Does the critical shoulder angle influence retear and functional outcome after arthroscopic rotator cuff repair? A systematic review and meta-analysis

Lower Reoperation Rate and Superior Patient-reported Outcome Following Arthroscopic Rotator Cuff Repair with Concomitant Acromioplasty: An Updated Systematic Review of Randomized Controlled Trials

PURPOSE

This study aims to systematically assess the postoperative outcomes in patients undergoing arthroscopic rotator cuff repairs with or without concomitant acromioplasty through a rigorous systematic review of randomized controlled trial s (RCTs).

METHODS

This systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, aimed to identify RCTs comparing clinical outcomes of patients with full thickness rotator cuff tears undergoing arthroscopic rotator cuff repair with acromioplasty versus those without at a minimum of 12 months follow-up. Databases searched included PubMed, Web of Science, Embase, and the Cochrane Library. The risk of bias in the included studies was assessed using the revised Cochrane Risk of Bias 2 (RoB2). Meta-analysis was conducted for outcomes with at least three studies reporting, with pooled effect estimates calculated using either fixed-effect or random-effects models based on heterogeneity levels. Results were presented as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). For outcomes with fewer than three studies reporting, a Fisher exact test was conducted, with continuity correction applied if necessary. Primary outcomes include rates of retear and reoperation, while secondary outcomes included improvement in American Shoulder and Elbow Surgeons (ASES) score, range of motion (ROM), and complication rate.

RESULTS

Five high-quality RCTs, with low bias risk, involving 409 patients, revealed demographics of 58.4% males, mean age 58.4 years, and acromion types: 12.2% type I, 70.7% type II, and 17.1% type III. Mean follow-up was 52.2 months. Retear (12.5% versus 16.1%, P = 0.536) and complication rates (OR, 3.11; 95% CI, 0.31-30.73; P=0.33) were comparable between the two groups. However, reoperation rate (5.3% versus 15.9%, P < 0.001) and improvement in ASES score (WMD, 3.99; 95% CI, 1.00-6.99; P=0.009) favored the acromioplasty group. Both groups showed significant improvements in ROM, but insufficient data prevented a comparison.

CONCLUSIONS

Compared to arthroscopic rotator cuff repair alone, arthroscopic rotator cuff repair with acromioplasty demonstrated similar rates of retear and complications, but a significantly lower reoperation rate and superior improvement in ASES score. The available data were insufficient to draw a definitive conclusion regarding ROM. This conclusion is fragile due to a limited sample size.

Critical Shoulder Angle in Patients With Cuff Tears

OBJECTIVE

The pathogenesis of rotator cuff tears (RCTs) is multifactorial. Critical shoulder angle (CSA), which represents the lateral extension of the acromion over the cuff, has been proposed as an extrinsic risk factor. The aim of the present systematic review and meta-analysis was to analyze the available literature regarding the correlation between RCT and CSA.

METHODS

A review was carried out in accordance with the "Preferred Reporting Items for Systematic reviews and Meta-Analyses" guidelines on July 17, 2023, using the following databases: PubMed, Ovid, and Cochrane Reviews. The following keywords were used: "critical shoulder angle," "rotator cuff tears," and "rotator cuff lesions." The methodological quality of the studies was assessed with the MINORS SCORE.

RESULTS

Twenty-eight studies were included. The average CSA among the 2110 patients with full-thickness RCT was 36.7 degrees, whereas the same value among the 2972 controls was 33.1 degrees. The average CSA in the 348 patients with partial-thickness RCT was 34.6 degrees, whereas it was 38.1 degrees in the 132 patients with massive RCT. The average MINORS score was 15.6.

CONCLUSIONS

CSA values were significantly higher in patients with RCT compared with the asymptomatic population. In addition, it appears that CSA values increase with the severity of rotator cuff involvement.

Suture Contamination During Arthroscopic Rotator Cuff Repair Is Associated With Significantly Higher Retear Rates in Magnetic Resonance Imaging: A Matched-Pair Analysis

PURPOSE

To evaluate the correlation between suture contamination and rotator cuff tendon retear after arthroscopic rotator cuff repair.

METHODS

Patients undergoing primary arthroscopic rotator cuff repair from April 1, 2020, to September 30, 2022, were enrolled. Those younger than 18 years, with a history of shoulder surgeries or shoulder infection episodes, or who declined participation were excluded. A 5-cm section of the first-cut suture, originating from the anchor eyelet ends, in each rotator cuff repair surgery was subjected to bacteria culture and polymerase chain reaction analysis. Patients with positive culture findings were matched 1:1 to those with negative culture reports based on age, sex, tear size as well as involved tendons, preoperative fatty infiltration grade (Goutallier grade), and preoperative muscle atrophy grade (Warner score). Postoperative rotator cuff tendon retear assessments were conducted at the 6-month mark using the Sugaya classification via magnetic resonance imaging. The Wilcoxon signed-rank test was used for matched-pair comparisons between the groups.

RESULTS

A total of 141 patients (60 men and 81 women) with a mean age of 61.0 ± 8 years were finally enrolled. Twenty-six patients (18 men and 8 women) had a positive culture, while 115 patients (42 men and 73 women) had a negative culture. After the propensity score matching process, 24 culture-negative patients (16 men and 8 women) were selected as the culture-negative group. Age, fatty infiltration grade, and muscle atrophy grade were not significantly different between matched groups. The retear grade in the culture-positive group was significantly higher than that in the culture-negative group (P = .020) under the matched-pair comparison. Cutibacterium acnes was the most prevalent bacterial species responsible for suture contamination.

CONCLUSIONS

The matched-pair analysis revealed that the presence of bacterial contamination on sutures was associated with a higher risk of retear on magnetic resonance imaging following arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Rotator Cuff Tears to Shoulder Instability: The Relationship Between Acromial Morphology and Shoulder Pathology

» The acromion is a well-studied region of the scapula that has demonstrated substantial relationships to various shoulder pathologies.» Abnormal acromial morphology is associated with rotator cuff pathology, and our understanding of this risk factor inspired acromioplasty as an adjunctive treatment for rotator cuff tears.» The acromion is linked closely to shoulder kinematics and biomechanics, as it serves as the origin for the deltoid muscle.» In degenerative shoulder disease, eccentric glenohumeral osteoarthritis has been associated with a higher, flatter acromial roof.» Increasing literature is emerging connecting morphology of the acromion with shoulder instability.

Comparison of Arthroscopic Single-row and Double-row Repair for Rotator Cuff Injuries With Different Tear Sizes: A Systematic Review and Meta-analysis

Background

There is no clinical gold standard for the indications for single-row (SR) versus double-row (DR) repair according to small, large, or massive rotator cuff tear size.

Purpose

To conduct a meta-analysis to compare the clinical outcomes and retear rates after arthroscopic SR and DR repair for rotator cuff injuries with different tear sizes.

Study Design

Systematic review; Level of evidence, 3.

Methods

On the basis of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, the PubMed, Embase, Cochrane Library databases, Web of Science, China National Knowledge Infrastructure, and China BioMedical Literature database were searched for relevant studies published before November 1, 2021, using the following search terms: "Rotator Cuff Injuries," "Rotator Cuff Tears," "Arthroscopy," "Arthroscopic Surgery," "single-row," and "double-row"; a total of 489 articles were retrieved. Quality evaluation was conducted for all the studies that met the inclusion criteria. This study evaluated the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, and range of motion (ROM) as well as retear rate. A fixed-effects or random-effects model was adopted to calculate the results and assess risk.

Results

A total of 10 clinical studies were included, with 404 cases of DR and 387 cases of SR. Regarding overall results, DR had better forward elevation ROM (mean difference [MD] = -4.03° [95% CI, -6.00° to -2.06°]; P < .0001; I 2 = 46%) and a lower retear rate (MD = 2.39 [95% CI, 1.40 to 4.08]; P = .001; I 2 = 0%) compared with SR repair. With regard to small tears (<3 cm), there was no noticeable difference on any of the 3 outcome scores between SR and DR. For large rotator cuff tears (≥3 cm), DR repair showed significantly better ASES scores (MD = -3.09 [95% CI, -6.19 to 0.02]; P = .05; I 2 = 73%) and UCLA scores (MD = -1.47 [95% CI, -2.21 to -0.72]; P = .0001; I 2 = 31%) compared with SR repair.

Conclusion

Our meta-analysis revealed that DR had better UCLA scores, ASES scores, and ROM in forward elevation and lower retear rates. In rotator cuff tears <3 cm, there were no statistical differences in clinical outcome between SR and DR.

Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears

Nonoperative and operative strategies exist to manage rotator cuff pathology. Although surgical repair is successful for most patients, others may experience retear or nonhealing of the rotator cuff. Several modifiable and nonmodifiable risk factors are associated with an increased retear rate. The literature shows consistency and agreement regarding many of these risk factors, most notably, patient age, tear size, and rotator cuff muscular atrophy, whereas others remain controversial. It is important that shoulder surgeons are familiar with modifiable and nonmodifiable risk factors associated with retear, to better advise patients and optimize their chances of success following rotator cuff repair surgery.