAL RELEVANCE

These findings may alleviate concerns that subacromial bursa might lose cellular proliferation potential when being used for biologic augmentation in massive and degenerated rotator cuff tears, thus assisting in predicting tendon healing and facilitating surgical decision-making.

Effects of applying platelet-rich plasma during arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomised controlled trials

Because of its healing properties, platelet-rich plasma (PRP) has been applied to the bone-tendon interface during arthroscopic rotator cuff repair to improve surgical outcomes. However, its effects remain ambiguous. Therefore, we conducted this systematic review and meta-analysis to assess the effects of PRP on retear rate and functional outcomes. Randomised control trials were identified and extracted. Data collection was completed on 15 February 2020. The results are expressed as the risk ratio (RR) for the categorical variables and weighted mean difference for the continuous variables, with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. Seven randomised controlled trials published from 2013 to 2018, with 541 patients in total, were included. The results revealed a significant decrease in retear rate [RR 0.38, 95% CI (0.22, 0.68), P = 0.0009). Furthermore, a significant improvement was observed regarding short-term Constant score [mean difference = 3.28, 95% CI (1.46, 5.11), P = 0.0004), short-term University of California at Los Angeles activity score [mean difference = 1.60, 95% CI (0.79, 2.42), P = 0.0001], and short-term visual analogue scale score [mean difference =  - 0.14, 95% CI (- 0.23, - 0.05), P = 0.002]. This systematic review indicates the efficacy of PRP when applied to the bone-tendon interface during arthroscopic rotator cuff repair.

A comparative study of arthroscopic débridement versus repair for Ellman grade II bursal-side partial-thickness rotator cuff tears

HYPOTHESIS

We aimed to report the clinical outcomes of arthroscopic débridement vs. repair for Ellman grade II bursal-side partial-thickness rotator cuff tears.

METHODS

Patients who presented with Ellman grade II bursal-side partial-thickness rotator cuff tears from September 2015 to August 2017 were included. On the basis of preoperative findings and patient preference, 20 patients underwent débridement whereas 26 underwent arthroscopic repair. The visual analog scale (VAS), Constant-Murley shoulder, American Shoulder and Elbow Surgeons, and University of California-Los Angeles scores were assessed. Magnetic resonance imaging and B-mode ultrasonography were performed preoperatively and at 6, 12, and 24 months postoperatively.

RESULTS

All 46 patients were available throughout follow-up. At 2 years postoperatively, the VAS score had improved from 6.42 ± 1.56 to 0.65 ± 0.51 in the débridement group and from 6.26 ± 1.32 to 0.75 ± 0.42 in the repair group. The VAS score differed significantly between the 2 groups at 6 months postoperatively. All patient-reported outcomes improved in both groups. The American Shoulder and Elbow Surgeons score (P = .009), Constant-Murley shoulder score (P = .014), and University of California-Los Angeles score (P = .030) differed significantly between the 2 groups (higher in the débridement group) at 6 months postoperatively. Finally, 44 patients having intact tendon repairs with no interval worsening of partial-thickness tears underwent postoperative scheduled magnetic resonance imaging and B-mode ultrasonography examinations.

CONCLUSION

Arthroscopic débridement and repair of Ellman grade II bursal-side partial-thickness rotator cuff tears achieved comparable clinical scores and low retear rates during 2 years of follow-up. However, débridement achieved better results, especially within 6 months postoperatively, and achieved a favorable prognosis up to 2 years postoperatively.

Superior Capsular Reconstruction With the Long Head of the Biceps Autograft Prevents Infraspinatus Retear in Massive Posterosuperior Retracted Rotator Cuff Tears

BACKGROUND

Materials and patches with increased biomechanical and biological properties and superior capsular reconstruction may change the natural history of massive rotator cuff tears (RCTs).

PURPOSE

To compare structural and clinical outcomes among 3 surgical techniques for the treatment of massive posterosuperior RCTs: double-row (DR) technique, transosseous-equivalent (TOE) technique with absorbable patch reinforcement, and superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) autograft.

STUDY DESIGN

Cohort study; Level of evidence 3.

METHODS

We retrospectively analyzed the 3 techniques in patients who underwent repair of massive posterosuperior RCTs between January 2007 and March 2017. All patients completed preoperative and 24-month postoperative evaluations: range of motion, subjective shoulder value, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale for pain, and Constant score. Tendon integrity was assessed with ultrasound 1 year postoperatively.

RESULTS

A total of 82 patients completed the final evaluation (28 patients, DR; 30 patients, TOE + patch; 24 patients, SCR with LHBT). Groups were statistically comparable preoperatively, except for active forward elevation and tendon retraction, which were significantly worse in the SCR group (P = .008 and P = .001, respectively). After 24 months, the mean ± SD scores for the respective groups were as follows: 76 ± 10, 72 ± 15, and 77 ± 10 for the Constant score (P = .35); 84 ± 10, 84 ± 15, and 80 ± 15 for the ASES (P = .61); 9 ± 2, 9 ± 3, and 8 ± 3 for the Simple Shoulder Test (P = .23); 82 ± 15, 80 ± 18, and 75 ± 18 for the subjective shoulder value (P = .29); and 1.4 ± 1.7, 1.8 ± 2, and 1.4 ± 1.4 for the visual analog scale (P = .65). The strength of the operated shoulder was 4 ± 3 kg, 4.7 ± 3 kg, and 6.4 ± 1.6 kg for the DR, TOE + patch, and SCR groups, respectively (P = .006). At 12 months postoperatively, 60.7% (17 of 28) of the DR group, 56.7% (17 of 30) of the TOE + patch group, and 91.7% (22 of 24) of the SCR group remained healed on ultrasound. The infraspinatus tendon remained healed in 75% of the DR group, 76.5% of the TOE + patch group, and 100% of the SCR with the LHBT group (P = .006).

CONCLUSION

In cases of massive posterosuperior RCTs, SCR with the LHBT should be considered a reliable, cost-effective treatment option that protects infraspinatus integrity.

Efficacy of Imaging Modalities Assessing Fatty Infiltration in Rotator Cuff Tears

BACKGROUND

Fatty atrophy is a diagnosis characterized by the combination of fatty infiltration and muscle atrophy of the rotator cuff. Studies have shown a strong positive correlation between the level of fatty infiltration and the risk of experiencing a chronic rotator cuff tear. Therefore, the purpose of the present study was to review the current literature on radiographic imaging of fatty infiltration and fatty atrophy to better aid surgeons in predicting functional outcome and to help guide patient decisions.

METHODS

We conducted a literature search in PubMed. The exact search queries included "rotator cuff" in the MeSH Terms field; "fatty atrophy," fatty infiltration," and "fatty muscle degeneration" in the Title/Abstract field; and various combinations of these searches. We initially found 184 articles using these keywords, including both human and animal studies. The 25 animal studies were excluded, leaving 159 articles. The abstracts of all remaining articles were reviewed and selected on the basis of our inclusion criteria of focusing on patients with rotator cuff tears (preoperatively and postoperatively), fatty infiltration, fatty atrophy, and imaging modalities. We excluded an additional 127 articles, leaving 32 articles that were selected for the final review and inclusion in this study.

RESULTS

Among 45 shoulder specialists across different studies, interrater agreement for Goutallier staging with use of magnetic resonance imaging (MRI) ranged from 0.24 to 0.82 and intrarater agreement for supraspinatus fatty changes ranged from 0.34 to 0.89. Our review also showed strong positive correlations when assessing the severity of fatty atrophy of the rotator cuff between MRI and ultrasound or ultrasound modalities such as sonoelastography.

CONCLUSIONS

Increasing fatty infiltration of the rotator cuff is associated with greater repair failure rates and hence poorer overall clinical outcomes. MRI remains the gold standard for the imaging of rotator cuff tears and postoperative healing. Ultrasound can decrease health-care expenditures associated with the assessment of repair integrity postoperatively, although ultrasound is not as precise and has some limitations compared with MRI.

Contribution of postoperative ultrasound to early detection of anchor pullout after rotator cuff tendon repair: Report of 3 cases

INTRODUCTION

Rotator cuff repair by suture bridge is now widely used. Few studies reported secondary pullout of radiotransparent anchors. The aim of the present prospective study was to demonstrate the contribution of in-office ultrasonography to detect pullout, and to describe the examination procedure.

MATERIAL AND METHOD

A total of 102 patients underwent arthroscopic rotator cuff repair by suture bridge, with impacted second-row anchors. Ultrasonography was performed by the surgeon in postoperative consultations.

RESULTS

At 6 weeks' follow-up, 3 patients showed mean 2nd-row implant pullout of 8.3mm. All underwent arthroscopic revision to extract the implant, which was mobile within its tunnel in all cases. Clinical progression was good, with mean Constant score 72 and no aggravation of the lesion on ultrasound at 3 months' follow-up.

DISCUSSION

The present series would seem to be the first to report: early radiotransparent in-vivo pullout 6 weeks after suture bridge cuff repair; ultrasound detection of pullout in consultation by the orthopedic surgeon; a description of the ultrasound technique for screening this rare and specific problem.

CONCLUSION

Ultrasound now enables radiotransparent anchor positioning to be monitored following rotator cuff repair as of the first postoperative days, without compromising tendon healing.

LEVEL OF EVIDENCE

II.

Comparison of Preparation Techniques for Isolating Subacromial Bursa-Derived Cells as a Potential Augment for Rotator Cuff Repair

PURPOSE

To identify an effective, nonenzymatic method for maximizing the yield of subacromial bursa-derived nucleated cells for augmenting rotator cuff repair.

METHODS

Subacromial bursa (minimum 0.2 g) was collected prospectively over the supraspinatus from patients (n = 7) with at least one full-thickness tendon tear undergoing arthroscopic primary rotator cuff repair. Samples were processed and analyzed prospectively using 4 different methods: (1) mechanical digestion with scissors (chopping), (2) collagenase digestion, (3) mechanical digestion with a tissue homogenizer, and (4) whole tissue with minimal manipulation. Tissue from each method were plated and cultured in a low oxygen tension, humidified incubator for 7 days. Following incubation, cellularity was assessed with nucleated cell count using a Coulter Counter. Flow cytometry was performed on the non-enzymatic method that demonstrated the greatest cell count to confirm the presence of mesenchymal stem cells (MSCs). The Kruskal-Wallis H test and post hoc Dunn's test were used for statistical analysis.

RESULTS

Following incubation, mean nucleated cell counts (cells/mL) were (1) 102,681 ± 73,249 for chopping, (2) 76,190 ± 66,275 for collagenase, (3) 31,686 ± 29,234 for homogenization, and (4) 11,162 ± 4016 for whole tissue. There was no significant difference between chopping and collagenase (P = .45) or between homogenization and collagenase (P = .52). Both chopping (P = .003) and collagenase (P = .03) produced significantly more cells when compared with whole tissue. Flow cytometry confirmed the presence of MSC markers on samples processed by chopping.

CONCLUSIONS

Mechanical isolation of subacromial bursa-derived cells using a chopping technique demonstrated similar nucleated cell count compared with collagenase, along with the confirmed presence of MSCs.

CLINICAL RELEVANCE

This study demonstrated a nonenzymatic, mechanical method for isolating subacromial bursa-derived cells to potentially augment rotator cuff repair. Further clinical studies are required to assess its possible advent in the tendon-bone healing process.

Examining the Potency of Subacromial Bursal Cells as a Potential Augmentation for Rotator Cuff Healing: An In Vitro Study

PURPOSE

To compare the potency of mesenchymal stem cells between the cells derived from the subacromial bursa to concentrated bone marrow aspirate (cBMA) taken from patients undergoing rotator cuff (RC) repair.

METHODS

Subacromial bursa and cBMA were harvested arthroscopically from 13 patients (age 57.4 ± 5.2 years, mean ± standard deviation) undergoing arthroscopic primary RC repair. Bone marrow was aspirated from the proximal humerus and concentrated using an automated system (Angel System; Arthrex). Subacromial bursa was collected from 2 sites (over the RC tendon and muscle) and digested with collagenase to isolate a single cellular fraction. Proliferation, number of colony-forming units, differentiation potential, and gene expression were compared among the cells derived from each specimen.

RESULTS

The cells derived from subacromial bursa showed significantly higher proliferation compared with the cells derived from cBMA after 5, 7, and 10 days (P = .018). Regarding colony-forming units, the subacromial bursa had significantly more colonies than cBMA (P = .002). Subacromial bursal cells over the RC tendon produced significantly more colonies than cells over both the RC muscle and cBMA (P = .033 and P = .028, respectively). Moreover, when compared with cBMA, cells derived from subacromial bursa showed significantly higher differentiation ability and higher gene expression indicative of chondrogenesis, osteogenesis, and adipogenesis.

CONCLUSION

The subacromial bursa is an easily accessible tissue that can be obtained during RC repair, with significant pluripotent stem cell potency for tendon healing. Compared with cBMA taken from the proximal humerus, bursal cells showed significantly increased differentiation ability and gene expression over time.

CLINICAL RELEVANCE

Failed RC repairs have been partly attributed to a poor healing environment. Biologic augmentation of the repair site may help increase healing potential and incorporation of the cuff at the tendon-bone interface.

The Effect of Tendon Delamination on Rotator Cuff Healing

BACKGROUND

While patient age, tear size, and muscle fatty infiltration are factors known to affect the rate of tendon healing after rotator cuff repair, the effect of tendon delamination is less known.

PURPOSE

To assess the effect of tendon delamination on rotator cuff healing after arthroscopic single-row (SR) repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients (N = 117) with chronic full-thickness rotator cuff tears underwent arthroscopic SR repair with the tension-band cuff repair. The mean ± SD age at the time of surgery was 60 ± 8 years. There were 25 small, 63 medium, and 29 large tears. Tendon delamination was assessed intraoperatively under arthroscopy with the arthroscope placed in the lateral portal. Patients were divided into 2 groups: those with nondelaminated (n = 80) and delaminated (n = 37) cuff tears. The 2 groups were comparable for age, sex, body mass index, preoperative pain, strength, and a Constant-Murley score. Repair integrity was evaluated with sonography (mean, 24 months after surgery; range, 6-62 months) and classified into 3 categories: type A, indicating complete, homogeneous, and thick coverage of the footprint; type B, partial coverage with a thin tendon; and type C, no coverage of the footprint.

RESULTS

The prevalence of tendon delamination observed under arthroscopy was 32% (37 of 117), which increased with tear size and retraction: from 15% in small tears to 32% in medium tears and 45% in large tears ( P = .028). Postoperatively, 83 patients had complete coverage of footprint (type A = 71%) and the cuff was considered healed, whereas 26 had partial coverage or a thin tendon (type B = 22%) and 8 had no coverage (type C = 7%). Overall, the rate of complete healing was 78% in nondelaminated cuff tears and 57% in the case of tendon delamination ( P = .029). In large retracted tears, the healing rate dropped from 81% in the absence of delamination to 39% when the tendons were delaminated ( P = .027).

CONCLUSION

Tendon delamination increases with tear size and retraction. Patients with chronic delaminated and retracted rotator cuff tears (stage 2 or 3) are at risk of failure after SR cuff repair, whereas patients with small delaminated rotator cuff tears (stage 1) involving only the supraspinatus can be treated with an SR cuff repair with a high chance of tendon healing. These results suggest that SR cuff repair may be insufficient to treat delaminated chronic cuff tears. To improve the anatomic outcomes of rotator cuff repairs, surgeons should consider treating delaminated tears with a double-row or double-layer repair.

Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis

BACKGROUND

Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes.

METHODS

PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate.

RESULTS

Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I² = 0%).

CONCLUSION

BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

Postoperative Mobilization After Superior Rotator Cuff Repair: Sling Versus No Sling: A Randomized Prospective Study

BACKGROUND

Patients are commonly advised to wear a sling for 4 to 6 weeks after rotator cuff repair despite negative effects of early immobilization and benefits of motion rehabilitation. The aim of this study was to compare clinical and radiographic outcomes up to 6 months following rotator cuff repair with and without postoperative sling immobilization.

METHODS

We randomized 80 patients scheduled for arthroscopic repair of a small or medium superior rotator cuff tear into sling and no-sling groups (40 patients each). Passive mobilization was performed in both groups during the first 4 postoperative weeks, and this was followed by progressive active mobilization. Patients were evaluated clinically at 10 days and 1.5, 3, and 6 months and using ultrasound at 6 months. Univariable and multivariable analyses were performed to determine if postoperative scores were associated with sex, age at surgery, immobilization, arm dominance, a biceps procedure, resection of the distal part of the clavicle, or preoperative scores.

RESULTS

The sling and no-sling groups had similar preoperative patient characteristics, function, and adjuvant procedures. At 10 days, there was no difference in pain between the 2 groups (mean pain score [and standard deviation], 5.2 ± 2.3 versus 5.2 ± 1.9, p = 0.996). In comparison with the sling group, the no-sling group showed greater mean external rotation (23.5° ± 15.6° versus 15.3° ± 14.6°, p = 0.017) and active elevation (110.9° ± 31.9° versus 97.0° ± 25.0°, p = 0.038) at 1.5 months as well as better mean active elevation (139.0° ± 24.7° versus 125.8° ± 24.4°, p = 0.015) and internal rotation (T12 or above in 50% versus 28%, p = 0.011) at 3 months. Ultrasound evaluation revealed no significant differences at 6 months in tendon thickness anteriorly (p = 0.472) or posteriorly (p = 0.639), bursitis (p = 1.000), echogenicity (p = 0.422), or repair integrity (p = 0.902). Multivariable analyses confirmed that the mean American Shoulder and Elbow Surgeons (ASES) score increased with patient age (beta, 0.60; p = 0.009), the Single Assessment Numeric Evaluation (SANE) decreased with sling immobilization (beta, -6.33; p = 0.014), and pain increased with sling immobilization (beta, 0.77; p = 0.022).

CONCLUSIONS

No immobilization after rotator cuff repair is associated with better early mobility and functional scores in comparison with sling immobilization. Postoperative immobilization with a sling may therefore not be required for patients treated for a small or medium tendon tear.

LEVEL OF EVIDENCE

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

Ultrasound-guided biodegradable subacromial spacer implantation in a patient with massive irreparable rotator cuff tears

The aim of this manuscript is to present a modification of the current arthroscopic implantation technique of a biodegradable subacromial spacer. This modified ultrasound-guided technique was intended to maximally reduce the invasiveness of the procedure. The ultrasound technique was used to measure the subacromial space for an optimal fit and to verify subacromial spacer placement in the sagittal and frontal planes. This finding is of particular importance for patients with contraindications to general or regional anesthesia. The follow-up (5 months) of subacromial spacer implantation using ultrasound in a patient with an irreparable rotator cuff tear showed correct spacer placement.

An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder

Ultrasound (US) imaging is an efficient, easy to use and inexpensive tool allowing for facilitated diagnosis and management of the painful shoulder. It remains primarily used by radiologists and rheumatologists, despite having shown excellent diagnostic accuracy when used by different medical specialities in their office-based consultation. It also has advantages over other imaging modalities in the evaluation of the postoperative shoulder for rotator cuff integrity and correct anchor and suture placement, as well as rotator cuff analysis following arthroplasty. Integration of US imaging into the orthopaedic surgeon's toolbox can be aided by a basic understanding of US principles, accompanied by a guide outlining basic techniques for evaluation of the healthy, pathological and postoperative shoulder as well as US-guided treatment possibilities.

Clinical and MRI Outcomes 10 Years After Repair of Massive Posterosuperior Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears are challenging to treat, with few or no studies on long-term outcomes of repair. The purpose of this study was to report 10-year outcomes following repair of massive posterosuperior rotator cuff tears, with and without extension into the subscapularis, and to determine prognostic factors that could influence clinical scores and retear rates.

METHODS

The records of 234 patients who underwent repair of a massive posterosuperior rotator cuff tear at a total of 15 centers were retrieved. Patients were asked to return for evaluation at 10 years; 78 patients could not be contacted, 7 had died, and 19 had undergone a reoperation. A total of 130 patients (68% men) with a mean age (and standard deviation) of 56.1 ± 7.7 years (range, 26 to 79 years) were evaluated clinically, and 102 of them were also evaluated using magnetic resonance imaging (MRI). The tear was confined to the supraspinatus and infraspinatus tendons in 94 shoulders and also involved the superior portion of the subscapularis in 36 shoulders. Univariable and multivariable regressions were performed to determine whether 10-year total Constant-Murley scores and repair integrity were associated with patient characteristics, tear patterns, or repair techniques.

RESULTS

In the study cohort, complications were noted in 14 shoulders (11%) (stiffness in 10 and infection in 4). For the 130 shoulders evaluated clinically, the mean total Constant-Murley score improved from 53.1 ± 15.9 (range, 14 to 83) preoperatively to 78.5 ± 11.3 (range, 36 to 98) at 10 years. Of the 102 shoulders evaluated using MRI, 32 had a retear (Sugaya type IV or V). Of the 19 shoulders that underwent a reoperation (excluded from the study cohort), 9 had a retear. The overall prevalence of retears was 34%. Multivariable regression analysis revealed a significant association between the 10-year Constant-Murley score and preoperative retraction of the infraspinatus tendon, but no association between retears and any of the variables. Involvement of the subscapularis had no significant effect on preoperative or postoperative Constant-Murley scores or retear rates.

CONCLUSIONS

Patients who had repair of a massive posterosuperior rotator cuff tear maintained considerable improvements in clinical and radiographic outcomes at 10 years. Partial concomitant tears of the subscapularis did not affect the total postoperative Constant-Murley scores or retear rates.

LEVEL OF EVIDENCE

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

Double-Row Arthroscopic Subscapularis Repair: A Surgical Technique

The subscapularis is the strongest rotator cuff muscle in the shoulder. Until recently, most surgical repairs were performed through an open approach. Furthermore, the reporting of arthroscopic repair techniques and outcomes is fairly limited. This is likely due to the difficulty involved in all-arthroscopic repairs and the relative rarity of this injury compared with injuries of the other rotator cuff tendons. Arthroscopic subscapularis repair can be challenging, even for an expert surgeon, and attempting a double-row repair adds further complexity. Given these issues, this article provides techniques to allow for successful arthroscopic double-row subscapularis repair and avoid potential complications. The key features of an arthroscopic double-row repair include portal placement, surgical technique, and tips to avoid potential pitfalls, all of which are discussed.

Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?

Background

Rotator cuff tears are associated with capsular contraction and stiffness that should be restored before surgical repair. Corticosteroid injections (CSIs) are frequently used as conservative treatments before surgical repair. This study aimed to determine the influence of preoperative and postoperative CSIs on clinical and anatomic outcomes after rotator cuff repair.

Methods

The authors analyzed the records of 257 patients who had arthroscopic rotator cuff repair, of whom 212 were evaluated at 3.1 ± 1.0 years (median, 2.9 years; range, 1.4-7.1 years) by clinical (Constant score) and ultrasound (Sugaya classification) examinations. Univariable and multivariable regressions were performed to determine associations between outcomes and administration of preoperative and postoperative CSIs, patient characteristics, and tendon characteristics.

Results

The Constant scores improved from 56.4 ± 15.1 to 80.8 ± 12.5. Multivariable regression confirmed that postoperative scores were associated with postoperative CSIs (P < .001), preoperative scores (P < .001), gender (P < .001), and fatty infiltration (P < .005). Retears (Sugaya types IV-V) were observed in 27 shoulders (13%). Multivariable regression clarified that retear rates were associated only with postoperative CSIs (P = .007) and stage 3 fatty infiltration (P = .001). Adjusting for confounders, an additional postoperative CSI would decrease scores by 4.7 points and double retear risks.

Discussion

Preoperative CSIs had no influence on clinical scores and retear rates, whereas postoperative CSIs were associated with lower scores and more retears. Although we can infer that preoperative CSIs do not affect outcomes, we cannot determine whether postoperative CSIs compromised outcomes or were administered in patients who had already poor outcomes. Our findings may resolve controversies about the administration of preoperative CSIs.

Fatty infiltration of stage 1 or higher significantly compromises long-term healing of supraspinatus repairs

BACKGROUND

Fatty infiltration (FI) compromises outcomes of rotator cuff repairs. Most clinicians consider FI of the infraspinatus, whether it is torn or intact, because it is most rapidly affected. The purpose of this study was to report long-term outcomes of isolated supraspinatus repairs and to determine their associations with FI of the infraspinatus and supraspinatus.

METHODS

The records of 182 patients who underwent repair of isolated supraspinatus tears and had preoperative magnetic resonance imaging were retrieved. Of these, 147 patients were evaluated at 10 years' follow-up using the Constant score and magnetic resonance imaging scans.

RESULTS

Preoperative FI was greater in the supraspinatus (52% stage ≥1) than in the infraspinatus (29% stage ≥1). The 10-year Constant scores were influenced by FI of the supraspinatus (P = .006) but not of the infraspinatus (P = .422). Multivariable regression confirmed that Constant scores were significantly lower for female patients, repetitive work, and stage 1 and stage 2 FI of the supraspinatus in addition to open surgery. Retear rates (Sugaya types IV-V) were also influenced by FI of the supraspinatus (P = .001) but not of the infraspinatus (P = .979). Shoulders with supraspinatus FI at stages 0, 1, and 2 had retear rates of 10%, 22%, and 31%, respectively. Multivariable regression affirmed that the odds of retears are significantly increased by both stage 1 and stage 2 FI of the supraspinatus.

CONCLUSIONS

The Constant scores and retear rates were significantly associated with FI of the torn supraspinatus (stage ≥1) but not of the intact infraspinatus. The authors recommend that rapid surgical intervention be considered, before accumulation of fat, especially for young, active patients.

Ten-Year Multicenter Clinical and MRI Evaluation of Isolated Supraspinatus Repairs

BACKGROUND

Early repair of isolated supraspinatus tears could prevent further deterioration of the rotator cuff; however, there is no consensus on the management of such tears because of a lack of long-term outcome studies. The purposes of this study were to report the 10-year outcomes of isolated supraspinatus repairs and to investigate the factors that favor healing and recovery.

METHODS

We retrieved the records of all 511 patients who, in 2003, underwent repair of full-thickness isolated supraspinatus tears, performed by 15 surgeons at 15 centers. In 2014, the patients were asked to return for evaluation at a minimum follow-up of 10 years. One hundred and eighty-eight patients could not be reached, and 35 were excluded because they had a reoperation (17 had a retear, 7 had conversion to an arthroplasty, and 11 had other causes). A total of 288 patients (50% were men) who had a mean age (and standard deviation) at index surgery of 56.5 ± 8.3 years (range, 32 to 77 years) were evaluated clinically, and 210 of them were also evaluated using magnetic resonance imaging (MRI).

RESULTS

Thirty shoulders (10.4%) had complications, including stiffness (20 shoulders), infection (1 shoulder), and other complications (9 shoulders). The total Constant score improved from a mean of 51.8 ± 13.6 points (range, 19 to 87 points) preoperatively to 77.7 ± 12.1 points (range, 37 to 100 points) at 10 years. At the 10-year follow-up evaluation, the mean Subjective Shoulder Value (SSV) was 84.9 ± 14.8 (range, 20 to 100), and the mean Simple Shoulder Test (SST) was 10.1 ± 2.2 (range, 3 to 12). Of the 210 shoulders evaluated using MRI, the repair integrity was Sugaya type I in 26 shoulders (12%), type II in 85 (41%), type III in 59 (28%), type IV in 27 (13%), and type V in 13 (6%). The total Constant score at the final follow-up was significantly associated with tendon healing (p < 0.005) and was inversely associated with preoperative fatty infiltration (p < 0.001). Neither the surgical approach nor the preoperative retraction influenced the outcomes.

CONCLUSIONS

Repairs of isolated supraspinatus tears maintained considerable improvement in clinical and radiographic outcomes at 10 years. Preoperative fatty infiltration and postoperative retear have a significantly detrimental effect on the long-term functional outcome of rotator cuff repair.

LEVEL OF EVIDENCE

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

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE

(1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score.

METHODS

From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value.

RESULTS

The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears.

CONCLUSIONS

The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy.

LEVEL OF EVIDENCE

Comparative case series, Level IV.

Critical period and risk factors for retear following arthroscopic repair of the rotator cuff

PURPOSE

The incidence of retear following rotator cuff repair remains a major concern, and the cause and timing of retear remain unclear. The aim of this study was to prospectively investigate the timing of retears following rotator cuff repair at multiple time intervals. The hypothesis was that the 'critical period' for retears extends beyond the first three post-operative months.

METHODS

The authors prospectively studied 206 shoulders that underwent arthroscopic double-row (without suture bridge) suture anchor repair for rotator cuff tears. Patients were recalled to three follow-up visits at the following post-operative time intervals: 3, 6, and 12 months or longer. Ultrasonography was performed at each visit, and Constant score was collected during the last visit.

RESULTS

A total of 176 shoulders attended all required follow-up visits with mean age 56.0 years. Ultrasonography revealed retears in 16 shoulders (9.1 %) at 3 months, in 6 shoulders (3.4 %) at 6 months, and in 5 others (2.8 %) at the last follow-up, while it confirmed intact rotator cuffs in 149 shoulders (84.7 %) at the last follow-up (median 35.5; range 12-61). The incidence of retears was significantly associated with tear size (p = 0.001) and tendon degeneration (p = 0.003).

CONCLUSION

The 'critical period' for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months. The risk of retear is greatest for massive 3-tendon tears, which may require longer periods of protection. The clinical relevance of this study is the identification of patients at risk of retear and the adjustment of their rehabilitation strategy and time for return to work.

LEVEL OF EVIDENCE

III.

What can be seen after rotator cuff repair: a brief review of diagnostic imaging findings

Diagnostic imaging plays an important role in the postoperative evaluation of the rotator cuff, as pain and disability may occur or persist after treatment. Postoperative imaging is therefore of paramount importance for clinicians before planning additional treatments. Multimodality imaging of the postoperative shoulder includes radiography, magnetic resonance (MR) imaging, MR arthrography, computed tomography (CT), CT arthrography, and ultrasound. Correct interpretation of imaging findings of the postoperative shoulder necessitates that the radiologist be familiar with the various treatment strategies, their possible complications and sources of failure, knowledge of normal and abnormal postoperative findings, and awareness of the advantages and weaknesses of the different imaging techniques. Imaging findings, however, should always be correlated with the clinical presentation because postoperative imaging abnormalities do not necessarily correlate with symptoms. This manuscript is a review of some of the most common treatment strategies for rotator cuff pathology, with a focus on expected postoperative imaging findings and postoperative complications.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

BACKGROUND

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair.

METHODS

In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff.

RESULTS

Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months.

CONCLUSION

Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Evaluating postoperative rotator cuff healing: Prospective comparison of MRI and ultrasound

BACKGROUND

The objective of this prospective comparative single centre study was to compare postoperative rotator cuff healing rates as assessed by magnetic resonance imaging (MRI) versus ultrasonography (US).

MATERIAL AND METHODS

Between October 2012 and February 2013, 61 patients underwent arthroscopic repair of postero-superior rotator cuff tears. Each patient underwent MRI and US 6 months later. The findings were assessed independently by two observers. We compared intra-observer and inter-observer levels of agreement regarding healing rates assessed by MRI and US.

RESULTS

Intra-observer agreement regarding the MRI interpretation was 95% (κ coefficient, 0.83) for one observer and 98% (κ coefficient, 0.94) for the other. Values of κ for inter-observer agreement ranged across readings from 0.76 to 0.90. When MRI was taken as the reference, US had 80% sensitivity and 98% specificity.

DISCUSSION

MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. Intra-observer and inter-observer agreements are very good.